Parkinsonian gait in elderly people: Significance of the threshold value of two and more falls per year.

OBJECTIVES: Parkinsonism in the elderly presents a major risk factor for recurrent falls (2 and more falls per year), which is associated with increased morbidity. The main objective was to investigate explanatory variables relating to the risk of being recurrent fallers (RF) in persons with parkinsonian gait. METHODS: Seventy-nine among 172 eligible persons were enrolled in this prospective study, the findings of which were analyzed at 12 months. Motor and non-motor features, as well as follow-up interviews to identify falls, loss of ability to walk, fluctuating cognition, traumatic falls, all-cause hospitalizations and deaths were collated and results compared between non RF (zero and one fall per year) and RF. Bayesian model averaging was used to predict the probability of patients being RF from their medical history as well as from cognitive assessment, gait velocity, vision and posture. RESULTS: N=79, 0.58 men, 50% had Parkinson's disease, 14% other neurodegenerative parkinsonian syndrome, 23% vascular parkinsonism and 13% Lewy body disease, 58% were RF. Median age 81.2 years and median MMSE 25/30. A history of falls and of hallucinations, median odds ratio respectively 9.06 (CI 2.34-38.22), 4.21 (CI 1.04-18.67) were associated with the highest odds ratios along with fluctuating cognition and abnormal posture. Two or more falls a year was a relevant threshold to distinguish a population with a high risk of comorbidity. CONCLUSION: The whole history of falls, hallucinations and fluctuating cognition can be considered predictive of recurrent falls in elderly people with parkinsonian gait and provide a tracking tool for patient management.

[Parkinson's disease dementia: correlations between clinical, neuropsychological and neuropathological features]. / Corrélats anatomocliniques au cours de la démence de la maladie de Parkinson.

INTRODUCTION: Cognitive disorders such as deficit of attention and executive and visuoconstructive dysfunctions occur in Parkinson's disease dementia (PDD). Memory impairment is not an early feature and statement not well delimited. CASE REPORT: A 78-year-old man with PDD underwent neuropsychological assessment and moreover demonstrated memory decline. After death, pathology examination of the brain and immunohistochemy analysis confirmed PD and showed Lewy body pathology (LBP) in the insula, limbic and especially in CA3 hippocampus areas. Hippocampus and gyrus parahippocampic also exhibited neurofibrillary tangles. Lack of senile plaque and lack of beta A4 amyloid deposition were noticeable in the whole brain examination. CONCLUSION: Severe executive dysfunctions are probably related to LBP and dysfunction in memory process may be related to DNF lesions in medial temporal area.

[Urinary tract infections due to wide spectrum beta lactamase producing enterobacteriaceae]. / Infections urinaires à entérobactéries productrices de bêta-lactamases à spectre étendu. Prévalence dans un service de médecine interne gériatrique.

OBJECTIVES: The aim of this study was to specify the characteristics of enterobacterial urinary infections producing wide spectrum beta-lactamase (WSBL) and the management strategies for these patients infected in geriatric wards. METHODS: The prevalence, bacteriological characteristics and treatment regimens of enterobacterial urinary infections producing WSBL, diagnosed in a geriatric department of internal medicine from May 1977 to April 2001, were studied retrospectively. RESULTS: Sixty-six enterobacterial urinary infections producing WSBL were diagnosed, with 53 (80%) of them acquired in the ward. They represented 1.6% of admissions and concerned 24 men and 42 women (sex ratio: 0.57), with a mean age of 87 years. Their prevalence was of 20 in the 1st year, 11 in the 2nd, 9 in the third and 26 in the 4th year. The mean duration of hospitalization of infected patients was 4.5-fold longer (90 vs. 20 days) and the mortality rate 2-fold higher (32 vs. 14%). Enterobacter aerogenes were responsible for half (46%) of the WSBL urinary infections. The skin was invaded by enterobacteria in 67% and the feces in 57% of cases. More than one third of the urinary infections treated relapsed, and digestive decontamination was only efficient in half of the patients treated. CONCLUSION: This 4-year study emphasizes the limits of antibiotherapy in eradicating WSBL-producing enterobacteria and the fact that only the strict respect of hygiene by all caregivers (isolation of patients exhibiting WSBL and washing-disinfection of the hands between each patient) limits the incidence of such infections.

