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Baptiste Gramont,1 Émilie Chalayer,1,2 Angélique Savall,3 Martin Killian,1 Thomas Celarier,1 Bernard Tardy21Department of Internal Medicine and Geriatrics, CHU, Saint Etienne, France; 2Centre d’Investigation Clinique, Inserm CIC-EC 1408, Saint Etienne, France; 3Department of Education and Research in General Practice, Jean Monnet University, Saint Etienne, FranceBackground: The thromboprophylactic efficacy of graduated compression stockings (GCS) has not yet been demonstrated in acutely ill medical patients, and guidelines vary considerably. Older acutely ill medical patients appear to constitute a distinctive population presenting high risks of both thrombosis and bleeding.Objective: To evaluate the practices and beliefs of a panel of French geriatricians regarding GCS management in acutely ill medical patients aged over 75 years.Methods: A survey was designed to study French geriatric practice concerning GCS use for thromboprophylaxis.Results: A total of 111 geriatricians answered the questionnaire. Among the responders, 46% declared frequent or very frequent prescription of GCS for preventing venous thromboembolism (VTE) in acutely ill, hospitalized medical patients, 54% declaring that they frequently re-evaluated GCS prescription during the patient’s hospitalization. The main reason reported for discontinuing GCS use was patient request. Regarding complications of GCS, 87% of responders declared having already noted adverse effects with the use of GCS, although 80% estimated the risk of complications to be low or very low. In the context considered, the efficacy of wearing GCS was believed to be high or very high for 73% of responders. GCS prescription was judged to be in accordance with evidence-based medicine for 69%.Conclusion: There is a gap between the frequent use of GCS to prevent VTE in older patients presenting an acute medical illness and the availability of data concerning their efficacy, safety, and management by nurses. Prospective trials including clinical and cost effectiveness are needed.Keywords: thromboprophylaxis, mechanical prophylaxis, thrombosis, geriatrics, elderly

Acquired deforming hypertonia (ADH) affects the daily care of numerous nursing home residents. The aim of this study was to analyze the practice, aims, and effectiveness of botulinum toxin injections (BTxis) in the treatment of older patients with contractures, an indication for which BTxis are still underused. Data were extracted retrospectively from medical records regarding population, contractures, and injections. A prospective analysis was conducted to evaluate treatment goals set by goal attainment scaling (GAS) at T0 and at T1, to evaluate the therapeutic effects. We also recorded the occurrence of side effects, using a telephone questionnaire. This study included 41 patients older than 70 years who had received one or more BTxis for the first time between January 2018 and December 2021. Most of the older people we included lived in an institution (66%), manifested severe dependence, and presented significant morbi-mortality (37% of the patients died in the year after the last injection). The main objectives of these injections were purely comfort, without any functional goals. The GAS scores suggested effectiveness for comfort GAS scores. No complications were recorded. This study highlights the BTxis potential to address the needs of a larger number of older patients with ADH.

Background: The Emergency unit of the hospital (Department) (ED) is the fastest and most common way for most French general practitioners (GPs) to respond to the complexity of managing older adults patients with multiple chronic diseases. In 2013, French regional health authorities proposed to set up telephone hotlines to promote interactions between GP clinics and hospitals. The main objective of our study was to analyze whether the hotlines and solutions proposed by the responding geriatrician reduced the number of hospital admissions, and more specifically the number of emergency room admissions., Methods: We conducted a multicenter observational study from April 2018 to April 2020 at seven French investigative sites. A questionnaire was completed by all hotline physicians after each call., Results: The study population consisted of 4,137 individuals who met the inclusion and exclusion criteria. Of the 4,137 phone calls received by the participants, 64.2% (n = 2 657) were requests for advice, and 35.8% (n = 1,480) were requests for emergency hospitalization. Of the 1,480 phone calls for emergency hospitalization, 285 calls resulted in hospital admission in the emergency room (19.3%), and 658 calls in the geriatric short stay (44.5%). Of the 2,657 calls for advice/consultation/delayed hospitalization, 9.7% were also duplicated by emergency hospital admission., Conclusion: This study revealed the value of hotlines in guiding the care of older adults. The results showed the potential effectiveness of hotlines in preventing unnecessary hospital admissions or in identifying cases requiring hospital admission in the emergency room. Hotlines can help improve the care pathway for older adults and pave the way for future progress., Trial Registration: Registered under Clinical Trial Number NCT03959475. This study was approved and peer-reviewed by the Ethics Committee for the Protection of Persons of Sud Est V of Grenoble University Hospital Center (registered under 18-CETA-01 No.ID RCB 2018-A00609-46)., (© 2023. The Author(s).)

