Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-06-19T14:02:38Z No. of bitstreams: 1 dilmersondeoliveira.pdf: 2352986 bytes, checksum: 6332b136df0076ac9534f43a017cd3f4 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-06-29T12:26:00Z (GMT) No. of bitstreams: 1 dilmersondeoliveira.pdf: 2352986 bytes, checksum: 6332b136df0076ac9534f43a017cd3f4 (MD5) / Made available in DSpace on 2017-06-29T12:26:00Z (GMT). No. of bitstreams: 1 dilmersondeoliveira.pdf: 2352986 bytes, checksum: 6332b136df0076ac9534f43a017cd3f4 (MD5) Previous issue date: 2013-03-21 / Introdução: O termo fragilidade, ao longo do tempo, vem sendo incorporado ao vocabulário de outros profissionais de saúde, além de geriatras e gerontólogos, ainda que não haja consenso em torno de sua utilização. Fragilidade pode ser sinônimo de incapacidade ou dependência para realização de atividades da vida diária, porém, recentemente, alguns autores vêm tentando padronizar sua definição, utilizando critérios para classificar esta síndrome. Anteriormente, acreditava-se que ela acometia somente idosos, mas agora é vista como algo mais complexo e que pode estar relacionada a desfechos desfavoráveis, mesmo em outras faixas etárias. Outros grupos etários vêm sendo alvo de pesquisas sobre a fragilidade, que está sendo relacionada a doenças crônicodegenerativas como: obesidade, doença renal crônica, doença pulmonar obstrutiva crônica e doenças cardiovasculares. Uma das hipóteses para a relação entre fragilidade e outras patologias, mesmo em jovens, é um desequilíbrio entre a produção de citocinas, levando à elevação de marcadores inflamatórios, além de um desequilíbrio do sistema neuroendócrino. Estas alterações levam à diminuição da massa magra com consequente sarcopenia, fraqueza muscular, exaustão e inatividade física. Sabendo que o lúpus eritematoso sistêmico (LES) tem como consequência a dor, fadiga, redução da massa óssea e o uso de imunossupressores em seu tratamento, notadamente os corticosteróides, acredita-se haver uma relação entre fragilidade e LES. O objetivo do presente estudo foi avaliar a prevalência, fatores clínicos, laboratoriais e a qualidade de vida (QV), associados à fragilidade nesta população. Pacientes e Métodos: Realizamos um estudo transversal, onde foram considerados elegíveis todos os pacientes atendidos pelo ambulatório de reumatologia do Hospital Universitário da Universidade Federal de Juiz de Fora. Os critérios de inclusão foram: pacientes com mais de 18 anos de idade com LES diagnosticado de acordo com os critérios estabelecidos pelo Colégio Americano de Reumatologia, ter idade mínima de 18 anos e ter assinado o termo de consentimento livre e esclarecido. Os critérios de não inclusão foram: pacientes sintomáticas do ponto de vista osteomioarticular, grávidas, com diabetes mellitus, doenças auto-imunes, doenças infecciosas agudas, hepatites virais B e C e SIDA. O Grupo Controle foi constituído por indivíduos saudáveis, pareados por idade, sexo e índice de massa corpórea (IMC) Avaliadas variáveis sociodemográficas, clínicas, atividade da doença (SLEDAI) e laboratoriais. Fragilidade foi avaliada segundo critério adaptado do proposto por FRIED. Análise Estatística: Foi realizada uma estatística descritiva, a normalidade foi avaliada pelo teste de Shapiro Wilk e as variáveis são descritas como média ± desvio padrão ou percentagem conforme a característica da variável. As variáveis do grupo paciente e do grupo controle foram comparadas através do Teste T de Student ou χ2. A comparação entre os grupos classificados como frágeis, pré frágeis e não frágeis foram realizadas através de ANOVA ou χ2. A associação de fatores clínicos, laboratoriais e síndrome da fragilidade foram feitas através da correlação de Pearson ou Spearmman. Foi calculado o odds ratio para fragilidade entre os grupos e adotado intervalo de confiança igual a 95% (p≤0,05). Todas as análises foram realizadas com a utilização do pacote estatístico SPSS versão 15.0. Resultados: Foram avaliadas 33 pacientes e 26 controles. A prevalência de fragilidade foi de 7 (21%) no grupo de pacientes e 0 (0%) no grupo controle, com um OR (15,0; IC: 0,81 a 276,16, p= 0,068). Observamos ainda correlação entre fragilidade IMC (p= 0,01, r= -0, 041), SLEDAI (p= 0,01, r= 0,44), dose de corticóide (p= 0,001, r= 0,56) e número de imunossupressores (p= 0,03, r= 0,37). Dentre as variáveis laboratoriais houve correlação entre fragilidade e hemoglobina sérica (p= 0,001, r= -0,56), globulina sérica (p= 0,04, r= 0,35), VHS (p= 0,005, r= 0,47), PCR (p= 0,03, r= 0,37) e IL6 (p= 0,01, r= 0,43) e tendência com cálcio sérico (p= 0,06, r= -0,036) e FAN (p=0,08, r= 0,30). Ao avaliarmos os domínios do SF-36 e a classificação de Fragilidade nos pacientes com LES, percebemos que apenas do Estado Geral de saúde foi estatisticamente significativo (p= 0,001), enquanto Dor