Do we know how to diagnose epilepsy early in Alzheimer's disease?

Epilepsy is an increasingly recognized comorbidity in Alzheimer's disease (AD). First described as generalized in dementia patients, epileptic AD patients are nowadays fully described in earlier stages of the disease (with mild or subjective cognitive impairment). At such early stages, patients may present not only with generalized seizures, but also with focal seizures (commonly localized in the frontal or temporal lobe). Thus, partial or generalized epilepsy is part of the semiological spectrum of AD that should be borne in mind at all stages of disease to ensure early identification and prevent the risk of repeated seizures (such as accidents, injury, progression of cognitive impairment). This review of the available (and still growing) literature shows that there are already sufficient data to inform physicians on seizure semiology, and on the diagnostic value of electroencephalography and brain imaging. Taken together, these tools can help to rapidly identify epilepsy in AD patients. Nevertheless, epilepsy diagnosis can be challenging, and test medication is sometimes necessary. Some cerebrospinal fluid biomarkers (or their ratios) may also prove to be good predictors of seizures in AD, but further studies are needed. Epilepsy in AD patients is frequently pharmacosensitive, and a good response can be obtained with standard doses of antiepileptic drugs. For all these reasons and based on our review of the literature, it appears that, at present, the diagnosis of epilepsy in AD is not only possible at any stage of the disease, but also to be recommended to improve the patient's prognosis.

Exploring anterograde memory: a volumetric MRI study in patients with mild cognitive impairment.

BACKGROUND: The aim of this volumetric study was to explore the neuroanatomical correlates of the Free and Cued Selective Reminding Test (FCSRT) and the Delayed Matching-to-Sample-48 items (DMS-48), two tests widely used in France to assess verbal and visual anterograde memory. We wanted to determine to what extent the two tests rely on the medial temporal lobe, and could therefore be predictive of Alzheimer's disease, in which pathological changes typically start in this region. METHODS: We analysed data from a cohort of 138 patients with mild cognitive impairment participating in a longitudinal multicentre clinical research study. Verbal memory was assessed using the FCSRT and visual recognition memory was evaluated using the DMS-48. Performances on these two tests were correlated to local grey matter atrophy via structural MRI using voxel-based morphometry. RESULTS: Our results confirm the existence of a positive correlation between the volume of the medial temporal lobe and the performance on the FCSRT, prominently on the left, and the performance on the DMS-48, on the right, for the whole group of patients (family-wise error, P < 0.05). Interestingly, this region remained implicated only in the subgroup of patients who had deficient scores on the cued recall of the FCSRT, whereas the free recall was associated with prefrontal aspects. For the DMS-48, it was only implicated for the group of patients whose performances declined between the immediate and delayed trial. Conversely, temporo-parietal cortices were implicated when no decline was observed. Within the medial temporal lobe, the parahippocampal gyrus was prominently involved for the FCSRT and the immediate trial of the DMS-48, whereas the hippocampus was solely involved for the delayed trial of the DMS-48. CONCLUSIONS: The two tests are able to detect an amnestic profile of the medial temporal type, under the condition that the scores remain deficient after the cued recall of the FCSRT or decline on the delayed recognition trial of the DMS-48. Strategic retrieval as well as perceptual/attentional processes, supported by prefrontal and temporo-parietal cortices, were also found to have an impact on the performances. Finally, the implication of the hippocampus appears time dependent, triggered by a longer delay than the parahippocampus, rather than determined by the sense of recollection or the encoding strength associated with the memory trace.

Subacute bacterial endocarditis presenting as polymyalgia rheumatica or giant cell arteritis.

OBJECTIVE: To report on several patients with subacute bacterial endocarditis who were initially presumed, incorrectly, to have polymyalgia rheumatica or giant cell arteritis. METHODS: We report 3 cases of subacute streptococcal endocarditis mimicking giant cell arteritis in 2 cases and polymyalgia rheumatica in one. We reviewed the literature through Medline search of French and English-language articles published between 1966 and 2005 and found 5 similar cases. RESULTS: Shoulder and/or pelvic girdle pain was associated with neck or back pain in all patients. Scalp tenderness, bilateral jaw pain, amaurosis fugax were present in 2 patients. One patient had no fever. Two patients were treated with corticosteroids with initial good clinical response in one. Appropriate antibiotic therapy resulted in the rapid disappearance of rheumatic complaints in 2 patients and achieved a definitive cure of endocarditis in all cases. CONCLUSION: Rheumatologic symptoms may hinder the correct diagnosis of infective endocarditis in patients who present with a clinical picture suggesting polymyalgia rheumatica or giant cell arteritis. In such cases, blood cultures should be systematically drawn.

[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.

[Dementia and falls]. / Démence et chutes.

INTRODUCTION: Dementia is now a frequent disease in elderly and may be a major risk of falling. Usually these falls are multiple and serious, but their consequences are not specific. All types of dementia (Alzheimer's disease, dementia with Lewy bodies, dementia in Parkinson's disease, fronto-temporal dementia, vascular dementiaellipsis) and all stages of evolution are concerned. DISCUSSION: These falls result from cognitive and behavioural disorders, visual and motor problems, gait and balance disturbances, malnutrition, adverse effects of medication and fear of falling. CONCLUSION: Prevention is possible. Attention must be given on the patient himself (keeping in good health, limitation in sedative treatment and mechanical restraintsellipsis) and on his environment (lighting, obstacles on the ground, stress levelellipsis). After a fall, especially after a complicated fall, rehabilitation modalities and aims must be adapted but caring must not be defeatist. Randomized studies need to be realized.

[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.