Search

Background & Aims: In view of the global demographic shift, a scientific symposium was organised by the European Society for Clinical Nutrition and Metabolism (ESPEN) to address nutrition-related challenges of the older population and provide an overview of the current state of knowledge., Methods: Eighteen nutrition-related issues of the ageing global society were presented by international experts during the symposium and summarised in this report., Results: Anorexia of ageing, dysphagia, malnutrition, frailty, sarcopenia, sarcopenic obesity, and the metabolic syndrome were highlighted as major nutrition-related geriatric syndromes. Great progress has been made in recent years through standardised definitions of some but not all syndromes. Regarding malnutrition, the GLIM approach has shown to be suitable also in older adults, justifying its continuous implementation. For anorexia of ageing, a consensus definition is still required. Intervention approaches should be integrated and person-centered with the aim of optimizing intrinsic capacity and maintaining functional capacity. Landmark studies like EFFORT and FINGER have impressively documented the potential of individualised and multifactorial interventions for functional and health benefits. Combining nutritional intervention with physical training seems particularly important whereas restrictive diets and drug treatment should generally be used with caution because of undesirable risks. Obesity management in older adults should take into account the risk of promoting sarcopenia., Conclusions: In the future, even more individualised approaches like precision nutrition may enable better nutritional care. Meanwhile all stakeholders should focus on a better implementation of currently available strategies and work closely together to improve nutritional care for older adults., Competing Interests: Conflict of interest All authors have declared their individual conflicts of interest according to the rules of the International Committee of Medical Journal Editors (ICMJE). None of the expert panel had to be excluded from the symposium faculty or from coauthorship because of serious conflicts. The conflict of interest forms are stored at the ESPEN office and can be reviewed with legitimate interest upon request to the ESPEN executive., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Born out of the COVID crisis, an innovative disposal called "Geriatric Team Healthcare Pathways" (GTHPs) has been implemented in the Occitania area in the south of France. GTHPs can be considered as geriatric "hotlines" providing expertise and knowledge to long-term care facility (LTCF) professionals, pursuing the general objective to promote a simplified, direct, and fair access to geriatric care for residents. This article highlights the history of their creation and their current use cases and operating modes for the year 2023, which includes a "quality of care approach" on good practices at a regional level (820 LTCFs), on topics such as the prevention of malnutrition and falls., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess the prevalence of potentially avoidable transfers (PAT) and identify factors associated with these transfers to emergency departments (EDs) among nursing home (NH) residents., Design: This is a secondary outcome analysis of the FINE study, a multicenter observational study collecting data on NH residents, NH settings, and contextual factors of ED transfers., Settings and Participants: NHs in the former Midi-Pyrénées region of the southwest of France (n = 312); a total of 1037 NH residents who experienced ED transfers (n = 1017) between January 2016 and December 2016., Methods: The analysis included resident baseline characteristics and NH and transfer decision-making characteristics. An expert group categorized the transfer status as either PAT or unavoidable. Multivariable analysis using a mixed logistic model, accounting for intra-NH correlation, was conducted to assess factors independently associated with PAT., Results: Among 1017 included transfers, 87.02% (n = 885) were identified as PAT and 12.98% (n = 132) unavoidable transfers. Multivariable analysis revealed that the following patient-related factors were associated with a likely high rate of PAT: usual behavior disturbances before transfer, including productive trouble (OR 2.04, 95% CI 1.25-3.33; P = .0044) and unusual symptom of falling during the week preceding the transfer (OR 4.55, 95% CI 1.76-11.82; P = .0019). On the other hand, distance between ED and NH (OR 0.98, 95% CI 0.97-0.998; P = .0231), NH staff trained in palliative care in the last 3 years (OR 0.52, 95% CI 0.29-0.95; P = .0324), the impossibility of direct hospitalization to an appropriate unit (OR 0.54, 95% CI 0.34-0.87; P = .0117), and the resident Charlson Comorbidity Index (OR 0.90, 95% CI 0.82-0.99; P = .0369) were associated with a lower probability of PAT., Conclusion and Implications: Transfers from NHs to hospital EDs were frequently potentially avoidable, meaning that there are still significant opportunities to reduce PAT. Our findings may help to specifically identify interventions that should be targeted at both NH and resident levels., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: To assess the annual costs 2 years before and 2 years after a hospitalized fall-related injury (HFRI) and the 2-year survival among the population 75+ years old., Design: We performed a population-based, retrospective cohort study using the French national health insurance claims database., Setting and Participants: Patients 75+ years old who had experienced a fall followed by hospitalization, identified using an algorithm based on International Classification of Diseases codes. Data related to a non-HFRI population matched on the basis of age, sex, and geographical area were also extracted., Methods: Cost analyses were performed from a health insurance perspective and included direct costs. Survival analyses were conducted using Kaplan-Meier curves and Cox regression. Descriptive analyses of costs and regression modeling were carried out. Both regression models for costs and on survival were adjusted for age, sex, and comorbidities., Results: A total of 1495 patients with HFRI and 4484 non-HFRI patients were identified. Patients with HFRI were more comorbid than the non-HFRI patients over the entire periods, particularly in the year before and the year after the HFRI. Patients with HFRI have significantly worse survival probabilities, with an adjusted 2.14-times greater risk of death over 2-year follow-up and heterogeneous effects determined by sex. The annual incremental costs between patients with HFRI and non-HFRI individuals were €1294 and €2378, respectively, 2 and 1 year before the HFRI, and €11,796 and €1659, respectively, 1 and 2 years after the HFRI. The main cost components differ according to the periods and are mainly accounted for by paramedical acts, hospitalizations, and drug costs. When fully adjusted, the year before the HFRI and the year after the HFRI are associated with increase in costs., Conclusions and Implications: We have provided real-world estimates of the cost and the survival associated with patients with HFRI. Our results highlight the urgent need to manage patients with HFRI at an early stage to reduce the significant mortality as well as substantial additional cost management. Special attention must be paid to the fall-related increasing drugs and to optimizing management of comorbidities., (Copyright © 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe nursing home residents (NHRs) transferred to the emergency department (ED) with pneumonia, and investigate the association of pneumonia with functional ability and mortality., Design: Case-control observational multicenter study., Setting and Participants: Participants of the FINE study, including 1037 NHRs presenting to 17 EDs in France over 4 nonconsecutive weeks (1 per season) in 2016, mean age 87.2 years ± 7.1, 68.4% women., Methods: Activities of daily living (ADL) performance evolution between (1) 15 days before transfer and (2) within 7 days after discharge back to the nursing home was compared in NHRs with or without pneumonia. The association of pneumonia with functional evolution was investigated by a mixed-effect linear regression of ADL and mortality was compared by a χ 2 test., Results: NHRs with pneumonia (n = 232; 22.4%) were more likely to have a lower ADL performance than NHRs without pneumonia (n = 805, 77.6%). They presented with a more severe clinical condition, were more likely to be hospitalized after ED and to stay longer in ED and in hospital. They showed a 0.5 decline in median ADL performance after transfer and a significantly higher mortality than NHRs without pneumonia (24.1% and 8.7%, respectively). Post-ED functional evolution did not differ significantly between NHRs with or without pneumonia., Conclusions and Implications: Pneumonia-associated ED transfers resulted in longer care pathways and higher mortality, but no significant difference in functional decline. This study identified a suggestive course of symptoms that could facilitate early identification of NHRs developing pneumonia and early management to prevent ED transfer., (Copyright © 2023 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To compare the evolution of quality of life (QoL) in nursing home residents (NHRs) with and without (hospitalization for) pneumonia., Design: Twelve-month prospective, observational