e Vitalidade apresentaram tendência com os valores (p= 0,073) e (p= 0,09). Em relação à composição corporal, observamos que os pacientes com LES e frágeis apresentaram maior média de massa magra com menor massa gorda comparados a outros grupos: IMC não frágil: 30,38 Kg/m2, pré-frágil 27,76 Kg/m2 e frágil 21,70 Kg/m2 (p= 0,049), percentual de gordura não frágil: 39,56%, pré-frágil 39,57% e frágil 30,01% (p= 0,009), percentual de massa magra não frágil: 55,12%, pré-frágil 55,64% e frágil 65,56% (p= 0,008), DMO Lombar não frágil: 1,32 g/cm2, pré-frágil 1,06 g/cm2 e frágil 1,07 g/cm2 (p= 0,057). Conclusão: Concluímos que houve uma maior prevalência da Síndrome da fragilidade entre pacientes que em controles (7 (21,21%) entre pacientes e 0 (0%) entre controles), associada principalmente a marcadores inflamatórios (VHS, p=0,011; PCR, p= 0,053 e IL-6, p=0,041). A avaliação da Fragilidade permitiu ainda nesta amostra, uma visão mais ampla do paciente que a avaliação dos domínios da qualidade de vida propostos pelo SF-36 isoladamente. Sobre a composição corporal vale ressaltar que nossos achadoses não corroboram com os vistos anteriormente na literatura. Contudo destacamos a baixa representatividade da amostra para avaliar este parâmetro e a necessidade de um delineamento de estudo prospectivo para acompanhamento dos possíveis desfechos. / Introduction: The term frailty, over time, has been used into the vocabulary of other health professionals, as well as geriatricians and gerontologists, although there is no consensus on its use. Frailty can be synonymous with disability or dependence in activities of daily life, but recently, some authors have attempted to standardize its definition, using criteria to classify this syndrome. Previously, it was believed that she attacked solely elderly, but is now seen as something more complex and may be related to unfavorable outcomes, even in other age groups. Other age groups have been the target of research about the frailty, being related to chronic diseases such as obesity, chronic kidney disease, chronic obstructive pulmonary disease and cardiovascular disease. One hypothesis for the relationship between frailty and other diseases, even in young people, is an imbalance between the production of cytokines, leading to elevation of inflammatory markers, as well as an imbalance in the neuroendocrine system. These changes lead to a decrease in lean body mass with consequent sarcopenia, muscle weakness, exhaustion and physical inactivity. Knowing that lupus erythematosus (SLE) has the effect of pain, fatigue, bone loss and the use of immunosuppressive drugs in their treatment, especially corticosteroids, is believed to be a relationship between fragility and LES. The aim of this study was to evaluate the prevalence, clinical, laboratory and quality of life (QOL), associated with frailty in this population. Patients and Methods: We performed a cross-sectional study, which were all eligible patients seen by rheumatology clinic of the University Hospital of the Juiz de Fora Federal University. Inclusion criteria were: patients older than 18 years diagnosed with SLE according to the criteria established by the American College of Rheumatology and have signed the informed consent form. The inclusion criteria were: symptomatic patients from the standpoint osteomioarticular, pregnant women with diabetes mellitus, other autoimmune diseases, acute infectious diseases, viral hepatitis B and C and AIDS. The control group consisted of healthy subjects, matched for age, sex and body mass index (BMI). Sociodemographic, clinical and laboratory data as well as disease activity (SLEDAI) were collected from medical records. Frailty was assessed according to criteria adapted by Fried. Statistical analysis: We performed descriptive statistics, normality was evaluated by Shapiro and Wilk. Variables were described as mean ± standard deviation or percentage as the characteristic of each variable. The variables in the patient group and the control group were compared using the Student T test or χ2. The comparison between groups classified as frail, pre frail and non-frail were performed using ANOVA or χ2. The correlation of clinical, laboratory data and frailty syndrome were made by Pearson or Spearmman correlation. We calculated the odds ratio for frailty among groups and adopted the confidence interval equal to 95% (p ≤ .05). All analyzes were performed using the statistical package SPSS version 15.0. Results: We evaluated 33 patients and 26 controls. The prevalence of frailty was 7 (21%) in the group of patients and 0 (0%) in the control group, with a confidence interval (15.0). We also observed weak correlation between BMI (p = 0.01, r = -0, 041), SLEDAI (p = 0.01, r = 0.44), corticosteroid dose (p = 0.001, r = 0.56) and the number of immunosuppressants (p = 