[Disabled elderly people waiting for institutionalization to a hospital ward: prospective study in the administrative district of Strasbourg (France)]. / Personnes âgées dépendantes en attente d'entrée en EHPAD depuis un service hospitalier: étude prospective sur la communauté urbaine de Strasbourg, France.

OBJECTIVES: Our aim was to estimate the number of non-satisfied instutionalization requests for inpatients and to describe the strategies elaborated to compensate for the waiting time. METHODS: This prospective follow-up study concerning all requests for institution admission for inpatients aged 75 years or older hospitalized in acute care and rehabilitation wards. Descriptive data were gathered throughout the social support process conducted during the hospitalization. A three months follow-up was conducted. RESULTS: Among 5200 hospitalizations, a social support process was initiated for 270 patients aged 75 years and over. Two thirds of the sample were women (n=163). Mean age was 82 years. Fifty-two percent of the subjects met the criteria for iso-resource grades (IRG) 1 to 2 and 90% in IRG 1 to 4. The mean length of hospitalized stay (MLOS) was 56.8+/-10.2 days; the MLOS of unjustified stay of 23.5+/-5.6 (n=222). The average time before the social worker was informed of the patient's situation was 13.6+/-2.0 days; in addition, the time required to establish the administrative documents necessary for initiation of the social support progress was 15.0+/-1.8. The principal reasons for social support were physical dependence (77%), mental dependence (60%), insufficient family support (36%) and/or disease progression (21%). At three months, 104 patients were institutionalized, 128 were still on institution waiting list (in hospital: 48%; at home: 16%) and 38 had died (14%). The estimated annual institutional deficit for disabled elderly people was 512 beds. CONCLUSION: In light of demographical perspectives, an overall re-organization of the geriatric network is absolutely necessary. A simple increase in the capacity to fulfil the institutional beds deficit would be insufficient.

[Home living conditions in Alsace of the disabled elderly aged 75 years and more]. / Description des conditions de vie de la population âgée de 75 ans ou plus vivant à domicile en Alsace.

OBJECTIVE: Our aim was to describe the living conditions of disabled elderly subjects aged 75 years and more living at home. DESIGN: This study was conducted in 1996-97 in the Alsace region in France and included two parts. First, a sample survey was mailed to 15,600 subjects randomly selected from a pension funds list. This survey provided with a reliable representation of the study population in terms of disabilities using the Colvez classification. In the second part, the most disabled individuals were selected and, among them, 1,259 subjects were visited at home. Their disabilities and living conditions were noted using a predefined set of questions. RESULTS: An estimated 71,000 subjects aged 75 years and more lived at home in the study region. The vast majority were free of significant disability. Help to wash and dress was needed by 6,000 until 1,500 were bedridden or confined to an armchair. Between 4,350 and 5,400 met the criteria for iso-resource grades (IRG) 1 to 3. Disability was associated with age, female gender, cognitive impairment and some social and professional characteristics. Family support was routine in almost every aspect of everyday life including personal hygiene. Professional support was mostly limited to technical interventions. Professional nursing care concerned only the most dependent persons. Nevertheless, needs for help in home and social activities remained high even in the least dependent individuals and were strongly age-dependent. Only 10% of individuals with IRG 1 to 3 complained of inadequate help. More than 80% of the elderly felt comfortable with their living conditions at home and were not thinking of moving from home to an institution for old people. CONCLUSION: The present study confirms the important commitment of family members and their close relationships toward their elderly.

[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.

[Candidemia in elderly people: apropos of 4 cases]. / Les candidémies chez le sujet âgé: à propos de quatre cas.

