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Atrial fibrillation (AF) is common in the elderly. The treatment of this condition is based on anticoagulation to prevent stroke and systemic arterial embolism. Vitamin K antagonists (VKAs) have long been the only anticoagulants available for the management of AF. Administration is complex and is one of the main causes of iatrogenic disease in the elderly. In the past 10 years, direct-acting oral anticoagulants (DOACs) have emerged, and large randomised trials (RE-LY, ROCKET-AF, ARISTOTLE, ENGAGE-AF) have demonstrated their superiority over VKAs in the management of AF. These trials were conducted on large numbers of patients (n=71,683), including 27,500 patients aged ≥75 years and nearly 8,000 subjects aged >80 years. Results from 11 recent meta-analyses of randomised trials and observational real-world studies of 660,896 elderly patients indicate that DOACs are more effective than VKA-based prophylaxis in preventing stroke (with a reduction in risk ranging from 13% to 26%), and carry a lower risk of cerebral haemorrhaging (50% reduction in risk). The risk of major haemorrhaging appears to be similar to, or lower than that with DOACs relative to VKAs (depending on the dosage, renal function, haemorrhagic site or type of DOAC). Moreover, improved outcomes with DOACs over VKA therapy have been demonstrated based on subgroup analyses in subjects aged over 75, in patients with renal insufficiency (creatinine clearance: 30-50 mL/min) and in those with a history of falls. Analyses indicate that DOACs are a better choice than VKAs in the elderly because elderly patients are at greatest risk of stroke and cerebral haemorrhaging. In summary, DOACs have a better efficacy/tolerance profile than VKAs, which justifies their first-line use in subjects over 75 years of age.

Frailty in the older population is a clinical syndrome which evaluate a risk level. The Frailty syndrome defines a reduction of the adaptation capacity to a stress. It can be modulated by physical, psychological and social factors. The screening of the frailty syndrome is relevant for older people without disability for basic activities of daily living. The clinical criteria of frailty must be predictive of the risk of functional decline and adverse outcomes, consensual at the international level, and easy to perform in primary care as well as in the clinical researches.

Background Demographic changes require an adaptation of the geriatric care offer, which is readily oriented towards the community and including the development of out-of-hospital mobile geriatric team (MGT). Although psychiatric disorders of older persons require a comprehensive, integrative and multidisciplinary approach, geriatrics and old age psychiatry mobile units often work in parallel without concertation for the management of complex pathologies. The aim of this paper is to present the organisation and the results of a out-of-hospital MGT with a geriatrician and old age psychiatrists (OAP) in a same unit. Method Data were collected during the first-year (2018) of the out-of-hospital MGT of Tours University hospital. After initial geriatric assessment and when old age psychiatry (OAP) intervention was needed, referral mode and justification, patient's characteristics and recommendations made by the team were collected. Results During the study period, 151 patients were assessed, 53% (n=80) had out-of-medical follow-up or difficulties to access to healthcare; 40% (n=60) had behavioural and psychological symptoms of dementia (BPSD), 30% (n=45) falls, 15% (n=23) social problems, 10% (n=15) alteration of overall health status and 5% (n=7) drug conciliation; 40% (n=60) benefited from an OAP evaluation; 100% (n=60) had out of medical follow-up, 83% (n=50) had severe BPSD, 17% (n=10) psychological symptom with psychiatric condition, 10% (n=6) misused psychotropic medications in charge of general comorbidities decompensation; 32% (n=19) had geriatric, OAP consultations and 33% (n=20) were in denial of care; 23% (n=14) with severe BPSD had a second OAP consultation. Discussion Relationship between geriatrician and OAP in the same MGT enables to deliver comprehensive care, including organic, psychiatric and cognitive comorbidities and collaborative assessment of iatrogenicity. A strengthened relationship with general practitioners is a possible option for these frail older patients, out-of-medical follow-up allowing their reintegration in the geriatric healthcare system.

The mild cognitive impairment (MCI) is described as an intermediate state of cognitive impairment whereby individuals present with mild clinical symptoms but with nearly normal daily living activities. These subjects do not meet the clinical criteria for dementia, yet their cognitive functioning is below what we would expect for age and education in healthy people. In the other hand, older adults are at risk for sleep disorders including obstructive sleep apnea syndrome, restless legs syndrome, REM sleep behavioral disorder and chronic insomnia, which could have an impact on cognitive functioning and are exclusion criteria for the MCI diagnosis. Moreover, REM sleep behavioral disorder represents a risk factor for the development of neurodegenerative diseases. In subjects more 65 years of age the association between chronic insomnia and cognitive changes is still debated. The main aim of this paper is to focus on identification of sleep disorders in the context of cognitive disturbances among professionals working with the elderly.

The DSM-5 introduces major modifications in the category of mental disorders due to brain lesions compared to the previous DSM versions, which are reviewed in this paper. The description of the category Major neurocognitive disorder, as a substitute for dementia, seems to fit better for patients and families, and more adapted to many neurodegenerative cognitive disorders for which memory impairment is not predominant. Similarly, the introduction of the category of Mild neurocognitive disorder appears to be an improvement although some difficulty still remains for distinguishing mild cognitive disorder from normal aging. The addition of new etiological categories such as fronto-temporal NCD or NCD with Lewy bodies should also to be considered as a significant improvement. Despite these advances, to circumscribe the mental disorders due to brain lesions to cognitive deficits and biological mechanisms remains highly questionable, and does not provide an adequate care for the patients and families if not complemented by a psychological and environmental approach.

A systematic review of the international literature concerning the organisation of the Geriatric Day Hospital (GDH) was performed. From 1987 till now, few papers were found describing the activity and the effectiveness of the GDH. All the studies comparing specific geriatric approaches to regular medicine demonstrate the efficiency of geriatric care, particularly the geriatric assessment. So, with a degree of evidence 1a, a better outcome is found for patients undergoing a geriatric assessment and intervention, compared to patients having no geriatric assessment at all. However, there is no evidence of benefit for the geriatric day hospital compared to patients treated in a geriatric ward or other location of geriatric care. Moreover, there is no clear consensus on the settings and activities of a geriatric day hospital. Terms as day unit, day hospital, day care, are used interchangeably and are not always covering the same activity. The same remark can be made on the exact composition of the geriatric multidisciplinary team and its role. However nurses and paramedical workers are always mentioned as all performing geriatric assessment. The diagnostic activities on the GDH are seldom described and studied. More information is available on rehabilitation activity, often developed in specific patient populations such as stroke patients, dementia patients, cardiac patients or patients with other chronic diseases. In this selected patient populations positive effects on outcome are shown in the GDH (level of evidence 1a). Another problem is the heterogeneity of the population. For scientific reason the GDH should focus on organising care for specific medical problems. Diseases as dementia, stroke, cardiac insufficiency, could be good models to investigate the efficiency of geriatric assessment and interventions within the setting of a GDH.