Abstract Objectives To update the evidence-based position statement published by the French National Authority for Health (HAS) in 2006 regarding the pharmacological treatment of postmenopausal ...osteoporosis, under the auspices of the French Society for Rheumatology and Groupe de Recherche et d’Information sur les Ostéoporoses (GRIO), and with the participation of several learned societies (Collège National des Gynécologues et Obstétriciens Français, Groupe d’Étude de la Ménopause et du Vieillissement hormonal, Société Française de Chirurgie Orthopédique, Société Française d’Endocrinologie, and Société Française de Gériatrie et de Gérontologie). Methods A multidisciplinary panel representing the spectrum of clinical specialties involved in managing patients with postmenopausal osteoporosis developed updated recommendations based on a systematic literature review conducted according to the method advocated by the HAS. Results The updated recommendations underline the need for osteoporosis pharmacotherapy in women with a history of severe osteoporotic fracture. In these patients, any osteoporosis medication can be used; however, zoledronic acid is the preferred first-line medication after a hip fracture. In patients with non-severe fractures or no fractures, the appropriateness of osteoporosis pharmacotherapy depends on the bone mineral density and FRAX® values; any osteoporosis medication can be used, but raloxifene and ibandronate should be reserved for patients at low risk for peripheral fractures. Initially, osteoporosis pharmacotherapy should be prescribed for 5 years. The results of the evaluation done at the end of the 5-year period determine whether further treatment is in order. Conclusions These updated recommendations are intended to provide clinicians with clarifications about the pharmacological treatment of osteoporosis.
Trabecular Bone Score: Where are we now? Bousson, Valérie; Bergot, Catherine; Sutter, Bruno ...
Joint, bone, spine : revue du rhumatisme,
10/2015, Letnik:
82, Številka:
5
Journal Article
Recenzirano
Abstract The Trabecular Bone Score is a rather new index obtained at the lumbar spine at the same time as a real bone mineral density. It was developed to reflect bone microarchitecture. It was ...proposed to be easily used in everyday practice as a surrogate of bone strength. Our aim was to review 1. technical points such as correlations between Trabecular Bone Score and bone microarchitectural parameters, Trabecular Bone Score and bone strength, the effects of dual-energy X-ray absorptiometry image spatial resolution, age, macroarchitecture, body mass index, and osteoarthritis, on Trabecular Bone Score, and 2. evidences to use Trabecular Bone Score for separating individuals with fragility fractures from controls, predicting fragility fractures, and for longitudinally monitoring changes related to treatments. Correlations between Trabecular Bone Score and bone microarchitectural parameters vary widely across bone sites, microarchitectural parameters, and study designs. In vivo, the Trabecular Bone Score explains little of the variance in trabecular microarchitectural parameters. We emphasize that it is a texture parameter. The Trabecular Bone Score is reduced in patients with fragility fracture. Several retrospective and prospective studies have shown its discriminative ability regarding the fracture risk. When combining the areal Bone mineral Density and Trabecular Bone Score, the Trabecular Bone Score remains a predictor of fracture but not the areal Bone Mineral Density. However in prospective studies, the best predictor of fracture remains hip areal bone mineral density. Due to the lack of evidence, we recommend not to use Trabecular Bone Score for following patients treated by anti-osteoporotic drugs.
Background: among elderly patients, readmission in the month following hospital discharge is a frequent occurrence which involves a risk of functional decline, particularly among frail subjects. ...While previous studies have identified risk factors of early readmission, geriatric syndromes, as markers of frailty have not been assessed as potential predictors. Objective: to evaluate the risk of early unplanned readmission, and to identify predictors in inpatients aged 75 and over, admitted to medical wards through emergency departments. Design: prospective multi-centre study. Setting: nine French hospitals. Subjects: one thousand three hundred and six medical inpatients, aged 75 and older admitted through emergency departments (SAFES cohort). Methods: using logistic regressions, factors associated with early unplanned re-hospitalisation (defined as first unplanned readmission in the thirty days after discharge) were identified using data from the first week of hospital index stay obtained by comprehensive geriatric assessment. Results: data from a thousand out of 1,306 inpatients were analysed. Early unplanned readmission occurred in 14.2% of inpatients and was not related with sociodemographic characteristics, comorbidity burden or cognitive impairment. Pressure sores (OR = 2.05, 95% CI = 1.0–3.9), poor overall condition (OR = 2.01, 95% CI = 1.3–3.0), recent loss of ability for self-feeding (OR = 1.9, 95% CI = 1.2–2.9), prior hospitalisation during the last 3 months (OR = 1.6, 95% CI = 1.1–2.5) were found to be risk factors, while sight disorders appeared as negatively associated (OR = 0.5, 95% CI = 0.3–-0.8). Conclusions: markers of frailty (poor overall condition, pressure sores, prior hospitalisation) or severe disability (for self-feeding) were the most important predictors of early readmission among elderly medical inpatients. Early identification could facilitate preventive strategies in risk group.