0.03, r = 0.37). Among the laboratory variables correlation between frailty and hemoglobin (p = 0.001, r = -0.56), serum globulin (p = 0.04, r = 0.35), ESR (p = 0.005, r = 0.47), CRP (p = 0.03, r = 0.37), IL6 ( p = 0.01, r = 0.43) and tendency related to serum calcium (p = 0.06, r = -0.036) and ANA (p = 0.08, r = 0.30). When evaluating the SF-36 and the classification of Frailty in SLE patients, we realized that only the State General health was statistically significant (p = 0.001), while Pain and Vitality tended to values (p = 0.073) and ( p = 0.090). Regarding body composition, we observed that patients with SLE and frail had higher average lean mass with less body fat compared to other groups: BMI not fragile: 30.38 kg/m2, pre-frail and 27.76 kg/m2 fragile 21.70 kg/m2 (p = 0.049), body fat percentage is not fragile: 39.56%, 39.57% pre-frail and frail 30.01% (p = 0.009), percent lean mass not fragile: 55.12%, 55.64% pre-frail and frail 65.56% (p = 0.008). Conclusion: We conclude that there was a higher prevalence of frailty syndrome in patients than in controls (0 (0%) among controls and 7 (21.21%) among patients), mainly associated with inflammatory markers (VHS, p = 0.011, PCR, p = 0.053 and IL-6, p = 0.041). The evaluation of this sample also allowed Frailty, a broader patient's assessment of the areas proposed in quality of life by SF-36 alone. About the data on body composition is noteworthy that these do not corroborate those seen previously in the literature. However we emphasize the low representativeness of the sample to evaluate this parameter and the need for a randomized prospective study to monitor the possible outcomes.

La fragilité augmente dans le monde à cause de l’augmentation de la population âgée faisant passer l’être humain de l’autonomie à la dépendance. La détection précoce de la fragilité et le repérage des personnes à risque durant la phase de réversibilité de la fragilité permet d’engager rapidement des actions correctives. Le phénotype de Fried est l’outil le plus répandu pour l’identification de la personne fragile suivant cinq paramètres (vitesse de la marche, activité physique, perte de poids, fatigue et force de préhension palmaire). Un autre moyen de détection de la fragilité est d’évaluer la diminution de la complexité dans les signaux physiologiques. Cette diminution est traduite par la diminution de la corrélation à long terme dans les signaux physiologiques. Cependant, aucune approche ne permet d’alimenter ces indicateurs au domicile sans intervention d’un professionnel de santé. L’objectif de cette thèse est de contribuer à la définition d’un dispositif de mesure technologique, simple à utiliser et totalement intuitif, visant à alimenter deux indicateurs de Fried dans un environnement non contrôlé et détecter le signal de la marche sur une longue durée permettant la détection du changement dans la complexité du signal : le smartphone équipé d’un accéléromètre triaxial permet de mesurer l’activité physique et l’intervalle entre stride et stride qui est un outil important pour calculer la longueur de chaque pas, la vitesse de la marche et la variabilité dans le signal de la marche. Une stride est définit comme le temps entre le premier contact du talon avec le sol et le prochain contact de ce même talon / The frailty around the world is increasing because of the increase in the elderly population passing the human being from autonomy to dependence. Early detection of frailty and identification of individuals at risk during the reversibility phase of frailty provides quick initiations of corrective actions. The Fried phenotype is the most common tool for the identification of the fragile person using these five parameters (walking speed, physical activity, weight loss, fatigue and palmar grip strength). Another mean of the detection of frailty occurs in the reduction of the complexity in the physiological signals. The reduction in complexity is reflected in the decrement of the long-term correlation in temporal physiological signals. But for now, neither approach provides to supply to these indicators at home without the intervention of a health professional. The objective of this thesis is to contribute a technological measuring device, simple to use and totally intuitive to supply a few Fried indicators in an uncontrolled environment and detect the signal of walking for a long time allowing the detection of any change the complexity of the signal: the smartphone equipped with a tri axial accelerometer is used to measure the physical activity and the interval between stride and stride which is an important tool to calculate the length of each step, the walking speed and the variability in the signal of the step. A stride is defined as the time between the first contact of the heel with the ground and the next contact of the same heel

