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Resume Propos Cet article presente le developpement et les premieres donnees de validation de la version francaise d’un nouveau questionnaire de mesure de la sante percue ou de la qualite de vie des personnes âgees (> 60 ans) : le module WHOQOL-OLD. Ce questionnaire, mis au point dans le cadre d’un projet international sous l’egide de l’OMS avec le soutien de l’Union europeenne, est destine a completer le questionnaire de qualite de vie generique WHOQOL-BREF. Il comporte 24 questions regroupees en six dimensions. Methodes Le developpement initial du questionnaire et les etudes pilotes realisees ont conduit a un premier questionnaire qui a fait l’objet d’etudes de terrain dans 20 centres repartis dans le monde entier. Elles ont concerne 5566 personnes et permis la validation du WHOQOL-OLD dans sa version finale. En ce qui concerne la version francaise, 281 sujets, d’âge moyen 74 ans, ont ete recrutes par trois centres (Paris, Nancy et Geneve). Resultats Les resultats de l’analyse des proprietes psychometriques du questionnaire, notamment l’analyse multitrait, sont compatibles avec les hypotheses sous-jacentes a la construction des scores. Par ailleurs, les scores presentent une precision suffisante pour utiliser cet instrument dans les comparaisons de groupes. Conclusion Au total, le questionnaire WHOQOL-OLD peut etre utilise aupres des personnes âgees dans les etudes de service de sante, la recherche clinique et les etudes epidemiologiques.

La polymedication est d’abord une chance pour les patients âges polypathologiques. Mais elle entraine une augmentation de l’iatrogenie. Pres de 20 % des hospitalisations des plus de 80 ans est liee a l’iatrogenie. Il est important d’avoir une reflexion systematisee sur la prescription medicamenteuse. Le domaine de la qualite foisonne de methodes dont les denominations varient. L’evaluation des pratiques professionnelles (EPP) est une demarche qui vise a l’analyse d’une pratique professionnelle en reference a des recommandations professionnelles. Le college professionnel des geriatres francais (CPGF) propose des kits d’audits cliniques (AC) a partir du programme PMSA (polymedication du sujet âge) utilisables facilement par les medecins amenes a soigner des patients de plus de 80 ans quels que soient leurs lieux d’exercice.

Resume La maladie d'Alzheimer est une demence qui se manifeste a la fois par une alteration des fonctions cognitives et par des troubles psychocomportementaux. Une etude sur les reactions de la famille a la demence d'un parent doit envisager plusieurs points de vue : a) La charge familiale. Le poids de la maladie d'Alzheimer sur la famille est tres important. La prise en charge a des effets physiques et psychiques sur l'aidant qui peut presenter un etat anxieux, une depression, un ethylisme et qui a un risque de mortalite eleve ; b) Les reactions aux symptomes de la maladie. La famille doit supporter les symptomes de la maladie d'Alzheimer : les troubles cognitifs et surtout les troubles psychocomportementaux. Les reactions de la famille peuvent etre le deni, l'hyperprotection, le maternage, l'hyperinvestissement dans les soins ; c) Les relations avec l'institution geriatrique. Elles ne sont pas toujours paisibles. Des conflits peuvent eclater entre le patient, la famille et l'institution, surtout quand la famille ressent de la culpabilite et est ambivalente par rapport a l'institutionnalisation ; d) Les relations pathologiques famille–dement. Des relations pathologiques entre la famille et le parent peuvent apparaitre, dues a la pathologie psychique de l'aidant aggravee par la maladie d'Alzheimer du parent ; e) Le soutien apporte a la famille. Avant l'institutionnalisation, l'aidant familial doit etre soutenu dans le cadre du suivi geriatrique du patient. Des medicaments a visee cognitive et des psychotropes peuvent reduire les troubles du comportement. Le plus important est d'organiser et d'adapter les aides a domicile, avec si possible une prise en charge en centre de jour. Apres l'institutionnalisation, l'aidant doit continuer a etre soutenu. La fin de vie et la mort sont particulierement difficiles, parce que la comprehension des sentiments et des sensations de la personne demente reste toujours incertaine. Et il semble que le deuil d'un patient institutionnalise soit plus douloureux que le deuil apres une periode longue et stressante d'aide a domicile.

La atencion medica de los ancianos con patologias demenciales no se limita al diagnostico y a la prescripcion farmacologica correspondiente. Exige tambien un control medico estricto del aspecto evolutivo de las funciones cognitivas y de la interaccion con otros procesos morbidos, asi como el tratamiento rapido y eficaz de las enfermedades agudas intercurrentes. La atencion debe ser global y abarcar el aspecto psicosocial de la situacion, el apoyo a los cuidadores y la puesta en marcha progresiva de la ayuda domiciliaria, todo ello adaptado al grado de la discapacidad. Llegado el momento, es esencial la preparacion material y psicologica para el internamiento, con el fin de limitar al maximo posible las situaciones de crisis.