Abstract The objective of this systematic literature review is to discuss the latest French recommendation issued in 2012 that a fall within the past year should lead to bone mineral density (BMD) ...measurement using dual-energy X-ray absorptiometry (DXA). This recommendation rests on four facts. First, osteoporosis and fall risk are the two leading risk factors for nonvertebral fractures in postmenopausal women. Second, BMD measurement using DXA supplies significant information on the fracture risk independently from the fall risk. Thus, when a fall occurs, the fracture risk increases as BMD decreases. Third, osteoporosis drugs have been proven effective in preventing fractures only in populations with osteoporosis defined based on BMD criteria. Finally, the prevalence of osteoporosis is high in patients who fall and increases in the presence of markers for frailty (e.g., recurrent falls, sarcopenia low muscle mass and strength, limited mobility, and weight loss), which are risk factors for both osteoporosis and falls. Nevertheless, life expectancy should be taken into account when assessing the appropriateness of DXA in fallers, as osteoporosis treatments require at least 12 months to decrease the fracture risk. Another relevant factor is the availability of DXA, which may be limited due to geographic factors, patient dependency, or severe cognitive impairments, for instance. Studies are needed to better determine how the fall risk and frailty should be incorporated into the fracture risk evaluation based on BMD and the FRAX® tool.
The aim of this study was to identify factors predictive of nursing home admission (NHA) over a period of 1 year among elderly subjects with dementia.
The study population was drawn from the SAFES ...cohort that was formed within a national research program into the recruitment of emergency departments in 9 teaching hospitals. Subjects were to have been hospitalized in a medical ward in the same hospital as the emergency department to which they were initially admitted. Subjects who experienced NHA before emergency department admission were excluded. Those with a confirmed diagnosis of dementia were considered in the present analysis. NHA has been defined as the incident admission into either a nursing home or other long term care facility within the follow-up period. Data obtained from a Comprehensive Geriatric Assessment were used in a Cox model to predict 1-year NHA.
The 425 subjects of the study were 86 ± 6 years old, and were mainly women (63%). NHA rate was 40% (n = 172). Four factors were identified to increase NHA risk: age 85 or older (hazard ratio HR = 1.5; 95% confidence interval CI = 1.1-2.1), inability to use the toilet (HR = 2.5; 95% CI = 1.5-4.2), balance disorders (HR = 1.5; 95% CI = 1.1-2.1), and living alone (HR = 1.5; 95% CI = 1.1-2.1). Three factors decreased this risk significantly: inability to transfer (HR = 0.5; 95% CI = 0.3-0.8), increased number of children (HR = 0.88; 95% CI = 0.96-0.99), and increased initial Mini-Mental State Examination score (HR = 0.97; 95% CI = 0.8-0.9).
NHA determinants in dementia are strongly linked to the patient's own characteristics but also to his or her physical or social environment. Interventions should target both members of the dyad "patient-caregiver" because both are affected by the disease.
OBJECTIVES: To identify early markers of prolonged hospital stays in older people in acute hospitals.
DESIGN: A prospective, multicenter study.
SETTING: Nine hospitals in France.
PARTICIPANTS: One ...thousand three hundred six patients aged 75 and older were hospitalized through an emergency department (Sujet Âgé Fragile: Évaluation et suivi (SAFEs) —Frail Elderly Subjects: Evaluation and follow‐up).
MEASUREMENTS: Data used in a logistic regression were obtained through a gerontological evaluation of inpatients, conducted in the first week of hospitalization. The center effect was considered in two models as a random and fixed effect. Two limits were used to define a prolonged hospital stay. The first was fixed at 30 days. The second was adjusted for Diagnosis Related Groups according to the French classification (f‐DRG).