Ce travail a eu pour objectif de proposer des modèles conjoints d'intensités de processus d'événements récurrents et d'un événement terminal dépendant. Nous montrons que l'analyse séparée de ces événements conduit à des biais d'estimation importants. C'est pourquoi il est nécessaire de prendre en compte les dépendances entre les différents événements d'intérêt. Nous avons choisi de modéliser ces dépendances en introduisant des effets aléatoires (ou fragilités) et de travailler sur la structure de dépendance. Ces effets aléatoires prennent en compte les dépendances entre événements, les dépendances inter-récurrences et l'hétérogénéité non-observée. Nous avons, en premier lieu, développé un modèle conjoint à fragilités pour un type d'événement récurrent et un événement terminal dépendant en introduisant deux effets aléatoires indépendants pour prendre en compte et distinguer la dépendance inter-récurrences et celle entre les risques d'événements récurrents et terminal. Ce modèle a été ajusté pour des données de patients atteints de lymphome folliculaire où les événements d'intérêt sont les rechutes et le décès. Le second modèle développé permet de modéliser conjointement deux types d'événements récurrents et un événement terminal dépendant en introduisant deux effets aléatoires corrélés et deux paramètres de flexibilités. Ce modèle s'avère adapté pour l'analyse des risques de récidives locorégionales, de récidives métastatiques et de décès chez des patientes atteintes de cancer du sein. Nous confirmons ainsi que le décès est lié aux récidives métastatiques mais pas aux récidives locorégionales tandis que les deux types de récidives sont liés. Cependant ces approches font l'hypothèse de proportionnalité des intensités conditionnellement aux fragilités, que nous allons tenter d'assouplir. Dans un troisième travail, nous proposons de modéliser un effet potentiellement dépendant du temps des covariables en utilisant des fonctions B-Splines. / This work aimed to propose joint models for recurrent events and a dependent terminal event. We show how separate analyses of these events could lead to important biases. That is why it seems necessary to take into account the dependencies between events of interest. We choose to model these dependencies through random effects (or frailties) and work on the dependence structure. These random effects account for dependencies between events, inter-dependence recurrences and unobserved heterogeneity. We first have developed a joint frailty model for one type of recurrent events and a dependent terminal event with two independent random effects to take into account and distinguish the inter-recurrence dependence and between recurrent events and terminal event. This model was applied to follicular lymphoma patient’s data where events of interest are relapses and death. The second proposed model is used to model jointly two types of recurrent events and a dependent terminal event by introducing two correlated random effects and two flexible parameters. This model is suitable for analysis of locoregional recurrences, metastatic recurrences and death for breast cancer patients. It confirms that the death is related to metastatic recurrence but not locoregional recurrence while both types of recurrences are related. However, these approaches do the assumption of proportional intensities conditionally on frailties, which we want to relax. In a third study, we propose to model potentially time-dependent regression coefficient using B-splines functions.

Objectives: The aim of this non-interventional observational study was to determine the prevalence of frailty in a cohort of 200 elderly patients and its correlation and dependence in relation to nutritional status and to evaluate the correlation of the items in the MNA - SF and SPPB test batteries and determine whether the weight loss is related to poor results in the evaluation of geriatric frailty, and to evaluate whether cognitive function affects nutritional status and if nutritional status in such circumstances affects subjects' self- sufficiency. Methods: Data was sourced from the results of standardized tests in Comprehensive Geriatric, Assessment, CGA at the 1. LF UK Geriatric Clinic, which include the assessment of selfsufficiency (ADL) and condition (SPPB), cognitive functions (MMSE) and the assessment of nutritional status (MNA - SF). Patients were also measured for bodyweight, height and BMI. Results: The study included a total of 200 patients, of whom 46 (23%) were men and 154 women (77%). Geriatric frailty was diagnosed in 59.5% of patients, with 21.5% of patients being classified as "pre-frailty" and 19 % of good physical condition. In this group 15.5% of patients were malnourished, 37.5% were at risk of malnutrition and 47 % were in a good nutritional condition. A statistically...

