Ethical dilemma for healthcare professionals facing elderly dementia patients during the COVID-19 pandemic.

The management of elderly patients with dementia and COVID-19 infections without access to an intensive care unit gives rise to serious ethical conflicts. Therapeutic decisions have been made in psychogeriatric units, leaving a heavy moral burden on staff. They had to deal with the most difficult patients without the support of appropriate guidelines. The gap between established rules and hospital reality led to psychological distress and burnout. Managing uncertainty in medical decisions is a skill that doctors and staff learn through experience. However, with the COVID-19 pandemic, uncertainty about patient outcomes seems no longer acceptable. Geriatric triage has challenged professional conscience, emotions and values. The principle of distributive justice, which consists of giving each person in society what is rightfully his or hers, is not being respected during this pandemic. Charity has been reduced to patient survival. Staffs need to make decisions together, and it is important to allow all carers access to a space for reflection. In our unit, the involvement of nurses and care assistants in the decision-making process for patient care is crucial especially for refusal of care. Their view of the patient's condition is different from that of the doctors, as they provide daily care to the patient and stay in the wards for several hours with them. By including as many people as possible in the reflection, we could avoid moral or personal prejudices related to these difficult decisions. The current pandemic can give new meaning to team thinking, giving everyone a voice without hierarchical barriers. With these new waves of COVID-19, we need to rethink our therapeutic conduct for elderly patients with dementia to avoid ethical failure.

Effectiveness of multidisciplinary consultation for older adults with Alzheimer's disease in response to acute situations.

BACKGROUND: To avoid emergency hospitalisation of elderly people with dementia, which often has negative consequences, there are two main approaches: consultation and day care hospitalisation. However, it usually takes some time to arrange a consultation, and geriatric day hospital facilities are over-subscribed and costly. In 2014, we created a "consultation de crise" (CMC) programme in our sector of Paris, with several special features: a short wait for an appointment, a consultation involving an interdisciplinary team, a weekly multi-disciplinary meeting to reassess complex patients, and the possibility of a rapid referral to a social worker. METHODS: To determine whether the CMC programme is a useful way to minimise hospitalization among elderly community-dwelling populations, and to examine its design criteria. Retrospective review of all CMC requests from April 2014 to January 2017 in comparison with consultation at the Memory Center and geriatric day hospital. CMC patients were followed up at one month after their assessment. RESULTS: Mini Mental Status and Neuro Psychiatric Inventory vary significantly different between the 3 groups. The CMC group had the lowest score on the MMSE scale and the highest for NPI. After one month, 60% of CMC patients were still at home (33 patients) or in the same nursing home (6 patients) and about 23% were hospitalized during the follow-up period. CONCLUSION: Our study showed the potential value of a less expensive multidisciplinary consultation, and confirmed that collaborative care resulted in a significant improvement in the quality of care.

Factors influencing time between onset of signs/symptoms and referral for dementia in elderly outpatients.

BACKGROUND: The few studies that have focused on Time between Onset of Signs and Symptoms and Referral (TOSR) for dementia to a memory center suggest a substantial delay of 1-3 years. This delay has a negative impact on both patients' and their caregivers' quality of life. OBJECTIVE: This study aimed to evaluate this delay and the factors associated with it in a cohort of community-dwelling elderly people attending a memory clinic, as well as assess the impact of the Third French National Alzheimer Plan (2008-2012). METHODS: All patients referred to the Bretonneau Memory Clinic for the first time between January 2006 (the clinic has maintained a specific database since then) and March 2016 were included in the study. RESULTS: Of the 8543 patients attending our Memory Clinic during the study period, 3353 attending for the first time and with complete data were included. Briefly, their ages were 82±7 years, and 67.2% were female; MMSE score was 21.2±6.6, IADL was 4.06±0.78 and the social-needs category of the Groupes Iso Ressources (GIR); Iso-Resource Group (IRG) scale was 4.04±0.37. The TOSR was, on average, 35.4±30.24 months, and increased after implementation of the Third French National Alzheimer Plan, from 26.68±26.28 months before 2009 to 40.08±31.2 months after 2009. Age and MMSE were associated with TOSR, but not the type of dementia, household composition and social characteristics. Also, there was a shorter TOSR for mild cognitive impairment than for dementia patients. CONCLUSION: Our results emphasize the need for more education and information among the general public about the early signs of cognitive impairment, especially in elderly people.

[Neuropsychological benefit of cataract surgery among sight impaired Alzheimer's patient]. / Modifications des troubles du comportement après l'opération de la cataracte chez les patients Alzheimer.

PURPOSE: Evaluation of neuropsychological benefits of cataract surgery for 46 Alzheimer patients on the basis of neuropsychiatric index (NPI), as the principal criterion of analysis of the VIVA study. METHODS: Prospective, monocentric neuropsychiatric study, performed from 2005 to 2011. All Alzheimer's patients with 10

Evaluation of visual recognition memory for the early diagnosis of Alzheimer's disease in patients over 75 years.