study., Setting and Participants: Participants of the Incidence of pNeumonia and related ConseqUences in nursing home Resident (INCUR) study were included. The INCUR study included 800 NHRs in France for which comprehensive assessments were performed at baseline, 6 months, and 12 months in 2012-2013., Methods: Participants' health related QoL was assessed at 3 time points: baseline, 6 months, and 12 months. NHRs with or without pneumonia and hospitalizations for this condition at any time during follow-up were compared using adjusted mixed effects linear regressions on the QoL outcome. Pre- and postpneumonia QoL were compared using a Wilcoxon signed-rank test., Results: A total of 622 NHRs (mean age 86.2 years; 73.3% women) were included; 13.8% (n = 86) died, 19.9% (n = 124) developed at least 1 episode of pneumonia and 6.4% (n = 40) were hospitalized for pneumonia. Median QoL was 70 at baseline [n = 436, interquartile range (IQR) = 50-90], 80 at 6 months (n = 546, IQR = 50-90), and 76 at 12 months (n = 468, IQR = 50-80). QoL in NHRs with pneumonia showed a 2-point decrease during the 12-month follow-up, whereas QoL in NHRs without pneumonia showed an 8-point increase during follow-up. QoL in NHR hospitalized for pneumonia showed a 16-point decrease during the 12-month follow-up, whereas QoL in NHRs in the control group showed a 6-point increase. In linear regressions, neither pneumonia nor hospitalization for pneumonia were significantly associated with the evolution of QoL during follow-up. No significant difference was found between pre- and postpneumonia QoL., Conclusions and Implications: QoL in NHRs remains stable over 12 months regardless of pneumonia events but seems to decline in NHRs hospitalized for pneumonia. Uncaptured short-term variations of QoL after pneumonia and/or related hospitalizations may occur., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: The predictive ability of the novel intrinsic capacity (IC) construct has been scarcely investigated in the nursing home setting. The objective of this study was to investigate the associations of IC and its individual domains with mortality, hospitalization, pneumonia onset, and functional status decline in a population of nursing home residents (NHRs)., Design: We undertook an analysis using data from the INCUR study, a prospective observational study. Data were collected at baseline, at 6 and 12 months by trained staff., Setting and Participants: A total of 371 NHRs (mean age 85.91 ± 7.34) dwelling in Southern France., Methods: A baseline IC composite score was constructed from scores in the Short Physical Performance Battery, Abbreviated Mental Test, 10-item Geriatric Depression Scale, The Short Form of the Mini-Nutritional Assessment, and self-reported hearing and vision impairments. Adverse outcomes were registered by medical records checking. Functional status evolution was evaluated through changes in the Katz Index. Cox regression was used for associations between IC and its domains and adverse outcomes. Linear mixed models were used in the case of functional status evolution., Results: Our analysis revealed associations between a composite score of IC and death [hazard ratio 0.33; 95% confidence interval (CI) 0.15-0.73] and functional status evolution (β = 0.14; 95% CI 0.018-0.29) in our population. Although greater values in IC vitality/nutrition domain were associated with survival (HR 0.84; 95% CI 0.70-0.99), IC cognitive domain was associated with decreased odds of hospitalization (HR 0.91; 95% CI 0.84-0.99) and lower declines in functional status (β = 0.04; 95% CI 0.01-0.07), whereas the IC locomotion domain was inversely associated with pneumonia incidence (HR 0.84; 95% CI 0.72-0.98)., Conclusions and Implications: Our results contribute to preliminary evidence linking greater IC levels and lower risk of late-life adverse outcomes., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Loss of skeletal muscle mass and function (sarcopenia) is common in individuals with obesity due to metabolic changes associated with a sedentary lifestyle, adipose tissue derangements, comorbidities (acute and chronic diseases), and during the ageing process. Co-existence of excess adiposity and low muscle mass/function is referred to as sarcopenic obesity (SO), a condition increasingly recognized for its clinical and functional features that negatively influence important patient-centred outcomes. Effective prevention and treatment strategies for SO are urgently needed, but efforts are hampered by the lack of an universally established SO Definition and diagnostic criteria. Resulting inconsistencies in the literature also negatively affect the ability to define prevalence as well as clinical relevance of SO for negative health outcomes., Aims and Methods: The European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO) launched an initiative to reach expert consensus on a Definition and diagnostic criteria for SO. The jointly appointed international expert panel proposes that SO is defined as the co-existence of excess adiposity and low muscle mass/function. The diagnosis of SO should be considered in at-risk individuals who screen positive for a co-occurring elevated body mass index or waist circumference, and markers of low skeletal muscle mass and function (risk factors, clinical symptoms, or validated questionnaires). Diagnostic procedures should initially include assessment of skeletal muscle function, followed by assessment of body composition where presence of excess adiposity and low skeletal muscle mass or related body compartments confirm the diagnosis of SO. Individuals with SO should be further stratified into Stage I in the absence of clinical complications, or Stage II if cases are associated with complications linked to altered body composition or skeletal muscle dysfunction., Conclusions: ESPEN and EASO, as well as the expert international panel, advocate that the proposed SO Definition and diagnostic criteria be implemented into routine clinical practice. The panel also encourages prospective studies in addition to secondary analysis of existing datasets, to study the predictive value, treatment efficacy, and clinical impact of this SO definition., Competing Interests: Conflict of interest None of the authors display any conflict of interest in the production of this manuscript., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: To determine the factors associated with the potentially inappropriate transfer of nursing home (NH) residents to emergency departments (EDs) and to compare hospitalization costs before and after transfer of individuals addressed inappropriately vs those addressed appropriately., Design: Multicenter, observational, case-control study., Setting and Participants: 17 hospitals in France, 1037 NH residents., Measures: All NH residents transferred to the 17 public hospitals' EDs in southern France were systematically included for 1 week per season. An expert panel composed of family physicians, emergency physicians, geriatricians, and pharmacists defined whether the transfer was potentially inappropriate or appropriate. Residents' and NHs' characteristics and contextual factors were entered into a mixed logistic regression to determine factors associated independently with potentially inappropriate transfers. Hospital costs were collected in the national health insurance claims database for the 6 months before and after the transfer., Results: A total of 1037 NH residents (mean age 87.2 ± 7.1, 68% female) were transferred to the ED; 220 (21%) transfers were considered potentially inappropriate. After adjustment, anorexia [odds ratio (OR) 2.41, 95% confidence interval (CI) 1.57-3.71], high level of disability (OR 0.90, 95% CI 0.81-0.99), and inability to receive prompt medical advice (OR 1.67, 95% CI 1.20-2.32) were significantly associated with increased likelihood of potentially inappropriate transfers. The existence of an Alzheimer's disease special care unit in the NH (OR 0.66, 95% CI 0.48-0.92), NH staff trained on advance directives (OR 0.61, 95% CI 0.41-0.89), and calling the SAMU (mobile emergency medical unit) (OR 0.47, 95% CI 0.34-0.66) were significantly associated with a lower probability of potentially inappropriate transfer. Although the 6-month hospitalization costs prior to transfer were higher among potentially inappropriate transfers compared with appropriate transfers (€6694 and €4894, respectively), transfer appropriateness was not significantly associated with hospital costs., Conclusions and Implications: Transfers from NHs to hospital EDs were frequently appropriate. Transfer appropriateness was conditioned by NH staff training, access to specialists' medical advice, and calling the SAMU before making transfer decisions., Trial Registration: clinicaltrials.gov, NCT02677272., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe nursing home residents' (NHRs) functional trajectories and mortality after a transfer to the emergency department (ED)., Design: Case-control observational multicenter study., Setting and Participants: In total, 1037 NHRs presenting to 17 EDs in France over 4 nonconsecutive weeks in 2016., Methods: Finite mixture models were fitted to longitudinal data on activities of daily living (ADL) scores before transfer (time 1), during hospitalization (time 2), and within 1 week after discharge (time 3) to identify groups of NHRs following similar functional evolution. Factors associated with mortality were investigated by Cox regressions., Results: Trajectory modeling identified 4 distinct trajectories of ADL. The first showed a high and stable (across time 1, time 2, and time 3) functional capacity around 5.2/6 ADL points, with breathlessness as the main condition leading to transfer. The second displayed an initial 37.8% decrease in baseline ADL performance (between time 1 and time 2), followed by a 12.5% recovery of baseline ADL performance (time 2‒time 3), with fractures as the main condition. The third displayed a similar initial decrease, followed by a 6.7% recovery. The fourth displayed an initial 70.1% decrease, followed by an 8.5% recover, with more complex geriatric polypathology situations. Functional decline was more likely after being transferred for a cerebrovascular condition or for a fracture, after being discharged from ED to a surgery department, and with a heavier burden of distressing symptoms during transfer. Mortality after ED transfer was more likely in older NHRs, those in a more severe condition, those who were hospitalized more frequently in the past month, and those transferred for cerebrovascular conditions or breathlessness., Conclusions and Implications: Identified trajectories and factors associated with functional decline and mortality should help clinicians decide whether to transfer NHRs to ED. NHRs with high functional ability seem to benefit from ED transfers whereas on-site alternatives should be sought for those with poor functional ability., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Difficulties with meal-related activities (preparing meals and food shopping) may influence food intake, and contribute to nutritional risk among elderly people. All known studies on this topic had a cross-sectional design, thereby no causal relationships could be derived. We aim to investigate if difficulties with meal-related activities can contribute to subsequent weight loss in community-dwelling older people., Methods: We used data of older subjects from the MAPT Study (n = 1531, median age = 74 years, 64% women), who provided prospective data on weight every 6 months and cognitive, physical condition, and functional capacities every year during a 3-year period. Difficulties preparing meals and shopping were evaluated each year with the Alzheimer's Disease Cooperative Study-Activities of Daily Living Prevention Instrument (ADCS ADL-PI) Scale. The risk of losing weight (≥5% or ≥ 3 kg in the following year) was estimated using a time-dependent Cox regression model., Results: During the 3-year follow-up, a total of 851 subjects experienced at least a 5% or 3 kg weight loss. Two hundred thirty-seven subjects declared having difficulties with meal preparation at least once, and 133 declared having difficulties shopping. Subjects reporting any meal-related difficulties were older (p < 0.001), had more depressive symptoms (p < 0.001), and a lower physical function (p < 0.001) compared to those without difficulties. They also had a lower cognitive score (preparing meals: p < 0.001; shopping: p = 0.005) and a lower body mass index (preparing meals: p = 0.005; shopping: p = 0.023) at the end of the study. Meal-related activities were not associated with weight loss in unadjusted analysis and after adjustment for sex, age, depression, physical and cognitive status., Conclusion: Difficulties preparing meals and shopping had no effect on weight loss in community-dwelling older people, despite their association with advanced age, functional decline, and depressive symptoms., Competing Interests: Conflicts of interest All authors have stated that they have no competing interests (financial or non-financial) related to the study., (Copyright © 2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background: Sarcopenic obesity is a clinical and functional condition characterized by the coexistence of excess fat mass and sarcopenia. Currently, different definitions of sarcopenic obesity exist and its diagnostic criteria and cut-offs are not universally established. Therefore, the prevalence and sensitivity of this condition for any disease risk prediction is affected significantly., Aim: This work was conducted under the auspices of the European Society for Clinical Nutrition and Metabolism (ESPEN) and the European Association for the Study of Obesity (EASO). An international expert panel performed a systematic review as an initial step to analyze and summarize the available scientific literature on the definitions and the diagnostic criteria for sarcopenic obesity proposed and/or applied in human studies to date., Methods: The present systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The search was conducted in April 2018 in three databases (PubMed, Scopus, Web of Science). Human studies conducted in both sexes, irrespective of ethnicity, and published from 2007 to 2018 were included; cohorts of individuals with obesity and acute or chronic conditions and treatments reported to negatively influence skeletal muscle mass and function independently of obesity were excluded from final analyses. The quality of the studies was evaluated using the Newcastle-Ottawa Scale (NOS) adapted for cross sectional studies., Results: The electronic search retrieved 2335 papers of which 75 met the eligibility criteria. A marked heterogeneity in definitions and approaches to diagnose sarcopenic obesity was observed. This was mainly due to differences in the definitions of obesity and sarcopenia, in the methodologies used to assess body composition and physical function, and in the reference values for the variables that have been used (different cut-offs, interquartile analysis, diverse statistical stratification methods). This variability may be attributable, at least in part, to the availability of the methodologies in the different settings, to the variability in specialties and backgrounds of the researcher, and to the different settings (general population, clinical settings, etc.) where studies were performed., Conclusion: The results of the current work support the need for consensus proposals on: 1) definition of sarcopenic obesity; 2) diagnostic criteria both at the level of potential gold-standards and acceptable surrogates with wide clinical applicability, and with related cut-off values; 3) methodologies to be used in actions 1 and 2. First steps should be aimed at reaching consensus on plausible proposals that would need subsequent validation based on homogeneous studies and databases, possibly based on analyses of existing cohorts, to help define the prevalence of the condition, its clinical and functional relevance as well as most effective prevention and treatment strategies., Competing Interests: Conflict of interest The authors declare no conflict of interest., (Copyright © 2019 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Objective: To assess the American Testing Guidance for Nursing Homes (NHs)-updated May 19, 2020-with a new COVID-19 case., Design: Case investigation., Setting and Subjects: All 79 residents and 34 health care personnel (HCP) of an NH., Methods: Seven days after identification of a COVID-19 resident, all residents and HCP underwent real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) testing for SARS-CoV-2 with nasopharyngeal swabs. This was repeated weekly in all previously negative subjects until the testing identified no new cases, and in all positive subjects until the testing was negative. COVID-19 infection prevention and control (IPC) measures were implemented in all residents and HCP with positive testing or with COVID-19 symptoms. Standard IPC was also implemented in all HCP. Six weeks after initial testing, all residents underwent testing for enzyme-linked immunosorbent assay-based IgG antibodies directed against the SARS-CoV-2. Symptoms were serially recorded in residents and HCP., Results: A total of 36 residents had a positive rRT-PCR at baseline and 2 at day 7. Six HCP had a positive rRT-PCR at baseline and 2 at day 7. No new COVID-19 cases were diagnosed later. Among the SARS-CoV-2-positive cases, 6 residents (16%) and 3 HCP (37%) were asymptomatic during the 14 days before testing. Twenty-five residents (92.3%) and all 8 HCP (100%) with a positive rRT-PCR developed IgG antibodies against SARS-CoV-2. Among the residents and HCP always having tested negative, 2 (5%) and 5 (11.5%), respectively, developed IgG antibodies against SARS-CoV-2. These 2 residents had typical COVID-19 symptoms before and after testing and 2/5 HCP were asymptomatic before and after testing., Conclusions and Implications: This study shows the validity of the updated American Testing Guidance for Nursing Homes (NHs). It suggests implementing COVID-19 IPC in both residents and HCP with positive testing or COVID-19 symptoms and warns that asymptomatic HCP with repeated negative rRT-PCR testing can develop antibodies against SARS-CoV-2., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate patients' preferences for sarcopenia outcomes., Design: Discrete-choice experiment (DCE) SETTING AND PARTICIPANTS: Community-dwelling individuals older than 65 years suffering from sarcopenia recruited in Belgium, France, Germany, Italy, Spain, and Switzerland, who visited the clinic and were cognitively able to understand and fill out the survey., Methods: In the DCE survey, participants were repetitively asked to choose which one of the 2 patients suffering from sarcopenia deserves treatment the most. The 2 patients presented different levels of risk for 5 preselected sarcopenia outcomes: quality of