The post-2007 global financial crisis, characterised by huge firm losses, especially in the USA and Europe, initiated a new strand of literature, where default models are adjusted for unobserved risk factors, including measurement errors, missing firm specific and macroeconomic variables. These new models assume that default correlations are not only driven by observable firm-specific and macroeconomic factors, but also by unobserved risk factors. This thesis present three empirical essays. The first essay estimates and predicts the within-sector failure rate and dependence of firms on the London Stock Exchange. The study offers an additive lognormal frailty model that accounts for both unobserved factors and regime changes. The analysis reveals that during distressed market periods the sector-based failure rates and dependencies tend to be high. The second essay proposes a novel approach based on a bias-corrected estimator to investigate the impact of informative firm censoring and unobserved factors on hazard rates of US firms. The approach uses inverse probability of censoring weighted scheme that explicitly accounts for firm specific factors, economic cycles, industry-level dependence and market activities induced by unobservable factors. The analysis shows that during distressed market periods the effect of informative censoring averagely increases the hazards rates, and varies across industries. The third essay employs a mixed effects Cox model to estimate the failure dependence caused by firms’ exposure to country-based and group-level unobserved factors within the Eurozone. The empirical results show that a higher failure dependence among firms in groups of countries with similar economic and financial conditions than countries with different conditions. Overall, the thesis contributes to the empirical literature on firm default in the broad area of corporate finance by offering a different approach of capturing default dependence and its variations during unfavourable market conditions and adjusting for the effects of non-default firm exit on active firms.

La « fragilité » fait référence à un état de forte vulnérabilité qui résulte d’une réduction des réserves adaptatives de multiples systèmes biologiques et physiologiques sous l’action conjuguée de l’âge, de maladies et du contexte de la vie. Ce syndrome accroit la vulnérabilité de l’individu ainsi que son risque de dépendance, de chutes, d’hospitalisations, d’entrée en institution et de mortalité. La définition la plus utilisée, celle de Fried et collaborateurs, est basée sur la prise en compte d’éléments exclusivement physiques mais la possibilité d’inclure à cette définition d’autres composantes non-physiques, parmi lesquelles la cognition, est actuellement débattue. Cette thèse aborde donc la question d’un point de vue épidémiologique du possible lien entre l’altération des performances cognitives et la fragilité grâce aux données de deux études en population, une cohorte française et une cohorte mexicaine. Les résultats présentés dans cette thèse nous permettent d’affirmer l’existence d’une association entre la fragilité et un déficit cognitif. Qu’il s’agisse de la cohorte de Coyoacan ou des 3 Cités, les deux premières études de cette thèse ont montré une force d’association majorée sur l’incidence d’incapacité, d’hospitalisation ou de décès lorsqu’on considère la fragilité et le déficit cognitif de manière combinée, un résultat plaidant en faveur de l’intégration de la mesure de la cognition dans la définition de la fragilité. Concernant le risque de survenue de démence en revanche, la troisième étude ne montre pas d’effet majoré lorsque ces deux conditions étaient présentes puisque seuls les participants ayant un déficit cognitif étaient à risque de démence, indépendamment de leur statut de fragilité. Enfin, si la fragilité ne constituait pas un risque en soi de démence tous types confondus, la dernière étude de cette thèse a montré une forte association entre l’état de fragilité et le risque de démence vasculaire. Les résultats de cette thèse, ajoutés aux données de la littérature décrivant la présence d’atteintes vasculaires et cérébro-vasculaires dans le syndrome de fragilité, nous ont conduits à formuler l’hypothèse selon laquelle la fragilité pourrait être un état prodromique de démence vasculaire. / “Frailty” is a clinical syndrome characterized by physiological loss of reserves and resilience and represents the summatory action of age, disease and living environment. This geriatric syndrome increases the vulnerability of elderly persons and their risk of disability, falls, hospitalization, institutionalization, and mortality. The definition most