Vaccination coverage is insufficient for influenza, pneumococcus, and herpes zoster in people over the age of 65 in France, even though these are common infectious diseases. Using a computerised questionnaire, the aim of our study was to assess the knowledge of general practitioners, geriatricians, infectious diseases specialists and interns in the Loire region about the vaccination against these three diseases in elderly subjects, to identify the obstacles to vaccination, and to evaluate whether the provision of knowledge modifies the prescriptions and vaccination recommendations made to patients. Of the 125 responses from doctors and interns, 90.2 % are correct for influenza, 69.2 % for pneumococcus, and 32.8 % for herpes zoster, with no significant difference between specialities. By providing information, practitioners are more willing to vaccinate their patients against influenza (99 %), pneumococcus (93 %), and herpes zoster (39 %). The main obstacles to vaccination are the patient's refusal (85 %), the doctor's lack of knowledge and time (70 % and 41 % respectively), doubts about the vaccine's effectiveness (28 %), and fear of side effects (21 %).

Background: Treating pneumonia in old patients remains challenging for clinicians. Moreover, bacterial antimicrobial resistance is a major public health threat., Objective: The PROPAGE study evaluated the interest of a strategy using serial measurements of procalcitonin (PCT) to reduce the duration of antibiotic therapy in old patients with pneumonia., Methods: PROPAGE took place from Dec.-2013 to Jun.-2016 in eight French geriatric units. It was a prospective, comparative, randomised, open-label study involving old patients (≥ 80 years) who had initiated antibiotic treatment for pneumonia in the previous 48 h. PCT was monitored in all patients and two decision-making PCT-based algorithms guided antibiotic therapy in patients from the PCT group., Results: 107 patients were randomised (PCT, n = 50; Control, n = 57). Antibiotic therapy exposure was reduced in the PCT group as compared to the Control group (median duration of antibiotic therapy, 8 vs. 10 days [rank-test, p = 0.001]; antibiotic persistence rates on Days 6 and 8, 54% and 44% vs. 91% and 72%) and no significant difference was found in recovery rate (84% vs. 89.5%; Pearson Chi² test, p = 0.402)., Conclusion: Although, the superiority of the strategy was not tested using a composite criterion combining antibiotic therapy duration and recovery rate was not tested due to the small sample size, the present study showed that monitoring associated with PCT-guided algorithm could help shorten antibiotic treatment duration in the very old patients without detrimental effects. Measuring PCT levels between Day 4 and Day 6 could be helpful when making the decision regarding antibiotic discontinuation., Trial Registration: NCT02173613. This study was first registered on 25/06/2014., (© 2022. The Author(s).)