INTRODUCTION: Candidemia, principally affecting neutropenic patients in departments of oncohematology and frail patients in intensive care units, can also be observed in frail elderly people in geriatrics. EXEGESIS: Authors report four observations of candidemia diagnosed in elderly dependent patients having several different diseases. Clinical sign was a persistent or recurrent fever after a wide-spectrum antibiotic therapy. Patients were treated by fluconazole leading to negative blood cultures in several days. Three out of four patients died within the weeks following antifungal therapy due to severity of associated diseases. CONCLUSION: These observations show that a diagnosis of candidemia should be made when a persistent fever is observed in a frail elderly person. Fluconazole, as efficient as amphotericin B and well tolerated by elderly people, should be the first treatment of candidemia in non-neutropenic patients.

[Influence of age on presentation and prognosis of tuberculosis in internal medicine]. / Effets de l'âge sur la présentation et le pronostic de la tuberculose en médecine interne.

OBJECTIVES: To compare the clinical, biochemical, radiological features and the outcome of elderly and young patients with tuberculosis. METHODS: Between 1980 and 1997, 83 patients diagnosed as having tuberculosis were treated in two departments of Internal Medicine and Geriatrics. They were divided into 42 young (< 65 years) and 41 elderly (> or = 65 years) patients and differences in presentation between the two groups were analysed. RESULTS: A past history of tuberculosis was found in 10% of young and in 18% of elderly patients (p = 0.43). Cancer was more often associated with tuberculosis in elderly patients (2% vs 15%, p = 0.09). The sites of disease were similar in both groups with 2/3 of pulmonary infection. Comparison of the presenting symptoms showed no significant difference for weight loss (52% vs 66%, p = 0.31), fever (52% vs 56%, p = 0.90) and cough (33% vs 32%, p = 1). The skin testing was positive for the majority of the young adults (84% vs 58%, p = 0.11). The commonly observed biochemical abnormalities in elderly patients were an increased erythrocyte sedimentation rate (49 vs 69 mm/h: p = 0.03) and lymphocytopenia (1724 vs 1059/microliter, p < 0.01). There was no significant difference in radiographic findings between both groups with miliary tuberculosis in about 10% of patients. During the first three months of treatment, the mortality was especially high (22%) for the elderly patients. CONCLUSIONS: Comparison of the clinical and radiological features of tuberculosis in internal medicine showed no significant difference in young and elderly patients.

[Clinical and prognostic aspects of spontaneous fractures in long term care units: a thirty month prospective study. Eastern Gerontology Society]. / Aspects cliniques et pronostiques des fractures spontanées en unités de soins de longue durée: une étude prospective de 30 mois. Société de Gérontologie de l'Est.

PURPOSE: Spontaneous fractures (stress and bone insufficiency fractures) are well described in young healthy patients; however, few studies were conducted in the elderly. METHODS: A 30-month prospective clinical and epidemiological survey including elderly patients from long-term nursing homes (LTNH) of the Société de Gérontologie de l'Est (70 centers; 11,495 elderly patients in total) was conducted. RESULTS: Sixty-seven spontaneous fractures were encountered in 30 LTNH (3,052 elderly patients) (five stress fractures of the foot, 62 bone insufficiency fractures). The mean age of bedridden patients was 85 +/- 7 years. The prevalence of spontaneous fractures (calculated from the number of patients admitted consecutively in LTNHs) was 0.34% in the whole population (11,495 beds). When the calculation was based on LTNH reports of spontaneous fractures (3,052 elderly patients), the prevalence reached 1.3%. Fractures of long bones were common in elderly patients and included 15 fractures of the femoral neck, 14 fractures of either the tibia or fibula, 13 fractures of the femoral shaft, and 11 fractures of the humerus. Fractures of the femoral shaft were associated with the highest mortality: seven out of 13 patients died versus two out of 15 patients with regard to fractures of the femoral neck (P < 0.05). CONCLUSION: Bone insufficiency fractures have not the same course in young healthy patients as those in elderly nursing home patients: they more often concern long bones and their prognosis is worse. Means of prevention still have to be defined.

[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.

[Surgical treatment of invalidating musculo-tendinous retractions in the dependent elderly]. / Traitement chirurgical des rétractions musculo-tendineuses invalidantes chez les vieillards dépendants.