widely used, the one proposed by Fried and collaborators, only includes physical elements. Nonetheless, the inclusion of other non-physical components, in particular cognitive function is currently debated. Therefore, the aim of this thesis was the study, from an epidemiological point of view, of the association between cognitive function and frailty using the data of two population-based studies, a French cohort and a Mexican one. The results are in favor of the existence of an association between frailty and cognitive impairment. In the first two studies presented in this thesis, an increased risk of incident disability, hospitalization, and death was found. Therefore, including cognitive function in the phenotype of frailty may be relevant since both processes seem to contribute to the development of negative health-related outcomes. However, regarding the risk of dementia, the results of the third study show that only elderly subjects with cognitive impairment have an increased risk of developing dementia irrespective of their frailty status. Nevertheless, if frailty per se may not be a risk factor of dementia, all types confounded, the last study evidences a strong association between frailty and the incidence of vascular dementia. Such results along with previous studies reporting the existence of vascular and cerebrovascular damage in frail elderly lead us to postulate that frailty could be a prodromal state of vascular dementia.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-01-07T16:36:26Z No. of bitstreams: 1 angelabeatrizcheinferes.pdf: 3287320 bytes, checksum: 92a5e582c5476a0f267c066edf8eb2ed (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-01-25T16:50:19Z (GMT) No. of bitstreams: 1 angelabeatrizcheinferes.pdf: 3287320 bytes, checksum: 92a5e582c5476a0f267c066edf8eb2ed (MD5) / Made available in DSpace on 2016-01-25T16:50:19Z (GMT). No. of bitstreams: 1 angelabeatrizcheinferes.pdf: 3287320 bytes, checksum: 92a5e582c5476a0f267c066edf8eb2ed (MD5) Previous issue date: 2015-02-03 / CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / O envelhecimento populacional traz consigo a importância de estudos relativos aos idosos, como é o caso da fragilidade e dos sintomas depressivos. Em vista dos estudos internacionais que já evidenciarem a associação entre fragilidade e depressão e a escassez de estudos brasileiros sobre o assunto, o objetivo deste estudo é quantificar esta associação em idosos não institucionalizados com uma metanálise de estudos observacionais selecionados por uma revisão sistemática, além de uma análise dos dados coletados em uma amostra representativa de idosos de Juiz de Fora - MG. Na revisão sistemática, as pesquisas nas bases de dados foram realizadas em Dezembro de 2012 e em Fevereiro de 2014. A partir de 33 artigos selecionados, 26 permitiram metanálise, evidenciando a associação, com um Odds Ratio combinado de 2.8 (IC 2,4; 3,2) de sintomas depressivos em relação à fragilidade, apesar da grande heterogeneidade entre os estudos. Nos estudos transversais observa-se moderado grau de concordância nos resultados, e isso se repete nos dados analisados dos dados de Juiz de Fora, em que os sintomas depressivos aparecem mais frequentemente nos sujeitos frágeis, entretanto, estes estudos não podem estabelecer a relação causa-efeito. / Aging of population demands the relevance of studies on the elderly, such as frailty and depressive symptoms. Considering international researches demonstrating the association between frailty and depression, and highlighting the lack of Brazilian studies in this field, this research is relevant in order to assess the relation between frailty and depressive symptoms. This study aims to quantify the relation between frailty and depression in non-institutionalized elderly by applying a meta-analysis of observational studies selected from a systematic review besides data collected from a representative sample of elderly in Juiz de Fora (MG). In the systematic review, the researches in database were held on December 2012 and on February 2014. From 33 selected articles, 26 had presented the measure of interest or information that enabled the estimative and indicate a positive association with a combined Odds Ratio of 2.8 (CI 2.4, 3.2) of depressive symptoms in relation to the frailty, despite the considerable heterogeneity between studies. In the cross-sectional studies, were observed convergence in the results in which depressive symptoms appear more frequently in frail people, although these studies cannot establish the cause-effect relationship between variables. The same were revealed from the analysis over collect data in Juiz de Fora.

No description available.

