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Resume Introduction Les residents en EHPAD sont une population fragile dont l’acces aux soins est limite. Ces dernieres annees, la telemedecine s’est developpee dans plusieurs specialites, dont l’ophtalmologie. L’objectif principal de notre etude est la validation d’un protocole de teleexpertise d’ophtalmologie en EHPAD. Materiel et methodes Il s’agit d’une etude retrospective, multicentrique et descriptive incluant 4 EHPAD autour de l’agglomeration de Rennes. Un orthoptiste examinait les residents une demi-journee par semaine. L’examen se faisait directement dans la chambre du patient, au lit ou au fauteuil, avec du materiel portable. Les examens sont interpretes a distance et en differe par un ophtalmologiste du service dans un delai de 7 jours. Une prise en charge adaptee medicale ou chirurgicale est alors proposee au patient selon le diagnostic. Resultats Nous avons inclus 113 residents. Un examen complet et interpretable a ete realise dans 84,1 % des cas. Une ou plusieurs pathologies ophtalmologiques ont ete diagnostiquees chez 57,5 % des residents. Parmi les residents ayant effectue une consultation au CHU, 65 % d’entre eux ont eu un acte chirurgical ou un laser programme. L’acuite visuelle a ete significativement amelioree apres la teleexpertise. Discussion Le taux de reussite d’un examen complet et interpretable nous permet, a ce jour, de valider notre procedure d’examen en EHPAD. En plus d’apporter un grand nombre d’informations initialement inconnues au personnel medical et paramedical de la structure, la teleexpertise d’ophtalmologie permet une amelioration significative de l’acuite visuelle. Conclusion Ce projet a permis de valider la faisabilite d’une teleexpertise d’ophtalmologie dans les EHPAD. Cette activite semble egalement pouvoir s’ouvrir a d’autres centres de soins (centres penitenciers, etablissement de sante mentale…).

International audience; Objective: this paper presents an innovative graphical user interface to visualize the attitude of a sensing device in a three-dimensional space, serving a wide-range of medical applications. Material and methods: based on inertial measurement units (IMU) or on magnetic, angular rate and gravity (MARG) sensors, a processing unit provides Euler angles using a sensor fusion technique to display the orientation of the device relative to the Earth frame in real-time. The device is schematized by linking six polygonal regions, and is subject to sequential rotations by updating the graph each 350 ms. We conduct comparative studies between the two sensing devices, i.e. IMUs and MARGs, as well as two orientation filters, namely Madgwick's algorithm and Mahony's algorithm. Results: the accuracy of the system is reported as a function of (i) the sampling frequency, (ii) the sensing unit, and (iii) the orientation filter, following two elderly care applications, namely fall risk assessment and body posture monitoring. The experiments are conducted using public datasets. The corresponding results show that Madgwick's algorithm is best suited for low sampling rates, whereas MARG sensors are best suited for the detection of postural transitions. Conclusion: this paper addresses the different aspects and discusses the limitations of attitude estimation systems, which are important tools to help clinicians in their diagnosis.

Assisted living residents are a fragile population with limited access to health care. In recent years, telemedicine has developed in several specialties, including ophthalmology. The main objective of our study is the validation of an ophthalmology telemedicine protocol in assisted living facilities.This is a retrospective, multicentric, descriptive study including 4 assisted living facilities in the Rennes area. An ophthalmic technician examined residents for one half-day per week. The examination was performed directly in the patient's room, in bed or in a chair, with portable equipment. An ophthalmologist from our service interpreted the results remotely on a deferred basis within 7 days. Appropriate medical or surgical care was then offered to the patient depending on the diagnosis.We included 113 residents. A complete, interpretable examination was achieved in 84.1% of cases. One or more ophthalmic conditions were diagnosed in 57.5% of the residents. Of the residents who were then seen at the university medical center, 65% underwent a scheduled surgical procedure or laser. Visual acuity was significantly improved subsequent to the telemedicine encounter.The success rate of a complete, interpretable examination allows us to now validate our nursing home examination procedure. In addition to bringing a large amount of initially unknown information to the medical and paramedical staff of the structure, ophthalmology telemedicine allows for a significant improvement in visual acuity.This project validated the feasibility of ophthalmology telemedicine in an assisted living setting. This protocol may also be applicable to other health care settings (penitentiaries, mental health institutions, etc.).

Background The international Choosing Wisely campaign seeks to improve the appropriateness of care, notably through large campaigns among physicians and users designed to raise awareness of the risks inherent in overmedication. Methods In deploying the Choosing Wisely campaign, the French Society of Geriatrics and Gerontology chose early operationalization via a tool for clinical audit over a limited area before progressive dissemination. This enabled validation of four consensual recommendations concerning the management of urinary tract infections, the prolonged use of anxiolytics, the use of neuroleptics in dementia syndromes, and the use of statins in primary prevention. The fifth recommendation concerns the importance of a dialogue on the level of care. It was written by patient representatives directly involved in the campaign. Results The first cross-regional campaign in France involved 5337 chart screenings in 43 health facilities. Analysis of the results showed an important variability in practices between institutions and significant percentage of inappropriate prescriptions, notably of psychotropic medication. Discussion The high rate of participation of target institutions shows that geriatrics professionals are interested in the evaluation and optimization of professional practices. Frequent overuse of psychotropic medication highlights the need of campaigns to raise awareness and encourage deprescribing.

Medication reconciliation (MR) is a systematic and comprehensive review of all medication a patient is taking. In this study, a discharge medication sheet (DMS) is given to patients upon discharge: it contains discharge prescription and any changes made to admission prescription with justifications. The aim of this study is to explore general practitioners' (GP) perceptions of this DMS in order to suggest improvements.In this prospective observational study, individual semi-directed interviews were conducted with GPs who received a DMS following the hospitalization of one of their patients. Answers were grouped by topic and subjected to descriptive analysis.Between October 2015 and July 2016, 33 DMS were completed. Among the 33 GPs, 16 had seen their patients with their DMS and agreed to be interviewed. The DMS was very appreciated and improved care pathway. However, this study highlights transmission difficulties for this sheet, attributed in particular to a lack of information of practitioners and patients and to the paper format, which appears to be inadequate. The main suggested improvement is real-time transmission of the DMS via email.Practitioners' opinion is in favor of the use of a DMS. Certain specific points need to be improved, such as better information of practitioners and patients, and transmission of the DMS via a secure email system.