Background: The time-course response after a single injection of botulinum toxin (BoNT) for post-stroke spasticity is debated. We addressed this issue by conducting a systematic review and a pharmacodynamic model-based meta-analysis., Methods: We searched Medline, PeDro and Google Scholar databases up to March 2020, selecting randomized controlled trials of post-stroke and traumatic brain injury patients with arm or leg muscle hypertonia, comparing BoNT to placebo, or different BoNT preparations. The main outcome was change in Modified Ashworth Scale (MAS) score. A non-linear mixed effect model was used to estimate maximal toxin and placebo effects (Emax and EPlacebo), the effect disappearance half-life (T1/2off) of BoNT and the doses achieving 50 and 80% of Emax (D50 and D80). The equivalence ratios between different BoNT preparations were calculated from D50 values. Adverse events were recorded., Results: Altogether, 2,236 unique records were screened by 2 independent reviewers: 35 eligible trials including 3011 patients (95% post-stroke) were identified. For all BoNT preparations, the BoNT Emax of -1.11 (95% credible interval -1.31; -0.29) was reached at 5 weeks; the maximal placebo effect was -0.30 (-0.37; -0.22). Both D50 and D80 differed significantly by muscle volume. At D50, the equivalence ratio was significantly higher for abobotulinumtoxinA (3.35) than onabotulinumtoxinA and lower for letibotulinumtoxinA (0.41). T1/2off was longer for abobotulinumtoxinA than for onabotulinumtoxinA and the other preparations (13.1 weeks [95% credible interval 7.7; 19.3] vs 8.6 weeks [7.1; 10.1]). Adverse events were minor, with a weak, but significant, dose-response relation for muscle weakness., Conclusions: This first pharmacodynamic model-based meta-analysis of individuals with stroke revealed that for all BoNT-A preparations, BoNT-A injections to treat spasticity have maximal effect at 5 weeks. The T1/2off was longer for abobotulinumtoxinA than other preparations. Differences between certain BoNT unit scales were also confirmed., Competing Interests: Declaration of Competing Interest Pascal Giraux and Etienne Ojardias received meeting sponsorship from Allergan, Ipsen, and Merz and compensation for consulting from Merz. Etienne Ojardias received through his institution a research support grant from Merz. Pascal Giraux is a co-founder of the Dessintey company. The other authors declare no conflict of interest., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Falls affects one of three people after 65 years old, and it can lead to serious consequences. Scientific evidence point out that physical exercise is the most efficient way to prevent falls among older adults. Objective: The main objective of this study is to determine if a social marketing program can increase the attendance rate of people aged 60 and over at group balance workshops. Methods: This quasi-experimental multicenter study is being conducted in three French Regions (Loire, Haute-Loire and Rhône) over a period of 18 months. The Social Marketing Campaign will be done in three ways. Firstly, a Communication Campaign will take place in the two Test Areas but not in the Control Area. Secondly, flyers have been designed to be distributed by local partners. Finally, conferences for older people will be organized in the areas of intervention in order to reach the target audience for the program. The study will include people aged 60 and older who want to participate in the Balance Program. Results: The Crédit Agricole Loire/Haute-Loire Foundation funded the study and the Jean Monnet University of Saint-Etienne reviewed it. The Ethics Committee of the University Teaching Hospital of Saint-Etienne approved and peer-reviewed it on September 6, 2019, under Reference Number IRBN622019/CHUSTE. Conclusion: The results of this first study will demonstrate whether or not social marketing for promoting group balance workshops in the elderly will increase their attendanceship in adapted physical activity sessions, especially those that prevent falls. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT04136938, identifier NCT04136938., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Goethals, Barth, Hupin, Chapoton, Guyot, Celarier, Roche, Gallopel-Morvan and Bongue.)

The objective of this study was to compare three hierarchical intervention strategies of an educational program for the prevention of falls in elderly people in a follow-up and rehabilitation care facility, and to evaluate the compliance with the recommendations related to extrinsic risk factors for falls, behavioral and environmental., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Faced with an aging French population, the demand for unscheduled care is growing. In order to avoid referring elderly patients to emergency departments, which are unsuitable for them, the Regional Health Agencies have created telephone hot lines dedicated to geriatrics. They are exclusively accessible to general practitioners in order to obtain advice or a place in a geriatric hospital. General practitioners are rarely asked about the value of this tool in their practice., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Older adults and those with pre-existing medical conditions are at risk of death from severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). In this period of quarantine, one of the reasons for going out is physical activity. This issue is important, as the impact of a sedentary lifestyle might be lower for children and young adults, but is far more severe for older adults. Although older adults need to stay at home because they have a higher risk of coronavirus disease (COVID-19), they need to avoid a sedentary lifestyle. Physical activity is important for older adults, especially to maintain their level of independence, mental health, and well-being. Maintaining mobility in old age is necessary, as it may predict loss of independence in older adults., Objective: Our first objective was to evaluate the impact of this quarantine period on physical activity programs and on the physical and mental health of older adults. Our second objective was to discuss alternatives to physical activity programs that could be suggested for this population to avoid a sedentary lifestyle., Methods: We conducted a qualitative survey using semistructured interviews with professionals (managers in charge of physical activity programs for older adults and sports trainers who run these physical activity programs) from the French Federation of Physical Education and Voluntary Gymnastics (FFPEVG) and older adults participating in a physical activity program of the FFPEVG. We followed a common interview guide. For analysis, we carried out a thematic analysis of the interviews., Results: This study suggests that the COVID-19 epidemic has affected, before quarantine measures, the number of seniors attending group physical activity programs in the two study territories. In addition, despite the decline in their participation in group physical activities before the quarantine, older adults expressed the need to perform physical activity at home. There is a need to help older adults integrate simple and safe ways to stay physically active in a limited space. A national policy to support older adults for physical activity at home appears essential in this context., Conclusions: Given the results of our study, it seems necessary to globally communicate how important it is for older adults to maintain physical activity at home. We are concerned about the level of independence and mental health state of older adults after the end of quarantine if there is no appropriate campaign to promote physical activity among them at home., (©Luc Goethals, Nathalie Barth, Jessica Guyot, David Hupin, Thomas Celarier, Bienvenu Bongue. Originally published in JMIR Aging (http://aging.jmir.org), 07.05.2020.)