life, mobility, domestic activities, fatigue, and falls. The DCE included 12 choice sets. Mixed logit panel model was used to estimate patients' preferences and latent class model was conducted to identify profiles of responses., Results: A total of 216 sarcopenic persons were included for the analysis (68% women; mean age 78 years). All 5 preselected sarcopenia outcomes were shown to be significant. Overall, the most important sarcopenia outcome was mobility (30%), followed by the ability to manage domestic activities (22%), the risk of falls (18%), fatigue (17%), and quality of life (14%). The latent class model identified 2 classes of respondents. In the first class (probability of 56%), participants valued mobility the most (42%), followed by the ability to manage domestic activities (23%) and risk of falls (17%). In the second class, fatigue was the most important outcome (27%) followed by domestic activities (19%) and risk of falls (19%). No statistically significant associations between the latent classes and sociodemographic characteristics were found., Conclusions and Implications: This study suggests that all 5 preselected outcomes were important for sarcopenic older individuals. Overall, the most important outcomes were mobility and the ability to manage domestic activities, although variations in preferences were observed between respondents. This could help in incorporating patient preferences when designing appropriate solutions for individuals with sarcopenia., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The European Society of Clinical Nutrition and Metabolism (ESPEN) has developed a consensus definition of malnutrition. This study aimed to determine the prevalence of malnutrition according to the ESPEN definition in otherwise healthy community-dwelling older women and to explore its value for predicting long-term mortality in this population., Methods: This prospective population-based cohort study included 181 women (age ≥75 years) from a subsample of the EPIDémiologie de l'OStéoporose (EPIDOS) study participants from Toulouse. Inclusion criteria were the availability of the data on variables required to apply the ESPEN definition and survival after 7 years of follow-up. Primary outcome was mortality at 12-year follow-up; main covariates were malnutrition assessment according to the ESPEN consensus and its components (unintentional weight loss, BMI, and FFMI). Body composition was assessed by dual-energy X-ray absorptiometry at baseline and at 7-year follow-up. Kaplan-Meier survival curves and adjusted Cox regressions were performed. Analysis was adjusted for age, hypertension, diabetes mellitus, and coronary heart disease as potential confounders., Results: Complete data were available for 179 of the 181 women in the EPIDOS-Toulouse cohort (83.1 ± 2.2 years) and 13 (7.3%) fulfilled the ESPEN definition for malnutrition at 7-year follow-up. Malnutrition was associated with increased risk of mortality (adjusted HR = 4.4 [95%CI: 1.7-11.3]). Among the ESPEN components, only BMI was associated with increased mortality (adjusted HR=0.6 [95%CI: 0.4-0.9])., Conclusions: Although malnutrition prevalence according to the ESPEN definition was relatively low (7.3%) in this sample of otherwise healthy community-dwelling older French women, malnutrition was associated with 4.4-fold higher mortality risk at 12-year follow-up., (Copyright © 2018 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Background & Aims: Malnutrition in older adults results in significant personal, social, and economic burden. To combat this complex, multifactorial issue, evidence-based knowledge is needed on the modifiable determinants of malnutrition. Systematic reviews of prospective studies are lacking in this area; therefore, the aim of this systematic review was to investigate the modifiable determinants of malnutrition in older adults., Methods: A systematic approach was taken to conduct this review. Eight databases were searched. Prospective cohort studies with participants of a mean age of 65 years or over were included. Studies were required to measure at least one determinant at baseline and malnutrition as outcome at follow-up. Study quality was assessed using a modified version of the Quality in Prognosis Studies (QUIPS) tool. Pooling of data in a meta-analysis was not possible therefore the findings of each study were synthesized narratively. A descriptive synthesis of studies was used to present results due the heterogeneity of population source and setting, definitions of determinants and outcomes. Consistency of findings was assessed using the schema: strong evidence, moderate evidence, low evidence, and conflicting evidence., Results: Twenty-three studies were included in the final review. Thirty potentially modifiable determinants across seven domains (oral, psychosocial, medication and care, health, physical function, lifestyle, eating) were included. The majority of studies had a high risk of bias and were of a low quality. There is moderate evidence that hospitalisation, eating dependency, poor self-perceived health, poor physical function and poor appetite are determinants of malnutrition. Moderate evidence suggests that chewing difficulties, mouth pain, gum issues co-morbidity, visual and hearing impairments, smoking status, alcohol consumption and physical activity levels, complaints about taste of food and specific nutrient intake are not determinants of malnutrition. There is low evidence that loss of interest in life, access to meals and wheels, and modified texture diets are determinants of malnutrition. Furthermore, there is low evidence that psychological distress, anxiety, loneliness, access to transport and wellbeing, hunger and thirst are not determinants of malnutrition. There appears to be conflicting evidence that dental status, swallowing, cognitive function, depression, residential status, medication intake and/or polypharmacy, constipation, periodontal disease are determinants of malnutrition., Conclusion: There are multiple potentially modifiable determinants of malnutrition however strong robust evidence is lacking for the majority of determinants. Better prospective cohort studies are required. With an increasingly ageing population, targeting modifiable factors will be crucial to the effective treatment and prevention of malnutrition., (Copyright © 2018 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: There has been an increase in the number of visits by older individuals to emergency departments (EDs). The primary cause of this is trauma. The objective of this study was to evaluate the temporal changes in the use of EDs by older individuals for traumatic injuries, characterize their trauma, and specify the mode of transport to the ED according to their place of residence (community-dwelling or nursing home resident)., Design: A monocentric, retrospective study of patients over 65 years of age, admitted to University Center Hospital ED for trauma between 2013 and 2017., Participants: In total, 20,741 patients were included., Results: The mean age was 81.8 years (standard deviation 9.1 years); 11,879 (57.3%) patients were community-living with family, 5077 (24.5%) were nursing home (NH) residents, and 3785 (18.22%) patients were community-dwelling living alone. Overall, 33.3% of the NH residents were transferred during the weekend compared with 28.04% of the community-dwelling individuals (P < .001). Ten percent (1577 patients) of the community-dwelling individuals compared with 21.8% (1109 patients) of the transfers of NH residents to ED occurred late at night (P < .001). The primary reason for use of the ED was head trauma (32.0%), followed by cutaneo-mucous wounds (28.7 %) and limb fractures (25.9%). In most cases, NH residents were transferred by ambulance (5000 residents; 98.4%), compared with community-dwelling individuals (11,118; 70.1%; P < .001). Overall, 7459 (36.0 %) patients were hospitalized., Conclusion and Implications: In comparison with community-dwelling individuals, ED transfers of NH residents in the context of trauma-related emergency were higher during after-hour periods, lengthes of stay at the ED were longer, and residents were admitted less to the in hospital., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Motoric cognitive risk syndrome (MCR) is a predementia stage associated with increased risk for falls. There are conflicting results regarding its association with recurrent falls and no information about its association with postfall fractures. The aim of the study was to examine the association of MCR and its components [ie, slow walking speed and subjective cognitive complaint (SCC)] with the occurrence of falls, their recurrence, and postfall fractures in older community-dwelling adults., Design: Observational prospective and longitudinal cohort study., Setting and Participants: French community-dwelling older women (n = 5958) recruited in the EPIDémiologie de l'OStéoporose (EPIDOS) study., Measures: MCR was defined as both the presence of SCC and slow walking speed in women free of major neurocognitive disorders. Falls (≥1), recurrent falls (≥2), and postfall fractures (any fractures and hip fractures) were prospectively recorded using mail and/or phone call questionnaires every 4 months over 4 years., Results: At baseline, the prevalence of SCC was 43.1% (n = 2569), slow walking speed 5.7% (n = 341), and MCR 9.9% (n = 591). Overall, 25.7% (n = 1533) of participants reported any fall during the follow-up. The incidence