Atrial fibrillation (AF) is the most common arrhythmia in older adults, and those with AF have an increased risk of developing stroke. Although the use of anticoagulants for stroke prevention is strongly recommended, many older people are not appropriately treated. Vitamin K antagonists (VKA) have been the only available oral anticoagulants for such patients, but recently, new oral anticoagulants have been approved for stroke prevention in AF as an alternative to VKA. Some characteristics make them an attractive treatment option; however, many gaps in evidence remain, especially in the population of older patients. This paper explores the use of anti-thrombotic treatment for the prevention of stroke in AF in old subjects in four different European countries. VKA seems to be the standard therapy in older patients, although anti-platelet drugs are still used widely in some countries. In many European countries, warfarin is replaced by coumadin derivatives. The use of new oral anticoagulants seems to be quite limited in older subjects and some degree of discrimination exists in access to these new drugs. European Society of Cardiology (ESC) 2010 and 2012 guidelines seem to be triggering a wide change in attitudes and practices. Many countries are incorporating such guidelines into official recommendations, and specific country recommendations on the use of new anticoagulants have been published, partly due to the high economic impact of these drugs. Geriatricians still have a marginal role in the prescription of anticoagulants, which in most countries usually lies on cardiologists. General practitioners are key for follow-up, as the role of anticoagulation clinics remains relevant only in The Netherlands. Most old patients have limited knowledge of anticoagulant treatment options, thus, their involvement in decision-making is low.

Le nombre de patients avec maladie d’Alzheimer ou autre demence (MAAD) en France metropolitaine a ete estime a 856000 en 2004 et les cas incidents (sujets>65 ans) a 225000. L’utilisation des bases de donnees medico-administratives pourrait etre proposee pour identifier ces patients a des fins epidemiologiques.Nous avons utilise l’EGB, echantillon individuel au 1/97e des beneficiaires du regime general de l’assurance maladie, representatif de 77% de la population francaise en 2007. Trois modes d’identification des patients>60 ans ayant une MAAD ont ete utilises : l’affection de longue duree n?15 (ALD15), la consommation de medicaments specifiques de la MAAD (MED) et les codages PMSI des syndromes dementiels (PMSI).3802 beneficiaires repartis en 7 populations disjointes ont ete identifies : les patients en ALD15 (17.3%), le groupe MED (21.4%), le groupe PMSI (14.4%) et les differentes combinaisons de ces 3 criteres (ALD15+MED (27.1%), ALD15+PMSI (2.5%), PMSI+MED (6.8%) et ALD15+MED+PMSI (9.7%)). Les patients ALD15 etaient plus âges (85.1±9.1 ans) que ceux du groupe MED (81.9±7.4 ans) ou du groupe PMSI (83.4±9.5 ans). La repartition des genres etait inegale (sex-ratio F/H : 3.0, 2.0 et 1.5, respectivement). Le taux de recours au generaliste etait de 57.6% chez les patients ALD15 contre 89.8% et 84.8% dans les 2 autres groupes, respectivement. Les taux de deces en 2007 etaient compris entre 8,6% (MED) et 34,4% (ALD15+PMSI).L’utilisation des differents moyens d’identification de la MAAD objective des groupes de caracteristiques sociodemographiques et de gravite differentes. L’institutionnalisation des patients et l’attente de declaration en ALD pourraient en partie expliquer ces discordances.

Le concept d’integration des soins et des services, bien que datant des annees 90, n’est que recemment apparu dans les politiques publiques en France. Ce concept doit s’articuler avec celui de « coordination » qui a prevalu dans la conduite de la majorite des politiques publiques touchant le champ gerontologique depuis les annees 60 en France. Afin de clarifier le concept et son adaptation a la realite du systeme de soins et de services francais, la Societe francaise de geriatrie et de gerontologie a mandate un groupe de travail interdisciplinaire. Les travaux de ce groupe sont synthetises dans cet article.

Background Better integration of healthcare is the focus of many current reforms in Western countries. The goal is to reduce fragmentation of health and social care delivery for patients with chronic diseases. In France, Alzheimer autonomy integration experimentations (Maison Autonomie Integration Alzheimer [MAIA]) were introduced as part of the 2008–2012 National Alzheimer Plan. To date, implementation of such organizations remains challenging. It is thus paramount to identify factors obstructing, and on the contrary facilitating, implementation of integrated care. Methods After an in-depth literature review of qualitative studies published from January 1995 to December 2010. We selected 10 qualitative studies on health care professionals’ perceptions of barriers and facilitators to the implementation of integrated care. Results Barriers and facilitating factors linked to the implementation of integrated care were identified at several levels: leadership; collaboration between services and clinicians; and funding and policy making. The operative strategy applied to change care delivery and the role of the leading pilot are key elements during the implementation phase. Conclusion Strong leadership and active involvement of a broad spectrum of professionals from clinical practitioners to healthcare managers is crucial for a successful implementation of integrated care services.

Resume Le concept d’evaluation geriatrique standardisee (EGS) ou approche gerontologique globale (AGG) est un fondement de la geriatrie moderne. Cette mise au point propose de tenter de clarifier les concepts sous-jacents, d’evaluer le niveau de preuves et de preciser les questions encore en debat. Le concept suppose la definition d’un processus interdisciplinaire d’evaluation multidimensionnel en vue de la production d’un plan coordonne. La notion centrale est celle de la systematisation de la multidimensionnalite et de l’interdisciplinarite qui reclame la mise en place de processus dedies (reunion, outils clinique, systeme d’information, etc.). Les dimensions qui doivent etre couvertes sont de nature sanitaire, sociale, economique, environnementale et psychologique. Tout processus d’evaluation qui pourrait conduire a oublier une de ses dimensions ne saurait donc etre assimile a une AGG. Le niveau de preuve est eleve a l’hopital en unite d’hospitalisation aigue mais il est bas dans tous les autres secteurs de soins meme si les donnees eparses de la litterature plaident pour un benefice de type qualitatif (amelioration de la qualite des soins voire de la qualite de vie). Les questions qui demeurent sont nombreuses parmi lesquelles le choix de strategie d’evaluation initiale (maximale versus minimale, d’emblee par de multiples professionnels ou graduee en fonction de l’evaluation minimale initiale), le choix de l’outil clinique, le lieu optimal, l’intensite necessaire du suivi et la population cible ideale.