Resume Mme A., 75 ans, a ete hospitalisee pour une depression severe avec delire de persecution. Elle etait suivie pour un trouble bipolaire type I depuis plus de 40 ans. Le traitement instaure s’est revele inefficace compte-tenu de la mauvaise observance liee au delire de persecution. L’etat de Mme A. s’est aggrave progressivement, avec apparition de caracteristiques melancoliques. L’indication d’un traitement par ECT a ete posee mais la famille s’y est opposee. L’accord de la famille a ete tres difficile a obtenir. L’etat de Mme A. a necessite 22 seances d’ECT pour etre ameliore mais Mme A. a ete completement transformee par ce traitement, avec disparition des idees depressives et du delire de persecution. Sa famille ne l’avait pas connue ainsi depuis des annees.

Resume Dans cet article est rapportee l’experience d’un service de Gerontologie, dans le traitement des troubles psycho-comportementaux, au moyen d’un centre de jour interne. Plusieurs approches therapeutiques sont necessaires et peuvent etre rassemblees dans le centre de jour. Une etude sur son efficacite a ete effectuee au bout d’un an et ses resultats nous ont permis de preciser ses indications et ses limites. Ainsi, le centre de jour peut prendre en charge beaucoup de patients, y compris ceux qui presentent des alterations cognitives severes avec des troubles associes et il doit, de plus, jouer un role d’observation, d’analyse et de recherche de facon a optimiser les soins dans l’ensemble du service.

Le programme MobiQual est une action nationale dont l’objectif est de soutenir l’amelioration de la qualite des pratiques professionnelles — qualite des soins et du prendre soin — en EHPAD, etablissements de sante et a domicile, au benefice des personnes âgees et handicapees. Les differentes thematiques de ce programme sont: la bientraitance, la douleur, les soins palliatifs, la depression (quatre thematiques en cours) ainsi que la maladie d’Alzheimer et les troubles du comportement, la nutrition et l’alimentation, les risques infectieux (trois thematiques a developper). Le College professionnel des geriatres francais (CPGF), organisme agree (OA) par la Haute Autorite de sante (HAS) pour l’evaluation des pratiques professionnelles (EPP), propose aux medecins plusieurs methodologies (audit clinique cible, chemin clinique…) visant a faciliter la realisation d’un programme d’EPP a partir de l’utilisation des outils du programme.

Under the auspices of the French Society of Gerontology and Geriatrics, a multidisciplinary group of experts, including geriatricians, neurologists, epidemiologists, psychiatrists, pharmacologists, and public health specialists developed consensus recommendations about care for patients with severe dementia. They defined 21 recommendations for general practitioners, long-term care physicians, and specialists, based on the knowledge currently available (2005). The aim of care at all stages is to mitigate the quality-of-life of patient, caregiver, and family insofar as possible, combining care and future planning until the end of life. Management, to take into account problems including nutritional status, behavior disorders, and ability (or inability) to perform activities of daily living, must be global, multidisciplinary, and coordinated and must optimize use of local medical and social resources. The group also stressed the importance of clinical research to improve knowledge of disease course and assess management strategies and recommended specific area for research.

STUDY OBJECTIVE--The aim was to compare digital and palmar dermatoglyphics in subjects with dementia of Alzheimer type and in mentally healthy elderly controls. DESIGN--This design was a case-control study. SETTING--The study was carried out in geriatric units and retirement communities in the Paris area. PARTICIPANTS--Cases were women with clinically diagnosed Alzheimer type dementia according to DSM III-R criteria (n = 82), mainly with late onset of the disease. Controls were women aged 85 years or older without cognitive deterioration (n = 76). MEASUREMENTS AND MAIN RESULTS--Finger and palm prints obtained from both hands by the classical ink method were examined. Fingerprints were classified into four types of figures. On palms, palmar flexion creases, palmar axial triradii, true patterns of the hypothenar area, and main line terminations were described. Examinations were performed by two examiners blind to the subjects's diagnostic category. For the different patterns studied, no major differences between dementia patients and elderly controls were found. Nor was there evidence of high frequencies of features commonly observed in Down's syndrome (trisomy 21), which have previously, though sporadically, been reported. CONCLUSIONS--On one of the largest samples of Alzheimer dementia patients studied, and with evaluation blind to diagnosis, no evidence has been found that particular dermatoglyphic patterns occur like those observed in Down's syndrome, a disease which is related to dementia of the Alzheimer type.