of postfall hip fractures was higher in participants with MCR compared to healthy participants and those with SCC (P ≤ .001). Cox regression models revealed that only participants with MCR had a significantly high risk for falls [hazard ratio (HR) = 1.22, P = .021], recurrent falls (HR = 1.46 with P = .030), and postfall hip fractures (HR = 2.54, P ≤ .001)., Conclusions/implications: There is an increased risk for falls, their recurrence, and postfall hip fractures associated with MCR but not with its individual components. This finding underscores the clinical interest of MCR for the detection of older adults at risk for falls and their related adverse events in order to start early appropriate interventions for fall reduction., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To determine whether an intervention based on education and professional support to nursing home (NH) staff would decrease the number of residents with a pain complaint, and to determine whether the intervention would improve pain management., Design: Nonrandomized controlled trial. NHs were nonrandomly allocated either to a strong intervention group consisting in audit, feedback, and collaborative work on quality indicators with a hospital geriatrician, or to a light intervention group (LIG) consisting in audit and feedback only., Setting: One hundred fifty-nine NHs located in France., Participants: A subgroup of 3722 residents., Measures: Information on pain complaint and pain-related covariates at the resident-related and at the NH level were recorded by NH staff at baseline and 18 months later. These covariates were included in a mixed-effects logistic regression on resident's pain complaint. Pain management was compared between intervention groups by chi-square tests., Results: A greater reduction of residents with a pain complaint after the strong intervention (odds ratio 0.69, 95% confidence interval 0.53, 0.90) and a better pain management (47.6% gold standard, vs 30.6% in the LIG, P < .001) than controls., Conclusion/implications: Combining educational and organizational measures, evaluating pain as a patient-reported outcome and as a process endpoint, and implementing a broad-spectrum intervention were original approaches to improve quality of care in NHs. Our results support nonspecific, collaborative, educational, and organizational interventions in NHs to decrease residents' pain complaint and improve pain management., (Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The hypothesis of reverse epidemiology holds that, obesity may reduce the risk of clinical adverse events in older subjects. However, this association is controversial and rarely explored according to the underlying health status. We tested this phenomenon by assessing the association between body mass index (BMI) and clinical adverse events in community dwelling older women according to their frailty status., Methods: EPIDOS is a multicenter prospective cohort of community-dwelling women aged 75 and older recruited between 1992 and 1994. At baseline, we collected demographics, BMI (<21 kg/m 2 : underweight; 21-24.9: normal weight; 25-29.9: overweight and ≥30: obesity), frailty through Fried model, and clinical characteristics. All-cause mortality, falls, hip fractures, and hospital admission were collected within 5 years of follow-up and were analyzed using univariate and multivariate survival analysis by using Kaplan-Meier methods and Cox Hazard Proportional models., Results: Of 6662 women (mean age, 80.4 years), 11.6%; 95% Confidence Interval (95% CI) CI [10.8%-12.3%] were frail. By multivariate analysis, the risk of death in frail women (compared to not-frail normal weight women) decreases with increase of BMI: adjusted Hazard Ratio (aHR) frail-underweight  = 2.04 [1.23-3.39]; aHR frail-normal weight  = 3.07 [2.21-4.26]; aHR frail-overweight  = 1.83 [1.31-2.56]; aHR frail-obese  = 1.76 [1.15-2.70]; p < 0.001. Frail overweight and obese women had a significant lower risk of death than frail normal-weight women (p = 0.004). Similar features were found for fall risk and hip fracture and for not-frail women. The relative risks of hospital admission for normal weight, overweight and obese frail women were similar (aHR frail-normal weight = 1.50 [1.22-1.84], aHR frail-overweight =1.48 [1.26-1.74] and aHR  frail-obese =1.53 [1.24-1.89], respectively)., Conclusion: Our results suggest that overweight and obesity reduce the risks of clinical adverse events in frail community-dwelling older women and that frailty definition through Fried model had to be re-calibrated for overweight and obese individuals., (Copyright © 2017. Published by Elsevier Ltd.)

There is a growing body of evidence that links nutrition to muscle mass, strength and function in older adults, suggesting that it has an important role to play both in the prevention and management of sarcopenia. This review summarises the discussions of a working group [ESCEO working group meeting 8th September 2016] that met to review current evidence and to consider its implications for preventive and treatment strategies. The review points to the importance of 'healthier' dietary patterns that are adequate in quality in older age, to ensure sufficient intakes of protein, vitamin D, antioxidant nutrients and long-chain polyunsaturated fatty acids. In particular, there is substantial evidence to support the roles of dietary protein and physical activity as key anabolic stimuli for muscle protein synthesis. However, much of the evidence is observational and from high-income countries. Further high-quality trials, particularly from more diverse populations, are needed to enable an understanding of dose and duration effects of individual nutrients on function, to elucidate mechanistic links, and to define optimal profiles and patterns of nutrient intake for older adults., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background & Aims: The aims of this systematic review were (i) to determine the prevalence of malnutrition and cachexia in older cancer patients in a chemotherapy setting, and (ii) to report the chemotherapy-related causes of malnutrition and (iii) the consequences of malnutrition on the outcomes of these patients., Methods: We searched MEDLINE for articles published in English or French between 2005 and 2016 and which reported retrospective or prospective, observational or interventional studies of the prevalence of malnutrition and its consequences in patients 65 years or older with solid tumors and chemotherapy-related causes of malnutrition., Results and Conclusion: Malnutrition is prevalent up to 83% in older patients with cancer scheduled to receive chemotherapy. One third or more of patients were malnourished before receiving chemotherapy. A weight loss of 10% or more during the past three or six months was reported in 8%-40% of cancer patients, while a body mass index <21 kg/m 2 was found in 10.7%-23%. Malnutrition was more prevalent in digestive (28%-75%) than in non-digestive cancers (8%-46.9%), and also in metastatic cancers (64%-76.5%). During the course of chemotherapy, weight loss was observed in 40%-91.6% of patients, depending on cancer location. The most frequently reported chemotherapy-related digestive symptoms likely to impair nutritional status were dry mouth, nausea, stomach pain, diarrhea and constipation. Low Mini-Nutritional-Assessment score was an independent predictor of early discontinuation of chemotherapy and increased the risk of mortality., (Copyright © 2016 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

MRI-based radiotherapy planning is a topical subject due to the introduction of a new generation of treatment machines combining a linear accelerator and a MRI. One of the issues for introducing MRI in this task is the lack of information to provide tissue density information required for dose calculation. To cope with this issue, two strategies may be distinguished from the literature. Either a synthetic CT scan is generated from the MRI to plan the dose, or a dose is generated from the MRI based on physical underpinnings. Within the first group, three approaches appear: bulk density mapping assign a homogeneous density to different volumes of interest manually defined on a patient MRI; machine learning-based approaches model local relationship between CT and MRI image intensities from multiple data, then applying the model to a new MRI; atlas-based approaches use a co-registered training data set (CT-MRI) which are registered to a new MRI to create a pseudo CT from spatial correspondences in a final fusion step. Within the second group, physics-based approaches aim at computing the dose directly from the hydrogen contained within the tissues, quantified by MRI. Excepting the physics approach, all these methods generate a synthetic CT called "pseudo CT", on which radiotherapy planning will be finally realized. This literature review shows that atlas- and machine learning-based approaches appear more accurate dosimetrically. Bulk density approaches are not appropriate for bone localization. The fastest methods are machine learning and the slowest are atlas-based approaches. The less automatized are bulk density assignation methods. The physical approaches appear very promising methods. Finally, the validation of these methods is crucial for a clinical practice, in particular in the perspective of adaptive radiotherapy delivered by a linear accelerator combined with an MRI scanner., (Copyright © 2017. Published by Elsevier SAS.)