Objectives: To evaluate the predictive ability of four clinical frailty indexes as regards one-year rapid cognitive decline (RCD — defined as the loss of at least 3 points on the MMSE score), and one-year institutional admission (IA) and mortality respectively; and to measure their agreement for identifying groups at risk of these severe outcomes. Design: One-year follow-up and multicentre study of old patients participating in the SAFEs cohort study. Setting: Nine university hospitals in France. Participants: 1,306 patients aged 75 or older (mean age 85±6 years; 65% female) hospitalized in medical divisions through an Emergency department. Measurements: Four frailty indexes (Winograd; Rockwood; Donini; and Schoevaerdts) reflecting the multidimensionality of the frailty concept, using an ordinal scoring system able to discriminate different grades of frailty, and constructed based on the accumulation of identified deficits after comprehensive geriatric assessment conducted during the first week of hospital stay, were used to categorize participants into three different grades of frailty: Gl — not frail; G2 — moderately frail; and G3 — severely frail. Comparisons between groups were performed using Fisher's exact test. Agreement between indexes was evaluated using Cohen's Kappa coefficient. Results: All patients were classified as frail by at least one of the four indexes. The Winograd and Rockwood indexes mainly classified subjects as G2 (85% and 96%), and the Donini and Schoevaerdts indexes mainly as G3 (71% and 67%). Among the SAFEs cohort population, 250, 1047 and 1,306 subjects were eligible for analyses of predictability for RCD, 1-year IA and 1-year mortality respectively. At 1 year, 84 subjects (34%) experienced RCD, 377 (36%) were admitted into an institutional setting, and 445 (34%) had died With the Rockwood index, all subjects who expenenced RCD were classified in G2; and in G2 and G3 when the Donini and Schoevaerdts indexes were used No significant difference was found between frailty grade and RCD, whereas frailty grade was significantly associated with an increased risk of IA and death, whatever the frailty index considered. Agreement between the different indexes of frailty was poor with Kappa coefficients ranging from −0.02 to 0.15. Conclusion: These findings confirm the poor clinimetric properties of these current indexes to measure frailty, underlining the fact that further work is needed to develop a better and more widely-accepted definition of frailty and therefore a better understanding of its pathophysiology

We studied the factors influencing the choice of admission to Geriatrics units, instead of other acute hospital units after an emergency visit. We report the results from a cohort of 1283 randomly selected patients aged >75 years hospitalized in emergency and representative of the French University hospital system. All patients underwent geriatric assessment. Baseline characteristics of patients admitted to Geriatrics and other units were compared. A center effect influencing the use of Geriatrics units during emergencies was also investigated. Admission to a Geriatrics unit during the acute care episode occurred in 499 cases (40.3%). By multivariate analysis, 4 factors were related to admission to a Geriatrics unit: cognitive disorder: odds ratio (OR)=1.79 (1.38-2.32) (95% confidence interval=95% CI); "failure to thrive" syndrome OR=1.54 (1.01-2.35), depression: OR=1.42 (1.12-1.83) or loss of Activities of Daily Living (ADL): OR=1.35 (1.04-1.75). The emergency volume of the hospital was inversely related to the use of Geriatrics units, with high variation that could be explained by other unstudied factors. In the French University Emergency Healthcare system, the "geriatrics patient" is defined by the existence of cognitive disorder, psychological symptoms or installed loss of autonomy. Nevertheless, considerable nation-wide variation was observed underlining the need to clarify and reinforce this discipline in the emergency healthcare system.

Le présent article analyse la réceptivité en contexte français d’un modèle québécois d’intégration des services aux personnes âgées en perte d’autonomie à partir d’une étude de mise en oeuvre de projets pilotes sur trois sites français. L’étude de la réceptivité constitue un analyseur puissant des conditions de possibilité d’une mise à jour d’un système socio-sanitaire. Dans une perspective néo-institutionnaliste, l’article cherche à mieux comprendre comment se déploie pour un système socio-sanitaire particulier la capacité d’innover. Il se compose de trois parties. La première problématise la question de l’intégration, la seconde analyse l’évolution du système socio-sanitaire français, tandis que la dernière expose la réceptivité d’un modèle d’intégration au regard de cette perspective néo-institutionnaliste. Cette analyse de la réceptivité révèle une tension entre deux logiques d’action publique en France en matière d’intégration des services, soit celle de la réduction de la complexité systémique et celle de son animation., This article examines the reception in France of a model developed in Quebec for integrating services to the elderly who are losing their ability to cope on their own. The study analyses the implementation of three pilot projects in France. A study of receptiveness reveals clearly the feasibility conditions for upgrading a system of health and social services. From a neo-institutionalist perspective, the article seeks to understand how the capacity to innovate is deployed in a given system. It consists of three parts. The first outlines the problem of integration, the second examines the evolution of the French system of health and social services, and the third describes the reception of an integration model, using a neo-institutional perspective. The receptiveness analysis reveals a tension between two attitudes toward public policy in France when it comes to integrating services : one that favours a reduction in system complexity and another that fosters it.

Resume Propos On dispose de peu d’informations sur les particularites geriatriques des malades âges frequentant les services d’urgences (SU) en France. Afin de developper une prevention adaptee de la venue de certains patients âges, les determinants de leur recours aux SU meritent d’etre mieux connus. Methodes Etude transversale realisee un jour donne aupres des SU en France. Un questionnaire standardise pour chaque patient de plus de 80 ans (Pts) a ete recueilli precisant les caracteristiques sociodemographiques, les circonstances du recours aux soins, la prise en charge au sein du SU et l’orientation des patients. Resultats Sur un echantillon de 1298 Pts, l’evenement de sante conduisant aux urgences debute au domicile dans 63,8 % des cas. Quand la demarche de recours au soin (RS) est initiee a partir du domicile, il est fait appel a un medecin plus souvent quand c’est la famille qui declenche le RS que lorsque c’est le patient lui-meme (69,6 et 61,9 % des cas, respectivement, p = 0,01). Lorsqu’un professionnel de sante initie la demarche de RS, il s’agit d’un medecin dans plus de 80 % des cas, quel que soit le lieu de declenchement. Apres le passage au SU, le retour au domicile est plus frequent lorsque le patient a initie lui-meme la demarche (34,5 % versus 22,9 % pour la famille et 16,0 % pour le professionnel de sante, p Conclusion L’acteur de la decision de venue aux urgences a un impact dans le RS, sur la consommation de ressources au SU, et sur l’orientation des Pts au decours du passage dans les SU. Cela implique des mesures de prevention ciblee.

