Prevalence rate and reasons for refusals of influenza vaccine in the elderly

RESUME Peu d'informations sont disponibles concernant la prévalence et les motifs de refus de la vaccination contre la grippe dans la population âgée. Le but de notre recherche était d'investiguer les vrais motifs de refus de la vaccination (c'est-à-dire pas uniquement les raisons de non-vaccination parfois indépendantes du patient lui- même) chez les personnes âgées. Tous les patients ambulatoires de plus de 65 ans consultant la Policlinique Médicale Universitaire (PMU) de Lausanne ou leur médecin traitant durant les périodes de vaccination contre la grippe 1999-2000 et 2000-2001 ont été inclus. Chaque patient recevait une information sur la grippe et ses complications, de même que sur la nécessité de la vaccination, son efficacité et ses effets seconda ires éventuels. En l'absence de contre-indication, la vaccination était proposée. En cas de refus, les motifs étaient investigués par une question ouverte. Sur 1398 sujets inclus, 148 (12%) ont refusé la vaccination. Les raisons principales de refus étaient la perception d'être en bonne santé (16%), de ne pas être susceptible à la grippe (15%) ou le fait de ne jamais avoir été vacciné contre la grippe dans le passé (15%). On retrouvait également la mauvaise expérience personnelle ou d'un proche lors d'une vaccination (15%) et l'impression d'inutilité du vaccin (10%). 17% des personnes interrogées ont donné des motifs autres et 12% n'ont pas explicité leur non-acceptation. Les refus de vaccination contre la grippe dans la population âgée sont essentiellement liés aux convictions intimes du patient quant à son état de santé et à sa susceptibilité à la grippe, de même qu'à l'efficacité supposée de la vaccination. La résistance au changement semble être un obstacle majeur à l'introduction de la vaccination chez les personnes de plus de 65 ans. SUMMARY More knowledge on the reasons for refusal of the influenza vaccine in elderly patients is essential to target groups for additional information, and hence improve coverage rate. The objective of the present study was to describe precisely the true motives for refusal. All patients aged over 64 who attended the Medical Outpatient Clinic, University of Lausanne, or their private practitioner's office during the 1999 and 2000 vaccination periods were included. Each patient was informed on influenza and its complications, as well as on the need for vaccination, its efficacy and adverse events. The vaccination was then proposed. In case of refusal, the reasons were investigated with an open question. Out of 1398 patients, 148 (12%) refused the vaccination. The main reasons for refusal were the perception of being in good health (16%), of not being susceptible to influenza (15%), of not having had the influenza vaccine in the past (15%), of having had a bad experience either personally or a relative (15%), and the uselessness of the vaccine (10%). Seventeen percent gave miscellaneous reasons and 12% no reason at all for refusal. Little epidemiological knowledge and resistance to change appear to be the major obstacles for wide acceptance of the vaccine by the elderly.

Reproducibility and relative validity of a food-frequency questionnaire for French-speaking Swiss adults.

BACKGROUND: Due to the distinct cultural and language differences that exist in Switzerland, there is little information on the dietary intake among the general Swiss population. Adequately assessing dietary intake is thus paramount if nutritional epidemiological studies are to be conducted. OBJECTIVE: To assess the reproducibility and validity of a food-frequency questionnaire (FFQ) developed for French-speaking Swiss adults. DESIGN: A total of 23 men and 17 women (43.1+/-2.0 years) filled out one FFQ and completed one 24-hour dietary recall at baseline and 1 month afterward. RESULTS: Crude Pearson's correlation coefficients between the first and the second FFQ ranged from 0.58 to 0.90, intraclass correlation coefficient (ICC) ranged between 0.53 and 0.92. Lin's concordance coefficients ranged between 0.55 and 0.87. Over 80% of participants were classified in the same or adjacent tertile using each FFQ. Macronutrient intakes estimated by both FFQs were significantly higher than those estimated from the 24-hour recall for protein and water, while no significant differences were found for energy, carbohydrate, fats (five groups), and alcohol. De-attenuated Pearson's correlation coefficients between the 24-hour recall and the first FFQ ranged between 0.31 and 0.49, while for the second FFQ the values ranged between 0.38 and 0.59. Over 40 and 95% of participants fell into the same or the adjacent energy and nutrient tertiles, respectively, using the FFQs and the 24-hour recall. CONCLUSIONS: This FFQ shows good reproducibility and can be used determining macronutrient intake in a French-speaking Swiss population in an epidemiological setting.