RESULTS: Nine hundred eight of the 1,306 hospital stays that made up the cohort were analyzed. Two centers (n=298) were excluded because of a large volume of missing f‐DRGs. Two‐thirds of subjects in the cohort analyzed were women (64%), with a mean age of 84. One hundred thirty‐eight stays (15%) lasted more than 30 days; 46 (5%) were prolonged beyond the f‐DRG‐adjusted limit. No sociodemographic variables seemed to influence the length of stay, regardless of the limit used. For the 30‐day limit, only cognitive impairment (odds ratio (OR)=2.2, 95% confidence interval (CI)=1.2–4.0) was identified as a marker for prolongation. f‐DRG adjustment revealed other clinical markers. Walking difficulties (OR=2.6, 95% CI=1.2–16.7), fall risk (OR=2.5, 95% CI=1.7–5.3), cognitive impairment (OR=7.1, 95% CI=2.3–49.9), and malnutrition risk (OR=2.5, 95% CI=1.7–19.6) were found to be early markers for prolonged stays, although dependence level and its evolution, estimated using the Katz activity of daily living (ADL) index, were not identified as risk factors.
CONCLUSION: When the generally recognized parameters of frailty are taken into account, a set of simple items (walking difficulties, risk of fall, risk of malnutrition, and cognitive impairment) enables a predictive approach to the length of stay of elderly patients hospitalized under emergency circumstances. Katz ADLs were not among the early markers identified.
To update the 2012 recommendations on pharmacotherapy for postmenopausal osteoporosis, under the aegis of the Bone Task Force of the French Society for Rheumatology (SFR) and of the Osteoporosis ...Research and Information Group (GRIO), in collaboration with scientific societies (Collège national des généralistes enseignants, Collège national des gynécologues et obstétriciens français, Fédération nationale des collèges de gynécologie médicale, Groupe d’étude de la ménopause et du vieillissement hormonal, Société française de chirurgie orthopédique, Société française d’endocrinologie, and Société française de gériatrie et de gérontologie).
Updated recommendations were developed by a task force whose members represented the medical specialties involved in the management of postmenopausal osteoporosis. The update was based on a literature review and developed using the method advocated by the French National Authority for Health (HAS).
The updated recommendations place strong emphasis on the treatment of women with severe fractures, in whom the use of osteoporosis medications is recommended. All the available osteoporosis medications are suitable in patients with severe fractures; zoledronic acid deserves preference as the fist-line drug after a hip fracture. In patients with or without non-severe fractures, the decision to use osteoporosis medications is based on bone mineral density values and in challenging cases, on probabilities supplied by prediction tools such as FRAX®. All osteoporosis medications are suitable; raloxifene should be reserved for patients at low risk for peripheral fractures. The fracture risk should be reevaluated every 2 to 3 years to decide on the best follow-up treatment. These updated recommendations discuss the selection of first-line osteoporosis medications and treatment sequences.
In France, there is evidence to suggest that 50% of elderly individuals are prescribed psychotropic medications. However, it is known that use of these agents increases the risk of falls, fractures ...and delirium in older people.
To study the consumption of 'potentially inappropriate medication' (PIM) among patients aged>or=75 years, paying particular attention to psychotropic drugs and the factors influencing the use of 'potentially inappropriate psychotropics' (PIPs).
This was a cross-sectional analysis of a prospective multicentre cohort of 1306 hospitalized French patients aged>or=75 years (the SAFEs Sujet Agé Fragile: Evaluation et suivi (Frail Elderly Subjects: Evaluation and follow-up) cohort). The present analysis involved the 1176 patients for whom there was information on the usual treatments being taken in the 2 weeks before hospitalization. The drugs were coded according to the Anatomical Therapeutic Chemical classification; the Beers list as updated in 2003 defined which medications were considered PIPs. Standardized geriatric assessment variables were recorded on inclusion in the study. Logistic regression analysis was performed to identify factors linked to use of psychotropics and PIPs.
The mean number of drugs taken was 5.7+/-2.9 per patient. Twenty-eight percent of patients took at least one PIM. The number of patients who had taken at least one psychotropic drug in the 2 weeks before hospitalization (mean 1.6+/-0.9 psychotropics per patient) was 589 (50.1%). More than half of both the 510 patients with a depressive syndrome and the 543 patients affected by dementia were treated with psychotropics. Multivariate analysis showed that prescription of psychotropics was linked to the presence of a dementia syndrome (odds ratio OR=1.4; 95% CI 1.1, 1.9; p=0.03), the presence of a depressive syndrome (OR=1.7; 95% CI 1.3, 2.1; p<0.001), living in an institution (OR=2.2; 95% CI 1.5, 3.4; p<0.001), use of more than five drugs (OR=3.2; 95% CI 2.5, 4.2; p<0.001) and Charlson's co-morbidity score>1 (OR=0.6; 95% CI 0.5, 0.8; p=0.001). Nineteen percent of all psychotropics prescribed were PIPs. Of these PIPs, 66.5% were anxiolytics, 28.4% were antidepressants and 5.1% were antipsychotics. Use of PIPs in the multivariate analysis was associated only with consumption of more than five drugs (OR=1.7; 95% CI 1.1, 2.5; p=0.01).