Background The French health and services system to maintain at home is characterized by its fragmentation, whereas the need of the people for intervention is generally total. This fragmentation have consequences: delay in services delivery, inadequate transmission of information, redundant evaluation, service conditioned by the entrance point solicited rather than by the need of the person and inappropriate use of expensive resources by ignorance or difficulty of access to the less expensive resources. Presentation of the innovation The purpose of integration is to improve continuity of interventions for people in loss of autonomy. It consists in setting up a whole of organisational, managerial and clinical common tools. Organisational model “Projet et Recherches sur l’Integration des Services pour le Maintien de l’Autonomie” (Prisma) tested in Quebec showed a strong impact on the prevention of the loss of autonomy in term of public health on a population level. This model rests on six principal elements: partnership, single entry point, case-management, a multidimensional standardized tool for evaluation, an individualized services plan and a system for information transmission. Contextual analysis Thus, it was decided to try to implement in France this organisational model. The project is entitled Prisma France and is presented here. The analysis of the context of implementation of the innovation which represents integration in the field of health and services for frail older reveals obstacles (in particular because of diversity of professional concerned and a presentiment of complexity of the implementation of the model) and favourable conditions (in particular the great tension towards change in this field). Conclusion The current conditions in France appear mainly favourable to the implementation of integration. The establishment of Prisma model in France requires a partnership work of definition of a common language as well on the diagnoses as on the solutions. The strategic and operational dialogue is thus a key element of the construction of integration. This stage currently occurs in parallel in three areas contrasted in France. The results of associated qualitative research should make it possible to define the factors fostering or hindering the realization of integration according to each site (analyzes contrasted) and in all the sites (related to the particular context of care and French services as a whole).

Resume Propos La non-pertinence hospitaliere correspond a l'inadaptation entre besoin des patients et technicite d'une unite de soins. Le nombre de prises en charge en geriatrie aigue augmentant, l'etude du taux de non-pertinence et de ses causes dans ce contexte parait interessante. Methodes Les patients ont ete inclus consecutivement dans deux services de geriatrie aigue : des variables medicales et socioeconomiques ont ete relevees, la pertinence des journees d'hospitalisation a ete evaluee par la version francaise de l'Appropriateness Evaluation Protocol et le protocole d'analyse des causes de non-pertinence. Les facteurs de risque de journee non pertinente durant un sejour ont ete recherches. L'influence des variables independantes sur le risque de non-pertinence hospitaliere a ete evaluee par un modele de regression logistique. Resultats Seuls l'existence de troubles cognitifs et le lieu d'hospitalisation ont ete retrouves comme facteurs explicatifs. Le classement de la non-pertinence par cause est similaire dans les deux services (> 25 % des journees non pertinentes sont expliquees par le choix du patient ou de sa famille) mais avec des taux statistiquement differents, notamment pour les causes liees a l'attente d'une admission dans un service de soins a moyen ou long terme et pour l'attente d'une prestation realisee en dehors de l'etablissement d'accueil du patient. Conclusion L'acces a une structure d'aval est la premiere cause de non-pertinence hospitaliere. L'importance du choix du patient ou de sa famille comme cause de non-pertinence des journees d'hospitalisation semble etre une specificite de la geriatrie. En outre, pour developper une demarche de reduction de la non-pertinence hospitaliere, la problematique des troubles cognitifs devra etre au premier plan.

Summary Objectives The aim of this study was to identify early indicators of prolonged hospital stays by elderly patients. Methods This prospective pilot study, conducted at Strasbourg University Hospital, included patients aged 75 years or older who were hospitalized via the emergency department (SAFES cohort: Sujet Âge Fragile: Evaluation et suivi, that is, Frail Elderly Subjects: Evaluation and Follow-up). A gerontologic evaluation of these patients during the first week of their hospitalization furnished the data for an exact logistic regression. Two definitions were used for prolonged hospitalization: 30 days and a composite number adjusted for diagnosis-related group according to the French classification (f-DRG). Results The analysis examined 137 hospitalizations. More than two thirds of the patients were women (73%), with a mean age of 84 years. Twenty-four hospitalizations (17%) lasted more than 30 days, but only 6 (4%) lasted beyond the DRG-adjusted limit. No social or demographic variables appeared to affect the length of stay, regardless of the definition of prolonged stay. No indicator was associated with the 30-day limit, but clinical markers were linked to prolongation assessed by f-DRG adjustment. A “risk of malnutrition” (OR = 14.07) and “mood disorders” (OR = 2,5) were both early markers for prolonged hospitalization. Although not statistically significant, “walking difficulties” (OR = 2.72) and “cognitive impairment” (OR = 5.03) appeared to be associated with prolonged stays. No association was seen with either the variables measured by Katz's Activities of Daily Living Index or its course during hospitalization. Conclusion Our study shows that when generally recognized indicators of frailty are taken into account, a set of simple items enables a predictive approach to the prolongation of emergency hospitalizations of the elderly.

La notion de fragilite est entree progressivement dans le vocabulaire geriatrique du fait de l’identification d’une sous-population de personnes âgees a plus grand risque de mortalite et d’incapacite. En deux decennies environ, sa definition a progressivement evolue, mais aujourd’hui encore, elle a du mal a faire consensus. Cependant, cliniciens, chercheurs et responsables politiques restent unanimes sur la necessite de developper des outils de depistage precoce afin de mettre en place une strategie de prise en charge adaptee et une demarche preventive coherente.

Two cases of invasive aspergillosis (IA) in immunocompetent patients with a fulminant fatal outcome are reported. Both patients were elderly and had a history of chronic lung disease treated with prolonged inhaled corticosteroids and a short course of systemic corticosteroids. They presented with dyspnea and fever, their respiratory function deteriorated rapidly, and they died 7 days after admission. Aspergillus fumigatus was cultured from respiratory samples. IA was confirmed in one case by necropsy that showed diffuse bilateral necrotizing pneumonitis and myocarditis. In the other case, IA diagnosis was established by thoracic CT scan plus detection of Aspergillus antigen in two blood samples. These two cases demonstrate that short-term corticosteroid therapy in immunocompetent patients with underlying chronic lung conditions is a risk factor for IA, and that its evolution can be fulminant.