Detecting and measuring deprivation in primary care: development, validity and reliability of a self-reported questionnaire - the DiPCare-Q

Background: General practitioners play a central role in taking deprivation into consideration when caring for patients in primary care. Validated questions to identify deprivation in primary-care practices are still lacking. For both clinical and research purposes, this study therefore aims to develop and validate a standardized instrument measuring both material and social deprivation at an individual level. Methods: The Deprivation in Primary Care Questionnaire (DiPCare-Q) was developed using qualitative and quantitative approaches between 2008 and 2011. A systematic review identified 199 questions related to deprivation. Using judgmental item quality, these were reduced to 38 questions. Two focus groups (primary-care physicians, and primary-care researchers), structured interviews (10 laymen), and think aloud interviews (eight cleaning staff) assured face validity. Item response theory analysis was then used to derive the DiPCare-Q index using data obtained from a random sample of 200 patients who were to complete the questionnaire a second time over the phone. For construct and criterion validity, the final 16 questions were administered to a random sample of 1,898 patients attending one of 47 different private primary-care practices in western Switzerland (validation set) along with questions on subjective social status (subjective SES ladder), education, source of income, welfare status, and subjective poverty. Results: Deprivation was defined in three distinct dimensions (table); material deprivation (eight items), social deprivation (five items) and health deprivation (three items). Item consistency was high in both the derivation (KR20 = 0.827) and the validation set (KR20 = 0.778). The DiPCare-Q index was reliable (ICC = 0.847). For construct validity, we showed the DiPCare-Q index to be correlated to patients' estimation of their position on the subjective SES ladder (rs = 0.539). This position was correlated to both material and social deprivation independently suggesting two separate mechanisms enhancing the feeling of deprivation. Conclusion: The DiPCare-Q is a rapid, reliable and validated instrument useful for measuring both material and social deprivation in primary care. Questions from the DiPCare-Q are easy to use when investigating patients' social history and could improve clinicians' ability to detect underlying social distress related to deprivation.

Postprandial thermogenesis at rest and during exercise in elderly men ingesting two levels of protein.

Seven elderly male subjects (69 +/- 3 yr, 67.8 +/- 9.2 kg, 24.5 +/- 3.6% body fat) lived for 12 consecutive weeks in a metabolic unit and maintained their weight with two different diets fed for 6 weeks each: Diet A, consisted of their habitual protein intake as determined on the outside by a dietary record (mean +/- SD, 1.12 +/- 0.22 g/kg d). Diet B was an isocaloric diet with reduced protein intake (70 mgN/kg d, i.e., 0.44 g protein/kg d) at the level of physiological protein requirement [7]. After 3 weeks on each diet, the thermogenic response to single meals A and B containing 38% of weight maintenance energy for each subject (731-994 kcal) was studied by indirect calorimetry under two situations: (1) at rest over a 4 hr period and (2) during graded exercise on a bicycle ergometer at four stepwise workloads (0,80, 200, and 300 kg/min). A postabsorptive control exercise was also performed in order to assess the net effect of the meal during exercise. Eating alone increased the energy expenditure by +0.18 +/- 0.07 kcal/min with meal A and +0.13 +/- 0.06 kcal/min with meal B. There was a positive correlation (r = 0.84, p less than 0.01) between the % energy derived from protein and the thermogenic response expressed as % of the energy content of test meal. Exercise failed to influence the thermogenic response to meals since the overall net increase in energy expenditure induced by the meals while exercising was not different from that obtained at rest: +0.22 +/- 0.17 kcal/min and +0.15 +/- 0.13 kcal/min with meal A and meal B, respectively. This study failed to show any interaction between exercise and postprandial thermogenesis in elderly individuals.