PIM use is common among hospitalized older adults in France. The most important determinant of risk of receiving a psychotropic medication or a PIP was the number of drugs being taken. The elderly, who have multiple co-morbidities, complex chronic conditions and are usually receiving polypharmacy, are at increased risk for adverse drug events. These adverse events are often linked to problems that could be preventable such as delirium, depression and falls. Regular review of prescriptions would help optimize prescription of psychotropics in the elderly. The Beers list is a good tool for evaluating PIMs but is too restrictive with respect to psychotropics; in the latter respect, the list could usefully be widened.
Background The preservation of autonomy and the ability of elderly to carry out the basic activities of daily living, beyond the therapeutic care of any pathologies, appears as one of the main ...objectives of care during hospitalization. Objectives To identify early clinical markers associated with the loss of independence in elderly people in short stay hospitals. Methods Among the 1,306 subjects making up the prospective and multicenter SAFEs cohort study (Sujet Agé Fragile: Évolution et suivi—Frail elderly subjects, evaluation and follow-up), 619 medical inpatients, not disabled at baseline and hospitalized through an emergency department were considered. Data used in a multinomial logistic regression were obtained through a comprehensive geriatric assessment (CGA) conducted in the first week of hospitalization. Dependency levels were assessed at baseline, at inclusion and at 30 days using Katz's ADL index. Baseline was defined as the dependence level before occurrence of the event motivating hospitalization. To limit the influence of rehabilitation on the level of dependence, only stays shorter than 30 days were considered. Results About 514 patients were eligible, 15 died and 90 were still hospitalized at end point (n = 619). Two-thirds of subjects were women, with a mean age of 83. At day 30 162 patients (31%) were not disabled; 61 (12%) were moderately disabled and 291 severely disabled (57%). No socio-demographic variables seemed to influence the day 30 dependence level. Lack of autonomy (odds ratio (OR) = 1.9, 95% confidence interval (CI) = 1.2–3.6), walking difficulties (OR = 2.7, 95% CI = 1.3–5.6), fall risk (OR = 2.1, 95% CI = 1.3–6.8) and malnutrition risk (OR = 2.2, 95% CI = 1.5–7.6) were found in multifactorial analysis to be clinical markers for loss of independence. Conclusions Beyond considerations on the designing of preventive policies targeting the populations at risk that have been identified here, the identification of functional factors (lack of autonomy, walking difficulties, risk of falling) suggests above all that consideration needs to be given to the organization per se of the French geriatric hospital care system, and in particular to the relevance of maintaining sector-type segregation between wards for care of acute care and those involved in rehabilitation
There is no protocol of vitamin D supplementation used worldwide due to a great disparity of vitamin D supplements available in different countries. The aim of this study was to evaluate the ...efficiency of the protocol most often used in France to correct vitamin D deficiency defined by a serum 25-hydroxy vitamin D (25OHD) level of less than 30ng/mL.
This was a pragmatic multicentric study of vitamin D supplementation in 257 osteopenic/osteoporotic, vitamin D deficient patients who received 100,000UI vitamin D3 vials every two weeks according to their initial serum 25OHD level (four vials when 25OHD less than 10ng/mL, three when 25OHD was 10–19ng/mL, two when 25OHD was 20–29ng/mL). Blood samples were obtained at baseline, one (M1), two (M2), and three months (M3), after the end of the supplementation protocol.
At M1, 198/257 (77%) patients had a serum 25OHD level more than 30ng/mL. Eighty-five percent of those with a BMI less than 25kg/m2 had a 25OHD concentration more than 30ng/mL, whereas only 66% of those with a BMI more than 25 had a level more than 30ng/mL. At M2 and M3, 25OHD levels decreased significantly with 55% and 46% having still a level more than 30ng/mL respectively, without any significant difference according to the initial 25OHD level.
This protocol was effective in rising serum 25OHD of most vitamin D insufficient patients with a BMI less than 25kg/m2, but not in overweight patients. As almost one half of our patients had a serum 25OHD level less than 30ng/mL at M2, we suggest that regular doses should be started quite soon after this initial supplementation.
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