Most of the therapeutic trials (VA Study, HDFP, Australian Therapeutic Trial, EWPHE Study, Coope's Study) are in favour of the benefit of antihypertensive treatment over the age of sixty. But, on the other hand, information is lacking on:--The effectiveness of treatment of isolated systolic hypertension;--The effectiveness of treatment in very old people, particularly over eighty;--The effectiveness of treatment in preventing conditions which were not included in the former trials such as vascular dementias. Two trials concerning elderly patients with systolic hypertension are in progress, the SHEP Study in the USA and the European study called Syst-Eur. It is expected that these trials will give answers allowing a more accurate management of this major risk factor for cardiovascular diseases in the Elderly.

The effectiveness and safety of perindopril in elderly hypertensive patients has clearly been demonstrated. In a randomized, double-blind drug versus placebo study involving 34 such patients of mean age 84 years, we observed a 10 p. 100 fall in systolic arterial pressure (p less than 0.01) and a 9 p. 100 fall in diastolic arterial pressure (p less than 0.01) in the perindopril group. The corresponding figures in the placebo group were 5 p. 100 and 4 p. 100 respectively, the difference between the two groups not being significant. The drug was well tolerated, both clinically and biochemically. However, a significant (p less than 0.01) increase in blood potassium level (albeit within normal limits) was observed in the treated group. An open trial conducted in 91 patients (mean age 79.1 years) followed up for 6 years confirmed the acceptability of the drug despite a transient decrease of creatinine clearance recorded in one patient. The effectiveness of perindopril, evaluated less unquestionably in this open trial, was excellent, the hypertension being controlled at the end of treatment in 92.5 p. 100 of the patients. In a trial performed on healthy volunteers, Reid found that perindopril had a greater effect of arterial pressure in elderly subjects, probably due in part to their high blood pressure and to an earlier and more prolonged inhibition of the angiotensin-converting enzyme (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

The purpose of this study was to investigate the efficacy and safety of labetalol, an alpha and beta-adrenergic receptor blocking agent in 32 patients aged from 72 to 97 years (mean = 85 years) with blood pressure (B.P.) greater than or equal to 160/95 mmHg. This study was carried out in a double-blind, randomized, placebo-controlled design. After 6 weeks of treatment with labetalol (mean dose = 235 +/- 47.5 mg/day), the systolic pressure was lowered from 187 +/- 24 to 145 +/- 28 mmHg (p less than 0.001) and the diastolic pressure from 98 +/- 10 to 82 +/- 9 mmHg (p less than 0.001). Likewise, in the placebo group, both systolic and diastolic pressures were significantly reduced but the changes were significantly greater in the labetalol group, -33 +/- 26 versus -13 +/- 20 mmHg and -14 +/- 10 versus -8 +/- 14 mmHg respectively. Labetalol achieved B.P. control (160/95 mmHg) in 64% of the treated patients, compared to 40% in the placebo group. Two patients on labetalol discontinued their treatment due to side-effects (one bradycardia and one cutaneous reaction) compared with one patient on placebo (cardiac failure). Two other cases in the labetalol group had side-effects (one fatigue and one dizziness) which prevented increasing the treatment as necessary.

The purpose of this study was to investigate the effectiveness and safety of enalapril in elderly people. A double-blind, randomized, placebo-controlled trial was carried out in 32 subjects aged from 75 to 97 years (mean: 86 years) with blood pressure values equal or superior to 160/90 mmHg. After 8 weeks of treatment with enalapril in doses of 20 to 40 mg/day, the systolic pressure was lowered from 190 +/- 16 to 151 +/- 19 mmHg (P less than 0.0001) and the diastolic pressure from 102 +/- 7 to 85 +/- 11 mmHg (P less than 0.0001). Systolic and diastolic pressures were also significantly reduced in subjects under placebo (from 183 +/- 16 to 165 +/- 21 mmHg, P less than 0.001; and from 101 +/- 9 to 91 +/- 13 mmHg, P less than 0.001, respectively), but the degree of reduction was significantly superior with enalapril (systolic: 39 +/- 25 vs 18 +/- 19 mmHg, P less than 0.005; diastolic: 17 +/- 13 vs 11 +/- 12, P less than 0.001); blood pressure was inferior to 160/90 mmHg in 67% of the subjects treated, as against 35% of those under placebo. Two patients under enalapril died: one on the 27th, the other on the 47th day of treatment. No relation could be established between these deaths and the drug, and this figure of 2 is not significantly different for the number of deaths expected over the same period in a population of that age-group. Among the patients under placebo, one had pulmonary embolism on the 34th day and another had a sudden increase in blood pressure on the 6th day, requiring discontinuation of treatment. It is concluded that enalapril administered alone is effective and well tolerated. Long-term studies are needed to find out whether this angiotensin-converting enzyme inhibitor is superior to a diuretic as initial treatment of arterial hypertension.