Objectives: Screening for sarcopenia in daily practice can be challenging. Our objective was to explore whether the SARC-F questionnaire is a valid screening tool for sarcopenia (defined by the Foundation for the National Institutes of Health [FNIH] criteria). Moreover, we evaluated the physical performance of older women according to the SARC-F questionnaire., Design: Cross-sectional study., Participants: Data from the Toulouse and Lyon EPIDémiologie de l'OStéoporose study (EPIDOS) on 3025 women living in the community (mean age: 80.5 ± 3.9 years), without a previous history of hip fracture, were assessed., Measurements: The SARC-F self-report questionnaire score ranges from 0 to 10: a score ≥4 defines sarcopenia. The FNIH criteria uses handgrip strength (GS) and appendicular lean mass (ALM; assessed by DXA) divided by body mass index (BMI) to define sarcopenia. Outcome measures were the following performance-based tests: knee-extension strength, 6-m gait speed, and a repeated chair-stand test. The associations of sarcopenia with performance-based tests was examined using bootstrap multiple linear-regression models; adjusted R 2 determined the percentage variation for each outcome explained by the model., Results: Prevalence of sarcopenia was 16.7% (n = 504) according to the SARC-F questionnaire and 1.8% (n = 49) using the FNIH criteria. Sensibility and specificity of the SARC-F to diagnose sarcopenia (defined by FNIH criteria) were 34% and 85%, respectively. Sarcopenic women defined by SARC-F had significantly lower physical performance than nonsarcopenic women. The SARC-F improved the ability to predict poor physical performance., Conclusion: The validity of the SARC-F questionnaire to screen for sarcopenia, when compared with the FNIH criteria, was limited. However, sarcopenia defined by the SARC-F questionnaire substantially improved the predictive value of clinical characteristics of patients to predict poor physical performance., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate mortality rate in elderly and very elderly (≥85 years) residents with Parkinson disease (PD) in nursing homes (NHs) with and without antipsychotic drugs., Design: Cross-sectional study., Participants: All residents with PD from the 6275 NH residents participating in the Impact d'une démarche QUAlité sur l'évolution des pratiques et le déclin fonctionnel des Résidents en Etablissement d'hébergement pour personnes âgées dépendantes (IQUARE) study., Setting: A total of 175 NHs in Midi-Pyrénées region, South-Western France., Exposure: Patients with PD taking antipsychotic drugs., Outcome Measurements: All-cause mortality between baseline and 18 months., Statistical Methods: Logistic regression was used to explore baseline characteristics associated with mortality rate and with antipsychotic use at 18 months., Results: At baseline, among 452 residents with PD, 72 (15.9%) received at least 1 antipsychotic drug. Mortality rates at 18 months in residents with PD with and without antipsychotic use were similar (34.3% and 38.2%, respectively, P = .58). Among factors associated with mortality, a statistically significant increase in mortality rate was found in very old residents (≥85 years of age) [odds ratio (OR) 2.0; 95% confidence interval (CI) 1.3-3.1] or in those with chronic pulmonary disease (OR 3.6; 95% CI 1.5-8.5). Among residents ≥85 years of age, we also found a statistically significant increase in mortality rate in individuals with arterial hypertension (OR 2.8; 95% CI 1.3-5.8). Moreover, a statistically significant increase in prescription of antipsychotic drugs was found in residents who tried to elope (OR 3.8; 95% CI 1.4-10.7) and in those with severe psychiatric diseases (excluding depression) (OR 7.5; 95% CI 4.1-13.6)., Conclusions: In this study investigating factors associated with mortality in old and very old residents with PD in NHs, no significant association was observed with the use of antipsychotics. However, our study suggests that age (≥85 years) or chronic pulmonary disease could be associated with mortality among patients with PD, as well as arterial hypertension in very old patients (≥85 years of age)., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

This article reports the findings of a survey on end-of-life (EOL) care in nursing homes of 18 long-term care experts across 15 countries. The experts were chosen as a convenience-based sample of known experts in each country. The survey was administered in 2016 and included both open-ended responses for defining hospice care, palliative care, and "end of life," and a series of questions related to the following areas-attitudes toward EOL care, current practice and EOL interventions, structure of care, and routine barriers. Overall experts strongly agreed that hospice and palliative care should be available in long-term care facilities and that both are defined by holistic, interdisciplinary approaches using measures of comfort across domains. However, it appears the experts felt that in most countries the reality fell short of what they believed would be ideal care. As a result, experts call for increased training, communication, and access to specialized EOL services within the nursing home., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Pneumonia is a frequent condition in older people. Our aim was to examine the total healthcare cost related to pneumonia in nursing home (NH) residents over a 1-year follow-up period., Design: This was a prospective, longitudinal, observational, and multicenter study that was a part of the Incidence of Pneumonia and related Consequences in Nursing Home Resident study., Setting: Thirteen NHs located in Languedoc Roussillon and Midi-Pyrénées regions in France were included., Participants: Resident in NH, older than 60 years and had a group iso-resource score ranging from 2 to 5., Measurements: Pneumonia events were characterized according to the Observatoire du Risque Infectieux en Geriatrie criteria. Direct medical and nonmedical costs were assessed from the French health insurance perspective. Healthcare resources was retrospectively gathered from the French Social Health Insurance database and valued using the tariffs reimbursed by the French health insurance. Sociodemographic variables, clinical factors, vaccinations, cognition, depression, functional status, frailty index, as well as group iso-resource score were also recorded., Results: Among the 800 patients initially included in the Incidence of Pneumonia and Related Consequences in Nursing Home Resident study, 345 which were listed in the database of the French Social Health Insurance were included in this economic study. Among them, 64 (18%) experienced at least 1 episode of pneumonia during the 1-year follow-up period. Mean annual total additional cost for a patient who experienced at least 1 episode of pneumonia during the 1 year follow-up period is 2813€. On average, total annual costs increased by 60% to 93% when a patient experienced at least 1 episode of pneumonia., Conclusions: NH-acquired pneumonia has a great impact on total cost of care for NH residents. Our results suggest the potential economic savings that could be achieved if pneumonia could be prevented in NHs., (Copyright © 2017. Published by Elsevier Inc.)