INTRODUCTION: Current diagnostic criteria of Alzheimer Disease (AD) are mainly based on clinical definition. In France, the Delayed Matching Sample (DMS48) test, a recently introduced test that explores visual object recognition, is recommended for the early diagnosis of AD. However, little is known on the DMS48 performances of older subjects over 75 years. Therefore, our aim was to assess its specific clinical value for early detection of AD in older patients. METHOD: We studied 93 consecutive patients over 75 years from an expert memory clinic in a geriatric hospital. This population included 31 patients with single domain amnestic Mild Cognitive Impairment (aMCI), 31 AD patients and 31 controls subjects. RESULTS AND DISCUSSION: The aMCI and AD performances on the DMS48 were significantly lower than those of the control subjects (set 1 and set 2, P<10(-7)). The DMS48 performances in the healthy group appeared closely related to the previously published normative data. However, the DMS48 performances appeared unexpectedly high in these older patients, especially in the AD subgroup (set 1, 82.2±12.1 and set 2, 75.2±16.2). Moreover, there was an unexpected frequent discordance between the results on the DMS48 and the Free and Cued Selective Reminding tests (FCSR). The DMS test appears useful for highlighting the heterogeneity of the syndromes of aMCI and AD in old-old people aged 75+: our results also underline the need for further characterization of cognitive impairment in this fastest growing subgroup of patients.

[Behavioral and psychological symptoms of dementia in a pilot psychogeriatric unit: management and outcomes]. / Expérience d'une unité pilote (unité cognitivocomportementale) spécialisée dans la prise en charge des symptômes comportementaux et psychologiques de la démence.

BACKGROUND: Behavioral and psychological symptoms in dementia (BPSD) are a major concern. The French government gave a consensual definition of reinforced intermediate-term care units for BPSD within the project "Plan Alzheimer 2008/2012". OBJECTIVE: Our aim was to report one of the first experiences of this unit in France. RESULTS: Fifty-two patients (38 females, 14 males) were included, mean age 82.07±7.84 (73-97). About 80% of patients were improved and there was a high discharge rate to home of about 30%. Night-time behaviors, aberrant motor behaviors and agitation were the most frequent symptoms. CONCLUSION: Our study confirms that demented elderly patients greatly benefit from a specific BPSD care unit in agreement with the objective of Plan Alzheimer 2008/2012.

[Clinical and EEG approach to the diagnosis of epilepsy in a population of old people with delusion]. / Apport d'une démarche électroclinique dans le diagnostic de l'épilepsie chez une population de sujets âgés confus.

BACKGROUND: Delusion symptoms often occur in old people; epilepsy is one of the main reasons behind these acute episodes. Current guidelines and recommendations from the Academy of Medicine have proposed a double clinical and electroencephalographic approach. Recently, a working group of French experts has issued an electro-clinical scale. The aim of our study was to compare the usual approach with the new one based on the electro-clinical score. METHOD: All EEG requests performed since December 2008 in Bretonneau Hospital for elderly people aged over 75 years for delusion syndromes were retained for this study. RESULTS: One hundred and fifteen old patients from a geriatric-hospital (age 83.5+/-6.06 years) were included in this protocol. The classical diagnostic process yielded the diagnosis of epilepsy for 50 subjects. The electro-clinical scale confirmed the diagnosis of epilepsy in 30 patients and ruled it out in 29 patients. CONCLUSION: This study underscores the importance of evidence-based medicine for the diagnosis of epilepsy in old people and points out the underuse of the new technical tool, EEG-monitoring, for the management of these patients.

[Gait analysis with simple and dual-task paradigm in community-dwelling old people attending a geriatric outpatient clinic]. / Analyse clinique au cours d'une marche simple et avec une double tâche chez une population de sujets âgés ambulatoires consultant en gériatrie.

INTRODUCTION: Gait and balance often change with age. Few studies are available on gait analysis in the elderly. In our work, we have focused on slow walking and variation in pace. Since first introduced by Lundlin, the dual-task paradigm has been largely used to test for the risk of falls and to better understand the link between mild cognitive decline and variation in gait. To our knowledge, very few clinical data are available on the gait changes observed in the elderly in the dual-task situation. In this study, we compared changes in gait and balance between the simple task and the dual-task situation in a 10-m walk test conducted in community-dwelling old people. METHODS: Eighty-nine subjects attending a geriatric outpatient clinic (age 80.76+/-2.82 years) were included in our protocol. Gait, balance and posture were systematically evaluated during a simple and dual-task 10-m walk using a specific 11-item clinical scale. Gait speed was noted. RESULTS: Few differences were found in the dual-task walk, only reduced speed, more stops during the walk and less compliance with instructions. These results were correlated with the Mini Mental Status (MMS) score. Systematic clinical analysis failed to identify any links with age, the MMS, the UPDRS, the Tinetti scale or gait speed except for the variables freezing, increased sustention polygon and ataxia. DISCUSSION: This kind of study appears to offer an attractive analytical approach but would require a more pertinent choice of variables for cognitive evaluation and a more exhaustive set of MRI criteria. Nonetheless, clinical gait analysis could improve our understanding of the consequences of mild cognitive impairment and aging.