Therapeutic patient education (TPE) allows elderly as well as young adults to evaluate patient's self-care and adaptation skills to their own clinical condition. Falling is a symptom present in various chronic diseases, which leads to loss of autonomy, fear of recidivism and frequent admissions into institutions. Study objective was to evaluate at 3 and 6 months the impact of TPE on fall recurrence, perceived quality of life and fear of falling, in elderly over 75 living at home., Methods: We performed a prospective study comparing two groups: a group participating in day hospital (group "TPE") and a control group (group "Hospitalized") of elderly patient not receiving TPE recruited in short geriatric stays following a fall at home., Results: 28 patients in the "TPE" group and 20 patients in the "Hospitalized" group were included. The "TPE" group reported significantly better perceived quality of life at 3 months and 6 months. At 6 months, fear of falling was twice as high in the "Hospitalized" group than in the "TPE" group., Conclusions: The group of subjects who was able to benefit from therapeutic education at home had an improved quality of life at 3 and 6 months and a decrease in the fear of falling at 6 months.

Background: In France, emergency departments (EDs) are the fastest and most common means for general practitioners (GPs) to cope with the complex issues presented by elderly patients with multiple conditions. EDs are overburdened, and studies show that being treated in EDs can have a damaging effect on the health of elderly patients. Outpatient care or planned hospitalizations are possible solutions if appropriate geriatric medical advice is provided. In 2013, France's regional health authorities proposed creating direct telephone helplines, "geriatric hotlines," staffed by geriatric specialists to encourage interactions between GP clinics and hospitals. These hotlines are designed to improve health care pathways and the health status of the elderly., Objective: This study aims to describe the health care pathways and health status of patients aged 75 years and older hospitalized in short-stay geriatric wards following referral from a geriatric hotline., Methods: The study will be conducted over 24 months in seven French university hospital centers. It will include all patients aged 75 and older, living in their own homes or nursing homes, who are admitted to short-stay geriatric wards following hotline consultation. Two questionnaires will be filled out by medical staff at specific time points: (1) after conducting the telephone consultation and (2) on admitting the patient to a short-stay geriatric medical care. The primary endpoint will be mean hospitalization duration. The secondary endpoints will be intrahospital mortality rate, the characteristics of patients admitted via the hotline, and the types of questions asked and responses given via the hotline., Results: The study was funded by the National School for Social Security Loire department (École Nationale Supérieure de Sécurité Sociale) and the Conference for funders of prevention of autonomy loss for the elderly of the Loire department in November 2017. Institutional review board approval was obtained in April 2018. Data collection started in May 2018; the planned end date for data collection is May 2020. Data analysis will take place in the summer of 2020, and the first results are expected to be published in late 2020., Conclusions: The results will reveal whether geriatric hotlines provide the most effective management of elderly patients, as indicated by shorter mean hospitalization durations. Shorter hospital durations could lead to a reduced risk of complications-geriatric syndromes-and the domino chain of geriatric conditions that follow. We will also describe different geriatric hotlines from different cities and compare how they function to improve the health care of the elderly and pave the way toward new advances, especially in the organization of the care path., Trial Registration: ClinicalTrials.gov NCT03959475; https://clinicaltrials.gov/ct2/show/NCT03959475., International Registered Report Identifier (irrid): DERR1-10.2196/15423., (©Laure Martinez, Noémie Lacour, Régis Gonthier, Marc Bonnefoy, Luc Goethals, Cedric Annweiler, Nathalie Salles, Nathalie Jomard, Jérôme Bohatier, Magali Tardy, Etienne Ojardias, Romain Jugand, Bienvenu Bongué, Thomas Celarier. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 13.02.2020.)