Looking for Validity or Testing It? The Perils of Stepwise Regression, Extreme-Scores Analysis, Heteroscedasticity, and Measurement Error

When researchers introduce a new test they have to demonstrate that it is valid, using unbiased designs and suitable statistical procedures. In this article we use Monte Carlo analyses to highlight how incorrect statistical procedures (i.e., stepwise regression, extreme scores analyses) or ignoring regression assumptions (e.g., heteroscedasticity) contribute to wrong validity estimates. Beyond these demonstrations, and as an example, we re-examined the results reported by Warwick, Nettelbeck, and Ward (2010) concerning the validity of the Ability Emotional Intelligence Measure (AEIM). Warwick et al. used the wrong statistical procedures to conclude that the AEIM was incrementally valid beyond intelligence and personality traits in predicting various outcomes. In our re-analysis, we found that the reliability-corrected multiple correlation of their measures with personality and intelligence was up to .69. Using robust statistical procedures and appropriate controls, we also found that the AEIM did not predict incremental variance in GPA, stress, loneliness, or well-being, demonstrating the importance for testing validity instead of looking for it.

Design and establishment of a biobank in a multicenter prospective cohort study of elderly patients with venous thromboembolism (SWITCO65+).

In the field of thrombosis and haemostasis, many preanalytical variables influence the results of coagulation assays and measures to limit potential results variations should be taken. To our knowledge, no paper describing the development and maintenance of a haemostasis biobank has been previously published. Our description of the biobank of the Swiss cohort of elderly patients with venous thromboembolism (SWITCO65+) is intended to facilitate the set-up of other biobanks in the field of thrombosis and haemostasis. SWITCO65+ is a multicentre cohort that prospectively enrolled consecutive patients aged ≥65 years with venous thromboembolism at nine Swiss hospitals from 09/2009 to 03/2012. Patients will be followed up until December 2013. The cohort includes a biobank with biological material from each participant taken at baseline and after 12 months of follow-up. Whole blood from all participants is assayed with a standard haematology panel, for which fresh samples are required. Two buffy coat vials, one PAXgene Blood RNA System tube and one EDTA-whole blood sample are also collected at baseline for RNA/DNA extraction. Blood samples are processed and vialed within 1 h of collection and transported in batches to a central laboratory where they are stored in ultra-low temperature archives. All analyses of the same type are performed in the same laboratory in batches. Using multiple core laboratories increased the speed of sample analyses and reduced storage time. After recruiting, processing and analyzing the blood of more than 1,000 patients, we determined that the adopted methods and technologies were fit-for-purpose and robust.

Review: Contact sport-related chronic traumatic encephalopathy in the elderly: clinical expression and structural substrates.

