Le syndrome confusionnel postopératoire (SCPO) chez la personne âgée (PA) est une complication fréquente et potentiellement grave. Sa prévention constitue donc un axe de travail essentiel dans une démarche globale et multidisciplinaire d’amélioration de la prise en soin des PA en chirurgie. Après une revue de la littérature, nous avons élaboré un programme multidisciplinaire de prévention du SCPO et sa méthodologie d’évaluation. Ce programme est actuellement en cours d’évaluation grâce à une étude interventionnelle, contrôlée, randomisée en stepped wedge (étude CONFUCIUS, financée par le Programme de Recherche en Qualité Hospitalière) au sein de trois services de chirurgie (orthopédie, digestif, urologie). À ce jour, 51 patients (âge moyen = 81,6 ans et 45% de femmes) ont été inclus. Le programme de prévention sera déployé à partir de novembre 2012 dans le service de chirurgie orthopédique en collaboration avec l’équipe mobile de gériatrie de l’établissement. Préalablement, nous avons évalué les connaissances et la perception des soignants relatives au SCPO grâce à une approche quantitative et qualitative. Celles-ci sont insuffisantes, tout particulièrement concernant les signes cliniques et le diagnostic. En effet, seuls 4% des soignants connaissaient la forme hypoactive et aucun l’outil diagnostique de référence, la Confusion Assessment Method. Une banalisation du SCPO a été mise en évidence, des croyances et des représentations persistent. Cela montre qu’il est nécessaire de lutter contre les idées reçues avant d’engager toute action de prévention. Nos travaux s’inscrivent dans une démarche globale et multidisciplinaire d’amélioration de la qualité et de la sécurité des soins en chirurgie et seront poursuivis, notamment par une étude permettant de déterminer le rôle prédictif des biomarqueurs du liquide céphalo-rachidien dans la survenue de SCPO et d’une démence 12 mois après l’intervention chirurgicale chez la PA / Postoperative delirium is common in elderly and is associated with a significant increase in mortality, complications, length of hospital stay and admission in long care facility. Although several interventions have proved their effectiveness to prevent it, the Cochrane advises an assessment of multifaceted intervention using rigorous methodology bases on randomized study design. After a review of literature, a multifaceted program of delirium prevention coordinated by a mobile geriatric team (MGT) was created. This program is currently being evaluated in a randomized, controlled, interventional, stepped wedge study (the CONFUCIUS study funding by the National French Program of Hospital Quality Research) within three surgical departments (orthopedics, gastroenterology, and urology). To date, 51 patients (mean age of 81.6 years; 45% female) have been included. The program will be rolled out from November 2012 in the department of orthopedic surgery in collaboration with the hospital’s MGT. Prior to the implementation of the prevention program, the knowledge base in older postoperative delirium. Only 4% of nursing staff knew the hypoactive form and none of nursing staff knew the Confusion Assessment Method. In addition, some stereotypes persist. This work is part of a comprehensive and multidisciplinary approach to improving quality and safety in surgical care. It will be followed by a study aiming to determine the capacity of cerebrospinal fluid biomarkers in predicting the onset of POD and dementia 12 months after surgery

Background: Although physical inactivity has been linked with numerous chronic health conditions and overall mortality, the majority of English adults report insufficient physical activity. To increase population physical activity levels, researchers have called for more community-level interventions. To evaluate these complex public health interventions, innovative study designs are required. The aim of this thesis was to evaluate whether a community-level physical activity intervention—‘Devon Active Villages’—increased the activity levels of rural communities. Methods: The Devon Active Villages intervention provided villages with 12 weeks of physical activity opportunities for all age groups. Community engagement helped tailor activity programmes for each village; communities were then supported for a further 12 months. 128 rural villages from south-west England were randomised to receive the intervention in one of four time periods, as part of a stepped wedge cluster randomised controlled trial. Data collection consisted of a postal survey of a random sample of adults (≥18 years), at baseline, and after each of the four intervention periods. The primary outcome of interest was the proportion of adults who reported sufficient physical activity to meet the current guidelines (≥150mins of moderate-and-vigorous, or ≥75mins of vigorous-intensity activity per week). The number of minutes spent in moderate-and-vigorous activity per week was analysed as a secondary outcome. Using data from all five periods, a comparison of study outcomes between intervention and control arms was performed, allowing for time period (as a fixed effect), and the random effect induced by correlation of outcomes (clustering) within villages. Additionally, the baseline data were analysed separately using logistic and linear regression models to examine the correlates of physical activity behaviour in rural adults. Results: Baseline study: 2415 adults completed the postal survey (response rate 37.7%). The following factors both increased the odds of meeting the recommended activity guidelines and were associated with more leisure-time physical activity: being male, in good health, greater commitment to being more active, favourable activity social norms, greater physical activity habit, and recent use of recreational facilities. In addition, there was evidence that younger age, lower body mass index, having a physical occupation, dog ownership, inconvenience of public transport, and using recreational facilities outside the local village were associated with greater reported leisure-time physical activity. Main study: 10,412 adults (4693 intervention, 5719 control) completed the postal survey (response rate 32.2%). The intervention did not increase the odds of adults meeting the physical activity guideline, although there was weak evidence of an increase in the minutes of moderate-and-vigorous-intensity activity per week. The ineffectiveness of the intervention may have been due to its low penetration—only 16% of intervention participants reported being aware of the intervention, and just 4% reported participating in intervention events. Conclusions: Baseline study: This study highlights potentially important correlates of physical activity that could be the focus of interventions targeting rural populations, and demonstrates the need to examine rural adults separately from their urban counterparts. Main study: A community-level physical activity intervention providing tailored physical activity opportunities to rural villages did not improve physical activity levels in adults. Greater penetration of such interventions needs to be achieved for them to have any chance of increasing the prevalence of physical activity at the community level.