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.

[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.

[Cholinesterase inhibitor therapy in long term care settings]. / Les anticholinestérasiques en soins de longue durée: analyse des pratiques actuelles à partir d'une étude observationnelle francoquébécoise.

PURPOSE: Cholinesterase Inhibitors (ChEIs) have proven efficacy in outpatients with mild to moderate Alzheimer's Disease (AD). The benefits of maintaining this treatment once patients are institutionalised remain controversial. The aim of this study was to present current therapeutic strategies regarding ChEIs use in long-term care settings (LTC). METHODS: A multicentric, retrospective, observational study was conducted on currently available ChEIs (donezepil, rivastigmine, galantamine) prescribed in LTC. Data were obtained from medical records. Judgement was based on three criteria: ChEIs indication, follow-up, and justification for maintenance of treatment. RESULTS: Among the 1,373 patients evaluated, 6% (N=81) were receiving ChEIs. They represented various stages of the disease, with cognitive and functional decline ranging from severe (18%) to very mild (10%). Among patients receiving ChEIs, 29% met neither the indication for which these drugs were approved, nor professional guidelines. Patient evaluation at entry was of high quality, with 90% of records including cognitive, functional and behavioural evaluation. Follow-up evaluations were weaker, with at least one assessment domain missing in 40% of the medical records. ChEIs treatment was maintained, although almost half of patients experienced a worsening of their clinical state. CONCLUSION: This study shows that follow-up of institutionalised patients receiving ChEIs could be improved. While treatment maintenance seems to be the rule, it should be questioned on ethical, efficacy, and economic grounds. The rationale for use and discontinuation of these therapeutic strategies in institutional settings requires urgent review.

[Calcium nadroparin in the prevention of thromboembolic disease in elderly subjects. Study of tolerance]. / Nadroparine calcique dans la prévention de la maladie thrombo-embolique chez le sujet âgé. Etude de la tolérance.

OBJECTIVE: To evaluate the safety of a low molecular weight heparin for the prevention of thromboembolic disease in elderly patients. METHODS: A multicentre, randomized, open study was conducted in 295 patients: 146 patients (mean age 82.8 +/- 0.5 years) received calcium nadroparin and 149 patients (mean age 83.8 +/- 0.6 years) received calcium heparin. All medical patients were hospitalized with transient locomotor disability, requiring prophylaxis for thromboembolism. Patients were randomized to 28-days treatments with either subcutaneous calcium nadroparin 0.3 ml (3075 anti-Xa IU) daily or subcutaneous calcium heparin twice a day (0.2 ml-5000 UI--if bodyweight was less than 70 kg or 0.3 ml-7500 IU--if bodyweight was over or equal to 70 kg). RESULTS: The overall objective was to assess tolerability in terms of premature discontinuation of treatment for any reason: Discontinuation was more frequent in the calcium heparin group (16.1%) than in the calcium nadroparin group (11%), but without statistical significance. Premature withdrawal of therapy definitively attributable to drug administration occurred in 10 patients from the calcium heparin group (1 deep vein thrombus, 1 pulmonary embolus, 4 major bleeding events, 1 thrombopenia, 3 allergic events) and in only 1 from the calcium nadroparin group (1 allergic event). The difference was statistically significant (p = 0.01). CONCLUSIONS: The results of this study offer new evidence to confirm the safety and simplicity of administration of calcium nadroparin in the prevention of thromboembolism in elderly patients.

[Parlodel in early combination with levodopa in the treatment of Parkinson disease. Comparison of 2 dosage forms]. / Introduction du Parlodel en association précoce à la lévodopa dans le traitement de la maladie de Parkinson. Comparaison de deux progressions posologiques.

In order to compare two titrations of Parlodel in early combination with levodopa in the treatment of Parkinson's disease a multicentre randomized open study was performed with a fast titration in group A (15 mg/day for 3 weeks) and slow in group B (15 mg/day for 5 weeks). 153 patients were included: 77 in group A and 76 in group B. The recommended titration was observed in 76% in group A and 88% in group B, the difference was not significant. The efficacy assessed by the Webster Scale was remarkable and similar in the two groups. This study confirms the additive benefit of bromocriptine on the symptoms and long term complications of levodopa therapy, but no absolute conclusion can be drawn regarding the best titration.

[Therapeutic trials in Alzheimer disease. Selection--recruitment and stratification]. / Essais thérapeutiques dans la maladie d'Alzheimer. Sélection--recrutement et stratification.

Therapeutic trials conducted in Alzheimer's disease have benefited from the standardization of diagnostic criteria based on internationally recognized scales (DSM III-R, NINCDS-ADRDA) which ensure more valid inclusions. Well specified exclusion criteria are also of the utmost importance, in particular depression, vascular dementia and concomitant psychotropic drugs. Cognitive and/or functional scales allow an appreciation of the severity of the disease. Due to the heterogeneity of Alzheimer's disease stratification methods on identified prognostic factors i.e. aphasia, extrapyramidal symptoms should be performed. Selection of responders during an enrichment phase has still to be discussed. Multicentric studies become imperative because of the large number of patients required and the difficulties in selecting the adequate patients. These raise the issues of investigators' experience, coordination and between center variability.