A. Costanza, K. Weber, S. Gandy, C. Bouras, P. R. Hof, P. Giannakopoulos and A. Canuto (2011) Neuropathology and Applied Neurobiology37, 570-584 Contact sport-related chronic traumatic encephalopathy in the elderly: clinical expression and structural substrates Professional boxers and other contact sport athletes are exposed to repetitive brain trauma that may affect motor functions, cognitive performance, emotional regulation and social awareness. The term of chronic traumatic encephalopathy (CTE) was recently introduced to regroup a wide spectrum of symptoms such as cerebellar, pyramidal and extrapyramidal syndromes, impairments in orientation, memory, language, attention, information processing and frontal executive functions, as well as personality changes and behavioural and psychiatric symptoms. Magnetic resonance imaging usually reveals hippocampal and vermis atrophy, a cavum septum pellucidum, signs of diffuse axonal injury, pituitary gland atrophy, dilated perivascular spaces and periventricular white matter disease. Given the partial overlapping of the clinical expression, epidemiology and pathogenesis of CTE and Alzheimer's disease (AD), as well as the close association between traumatic brain injuries (TBIs) and neurofibrillary tangle formation, a mixed pathology promoted by pathogenetic cascades resulting in either CTE or AD has been postulated. Molecular studies suggested that TBIs increase the neurotoxicity of the TAR DNA-binding protein 43 (TDP-43) that is a key pathological marker of ubiquitin-positive forms of frontotemporal dementia (FTLD-TDP) associated or not with motor neurone disease/amyotrophic lateral sclerosis (ALS). Similar patterns of immunoreactivity for TDP-43 in CTE, FTLD-TDP and ALS as well as epidemiological correlations support the presence of common pathogenetic mechanisms. The present review provides a critical update of the evolution of the concept of CTE with reference to its neuropathological definition together with an in-depth discussion of the differential diagnosis between this entity, AD and frontotemporal dementia.

Infection VIH et personnes âgées [HIV infection and the elderly].

HIV infection is becoming a chronic disease, due to decreased mortality induced by the introduction of combined antiviral treatments. The HIV positive population is aging progressively. HIV infection in the elderly has certain specificities, including a late initial diagnosis, a less marked immune response to treatment and the potential association of multiple comorbidities associated with HIV infection and aging. These factors may affect the quality of life of elderly patients and ultimately lead to increased functional dependence. Screening and specific treatment of comorbidities associated with HIV and aging are particularly recommended.

Effect of supplementation with vitamin D3 and calcium on quantitative ultrasound of bone in elderly institutionalized women: a longitudinal study.

Supplementation of elderly institutionalized women with vitamin D and calcium decreased hip fractures and increased hip bone mineral density. Quantitative ultrasound (QUS) measurements can be performed in nursing homes, and easily repeated for follow-up. However, the effect of the correction of vitamin D deficiency on QUS parameters is not known. Therefore, 248 institutionalized women aged 62-98 years were included in a 2-year open controlled study. They were randomized into a treated group (n = 124), receiving 440 IU of vitamin D3 combined with 500 mg calcium (1250 mg calcium carbonate, Novartis) twice daily, and a control group (n = 124). One hundred and three women (42%), aged 84.5 +/- 7.5 years, completed the study: 50 in the treated group, 53 in the controls. QUS of the calcaneus, which measures BUA (broadband ultrasound attenuation) and SOS (speed of sound), and biochemical analysis were performed before and after 1 and 2 years of treatment. Only the results of the women with a complete follow-up were taken into account. Both groups had low initial mean serum 25-hydroxyvitamin D levels (11.9 +/- 1.2 and 11.7 +/- 1.2 micrograms/l; normal range 6.4-40.2 micrograms/l) and normal mean serum parathyroid hormone (PTH) levels (43.1 +/- 3.2 and 44.6 +/- 3.5 ng/l; normal range 10-70 ng/l, normal mean 31.8 +/- 2.3 ng/l). The treatment led to a correction of the metabolic disturbances, with an increase in 25-hydroxyvitamin D by 123% (p < 0.01) and a decrease in PTH by 18% (p < 0.05) and of alkaline phosphatase by 15% (p < 0.01). In the controls there was a worsening of the hypovitaminosis D, with a decrease of 25-hydroxyvitamin D by 51% (p < 0.01) and an increase in PTH by 51% (p < 0.01), while the serum calcium level decreased by only 2% (p < 0.01). After 2 years of treatment BUA increased significantly by 1.6% in the treated group (p < 0.05), and decreased by 2.3% in the controls (p < 0.01). Therefore, the difference in BUA between the treated subjects and the controls (3.9%) was significant after 2 years (p < 0.01). However, SOS decreased by the same amount in both groups (approximately 0.5%). In conclusion, BUA, but not SOS, reflected the positive effect on bone of supplementation with calcium and vitamin D3 in a population of elderly institutionalized women.