Case management is a new professional field in France. It is addressed to elderly persons living in community whose situation is regarded as particularly complex. Case managers have to assess needs and coordinate necessary services. One common criteria of complexity is refusal of care. The objective of this study is to compare the words of users with those of case managers about refusal of care, in order to understand its meaning, professionals' attitudes and ethical challenges.Two researchers have cooperated on this qualitative research: the first one, anthropologist, interviewed 19 individuals, and 11 of their caregivers. The second one, geriatrician and researcher in medical ethics, lead four focus groups gathering a total of 18 case managers.Refusal of care often is the result of the will of preserving one's identity, compromised by illness. Individuals seek control on their life. Facing this behaviour, case managers try to secure the individual, by establishing a personal relationship that respects their choices, even if care has to be delayed. Refusal of care may sometimes disclose a desire to vanish, in front of which professionals meet their own limits.To recognise an elderly person that refuses care as a unique individual who can make choices secure his identity, and allow him to change.

Introduction et but de l’etude Nous assurons les consultations dietetiques a l’Hopital de Jour Geriatrique (HDJ), interface de l’hopital et de la medecine de ville. Les patients presentent des problemes medico-psycho-sociaux souvent intriques. Nous savons que pour limiter les risques et le developpement d’une sarcopenie, un bon etat nutritionnel associe a une activite physique optimale sont preconises. Nous souhaitons savoir si les patients depistes sarcopeniques a l’HDJ sont accompagnes et conseilles de maniere adaptee. Materiel et methodes La circonference du mollet (CM) est mesuree systematiquement pour renseigner le Mini Nutritional Assessment. Nous reperons les patients sarcopeniques sur le critere CM Nous menons une etude exploratoire sur une periode de 4 mois pour savoir si tous les patients reperes sarcopeniques ont beneficie d’une consultation dietetique et d’un bilan kinesitherapique. L’existence d’une eventuelle denutrition a ete mise en parallele (selon les criteres HAS : IMC, albuminemie, MNA) Resultats et Analyse statistique Nous avons consideres 87 patients. Les 28 patients avec un CM Ces resultats seront discutes en fonction des recommandations et des criteres HAS ainsi que des missions de l’HDJ. Conclusion Pour ameliorer l’accompagnement des patients, la prise en charge pluridisciplinaire est necessaire. Il est convenu qu’une sensibilisation aux risques lies a la sarcopenie sera faite aupres des geriatres. Aussi, la sarcopenie sera signalee explicitement dans les comptes rendus adresses aux medecins afin qu’ils delivrent des conseils cibles. Dans le suivi des patients sarcopeniques les evaluations dietetique et kinesitherapique seront systematiquement prescrites. Nous poursuivrons cette etude pour verifier le suivi des conseils transmis et leurs effets.

The concept of comprehensive gerontological assessment is a foundation of modern geriatrics. Our focus was to try to clarify the underlying concepts, assess the level of evidence and clarify the issues still under debate. The concept implies the definition of an interdisciplinary process for a multidimensional assessment in order to produce a coordinated plan. The central notion is that the systematization of this multidimensionality and interdisciplinarity needs the establishment of dedicated process (meeting tools, clinical information system, etc.). Following dimensions should be covered: health, social, economic, environmental and psychological. Any assessment process that could lead to forgetting one of its dimensions cannot be viewed as a comprehensive gerontological assessment. The level of evidence is higher in hospital acute inpatient unit but it is still low in all other areas of health care but the scattered data in the literature argues for qualitative benefits (improved quality of care or quality of life). The questions that remain are numerous including the choice of strategy for initial evaluation (maximum versus minimum; from the outset by many professionals versus graduated based on the minimum initial evaluation), the choice of tool, the optimal location, the required intensity of monitoring and the ideal target population.

L’âge est un facteur de risque independant de mortalite hospitaliere apres admission en reanimation [1]. Cependant, alors que la gravite de l’affection estimee d’apres le score APACHE III explique 80% de la mortalite hospitaliere, l’âge n’en explique que 13% [1]. Le mecanisme de la surmortalite independante de la gravite des patients âges n’est pas clairement elucide. Cette surmortalite peut etre liee a un traitement moins intensif chez les patients âges, ou a une cause intrinseque due (a traitement equivalent) a une plus grande vulnerabilite aux affections, ou encore due (a traitement equivalent) a une moins bonne reponse, voire meme a une moins bonne tolerance des therapeutiques utilisees en reanimation. Dans les deux dernieres hypotheses, ce sont des particularites physiologiques specifiques des patients âges qui interviennent. Cela amene a poser la question de ces specificites.

Better integration of healthcare is the focus of many current reforms in Western countries. The goal is to reduce fragmentation of health and social care delivery for patients with chronic diseases. In France, Alzheimer autonomy integration experimentations (Maison Autonomie Intégration Alzheimer [MAIA]) were introduced as part of the 2008-2012 National Alzheimer Plan. To date, implementation of such organizations remains challenging. It is thus paramount to identify factors obstructing, and on the contrary facilitating, implementation of integrated care.After an in-depth literature review of qualitative studies published from January 1995 to December 2010. We selected 10 qualitative studies on health care professionals' perceptions of barriers and facilitators to the implementation of integrated care.Barriers and facilitating factors linked to the implementation of integrated care were identified at several levels: leadership; collaboration between services and clinicians; and funding and policy making. The operative strategy applied to change care delivery and the role of the leading pilot are key elements during the implementation phase.Strong leadership and active involvement of a broad spectrum of professionals from clinical practitioners to healthcare managers is crucial for a successful implementation of integrated care services.