The authors have reviewed 37 patients aged 64 to 91 years or their charts in the purpose to evaluate the results of surgical treatment of severe acquired contractures of arms hands and legs. They describe the deformations, surgical technique, morbidity, and the results. 4 patients deceased within the first week after surgery; morbidity was very low. The results were satisfactory: nursing was greatly facilitated and pain during nursing care and toilet disappeared, the patients could again seat in a wheel chair. They conclude that this surgery can be very helpful for these disabled patients.

[Hospital discharge for elderly persons: a cross-sectional study in Alsace]. / Sorties d'hospitalisation pour les personnes âgées: une enquête transversale en Alsace.

The objectives of this study are to analyse in the Alsacian region the needs of people aged 75 years old and over after a stay in hospital. It is also to identify the matching point between the ideal patient discharge and the one feasible in reality. Finally, if no matching point is found, the study examines the reasons for this. This is an exhaustive overview conducted 8th December 1994 in the 96 Alsacian hospitals on all patients aged 75 and over than 10 days in short stay services and over 20 days in medium stay services. Thus 965 questionnaires were analysed. On leaving hospital, 60% of ideal discharge are feasible. This percentage varies according to the kind of discharge. From 18% for the Alzheimer units it reaches 91% for "home stay without arrangement". When the ideal discharge is "long stay", it is often not feasible due to structural causes. On the contrary, when going home is the ideal solution, this is often not feasible due to lack of motivation either from the patient or their family.

[Progressive multifocal leukoencephalopathy. Contribution of nuclear magnetic resonance imaging]. / La leucoencéphalopathie multifocale progressive. Apport de l'imagerie par résonance magnétique nucléaire.

Progressive multifocal leucoencephalopathy is a white matter infection caused by a papovavirus. Immunocompromised patients are predominantly affected. We report the case of a 74-year old woman with abdominal lymphoma resistant to chemotherapy. The diagnosis was suggested by cerebral CT and NMR images and was confirmed at postmortem pathological examination. The contribution of complementary examinations to the diagnosis is discussed in the light of recently published studies.

Somatostatin-like immunoreactivity in the cerebrospinal fluid of aged patients with Parkinson's disease. The effect of dopatherapy.

Cerebrospinal fluid (CSF) somatostatin concentrations were measured in 35 aged patients with Parkinson's disease (mean age, 79.5 years) and 11 control subjects (mean age, 82.3 years). In patients with Parkinson's disease the levels of somatostatin-like immunoreactivity were lower than in controls (P less than .02); these values were lowest in the untreated group. Somatostatin-like immunoreactivity levels in the CSF tended to increase with treatment but not significantly (P = .11). Somatostatin values were not correlated to age, sex, or duration of the disease. Somatostatin concentrations tended to be lower in more severely affected patients with higher scores on the Hoehn and Yahr (P = .13) and Webster staging scales (P = .13) and lower scores on Mini-Mental State (P = .10), but without statistical significance for these correlations.

Immunoreactive substance P and somatostatin in the cerebrospinal fluid of senile parkinsonian patients.

The concentration of substance-P-like immunoreactivity (SPLI) and somatostatin-like immunoreactivity (SLI) in the lumbar spinal fluid of senile parkinsonian patients (mean age 77.6 +/- 6.7 years) and senile control patients (mean age 83.5 +/- 5.6 years) were determined by specific radioimmunoassays. Mean SPLI and SLI levels in the control group were 8.1 +/- 2.0 (SD) and 32.5 +/- 12.0 fmol/ml, respectively. The mean SPLI levels were not significantly different in the groups. The mean SLI level was significantly lower in the group of patients with Parkinson's disease (19.8 +/- 9.0 fmol/ml). A comparison with results in patients with senile dementia of Alzheimer type (SDAT) shows that, in addition to clinical and pathological correlations, Parkinson's disease of late onset may share a deficit in somatostatinergic neuromodulation with SDAT.