The family alliance assessment scales : steps toward validity and reliability of an observational assessment tool for early family interactions

We present the first steps in the validation of an observational tool for father-mother-infant interactions: the FAAS (Family Alliance Assessment Scales). Family-level variables are acknowledged as unique contributors to the understanding of the socio-affective development of the child, yet producing reliable assessments of family-level interactions poses a methodological challenge. There is, therefore, a clear need for a validated and clinically relevant tool. This validation study has been carried out on three samples: one non-referred sample, of families taking part in a study on the transition to parenthood (normative sample; n = 30), one referred for medically assisted procreation (infertility sample; n = 30) and one referred for a psychiatric condition in one parent (clinical sample; n = 15). Results show that the FAAS scales have (1) good inter-rater reliability and (2) good validity, as assessed through known-group validity by comparing the three samples and through concurrent validity by checking family interactions against parents' self-reported marital satisfaction.

Hippocampal and amygdalar volume changes in elderly patients with Alzheimer's disease and schizophrenia.

Patients with Alzheimer's disease (AD) and schizophrenia display cognitive, behavioural disturbances and morphological abnormalities. Although these latter reflect progressive neurodegeneration in AD, their significance in schizophrenia is still unclear. We explored the patterns of hippocampal and amygdalar atrophy in those patients and their associations with clinical parameters. Structural magnetic resonance imaging was performed in 20 elderly schizophrenia patients, 20 AD and 19 healthy older controls. Hippocampal and amygdalar volumes were obtained by manual segmentation with a standardized protocol and compared among groups. In both schizophrenia and AD patients, left hippocampal and amygdalar volumes were significantly smaller. The hippocampus/amygdala ratio was significantly lower in schizophrenia compared to both AD cases [2.4 bilaterally, 95% C.I. 2.2 to 2.7] and healthy controls bilaterally [2.5, 95% C.I. 2.3 to 2.9 in left and 2.7, 95% C.I. 2.4 to 3.1 in right hemisphere]. In schizophrenia patients, a significant positive correlation was found between age at disease onset and the right hippocampus/amygdala volume ratio (Spearman rho=0.56). Negative symptoms correlated with higher right/left amygdala volume ratio (Spearman's rho=0.43). Our data show that unlike AD, the hippocampus/amygdala ratio is abnormally low and correlates with the age at onset in schizophrenia, being a neurodevelopmental signature of the disease.

Cognitive impairment in elderly medical inpatients: detection and associated six-month outcomes.

OBJECTIVE: The authors examined the relationship of cognitive impairment at hospital admission to 6-month outcome (hospital readmission, nursing home admission, and death) in a cohort of elderly medical inpatients. METHODS: A group of 401 medical inpatients age 75 and older underwent a comprehensive geriatric assessment at hospital admission and were followed up for 6 months. Cognitive impairment was defined as a score <24 on the Mini-Mental State Exam. Detection was assessed through blinded review of discharge summary. Follow-up data were gathered from the centralized billing system (hospital and nursing home admissions) and from proxies (death). RESULTS: Cognitive impairment was present in 129 patients (32.3%). Only 48 (37.2%) were detected; these had more severe impairment than undetected cases. During follow-up, cognitive impairment, whether detected or not, was associated with death and nursing home admission. After adjustment for health, functional, and socioeconomic status, an independent association remained only for nursing home admission in subjects with detected impairment. Those with undetected impairment appeared to be at intermediate risk, but this relationship was not statistically significant. CONCLUSION: In these elderly medical inpatients, cognitive impairment was frequent, rarely detected, and associated with nursing home admission during follow-up. Although this association was stronger in those with detected impairment, these results support the view that acute hospitalization presents an opportunity to better detect cognitive impairment in elderly patients and target further interventions to prevent adverse outcomes such as nursing home admission.