Neuropathological epidemiology of cerebral aging: a study of two genetic polymorphisms.

We studied whether ApoE and -219 GT (ApoE promoter) polymorphism modulates neurofibrillary tangle (NFT) and senile plaque (SP) development in aging among 190 non-institutionalized individuals (mean age 79.5 years). Analysis revealed that the mean Braak stage was higher in epsilon4 allele carriers. Once individuals with Braak stage V were excluded (n = 5), relationships between NFT and the two genotypes studied were weak, whereas in epsilon4 allele carriers, the risk of SP was multiplied by 4 to 7 in four areas (CA1, subiculum, isocortex and entorhinal cortex). This association was more pronounced in subjects under 80 years and was also observed when analysis was restricted to Braak stages 0, I and II. Epsilon 2 allele carriers appeared to have fewer lesions but, due to limited numbers, this trend was not significant. In two regions (CA1, subiculum), the number of SP increased significantly for individuals who were homozygous for the T allele of -219 GT. However the association was no longer significant when controlling for ApoE epsilon4. It should be noted that the brain of elderly subjects carrying one epsilon4 allele may not undergo senile changes.

[Extra-pyramidal syndrome induced by donepezil]. / Syndrome extrapyramidal sous donepezil.

BACKGROUND: The cholinergic hypothesis of Alzheimer's disease is the basis of a new class of drugs: acetylcholinesterase inhibitors. These drugs have few side effects, mainly digestive disorders. CASE REPORTS: Extra-pyramidal side effects with severe gait disorders were observed in 3 patients with Alzheimer's dementia treated with donepezil. This drug was associated with paroxetine or a neuroleptic. In 2 of the 3 cases, the extra-pyramidal effects disappeared when donepezil was discontinued. DISCUSSION: Extra-pyramidal syndromes in elderly subjects with cognitive impairment are difficult to interpret. The possible causes include interactions between acetylcholinesterase inhibitors, neuroleptics and serotonine reuptake inhibitors and Lewy body dementia.

Spontaneous insufficiency fractures of long bones: a prospective epidemiological survey in nursing home subjects.

A 30-month prospective observational cohort study was led to assess the prevalence of and describe the clinical features of spontaneous long bone insufficiency fractures (LBIF) in the 'oldest old' patients of long-term nursing homes (LTNH). The study was conducted in 30 LTNH in northeast France, which represented 3052 beds. Subjects aged 65 and more showing LBIF were included in the present study. Clinical data and outcome were collected. Fifty-five LBIF were found. The prevalence of LBIF calculated on the basis of the number of patients consecutively admitted in LTNH was 1%. The mean age of the subjects was 85+/-7 years. The LBIF sites were as follows (1) hip fractures in 15 subjects (27%); (2) femoral shaft fractures in 13 subjects (24%); (3) tibia and/or fibula fractures in 14 subjects (25%); (4) humerus fractures in 11 subjects (20%); (5) cubitus in 2 subjects. The global mortality at 2 months was 24%. The poorest outcome was observed in the group with femoral shaft fracture who showed mortality of 54% at 2 months. The dramatic repercussions in outcome and quality of life in bedridden patients show that the detection of LBIF should not be neglected in nursing homes. There is no consensus for a preventive pharmacological treatment in these patients. Educational programs for 'proper handling' by the nursing staff are highly recommended.

Landau-Kleffner syndrome: a clinical and EEG study of five cases.