Objectives: The aim of the study was to identify factors related to institutionalisation within one-year follow up of subjects aged 75 or over, hospitalised via the emergency department (ED). Design: Prospective multicentre cohort. Setting: Nine French university teaching hospitals. Participants: One thousand and forty seven (1 047) non institutionalised subjects aged 75 or over, hospitalised via ED. A sub-group analysis was performed on the 894 subjects with a caregiver. Measurements: Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. Cox survival analysis was performed to identify predictors of institutionalisation at one year. Results: Within one year after hospital admission, 210 (20.1%) subjects were institutionalised. For the overall study population, age >85 years (HR 1.6; 95%CI 1.1-2.1; p=0.005), inability to use the toilet (HR 1.6; 95%CI 1.1-2.4; p=0.007), balance disorders (HR 1.6; 95%CI 1.1-2.1; p=0.005) and presence of dementia syndrome (HR 1.9; 95%CI 1.4-2.6; p

Background The objective of the study was to identify factors predictive of 6-month institutionalization or mortality in frail elderly patients after acute hospitalization. Methods A prospective cohort of elderly subjects 75 years and older was set up in nine French teaching hospitals. Data obtained from a comprehensive geriatric assessment were used in a Cox model to predict 6-month institutionalization or mortality. Institutionalization was defined as incident admission either to a nursing home or other long-term care facility during the follow-up period. Results Crude institutionalization and death rates after 6 months of follow-up were 18% and 24%, respectively. Independent predictors of institutionalization were: living alone (HR = 1.83; 95% CI = 1.27–2.62) or a higher number of children (HR = 0.86; 95% CI = 0.78–0.96), balance problems (HR = 1.72; 95% CI = 1.19–2.47), malnutrition or risk thereof (HR = 1.93; 95% CI = 1.24–3.01), and dementia syndrome (HR = 1.88; 95% CI = 1.32–2.67). Factors found to be independently related to 6-month mortality were exclusively medical factors: malnutrition or risk thereof (HR = 1.92; 95% CI = 1.17–3.16), delirium (HR = 1.80; 95% CI = 1.24–2.62), and a high level of comorbidity (HR = 1.62; 95% CI = 1.09–2.40). Institutionalization (HR = 1.92; 95% CI = 1.37–2.71) and unplanned readmission (HR = 4.47; 95% CI = 3.16–2.71) within the follow-up period were also found as independent predictors. Conclusion The main factors predictive of 6-month outcome identified in this study are modifiable by global and multidisciplinary interventions. Their early identification and management would make it possible to modify frail elderly subjects’ prognosis favorably.

Introduction: The PRISMA France pilot project is ongoing since 2006. This project aims to implement an integrated services delivery (ISD) for elderly people, based on the PRISMA methodology. The experimentation is coupled with an implementation study to identify factors that facilitate and hinder the implementation. The fragmentation of public authorities represents one of the first barriers identified. In 2009, a large-scale institutional reform has been initiated. It consists of merging various structures having strategic authorities on medical and social care within a single entity: the Health Regional Agencies (HRA). One could anticipate that this reform should facilitate the implementation of ISD. Aims: To analyze the influence of institutional reforms on a pilot program aiming to implement an ISD. In the framework of our qualitative study we analyze the way the actors conceive the HRA. Conclusions: The potential to facilitate ISD of the HRA has been identified. It is hope that they should reduce the institutional fragmentation. Nonetheless, the link between these agencies and the implementation of ISD in the pilot project was rarely made. The extent of institutional change is bought into question by the past of the French system of social welfare.

At a time when many countries are working on programs to integrate services for frail older adults, methods need to be developed to determine the exact content of these programs. Our work proposes an approach to measuring integration that can help public authorities develop, implement and evaluate a public policy for service integration. In addition, the possibility of transferring this approach to other countries and other target populations (disabled persons, troubled adolescents, for example) could provide opportunities for comparative analyses.

Introduction: The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. In the PRISMA-France study, we qualitatively studied the implementation process of this model in French settings. Method: Our analyses were based on in-depth interviews, meeting observations and the documentation produced. Results: We adapted the implementation scale inherent to the PRISMA model to fit the French context and, using this scale, were able to appreciate a 15% progression of implementation, from 5% to 20%, in the first 18 months of the study. The factors that contributed to this rate of progression are of three main types. To begin with, contextual factors intrinsic to the French setting complexified the incorporation of integration into the public policy agenda and the means to achieve this feat. Secondly, factors related to the background of the concerned managers and professionals were identified. Thirdly, factors related to the particularities of the PRISMA-Experiment’s governance were noted. Our experience leads to consider time as the answer to these hindering contextual, professional and governance issues. Conclusion: These observations hold an important strategic value in a time where a wider integration experimentation is planned by the ‘plan-Alzheimer’ in France.

Objectives: The aim of the study was, by early identification of deleterious prognostic factors that are open to remediation, to be in a position to assign elderly patients to different mortality risk groups to improve management.Design: Prospective multicentre cohort.Setting: Nine French teaching hospitals.Participants: One thousand three hundred and six (1 306) patients aged 75 and over, hospitalised after having passed through Emergency Department (ED).Measurements: Patients were assessed using Comprehensive Geriatric Assessment (CGA) tools. A Cox survival analysis was performed to identify prognostic variables for six-week mortality. Receiver Operating Characteristics analysis was used to study the discriminant power of the model. A mortality risk score is proposed to define three risk groups for six-week mortality.Results: Crude mortality rate after a six-week follow-up was 10.6% (n=135). Prognostic factors identified were: malnutrition risk (HR=2.1; 95% CI: 1.1–3.8; p=.02), delirium (HR=1.7; 95% CI: 1.2-2.5; p=.006), and dependency: moderate dependency (HR=4.9; 95% CI: 1.5–16.5; p=.01) or severe dependency (HR=10.3; 95% CI: 3.2–33.1; p< .001). The discriminant power of the model was good: the c-statistic representing the area under the curve was 0.71 (95% IC: 0.67 – 0.75; p< .001). The six-week mortality rate increased significantly (p< .001) across the three risk groups: 1.1% (n=269; 95% CI=0.5–1.7) in the lowest risk group, 11.1% (n=854; 95% CI=9.4–12.9) in the intermediate risk group, and 22.4% (n=125; 95% CI=20.1–24.7) in the highest risk group.Conclusions: A simple score has been calculated (using only three variables from the CGA) and a practical schedule proposed to characterise patients according to the degree of mortality risk. Each of these three variables (malnutrition risk, delirium, and dependency) identified as independent prognostic factors can lead to a targeted therapeutic option to prevent early mortality.

