[Myasthenia in the aged: a case with unusually late onset]. / Myasthénie du sujet âgé. Un cas de révélation particulièrement tardive.

BACKGROUND: Myasthenia is an uncommon autoimmune condition that can occur at any age. Peak frequency is seen around the age of 65 years. We report a case with a particularly late onset and discuss the particular conditions of myasthenia in the elderly subject. CASE REPORT: A 97-year-old patient was hospitalized for dysphonia and dysphagia associated with exercise-induced dyspnea. The general picture suggested generalized myasthenia confirmed by the electromyography exploration and a positive anticholinesterase test. Treatment with acetylcholinesterase inhibitor was effective although cure was incomplete. Further improvement was obtained with immunosuppressor therapy using azathioprine. DISCUSSION: The clinical presentation of very late onset myasthenia differs little from that in younger subjects excepting the very high frequency of brain stem involvement in the initial presentation. Diagnosis may however be more difficult as other conditions are more easily taken to be the causal element. Thus, for the elderly patient, the real problem is to envisage the diagnosis of myasthenia. Positive diagnosis is based on the same criteria as in younger subjects. Clinicians should be aware of the possibility of myasthenia in the geriatric population as specific treatment can improve functional prognosis with satisfactory efficacy.

[Dementia syndromes and length of stay of elderly patients in internal medicine]. / Syndromes démentiels et durée de séjour des patients âgés en Médecine Interne.

Dementia is frequently observed in elderly patients admitted in Internal Medicine Units. Study of prospective data allowed comparison between 199 demented patients and 601 non demented ones, for life conditions, hospitalization parameters, way of discharge and associated diseases. Age and sex ratio are equal. Demented patients live more frequently in geriatric institutions and require more often nurse care at home. For them, social care is more frequent during hospitalization. There is no significant difference for mean duration of stay, discharge in step down unit and mortality. In both groups the predictive factors for the duration of stay are the need for social care during hospitalization and the number of comorbidities. In patients with degenerative dementia, hypertension and cardiopathies are less frequent than among other patients. These data suggest that adequate care, including social care, may produce the same duration of stay and way of discharge for demented and non demented elderly patients in Internal Medicine Units.

[Medicalization of information systems in Internal Medicine and Geriatrics: a true medical challenge]. / Médicalisation des systèmes d'information en Médecine Interne et Gériatrie: un véritable enjeu médical.

Elderly people constitute an ever growing part of short-stay hospital patients. At the moment, 25% of these patients age aged 75 or more. The demographic curve, the effect of public health policies favouring treatment at home and the new characteristics of demand for care by the oldest patients will undoubtedly result in an increasing number of these hospitalizations. This tendency has repercussions on the organization of hospital structures, but it also raises the problems of specificity of consumption of goods and medical hospital units by elderly patients and of their financing as part of budget allotments. The progressive but imperative installation, forced on us by decrees, of medicalized management tools (e.g. the Information System Medicalization Programme) in public hospitals and some private clinics throws doubt on the value of this tool to describe the stays of elderly people.

[Dementia syndrome and intercurrent pathologies in the elderly. A study of 100 patients over 75 years of age in a geriatrics internal medicine unit]. / Syndrome démentiel et pathologies intercurrentes chez les sujets âgés. Etude de 100 patients de plus de 75 ans en Unité de médecine interne gériatrique.

Elderly people with dementia are admitted in ever increasing number to Internal Medicine units for exploration of dementia and treatment of intercurrent diseases. The purpose of this prospective study of 100 demential subjects aged 75 or more (mean: 85.3 +/- 5.4 years) was to discover the cause of dementia, to investigate the associated diseases and to evaluate the effects of treatment of these pathologies on the patients' cognitive performance. The mean duration of stay in hospital was 25.5 +/- 14.5 days (extreme: 6-100 days); 69 returned home, 17 were institutionalized and 14 died. Dementia was degenerative and of the Alzheimer type (73%) with vascular lesions (24%) associated with brain tumours (2%) or normal-pressure hydrocephalus (1%). On average, 2 pathologies were associated with Alzheimer's dementia and 3.5 with dementia cum vascular brain lesions. Repeated evaluation of cognitive performance was carried out using Folster's Mini Mental Status (MMS), a global evaluation test. It showed that 18% of the patients were significantly improved while the other diseases were being treated. The hypothesis of regressive confusional elements superimposed on dementia is accepted by the authors as it fits the model of geriatric multipathology morbidity. Since there is no specific treatment for most types of dementia, particular attention must be paid to associated diseases likely to aggravate the clinical expression of dementia.

[Hospitalization in internal medicine of nonagenarians. Study of 150 cases]. / Hospitalisation en médecine interne des nonagénaires. Etude de 150 séjours.

Very elderly patients represent an increasing rate of hospitalized patients in internal medicine unit. Their admission and discharge modes, their morbidity and explaining factors for length of stay are still bad knowned. This prospective study concerns 150 patients stays, over 90, in an internal medicine and geriatric unit. Morbidity is mainly related with a high number of diagnoses (3.4 +/- 1.5). Most of them (2.8 +/- 1.3) are relevant for the hospitalization. The major categories of observed diseases are degenerative dementia, arrhythmias and adverse drug reactions. The main hospitalization mode is the non programmated one. We noted a high rate of death during hospitalization (17%). The main discharge mode is return home (88%). The length of stay among the survivals is significantly correlated (P < .001) with the number of diagnoses, the need for institutionalization and the sex. This pattern explains more than 20% of the variance of the length of stay. The data confirm the specificity of the medical care of very elderly patients. They also suggest that the french model of medicalization of the information system must be adapted to increase its pertinency among very elderly.