Cholesterol as risk factor for mortality in elderly women.

92 women aged 60 years and over (mean 82.2, SD 8.6) living in a nursing home and free from overt cancer were followed-up for 5 years. 53 died during this period; necropsy revealed cancer in only 1 patient. Serum total cholesterol at entry ranged from 4.0 to 8.8 mmol/l (mean 6.3, SD 1.1). Cox's proportional hazards analysis showed a J-shaped relation between serum cholesterol and mortality. Mortality was lowest at serum cholesterol 7.0 mmol/l, 5.2 times higher than the minimum at serum cholesterol 4.0 mmol/l, and only 1.8 times higher when cholesterol concentration was 8.8 mmol/l. This relation held true irrespective of age, even when blood pressure, body weight, history of myocardial infarction, creatinine clearance, and plasma proteins were taken into account. The relation between low cholesterol values and increased mortality was independent of the incidence of cancer.

Psychometric procedures for analysis of memory losses in the elderly.

This study aimed to assess and compare the discriminative validity of two psychometric procedures which have been proposed to investigate memory losses in elderly. The first one relies on the use of the serial position curve paradigm in a test of immediate memory, the second one being a single recognition task. These two procedures were applied to the five following groups of subjects: 95 young-elderly normals, 33 elderly normals, 26 patients with mild senile dementia of the Alzheimer type (SDAT), 17 patients with moderate or moderately severe SDAT and 24 elderly depressed patients. Results from both psychometric procedures confirm the findings of previous studies and support the view that memory impairment associated with SDAT is qualitatively different from that observed in normal aging or in depression. They also suggest that memory loss in elderly depressed patients differs only quantitatively from that of normal controls. However the recognition task seems to have the best validity to qualitatively discriminate the patients with mild dementia from both the normal controls and the elderly depressed patients.

Ergoloid mesylates ('Hydergine') in the treatment of mental deterioration in the elderly: a 6-month double-blind, placebo-controlled trial.

A double-blind, placebo-controlled trial was carried out in 97 elderly patients with age-related mental deterioration to assess the efficacy of ergoloid mesylates in improving their symptoms. Patients were allocated at random to receive either 4.5 mg ergoloid mesylates per day or a matching placebo tablet and were followed-up for 6 months after the start of treatment. Clinical examinations were performed by the doctor, using the EACG rating scale (a French version of the Sandoz Clinical Assessment Geriatric scale), and by the nurse, using the NOSIE scale, when patients entered the trial and repeated after 2, 4 and 6 months. Changes in the factors (symptom groups) covered by these scales were subjected to statistical analysis. After 6-months' treatment, a statistically significant difference in favour of the ergoloid mesylates group was observed for cognitive deficits (p less than 0.05), anxiety and mood depression (p less than 0.01), unsociability (p less than 0.01), retardation (p less than 0.05) and irritability (p less than 0.001). Treatment was very well tolerated. It was also observed that there was a progressive increase in efficacy throughout the trial; this indicates that treatment with ergoloid mesylates in patients with mental deterioration should be long-term.

[Longitudinal study of the relation between environmental conditions and the health of patients in a long-stay hospital]. / Etude longitudinale sur les relations entre les conditions d'environnement et la santé des pensionnaires d'un hôpital de long séjour.

A longitudinal survey has been conducted for a 30-month period in the long-term care hospital of Ivry, in Paris urban area. 1500 people were medically monitored daily by the doctors who were in charge of each unit of the hospital; each individual pathological event was exactly recorded, with complete development. This follow-up permitted to report 6300 acute illnesses. Environmental physical parameters (NOx, SO2, particulates, temperature, humidity, atmospheric pressure) were recorded indoors and outdoors during the whole period. The relation of environmental conditions to health has been studied with the cross-correlations method, applied to respiratory disease incidence rates and physical parameters series. It appeared that only NOx was significantly related to an increase of respiratory disease incidence rates.

[Retrospective study of 290 cases of hyperthyroidism after 55 years of age without previously documented thyroid disorders]. / Etude rétrospective de 290 observations d'hyperthyroïdie après 55 ans sans antécédent thyroïdien connu.

Previous studies having shown differences in the clinical presentation of hyperthyroidism in the young and in the over sixty-years old patients, we studied the presentation of hyperthyroidism of late onset without previous thyroid disorder to determine if it continued to change with age after 55 years. Two hundred and ninety cases of hyperthyroidism presenting after the age of 55 years without a previous history of goitre, collected in the Department of Nuclear Medicine of the Pitié Hospital between January 1976 and May 1980, were analysed retrospectively. There was no significant correlation between age and heart rate or total circulating thyroxine (T4) and triiodothyronine (T3) concentration. A positive correlation with weight loss and a negative correlation with I 131 fixation were observed. It was higher in cases of atrial fibrillation and hyperthyroidism with normal thyroid scintigraphy. Graves' disease with goitre was associated with the most overt signs of thyrotoxicosis and the highest hormonal concentrations, contrarily to toxic adenoma. The T3 but not T4 concentration correlated positively with heart rate. T3 and T4 were positively correlated with weight loss, and this correlation remained significant at constant T4 and T3 concentrations.