Introduction: Geriatrics Mobile Units are a new organisation operating in nursing homes. Their mission is to propose globally oriented neuro-psychiatric and geriatric care. The purpose of the study is to assess their activity and impact over a 21-month period., Method: A prospective single center study of UMNPG's data including intervention characteristics, patient characteristics, recommendations and reassessment after intervention. The Neuropsychiatric Inventory Nursing Home version (NPI-NH) was measured during intervention and reassessed after 30 days (Student's t-test)., Results: From March 2014 to December 2015, UMNPG conducted 288 interventions mainly for medical advices (81%), clinical assessments (54%) and health care team support (46%). The average age was 84.6±7.3years, 73.3% of whom were women. The patients were dependent (62% of GIR 1 or 2) with dementia (60%) and under several medications (83.7%). The symptoms were mainly agitation/aggression (76.4%), anxiety (75%), depression (66.7%), irritability (60.4%), aberrant motor behaviour (55.9%) and delusions (48.6%). The main proposals of UMNPG were a change in treatment (79.5%), a health care team support (85.4%) and hospitalization (8.4%). The rate of follow-up on recommendation was 83% on the 15th day and 80% on the 30th day. The rate of avoided hospitalizations was 16%. The average NPI-NH decreased (on day 0 NPI=50±19.2; on day 30 NPI=33.9±19.6, p<0.001)., Conclusion: UMNPG-EHPAD intervenes for frail elderly residents with multiple disorders in crisis situations. Medical recommendations help to support people in nursing homes and decrease NPI-NH. UMNPG-EHPAD is part of geriatric network strengthening the city/hospital connection., (Copyright © 2018 L'Encéphale, Paris. Published by Elsevier Masson SAS. All rights reserved.)

Management of undernutrition is based on young adults analysis. However, enteral nutrition is mainly discussed in the elderly. The aim of this study was to analyse factors related to laying gastrostomy, in geriatrics. A prospective, descriptive study, was conducted in the Loire department, from 2014 to 2016, in geriatric and palliative units. All patients over 70 years who had a theorical indication of gastrostomy were included. Decision-making process was analyzed from data affecting the reflection. Patients were followed for three months. Twenty-six patients were included with an average of 81 years old. They were frailty with a low mean serum albumin (29.2 g/L), an undernutrition (85%), an extended bedridden (73%), a medical history of aspiration pneumonia (46%) and with pressure ulcers (27%). The main diagnoses were strokes (38%) and dementia (23%). After a singular decision-making, only 15% received a gastrostomy. At three months, 69.2% of patients had died. Patients over 70 years old, with a vital prognosis at short term, are not good candidates for gastrostomy. In geriatrics, decision-making for gastrostomy laying is complex because managed by contradictory recommendations. It requires a global assessment to identify risk situations. The early detection of undernutrition is the key to successful management, for patients requiring gastrostomy.

In the past decade, a significant improvement has been done in the management of pulmonary arterial hypertension, a devastating disease. Beside the aging population, one of the next challenges is to develop a specific management of a pulmonary hypertension's suspicion, in the aged patients. In fact, recent data have shown that if pulmonary hypertension were mostly related to chronic heart or lung failure, or pulmonary embolism, some elderly may in fact develop a real pulmonary arterial hypertension. Because of the potential therapies which may be proposed, the evaluation of a pulmonary hypertension's suspicion in the elderly needs a stringent evaluation by trained physicians, in collaboration with geriatricians.

Objective: To show the botulinum toxin interest and limits in the elderly presenting a limbs spastic hypertonia and/or a dystonia, through a clinical study and a literature review., Method: We report a 6 years and 8 months retrospective single center study, concerning 49 patients, all of them was more than 70 years old and had received one or several botulinum toxin injections for a limbs spastic hypertonia and/or a dystonia., Results: The population average was 76,9 years old (70 to 92 years old). It was possible to realize several sessions for the same patient if respecting a three months interval between two sessions. No major side effects was noticed. More than half of the patients felt a significant improvement of their life quality, their functional status and/or on pain. A multidisciplinary care was systematically associated with the botulinum toxin., Conclusion: The botulinum toxin is an additional asset for the spasticity care of the geriatric patient in rehabilitation, if indications and contraindications are advisedly targeted. The age cannot be considered as a limitating factor.