A ten year longitudinal survey of 191 female elderly subjects (mean age 80 - Range 61 to 101 years) was set up to demonstrate that even a moderate isolated systolic hypertension is a powerful contributor to the incidence of cerebrovascular complications in the elderly. The incidence of cerebrovascular events was carefully recorded and was correlated with a number of parameters registered at entry into the study. The results show that isolated systolic hypertension as well as diastolic hypertension is significantly correlated to the incidence of strokes independently of other parameters (Blood Cholesterol, Blood Sugar) which do not appear in this population as risk factors of cardiovascular morbidity. This underlines the high interest of controlled therapeutic studies run in this field in elderly patients.

The pharmacokinetics of amitryptyline (AMI) have been evaluated in six healthy elderly volunteers (72-83 years of age) after a single dose of 125 mg of AMI-HCl. AMI was absorbed rather slowly (mean peak time 10.4 +/- 1.6 hrs) but very efficiently (F: 0.59-0.75). The rate of formation of nortriptyline (NT) as well as the appearance clearance values (0.18-0.45 l/h/kg) of AMI were significantly lower than those previously described for younger subjects. Reversible alterating ECG were observed in 5 cases concomitantly with AMI peak plasma concentrations. The results indicate the desirability of reduced and/or divided daily doses of AMI in the elderly.

The efficacy and safety of perindopril in hypertension (HT) in the elderly have now been clearly demonstrated. In a randomized, double-blind placebo-controlled study conducted in 34 patients with a mean age of 84 years, we observed a significant reduction in systolic blood pressure (SBP) by 10% (p less than 0.001) and in diastolic blood pressure (DBP) by 9% (p less than 0.01) in the perindopril group. In the placebo group, the reduction observed was 5% and 4% respectively, although the difference between the two groups was not significant. The clinical and laboratory safety was satisfactory. However, in the treated group, there was a significant increase in serum potassium (p less than 0.01), which nevertheless remained within normal limits. An open study conducted in 91 patients with a mean age of 79.1 years, followed over a period of 6 months, confirmed the very good acceptability of the drug, despite the transient reduction in creatinine clearance observed in one female patient. The efficacy, evaluated less reliably in an open study, appeared to be excellent as 92.5% of patients were controlled by the end of treatment. In a study in healthy subjects, Reid observed a more intense effect on blood pressure (BP) in elderly subjects, which could be partly explained by a higher blood pressure level and by earlier and more prolonged converting enzyme inhibition (not significant). The practical value of this angiotensin converting enzyme (ACE) inhibitor, related to its efficacy and safety, is reinforced by a theoretical value: its action on arterial compliance, its beneficial effect on cardiac function, its potential action on the renin-angiotensin system of the brain, the structural modifications induced in the arterial wall open extremely stimulating prospects in the field of aging.

Pharmacokinetic profiles of imipramine and a newer tetracyclic antidepressant, maprotiline, were studied in elderly (75–83 years of age) subjects who were given a single oral dose of 125 and 175 mg, respectively, of these drugs. The apparent elimination half-life of imipramine was 20.8–34.9 h (mean 26.4 h), its biovailability (F) was 40–64% (mean 57%), and the apparent plasma clearance was from 0.27–0.57 h/kg (mean 0.41 h/kg). Maprotiline had a longer half-life (mean 31.5 h range 20.6–51.8 h, but its bioavailability (mean 50%) and plasma clearance (mean 0.49 h/kg) values were in the range similar to those seen after imipramine. It appears that the elimination half-life of imipramine is longer and its plasma clearance is markedly reduced in elderly subjects when compared to values reported in young adults. Subjective clinical side effects were minimal with the two drugs. However, alterations in heart rate, blood pressure, or electrocardiogram occurred in all subjects. This suggests that caution should be exercised before initiating and during the treatment of elderly patients with these antidepressant drugs.

The difficulty of defining a precise nosologic framework for mental decline is linked, on the one hand, to the contradictions surrounding the term normalcy as age increases, and, on the other, to the fact that mental decline has been mired for years under a term that must be definitively proscribed: "psycho-compartmental disorders of senescence". In this catch-all++ proscribed: "psycho-compartmental disorders of senescence". In this catch++-all it is, in fact, essential to identify diseases whose nature, prognosis and, above all, therapeutic approaches differ fundamentally one from the other; to confuse them is to risk dramatic consequences. Standardization of diagnostic criteria through the combined use of clinical data, the DSM III classification, scored tests (MMS, Hachinsky, etc.), as well as scannography, presently makes it possible to arrive at the diagnosis of dementia with reasonable accuracy. This standardization++ has its limits and is not necessarily useful in atypical cases. It is nevertheless an indispensable tool for epidemiological studies and therapeutic trials.