Purpose: Recent work on diffusion of innovation insists on the importance of the processual dimensions of an innovation’s adoption. Context: In the course of a pilot-project aiming to implement three service integration networks for people losing their autonomy, we performed an analysis of the prior conceptions the various actors held of two founding principals: integration and coordination. This research aims to identify the prior conceptions held by the actors and to elucidate the adjustments they do to sustain the adoption of the innovation. Data sources: We conducted 32 interviews with the various key actors pertaining, as well to the strategic, tactical and operational levels of the three different sites. Case description: A content analysis of the conflicts of conception and adjustments elaborated by the adoptants during the course of the interviews was conducted. Conclusion: We notice differences in regards to the operational conceptions of the actors about the founding principles of the innovation. The capacity of working out compromises between these different conceptions is considered as predictive of the adoption of the innovation. Discussion: The adjustments they have elaborated favour a progressive adoption of the innovation and found the next step of the process of diffusion of innovation, which is local appropriation.

Introduction: The fragmentation of the French health and services system has a negative impact on the quality of the services offered because dependant community-dwelling older persons receive services from a mean of three interveners, and 25% of the most dependent ones perceive assistance from at least 6 interveners. In 2006, the Ministry of Health funded an experimentation of implantation of an evidence-based model of integration based on case management: PRISMA. Aims and objective: An implementation evaluative research was associated with the experimentation undertaken by an international (France, Quebec) and multidisciplinary (medical doctors, sociologists, economists) group of research. Methods: This evaluation is carried out continuously all along the implementation process. It is essentially based on research-action framework. A multi-case qualitative analysis is performed on three sites contrasted in regard of the health and services local organisation: rural, urban and megalopolitan. Results: Initial implementation seems to be low during the first 18 months. First objective signs of integration after 12 months were the emergence of a coordination process on a strategic level, the adoption of a unique assessment tools by all the partners and the project of constituting a multi-professional team of case managers. Sociological and political identified barriers will be discussed.

Introduction: The PRISMA implementation research has used an innovative tool: the penetration rate of integrated model in the system. The experimentation in France of the PRISMA adopts and adapts this methodology. Aims and objective: This measurement relates to the functions of the 6 tools and mechanisms of the model: coordination boards, single entry point, case-management, single assessment instrument, individualised services plan and information system. In contrast with Quebec, no public policy in France incites to move towards this model of integration. In addition, in the French system the construction of coordination boards is complex because there is as much as ten supervision authorities and about fifteen organisation managers involved in each experimental site. Methods of adaptation of the tool in France: The measurement was not only the absence, partial existence or existence of the 6 components but takes into account the appropriation process for each one, the administrative time and the new definition of thresholds to reach as compared to the model. Results: This research tool presents two advantages. The measurement scale enables also the partners to appropriate the function of each model component and more precisely the global model of the integration. Actors do not feel evaluated but accompanied.

To identify predictive factors for 2-year mortality in frail elderly patients after acute hospitalisation, and from these to derive and validate a Mortality Risk Index (MRI). A prospective cohort of elderly patients was set up in nine teaching hospitals. This cohort was randomly split up into a derivation cohort (DC) of 870 subjects and a validation cohort (VC) of 436 subjects. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 2-year mortality and to identify risk groups for mortality. A ROC analysis was performed to explore the validity of the MRI. Five factors were identified and weighted using hazard ratios to construct the MRI: age 85 or over (1 point), dependence for the ADL (1 point), delirium (2 points), malnutrition risk (2 points), and co-morbidity level (2 points for medium level, 3 points for high level). Three risk groups were identified according to the MRI. Mortality rates increased significantly across risk groups in both cohorts. In the DC, mortality rates were: 20.8% in the low-risk group, 49.6% in the medium-risk group, and 62.1% in the high-risk group. In the VC, mortality rates were respectively 21.7, 48.5, and 65.4%. The area under the ROC curve for overall score was statistically the same in the DC (0.72) as in the VC (0.71). The proposed MRI appears as a simple and easy-to-use tool developed from relevant geriatric variables. Its accuracy is good and the validation procedure gives a good stability of results.

We have little information on the geriatric characteristics of elderly patients visiting the emergency departments (ED) in France. In order to develop an adapted prevention of the arrival of some elderly patients, the determinants of their arrival to the ED deserves to be better known.A one-day cross-sectional study was conducted in French ED. A standardized questionnaire was used for each patient over 80 years (Pts), specifying the sociodemographic characteristics, the circumstances of visit to and care received in the ED, and the orientation of the patients after consulting the ED.On a sample of 1298 Pts, health event leading to ED started at home in 63.8% of cases. When the patients initiated themselves the recourse to health care (RHC), they called less often a general practitioner (61.9% of cases) than when the RHC was triggered by their family (69.6%, p=0.01). When a health care professional initiated the RHC, it was a GP in more than 80% of cases. Return to residence was more frequent when the patient triggered the RHC (34.5% versus 22.9% for the family and 16.0% for the professional health care, p0,001).The actor of the decision of arrival to the ED has an impact in the RHC, in resources utilisation, and on the patient's orientation after coming in ED. The results of this study may help to design strategies aiming at avoiding unnecessary ED consultations of elderly persons.

The French health and services system to maintain at home is characterized by its fragmentation, whereas the need of the people for intervention is generally total. This fragmentation have consequences: delay in services delivery, inadequate transmission of information, redundant evaluation, service conditioned by the entrance point solicited rather than by the need of the person and inappropriate use of expensive resources by ignorance or difficulty of access to the less expensive resources.The purpose of integration is to improve continuity of interventions for people in loss of autonomy. It consists in setting up a whole of organisational, managerial and clinical common tools. Organisational model "Projet et Recherches sur l'Intégration des Services pour le Maintien de l'Autonomie" (Prisma) tested in Quebec showed a strong impact on the prevention of the loss of autonomy in term of public health on a population level. This model rests on six principal elements: partnership, single entry point, case-management, a multidimensional standardized tool for evaluation, an individualized services plan and a system for information transmission.Thus, it was decided to try to implement in France this organisational model. The project is entitled Prisma France and is presented here. The analysis of the context of implementation of the innovation which represents integration in the field of health and services for frail older reveals obstacles (in particular because of diversity of professional concerned and a presentiment of complexity of the implementation of the model) and favourable conditions (in particular the great tension towards change in this field).The current conditions in France appear mainly favourable to the implementation of integration. The establishment of Prisma model in France requires a partnership work of definition of a common language as well on the diagnoses as on the solutions. The strategic and operational dialogue is thus a key element of the construction of integration. This stage currently occurs in parallel in three areas contrasted in France. The results of associated qualitative research should make it possible to define the factors fostering or hindering the realization of integration according to each site (analyzes contrasted) and in all the sites (related to the particular context of care and French services as a whole).