In five children with normal initial psychomotor development, a Landau-Kleffner syndrome appeared at age 3-7 years. No neuroanatomic lesions were noted. Aphasia and hyperkinesia were isolated in three patients and associated with global regression of higher cortical functions in one patient. Massive intellectual deterioration and psychotic behavior were associated with transient aphasia in one patient. The epilepsy (focal motor and generalized tonic-clonic seizures, subclinical EEG focal seizures during sleep, and atypical absences) always regressed spontaneously or with antiepileptic drug (AED) treatment. The EEG in waking patients showed focal and generalized spike-wave discharges on a normal background rhythm. Discharge topography and pattern changed frequently. During sleep, discharges always increased. At some time during syndrome development, all patients had bilateral spike-waves for greater than 85% of the sleep period, while at other times the discharges were discontinuous or continuous but focal or unilaterally hemispheric. Discharge topography and abundance changed from night to night. The abnormal EEG and the impaired higher functions developed and regressed together, but not with strict temporal correlation. Our own experience suggests that the Landau-Kleffner syndrome and epilepsy with continuous spike-wave activity in slow-wave sleep cannot be clearly differentiated. They may be different points on the spectrum of a single syndrome.

[Isolated paralysis of the ocular motor nerve caused by infarction of fascicular fibers]. / Paralysie isolée du nerf moteur oculaire commun par infarctus de ses fibres fasciculaires.

We report the case of an 80 year-old woman who developed an unilateral brainstem infarction with a lesion of the intraparenchymatous fibres of the IIIrd cranial nerve. Intraaxial lesions of this nerve are usually part of the alternate paralysis syndrome. Our case might be the second since the report of Achard and Levi in 1901. Infarction limited to the fascicular fibres of the oculomotor nerve sparing the oculomotor nuclei results in characteristic clinical manifestations. This in turn results from the highly selective distribution of the terminal arterial territories in the midbrain.

[Biochemical analysis of the cerebrospinal fluid in multiple sclerosis: study of various formulas]. / Analyse biochimique du liquide céphalorachidien au cours de la sclérose en plaques: étude de différentes formules.

Multiple sclerosis (MS) is often characterized by a intrathecal synthesis of immunoglobulins (Ig) in cerebrospinal fluid (CSF), which may be evaluated in several ways: ratio methods (IgG index, Schuller's or Tourtelotte's formulae) or demonstration of an oligoclonal distribution, or both. In a retrospective study, 256 CSF analyses were evaluated. The 4 parameters studied were disturbed in about the same proportions in each of the 3 MS subgroups of Mac Alpine's classification. An oligoclonal distribution is more rarely present in pathologies other than MS. None of these tests is specific for the diagnosis of MS. Haptoglobin index variations do not distinguish between the different groups of patients. From a physiopathological point of view, however, they may perhaps reveal an acute local inflammatory reaction, different from the immune reaction giving rise to the Ig synthesis.

[Magnetic resonance imaging and herpetic encephalitis]. / Imagerie par résonance magnétique et encéphalite herpétique.

Cerebral lesions in two cases of herpetic encephalitis were detected by MRI using a spin-echo sequence and delayed echo signal recordings, whereas CT scans were normal. In one case pathology showed lesions to be more extensive than MRI anomalies. This suggests that even in the absence of EEG and CT anomalies, an encephalitis can be suggested by MRI.

Audiogenic seizures in Wistar rats before and after repeated auditory stimuli: clinical, pharmacological, and electroencephalographic studies.