Background & Aims: A protective effect of obesity on death has been reported in the context of various co-morbidities. We studied if the obesity paradox applied to nursing home (NH) older residents according to dementia status., Methods: Prospective data from 3741 NH residents from France. All-cause mortality was the dependent measure. Subjects were categorized according with body mass index (BMI) as underweight, normal-weight, overweight, and obese. Dementia status was obtained from medical charts. Cox regressions were performed., Results: There were 344 (9.2%) residents who were underweight, 1367 (43.8%) normal weight, 1069 (28.6%) overweight and 691 (18.5%) obese. 1083 (28.9%) people died during follow-up. In residents with dementia, mortality risk was reduced by almost half in overweight and obese people (HRs of 0.60 [0.48-0.76] and 0.53 [0.38-0.75], respectively; p < 0.001), and increased in underweight (HR = 1.65 [1.29-2.12]; p < 0.001) compared to normal-weight residents; moreover, each 1 kg/m 2 increase in BMI decreased the risk of death by 12% and 9% in underweight and normal-weight subjects with dementia. For people without dementia, mortality risk was reduced in overweight and obese people (HRs of 0.80 [0.65-0.99], p = 0.042, and 0.77 [0.60-0.99], p = 0.044, respectively) compared to normal-weight; the 1-unit increase in BMI reduced the risk of death (23% reduction) only in underweight people., Conclusions: This study showed that the presence of dementia amplifies the obesity paradox in very old and functionally limited NH residents. Therefore, weight loss in NH residents, particularly in people with dementia, should be considered with extreme caution even for obese people., (Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Institutionalization is generally a consequence of functional decline driven by physical limitations, cognitive impairments, and/or loss of social supports. At this stage, intervention to reverse functional losses is often too late. To be more effective, geriatric medicine must evolve to intervene at an earlier stage of the disability process. Could nursing homes (NHs) transform from settings in which many residents dwell to settings in which the NH residents and those living in neighboring communities benefit from staff expertise to enhance quality of life and maintain or slow functional decline? A task force of clinical researchers met in Toulouse on December 2, 2015, to address some of these challenges: how to prevent or slow functional decline and disabilities for NH residents and how NHs may promote the prevention of functional decline in community-dwelling frail elderly. The present article reports the main results of the Task Force discussions to generate a new paradigm., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Aging can be affected by frailty and chronic diseases causing physical, cognitive, sensory, and functional decline evolving gradually to disability. The assessment of older patients is carried out in some geriatric day hospitals (GDHFs). However, it seems difficult to assess all patients in these GDHFs. In this context, a care model, which uses a specialist nurse trained in primary care and geriatric assessment, has been developed. In this article, we describe the organization, details of the evaluation, and provide the main characteristics of the first 200 patients assessed over a 6-month period., Methods: Persons aged 70 years and older were invited to undergo an evaluation at the general practitioner's (GP) office by a nurse if the GP thought that the patient was frail or if the patient had cognitive complaint or for both reasons., Results: A total of 200 patients from 14 GP offices were assessed. Overall, the mean age was 81.3 (±5.92) years. More than one-half were female (66%), and 32% of participants lived alone. The average Mini-Mental State Examination score was 25.2 (±4.23); 16.7% had dementia; 12% of mild cognitive impairment were identified; 78% of patients were followed by their GP; and 2.5% were referred to a GDHF, 12% to specialized memory center, and 7.5% to geriatric consultation., Conclusions: This work foreshadows any other ambulatory options for older persons in his/her living area representing an alternative to the GDHF. It seems to meet the needs for this population and demonstrates the feasibility to implement in primary care a nurse trained to assess older patients in a GP office., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Usual gait speed (UGS) is recognized as a good indicator of a variety of health conditions as well as a predictor of future disability and mortality. There is evidence that UGS increases with physical activity. Muscle function and body composition changes may mediate these changes. However, we do not know exactly which of these factors contribute to the effect of physical activity on gait speed or the magnitude of their contribution., Methods: Data are from 1378 women aged 75 years and older recruited in the Toulouse EPIDémiologie de l'OStéoporose cohort. Body weight and composition (dual energy X-ray absorptiometry), knee extension strength, and physical activity habits were assessed. The INDIRECT macro for SPSS (SPSS Inc, Chicago, IL) was used to determine total and specific indirect effects of physical activity on UGS through body weight (BW) and composition as well as muscle mass and strength., Results: Knee extension strength [95% confidence interval (CI) 0.0091, 0.0231] and BW (95% CI 0.0037, 0.0412), but not fat mass or muscle mass, were mediators of the relationship between physical activity and gait speed. However, muscle mass significantly mediated the relationship between physical activity and muscle strength (95% CI -3.0722, -0.6265)., Conclusions: Results suggest that muscle strength and BW are the most significant mediators of the relationship between physical activity and UGS. Although the specific effect of muscle mass appears negligible at first sight, its role should not be overlooked given its impact on muscle strength., (Copyright © 2016. Published by Elsevier Inc.)

Background & Aims: Identifying factors associated with oral nutritional supplement (ONS) prescription in nursing homes (NH) may help to treat malnutrition in this very old and vulnerable population., Objectives: The aim of the study was to investigate if resident-related and NH-related characteristics were associated with ONS prescription., Design: Cross-sectional study using medical and demographic data from 6275 NH residents and data on the structure and organization (e.g., presence of a dietitian, organization of the meal) of 175 NHs in southwestern France. The main outcome measure was ONS prescription (dichotomous variable: yes/no)., Results: ONS were prescribed for 7.8% (n = 489) of NH residents. In a multivariate binary logistic regression, resident-related factors associated with the prescription of ONS were age, clinical markers of undernutrition (body mass index and weight loss), disability in activities of daily living, pain, pressure sores, and hospitalization in the last 12 months. NH-related factors associated with ONS prescription were: presence of a dietitian (Odds Ratio (OR): 1.46, 95% Confidence Interval: 1.18-1.88), NH coordinating physician with specific training in geriatrics (OR: 2.58, 95% CI: 1.48-4.49), organization of evening snack (OR: 1.63, 95% CI: 1.28-2.07), number of general practitioners per NH bed (OR: 0.49, 95% CI: 0.38-0.64 intermediate tertile; OR:0.77, 95% CI:0.59-1.06 highest tertile. Reference category: lowest tertile) and number of drug prescriptions (OR: 0.97, 95% CI: 0.94-0.99)., Conclusions: Both resident's characteristics and NH characteristics were associated with ONS prescription independently of each other. Our results showed that NH organizational aspects are associated with ONS prescribing, suggesting that modifiable aspects may contribute to achieve optimal nutritional status in the NH setting., (Copyright © 2015 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

A taskforce, under the auspices of The International Association of Gerontology and Geriatrics-Global Aging Research Network (IAGG-GARN) and the IAGG European Region Clinical Section, composed of experts from the fields of exercise science and geriatrics, met in Toulouse, in December 2015, with the aim of establishing recommendations of physical activity and exercise for older adults living in long-term care facilities (LTCFs). Due to the high heterogeneity in terms of functional ability and cognitive function that characterizes older adults living in LTCFs, taskforce members established 2 sets of recommendations: recommendations for reducing sedentary behaviors for all LTCF residents and recommendations for defining specific, evidence-based guidelines for exercise training for subgroups of LTCF residents. To promote a successful implementation of recommendations, taskforce experts highlighted the importance of promoting residents' motivation and pleasure, the key factors that can be increased when taking into account residents' desires, preferences, beliefs, and attitudes toward physical activity and exercise. The importance of organizational factors related to LTCFs and health care systems were recognized by the experts. In conclusion, this taskforce report proposes standards for the elaboration of strategies to increase physical activity as well as to prescribe exercise programs for older adults living in LTCFs. This report should be used as a guide for professionals working in LTCF settings., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Exercise may lead to improvements on functional ability, physical function, and neuropsychiatric symptoms (particularly depression) in people with dementia (PWD). However, high-quality randomised controlled trial (RCT), controlling for the socialisation aspect of group-based exercise interventions, and designed to delay the declines on the functional ability of PWD in the nursing home (NH) setting is almost inexistent. This article describes the protocol of the LEDEN study, an exercise RCT for PWD living in NHs., Methods/design: LEDEN is a cluster-randomised controlled pilot trial composed of two research arms: exercise training (experimental group) and social/recreational activity (control group). Both interventions will be provided twice a week, for 60 min, during the 6-month intervention. The total duration of the study is 12 months, being