INTRODUCTION : La majorité des cancers survient chez la personne âgée. Cette population est hétérogène du fait de la prévalence de comorbidités, d’incapacités et de syndromes gériatriques contribuant à la fragilité. Ces éléments rendent complexe le choix de la stratégie thérapeutique à adopter. L’évaluation gériatrique approfondie (EGA) est recommandée pour évaluer la fragilité de ces patients. L’objectif général était d’identifier parmi les patients âgés de 70 ans et plus atteints de cancer, ceux qui présentaient un haut risque de morbi-mortalité afin de limiter les thérapeutiques agressives et proposer une prise en charge adaptée. Les objectifs spécifiques étaient : 1/d’identifier les facteurs oncologiques et paramètres de l’EGA conjointement associés au décès à 1 an, 2/d’identifier des profils de santé et de les valider sur la morbi-mortalité, 3/ d’évaluer la concordance entre 4 classifications de fragilité et de comparer leurs performances pronostiques. METHODES : ces travaux ont été réalisés à partir de la cohorte dynamique prospective ELCAPA (Elderly CAncer PAtient) qui inclut consécutivement tous les patients âgés de 70 ans et plus, avec un diagnostic de cancer solide ou hématologique et adressés en consultation d’oncogériatrie, dans 2 centres hospitalo-universitaires parisiens. Entre 2007 et 2012, 1 021 patients ont été inclus. Les critères de jugements étaient la mortalité globale à 1 an, les hospitalisations non programmées à 6 mois et la décision finale de traitement (curative, palliative). Nous avons analysé les facteurs associés au décès à 1 an de 993 patients à l’aide de modèles de Cox. Nous avons ensuite réalisé une analyse en classes latentes (ACL) sur cas-complets (n=821), avec analyses de sensibilité incluant les données manquantes (n= 1 021), puis selon le statut métastatique et validé cette typologie sur 375 nouveaux patients inclus dans la cohorte. La dernière étude a été réalisée sur 763 patients avec données complètes pour 4 classifications étudiées à l’aide de modèles de Cox (décès) et régression logistique (hospitalisations).RESULTATS: L’âge moyen était de 80,2 ans, 51,2% étaient des hommes, 21,4% avaient un cancer colorectal et 45% des métastases. Le nombre de comorbidités sévères (P≤0,05), la dénutrition (P<0,001), l’âge >80 ans (P≤0,05), le site tumoral et statut métastatique (P<0,001) étaient associés au décès à 1 an indépendamment de la perte d’autonomie (ADL ou PS) et de l’altération de la mobilité (GUG) (P<0,001). L’ACL nous a permis d’identifier 4 profils: ceux relativement en bonne santé [LC1, 28,3%], dénutris [LC2, 35,8%], avec troubles cognitifs et humeur [LC3, 15,1%] et globalement altérés [LC4, 20,8%]. Les comparaisons 2 à 2 ajustées montraient que les patients LC2, LC3 et LC4 avaient un risque de décès, d’hospitalisations et de décision palliative plus élevé que les LC1. Les patients LC4 avaient un risque de décès et de décision de traitement palliatif plus élevé que les patients LC2 et LC3. Aucune différence entre les LC2, LC3 et LC4 n’était observée pour les hospitalisations. La distribution des patients variait selon les 4 classifications, i.e., la typologie en classes latentes, la classification de Balducci, et les classifications SIOG 1 et 2 (P<0,001). La concordance entre ces 4 classifications était globalement faible à modérée. Pour le décès, la discrimination était bonne pour les 4 modèles (C≥0,70) avec des performances légèrement supérieures pour la classification SIOG 1. Pour les hospitalisations, les performances de ces 4 classifications étaient bonnes et similaires (C≥0,70). Aucune classification n’a montré de meilleures performances pour l’ensemble des cancers les plus fréquents. CONCLUSIONS : Nous avons montré l’utilité de l’EGA notamment de certains paramètres pour identifier parmi les patients âgés atteints de cancer, ceux qui sont « fragiles ». Des études sont nécessaires pour évaluer l’impact de l’EGA sur la morbi-mortalité et la qualité de vie de ces patients. / INTRODUCTION: The majority of cancers are diagnosed in the elderly. This population is heterogeneous due to the prevalence of comorbidities, disability and geriatric syndromes that contribute to frailty. These elements make the decision complex as well as the choice of the optimal therapeutic strategy. Geriatric assessment (GA) is recommended to assess frailty in older patients with cancer. The aim of this thesis was to identify among patients aged ≥70 years who had solid or hematologic malignancies, those with a higher risk of morbidity and mortality, to limit aggressive treatments, and improve their management. Specific objectives were : 1/ to identify both cancer-related factors and CGA findings associated with 1-year mortality, 2/ to identify health profiles based and validate these profiles on morbimortality, and 3/ to compare agreement among four frailty