A strain of Wistar rats was inbred for susceptibility to audiogenic seizures characterized by one or two wild running fits followed by tonic dorsiflexion with open mouth and then a catatonic state. During the tonic phase, the cortical EEG was flat for 1 to 2 sec, then changed to a slow, regular low-amplitude discharge, 9 to 12 c/s, for 25 to 60 sec. In these rats exposed to 40 daily 90-sec auditory stimuli, behavior and EEG changed. The wild running became disorganized by myoclonic jerks of the limbs and body. In some animals, the tonic extension disappeared and a myoclonic seizure developed progressively, with facial and forelimb clonus, and rearing and falling. In others, the tonic phase was followed by a generalized clonic phase. The EEG during the myoclonic and tonic-clonic seizures showed high-amplitude rhythmic spikes, polyspikes and spike-waves, 1 to 10 c/s, for 40 to 120 sec, often outlasting the sound stimulus. The effects of ethosuximide, carbamazepine and phenytoin were the same on primary and modified audiogenic seizures. The progressive behavioral and EEG modifications of audiogenic seizures following repeated auditory stimuli suggest that kindling had developed, the seizures being propagated from the brain stem to forebrain structures.

Kindling of audiogenic seizures in the rat.

A strain of Wistar rats was inbred in our laboratory for its susceptibility to sound. The seizures are characterized by one or two wild running fits which terminate in a tonic dorsiflexion with open mouth, followed by a catatonic state. During the tonic phase of the seizure, the cortical EEG is flattened for 2 to 3 s. Then, a slow and regular low-voltage (9-12 c/s) activity is observed during 40 to 60 s. When these animals are submitted to daily sound-stimulations, the behavioral as well as the EEG manifestations of the audiogenic seizures change progressively. After 5 to 30 exposures, the wild running becomes disorganized by occurrence of myoclonic jerks of the limbs and the body. In some animals, the tonic extension disappears and a myoclonic seizure develops progressively with facial and forelimb clonus, rearing and falling. In other animals, the tonic phase still occurs and is followed by a generalized clonic phase. During both the myoclonic and the tonicoclonic seizures, rhythmic spikes, polyspikes and spike and waves of high amplitude (1-10 c/s) during 40 to 120 s are observed on EEG recordings. These EEG modifications often outlast the sound stimulation. The pharmacological reactivity in rats exposed to single or repeated audiogenic seizures is similar: phenytoin and carbamazepine suppress both kinds of seizures at low doses whereas ethosuximide is efficacious only at high doses. In order to know whether the repeated exposure to sound or the repetition of seizures are responsible of the observed changes in audiogenic seizures, animals susceptible to sound were exposed daily to the seizure-inducing sound after previous injection of Diazepam, which prevented them from convulsing. On the other hand, sound susceptible animals were injected daily with a dose of PTZ inducing one or several convulsions without exposure to sound. None of these treatments ever facilitated the development of kindled audiogenic seizures. The progressive modification of behavioral and EEG modifications occurring when audiogenic seizures are repeated suggests that kindling has developed, the seizure extending from the brainstem to forebrain structures.

Kindling of audiogenic seizures in Wistar rats: an EEG study.

The EEG of 20 Wistar rats inbred for audiogenic seizures was recorded during 40 daily auditory stimuli 90 s long. The first stimuli provoked wild running, with no cortical EEG abnormality, and then a tonic phase with a characteristic EEG of a brief flat trace 2 to 3 s long followed by low-amplitude regular activity, 10 to 12 c/s, lasting 40 to 60 s. The lack of paroxysmal EEG patterns suggests that the cortex plays only a minor role in audiogenic seizure development. After 5 to 15 daily stimuli, the EEG during the running period exhibited brief spike and spike-wave discharges preceding the EEG pattern of the tonic phase. After a few more daily stimuli these paroxysmal discharges progressively increased in amplitude and duration, overlapping with the regular activity of the tonic phase. After 20 to 30 stimuli, only high-amplitude spikes and spike-waves, 1 to 10 c/s, were seen for 40 to 120 s. The modified EEG persisted 2 to 4 months after daily stimulation was discontinued. Thus, with stimulus repetition, a paroxysmal discharge progressively involved cortical structures. These data suggest that repetition of audiogenic seizures induced a phenomenon related to kindling in Wistar rats susceptible to sound-induced epilepsy.