six months of intervention plus six months of observational follow-up. Eight French NHs volunteered to participate in LEDEN; they have been randomised to either exercise intervention or social/recreational intervention in a 1:1 ratio., Results: The primary objective is to investigate the effects of exercise, compared to a social/recreational intervention, on the ability of PWD living in NHs to perform activities of daily living (ADL). Secondary objectives are related with the cost-effectiveness of the interventions, and the effects of the interventions on patients' physical function, neuropsychiatric symptoms, pain, nutritional status, and the incidence of falls and fractures., Discussion: LEDEN will provide the preliminary evidence needed to inform the development of larger and more complex interventions using exercise or non-exercise social interventions., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Drug-induced adverse effects are one of the main avoidable causes of hospitalization in older people. Numerous lists of potentially inappropriate medications for older people have been published, as national and international guidelines for appropriate prescribing in numerous diseases and for different age categories. The present review describes the general rules for an appropriate prescribing in older people and summarizes, for the main conditions encountered in older people, medications that are too often under-prescribed, the precautions of use of the main drugs that induce adverse effects, and drugs for which the benefit to risk ratio is unfavourable in older people. All these data are assembled in educational tables designed to be printed in a practical pocket format and used in daily practice by prescribers, whether physicians, surgeons or pharmacists., (Copyright © 2015 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Background: In older patients, hospitalization is often associated with new or worsening disability. This hospitalization-associated disability may be explained in part by the cumulative effect of aging, frailty, comorbidities, and illnesses that led to hospitalization but may also result from health care management issues and the hospital environment. Our objective was to determine the frequency, causes, and the preventability of disability induced by the processes of care or "iatrogenic disability.", Methods: A total of 503 patients, aged 75 years and older, hospitalized in the 105 medical and surgical units of Toulouse University Hospital between October 2011 and March 2012, with a minimal length of stay of 2 days, were included. Hospitalization-associated disability was defined as a loss of 0.5 points or more in the Katz Activity of Daily Living Score between the time of hospital admission and discharge. To determine the iatrogenic component of hospitalization-associated disability, an expert panel in geriatric medicine reviewed each medical chart using a standardized record review and identified precipitating iatrogenic adverse events resulting in functional decline., Results: Incidence of iatrogenic disability was 11.9% (95% confidence interval, 9.2%-15.1%). Of the 60 cases of iatrogenic disability, 49 (81.7%, 95% confidence interval, 69.6%-90.5%) were judged to be potentially preventable. The most common health management issues identified in patients with preventable iatrogenic disability were low mobilization [by excessive bed rest (26.5%) and lack of physical therapist intervention (55.1%)], overuse of diapers (49.0%), and transurethral urinary catheterization (30.6%)., Conclusions: The present study suggests that a significant proportion of hospitalization-associated disability may be induced by iatrogenic events, and that most of them are potentially preventable. Health care professionals need to be educated on the specific needs of elderly hospitalized patients and should consider hospitalization-associated disability as an outcome of care., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether the number of attending general practitioners (GPs) in nursing homes and other facility characteristics are associated with inappropriate neuroleptic prescribing., Design: Cross-sectional study., Setting: One hundred seventy-five nursing homes in France participating in the IQUARE (Impact d'une démarche QUAlité sur l'évolution des pratiques et le déclin fonctionnel des Résidents en EHPAD) study., Participants: A total of 6275 residents included between May and July 2011., Measurements: The outcome measure was potentially inappropriate prescribing of neuroleptic drugs according to the approved indications and French guidelines. Resident characteristics and nursing home characteristics were electronically recorded by the nursing home's coordinating physician. Because of the hierarchical structure of data (resident level and nursing home level), multivariate analysis using a multilevel binary logistic model was carried out to investigate factors associated with inappropriate neuroleptic prescribing., Results: Of 6275 residents enrolled, 1532 (24.4%) had at least 1 prescription for a neuroleptic drug. This corresponded to 513 residents (33.5%) with appropriate prescribing (with regard to indication, substance and dose) and 1019 (66.5%) with potentially inappropriate prescribing. The multilevel binary logistic model showed that residents who lived in a nursing home with 30 GPs or more/100 beds had a higher likelihood of potentially inappropriate prescription than those who lived in nursing homes with fewer than 10 GPs/100 beds [adjusted odds ratio (aOR) 1.80; 95% confidence interval (CI) 1.04-3.12]. Residents who were ≥ 85 years old and those with dementia were more likely to have inappropriate prescription (aOR 1.75; 95% CI 1.32-2.32 and aOR, 2.06; 95% CI 1.56-2.74, respectively) such as the statement "no psychotropic drug prescription," whereas the resident did in fact have a prescription (aOR 1.96; 95% CI 1.03-3.74)., Conclusions: Organizational difficulties because of a large number of physicians probably explain the association with inappropriate prescribing of neuroleptics., (Copyright © 2015 AMDA - The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

There is much ambiguity regarding the term "nursing home" in the international literature. The definition of a nursing home and the type of assistance provided in a nursing home is quite varied by country. The International Association of Gerontology and Geriatrics and AMDA foundation developed a survey to assist with an international consensus on the definition of "nursing home.", (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Atropinic drugs can increase the risk of falls, cognitive impairment, and mortality in older patients; however, whether exposure to atropinic drugs is associated with frailty status remains unknown. Our aim was to assess the association between frailty status and exposure to atropinic drugs in a geriatric day hospital population., Methods: We carried out a cross-sectional study that included all the patients consulting for the first time at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability in Toulouse, France, from January 2013 to October 2013. Frailty was defined by 3 or more of Fried et al's criteria. Atropinic drugs were those with clinical antimuscarinic effect from the Anticholinergic Drug Scale (excluding drugs weighted 1 point and not listed by Durán et al) and from Laroche et al list (to include drugs marketed in France not present in the Anticholinergic Drug Scale). To explore a dose-effect relationship, we calculated the atropinic burden using the Anticholinergic Drug Scale weights. We performed logistic regression models adjusted for age, gender, comorbidities, being community dwelling or not, cognitive status, educational level, and polypharmacy (≥6 drugs)., Results: We included 437 patients (227 frail and 210 robust or prefrail). Exposure to at least one atropinic drug was associated with frailty (odds ratio 1.97, 95% confidence interval 1.10-3.53, P = .02). Due to a statistically significant interaction between age and atropinic burden, a dose-effect relationship for atropinic burden was explored in patients younger than 85 years, showing a significant association between atropinic burden score and frailty (P = .01). The Odds ratio for an atropinic burden greater than or equal to 3 versus 0 was 3.84, 95% confidence interval 1.43-10.34 (P < .01)., Conclusions: In a geriatric day hospital, population frailty is associated with a high atropinic burden., (Copyright © 2015 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The role of body composition as a risk factor for death remains controversial in older persons., Objective: We determined the role of body-composition variables in mortality in older women., Design: Longitudinal analyses were performed in a prospective cohort study of older women. Participants were 4574 community-dwelling women aged ≥ 75 y at the baseline visit (between January 1992 and April 1994). Several body-composition variables were assessed by using anthropometric measures and dual-energy X-ray absorptiometry at the baseline visit. The main outcome was overall mortality. Body-composition variables were body mass index (BMI; in kg/m(2)), hip circumference, waist circumference, waist-to-hip ratio, fat mass/height(2), lean mass/height(2), percentage of fat mass, percentage of lean mass, and the lean mass:fat mass ratio., Results: The mean (± SD) age at baseline was 80.2 ± 3.8 y. During the 17.7 y (IQR: 17.2-18.1 y) of follow-up, 2876 women died. U-shaped in crude analyses and reversed J-shaped relations in adjusted analyses between BMI, hip and waist circumferences, fat mass/height(2), and risk of death were shown. Adjusted risk of death was significantly higher in participants with BMI ≤ 24.6 and fat mass/height(2) ≤ 8.2 kg/m(2). There was a negative linear association between fat mass (%) and risk of death: a 10% increase in fat mass was associated with a 12% reduction of mortality risk (adjusted HR: 0.88; 95% CI: 0.84, 0.92; P < 0.001). Linear and statistically significant relations were shown between lean mass/height(2) and risk of death in crude but not adjusted analyses., Conclusions: Risk of mortality was consistently higher in older women with low adiposity. No lean mass indicator was associated with risk of death. Clinicians should be alerted by low adiposity in older women., (© 2014 American Society for Nutrition.)