classifications based on GA findings and to compare their performance in predicting 1-year overall mortality and 6-month unscheduled admissions.METHODS: These various works were carried out from the prospective ELCAPA (ELderly CAncer PAtient) cohort study that includes consecutive patients aged 70 years or older who had newly diagnosed solid or hematologic malignancies and were referred to two geriatric oncology clinics in teaching hospitals in the Paris urban area, France. Between 2007 and 2012, 1021 patients were included. The primary outcomes included 1-year overall mortality, 6-month unscheduled hospitalizations, and the final planned treatment decision (curative, palliative). We assessed factors associated with 1-year overall mortality among 993 patients using Cox models. Then, we performed a complete-cases latent class analysis (LCA, n=821) with the following sensitive analyses: among patients with missing data (n=1 021), according to metastatic status, and then validating our typology in a different patient sample of the ELCAPA cohort (n=375). Finally, the last study included 763 patients with complete data for the 4 studied classifications using Cox models (mortality) and logistic regression models (hospitalizations).RESULTS: Mean age was 80.2 years, 51.2% were male, 21.4% had a colorectal cancer and 45% a metastatic disease. A higher number of severe comorbidities (P<0.05), malnutrition (P<0.001), age >80 years (P<0.05), tumor site and metastatic status (P<0.001) were associated with death independently from impaired ECOG-PS (P<0.001), ADL (P<0.001), and GUG (P<0.001). LCA displayed 4 health profiles: those relatively healthy [LC1, 28.3%], malnourished [LC2, 35.8%], with cognitive and/or mood impairments [LC3, 15.1%], and gloablly impaired [LC4, 20 8%]. In adjusted pairwise comparisons, compared to LC1, the three other LCs were associated with higher risks of palliative treatment, death, and unplanned admission. LC4 was associated with 1-year mortality and palliative treatment compared to LC2 and LC3. For unplanned admissions, no differences were demonstrated across these three LCs. Patient distribution differed significantly across the four classifications, i.e., Latent class Typology, Balducci, SIOG1 and SIOG2 (P<0.001). Agreement between these four classifications was globally poor to moderate. For mortality, discrimination was good for the 4 models (C-index ≥0.70) with slightly better performance for SIOG 1-model. For hospitalizations, performance was good and close between the four models (C-index ≥0.70). None of the four classifications performed best for all the three tumor sites.CONCLUSIONS: We showed the usefulness of GA and especially some GA-parameters to identify among older patients, those who are frail. Intervention studies are needed to assess the impact of GA on morbi-mortality and quality of life of those patients.

Background: Geriatric impairments and obstructive sleep apnea (OSA) are prevalent among patients with atrial fibrillation (AF) and adversely impact patient’s long-term outcomes. Little is known, however, about the association between OSA and frailty, cognitive performance, and AF-related quality of life in older men and women with AF. Objective: To examine the association of OSA with frailty, cognitive performance, and AF- related quality of life among older adults with AF. Methods: Data from the Systemic Assessment of Geriatrics Elements-AF study were used which includes participants ≥ 65 years with AF and a CHA2DS2-VASc ≥ 2. Multivariable adjusted logistic regression models were used to examine the association between OSA, as measured by the STOP-BANG questionnaire, and geriatric impairments including frailty, cognitive performance, and AF-related quality of life. Results: A total of 970 participants with AF (mean age 75 years, 51% male) were included in the analysis. Among the 680 participants without a medical history of OSA, 179 (26%) participants had low risk of OSA, 360 (53%) had an intermediate risk, and 141 participants (21%) had a high risk for OSA. Compared to those with low risk of OSA, those at intermediate or high risk for OSA were significantly more likely to be frail (aOR= 1.66, 95% CI: 1.08–2.56; aOR= 3.00, 95% CI: 1.69-5.32, respectively) after adjusting for sociodemographic, clinical, and health behavioral variables. Risk of OSA was not associated with cognitive performance and AF- related quality of life after adjusting for several potentially confounding factors. Conclusions: Older adults with AF who are at intermediate or high risk for OSA have a greater likelihood of being frail. Our findings identify a group of patients at high risk who would benefit from early screening for OSA. Future longitudinal studies are needed to assess the effect of OSA treatment on frailty, physical functioning, and QoL among patients with AF.