[Chronic enterocolopathies and SAPHO syndrome. 8 cases]. / Entérocolopathies chroniques et syndrome SAPHO. 8 observations.

In a group of 61 patients with SAPHO syndrome involving bone, 8 cases of chronic inflammatory bowel diseases have been observed. 6 cases are considered as Crohn's disease and 2 as ulcerative colitis. 5 patients presented with sacro-iliitis, 4 with palmoplantar pustulosis, 3 with plain psoriasis and 1 with disseminated acne. 4 patients have HLA B27 antigen. These findings bring some evidences to lump SAPHO syndrome with the spondylarthropathies.

[Polypathology and co-morbidity: a dynamic way for describing morbidity in aged patients. Study of 100 patients, aged 80 and over, in a short-stay geriatric internal medicine unit]. / Polypathologie et co-morbidité: un mode dynamique de description de la morbidité chez les sujets âgés. Etude de 100 patients de 80 ans et plus en Unité de Médecine Interne Gériatrique de court séjour.

Descriptive epidemiology has demonstrated the increase with age of the number of identifiable diseases per subject. However, the clinical relevance of this polypathology varies according to the type of affliction, and all pathologies are not necessarily implicated in all morbid events. This prospective study analyzed the length of hospitalization (mean stay: 17.26 +/- 10.52 days) of 100 subjects at least 80 years old (mean age: 85.2 +/- 4.35 yr). The mean total number of recognized diseases per patients was 4.12 +/- 1.83 (range: 1-10). The mean number of diseases concerned by the hospitalization studied was 3.13 +/- 1.60 (range: 1-9). Dynamic analysis of the morbidity of these patients led to their classification into two groups: a) co-morbid patients with several diseases among which interaction is not possible; and b) polymorbid patients with several diseases able to interact. In a polymorbid patient, a disease event can occur as the result of such an interaction (leading to multiple organ failure) or the evolution of a single entity. The number of diseases concerned by the hospitalization varied significantly according to the different models of morbidity, which reflect the different types of medical activity. The lengths of the hospital stay observed did not seem to be influenced by the morbidity model, thereby indicating the existence of other factors prolonging hospitalization. The data collected supported the validity of this approach to disease in the elderly whose objective is a new description of medical activity in this population.

[How to reduce iatropathology in elderly patients]. / Comment diminuer la iatropathologie chez les personnes âgées.

Adverse reactions to drugs are known to be more frequent in elderly people than in young adult subjects, but there is no doubt that they could be considerably reduced if certain rules of prescription were applied. Iatropathology is not unavoidable. The various points in prescriptions that might induce adverse reactions and the means of avoiding such reactions based on the particularities of geriatric medicine are reviewed in the article.

[Heavy gamma-chain diseases. A new case and review of the literature]. / "Maladie" des chaînes lourdes gamma. Un nouveau cas et revue de la littérature.

IgG heavy chain disease is a rare disorder in which incomplete monoclonal immunoglobulins are synthesized. We report herein a new case diagnosed in an 84 year old woman and present a review of the different descriptions available in the literature. This pathology often has an insidious onset. Its clinical and evolutive aspects are highly variable and linked to an associated disease, which has led us to emphasize the diagnostic difficulties and to discuss the nosology of this disorder.

[AIDS in elderly patients. Apropos of 22 cases observed in the Paris region]. / Le SIDA gériatrique. A propos de 22 cas observés dans la région parisienne.

If geriatric AIDS is defined as the occurrence of this disease in individuals over 60 years old, it represents about 5% of the cases reported to the Direction Générale de la Santé by the end of 1988. We retrospectively analyzed 22 clinical cases of geriatric AIDS observed between 1985 and 1987, i.e. 21% of the cases reported at that time. In 55% of them, infection resulted from contaminated blood transfusions. Initially, hospitalization was indicated due to a significant deterioration of the patient's general condition, however, neuropsychiatric disorders and intellectual degeneration were present in 18% of the cases. Biological anomalies at the time of admission were classical with the exception of a high frequency of leukopenia often associated with anemia or thrombopenia. During the evolution of the disease, opportunistic infections were very common (90% of the cases). However, the major characteristic of this clinical form of AIDS is the high percentage (55%) of patients suffering from major neurological and psychiatric disorders, including subacute encephalitis in more than half of these patients. The prognosis is very bad, with an average survival time of 4.3 months from the time of diagnosis (median 2.5 months). The cumulative effect of the delay in diagnosing AIDS during the first hospitalization and the classical seriousness of encephalitis suffice to explain the very poor prognosis in patients whose age can play a role in altering the immune response.

[Subacute infectious endocarditis in the elderly. Retrospective study of 33 cases]. / L'endocardite infectieuse subaiguë du sujet âgé. Etude rétrospective de 33 cas.

The authors reviewed 33 cases of infectious endocarditis in patients over 65 years of age and classified according to Von Reyn's diagnostic criteria. Twenty-four patients had organic valvular disease, 4 had a prosthetic valve, and in 4 cases the diagnosis of the murmur was uncertain. Positive blood cultures were obtained in 79 p. 100 of cases. The commonest infecting organism was the streptococcus (21 out of 26). In 11 patients, it was a Group D streptococcus and a recto-sigmoid colonic tumour was found in 3 cases. A dental portal of entry was suspected in 55 p. 100 of patients and this should guide the choice of prophylactic antibiotic therapy. The initial choice of antibiotic had to be changed in 19 patients, usually because of poor tolerance. Eight patients died and one underwent valve replacement within two months of hospital admission.