Background: The preservation of autonomy and the ability of elderly to carry out the basic activities of daily living, beyond the therapeutic care of any pathologies, appears as one of the main objectives of care during hospitalization. Objectives: To identify early clinical markers associated with the loss of independence in elderly people in short stay hospitals. Methods: Among the 1,306 subjects making up the prospective and multicenter SAFEs cohort study (Sujet Agé Fragile: Évolution et suivi—Frail elderly subjects, evaluation and follow-up), 619 medical inpatients, not disabled at baseline and hospitalized through an emergency department were considered. Data used in a multinomial logistic regression were obtained through a comprehensive geriatric assessment (CGA) conducted in the first week of hospitalization. Dependency levels were assessed at baseline, at inclusion and at 30days using Katz's ADL index. Baseline was defined as the dependence level before occurrence of the event motivating hospitalization. To limit the influence of rehabilitation on the level of dependence, only stays shorter than 30days were considered. Results: About 514 patients were eligible, 15 died and 90 were still hospitalized at end point (n=619). Two-thirds of subjects were women, with a mean age of 83. At day 30 162 patients (31%) were not disabled; 61 (12%) were moderately disabled and 291 severely disabled (57%). No socio-demographic variables seemed to influence the day 30 dependence level. Lack of autonomy (odds ratio (OR)=1.9, 95% confidence interval (CI)=1.2-3.6), walking difficulties (OR=2.7, 95% CI=1.3-5.6), fall risk (OR=2.1, 95% CI=1.3-6.8) and malnutrition risk (OR=2.2, 95% CI=1.5-7.6) were found in multifactorial analysis to be clinical markers for loss of independence. Conclusions: Beyond considerations on the designing of preventive policies targeting the populations at risk that have been identified here, the identification of functional factors (lack of autonomy, walking difficulties, risk of falling) suggests above all that consideration needs to be given to the organization per se of the French geriatric hospital care system, and in particular to the relevance of maintaining sector-type segregation between wards for care of acute care and those involved in rehabilitation

Objectif Les unites de soins de longue duree (USLD) presentent une population fragile, ou la prevalence des maladies cardiovasculaires est elevee, et ou le risque hemorragique, lie aux polypathologies, a l’insuffisance renale, ou au risque de chutes, est important. L’objectif principal de ce travail est d’evaluer l’adequation des prescriptions d’antithrombotiques, dans une USLD, par rapport aux recommandations actuelles. Les objectifs secondaires sont d’evaluer la qualite de la surveillance de ces traitements et en cas d’inadequation de la prescription et des recommandations, d’interroger le prescripteur en vue d’identifier des possibilites d’amelioration des prescriptions. Materiels et methodes Un releve des donnees concernant la prescription d’antithrombotiques a ete realise sur tous les patients presents dans l’USLD du CHU de Rennes entre le 16 juin et le 23 juin 2014. Ces donnees ont ete comparees aux recommandations actuelles internationales. Resultats Cent-seize patients etaient presents en USLD. La moyenne d’âge etait de 84 (± 8,5) ans. Vingt-trois patients etaient sous anticoagulant, principalement sous antivitamine K, pour une fibrillation atriale. Cinquante patients recevaient un antiplaquettaire, principalement de l’aspirine, pour un antecedent d’accident vasculaire cerebral. Sept patients recevaient a la fois un anticoagulant et un antiplaquettaire. Deux prescriptions d’anticoagulant et six prescriptions d’antiplaquettaire n’etaient pas conformes aux recommandations actuelles. Parmi les 50 patients ne recevant ni anticoagulant ni antiplaquettaire, 8 avaient une indication a un traitement antithrombotique. Au total, 16 prescriptions (14 %) etaient inadequates et ont ete modifiees (arret, ajout ou modification de traitement) ; 3 concernaient les anticoagulants et 13 les antiplaquettaires. Tous les patients sous antivitamine K beneficiaient d’un suivi par INR regulier. Plus de deux patients sur trois passaient la moitie du temps dans la fenetre therapeutique d’INR. Conclusion La majorite des prescriptions de l’USLD etaient conformes aux recommandations actuelles. Notre etude a cependant retrouve plusieurs situations ou la confrontation des prescriptions et des recommandations a entraine une modification du traitement, soulignant l’interet de la demarche. Si la gestion des anticoagulants semble bien maitrisee, notre etude montre que les situations qui ont conduit a une modification des prescriptions concernent, avant tout, les antiplaquettaires.

The authors report the case of a 62-year-old patient complaining of recent onset of disabling breathlessness on exertion, and presenting clinical signs of previously undiagnosed scleroderma. Echocardiography revealed a diagnosis of precapillary pulmonary hypertension (74/14 mmHg) (PHT), with no pulmonary cause revealed by pulmonary ventilation-perfusion scintigraphy or by thoracic fine section computed tomography. The diagnosis of PHT in the context of circumscribed scleroderma was confirmed by x-rays of the hands, capillaroscopy, oesophageal investigations and positive anticentromere antinuclear antibodies. The clinical course was marked by rapid deterioration of the symptoms, requiring treatment with prostacyclin by continuous intravenous infusion. The appearance of PHT in a context of circumscribed scleroderma, usually a relatively benign disease, is a rare, late event, exceptionally revealing the disease, as in this case, and indicating a very unfavourable prognosis.

Infection is a common problem in diabetic patients with foot ulcers. The diagnosis of infection is not always easy to establish, but must be made for proper therapeutic decision making. In addition to local care, search for arteriopathy and strict control of blood glucose, treatment of infected foot ulcers requires an appropriate anti-infectious strategy. We developed diagnostic and therapeutic decisional algorithms from data available in the literature in order to establish a management strategy for different clinical situations. The fundamental role of clinical assessment is underlined and the different causal microorganisms are recalled, together with the anti-microbial activity and bone concentrations of the main antibiotics used. An optimal anti-infection work-up can undoubtedly significantly reduce the number of amputations in diabetic patients.