Clinicians should not apply observational scales routinely in severely demented patients, because many are capable of reliably reporting their own pain.

Self-assessment pain scales can be used reliably in the vast majority of older hospitalized patients with mild to moderate dementia and in nearly half of those with severe dementia. Observational pain rating scales correlate only moderately with self-assessment and should be reserved for those few patients who have demonstrated that they cannot complete a self-assessment.

values are likely to be seen in intervention studies among older people, despite their being randomized, since the studies are often relatively small. However, this seems not to have been considered in the Cochrane Review for all included studies. For example in a study by Skelton et al., the effect regarding knee extensor strength, as presented in the review, was negative although the improvement from baseline to follow-up was considerably greater in the intervention group than in the control group (127% vs 13%). 2 The calculations of SMD for this study seem to be based in the review on the unadjusted outcome values at the followup and do not take into consideration the fact that baseline values were lower in the intervention group than in the control group. An alternative way of calculating the effect size is to use the change in the outcome from baseline to follow up (both the difference between groups and the standard deviation), based on estimated marginal means for the outcome at the follow-up adjusted for baseline values. 3 This approach takes into account differences between groups at baseline and variations in ability between participants. Hopefully, in future, a consensus will be reached concerning how to calculate effect sizes in randomized trials. For the present, it is recommended that effect sizes are presented but the definitions in the CONSORT statement, 4 e.g., for continuous outcome ''difference in means,'' need to be clarified to ensure that the calculation is made in the same way in all studies.

BAFTA investigators; Midlands Research Practices Network (MidRec). Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet 2007; 370: 493-503.

Résumé Le diagnostic est encore parfois annoncé à la famille plutôt qu’au patient âgé lui-même, celle-là présupposant l’incapacité de celui-ci à affronter la mauvaise nouvelle. Néanmoins, le respect de l’autonomie du patient est indispensable à la qualité d’un accompagnement en fin de vie, tant pour lui-même que pour la famille. Une situation clinique vécue lors d’une intervention auprès d’une équipe d’unité de soins interdisciplinaires gériatriques a fait émerger de nombreuses et différentes questions sur la communication et l’annonce d’une mauvaise nouvelle.