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Background To our knowledge, there are few indices that can assess oral health in the elderly. Those that are currently used are subjective and test the impact of oral health on quality of life. It appears to be relevant to create an easy and reproducible index, based on an oral health clinical exam that can be correlated with infectious disease risk in the elderly. Objectives This article aims to explain the methodology used to create an oral health index to assess infectious disease risk in elderly patients more than 65 years old. Design Cluster randomized trial. Setting Long-term care and rehabilitation facilities. Participants All patients who were included were 65 years old or older and were present in participant wards at the beginning of the study or were admitted during the study period. Measurements The assessment index was developed with the assistance of two dentists, after conducting a literature review. This was an index composed of eight criteria, which included most oral health problems associated with infections in the elderly. A score of 1 was given if a single criterion was observed. The final score ranged from 0 to 8 (0 for a healthy oral health index and 8 for a bad index). Results The oral health index was used in 2513 patients. This index grew significantly with age (P = 0.002) and malnutrition (P = 0.004). The pneumonia incidence rate was significantly correlated with the oral health index (P = 0.002). Conclusion This index is easy to use, with few items, and it takes into account most infectious disease risk factors. It would be interesting to integrate this score into a routine admission check-up process in the elderly for the purpose of preventing infectious diseases.

International audience; PURPOSE: Idiopathic generalized epilepsies (IGE) are age-related epileptic syndromes mainly described in children and adolescence. Our aim is to describe their electroclinical features in the elderly. METHODS: Patients aged 70 years or more were prospectively selected in a geriatric EEG laboratory on the basis of rhythmic generalized spikes and waves discharges. Their clinical data were then examined to ascertain the syndromic diagnosis. RESULTS: Among 1181 geriatric patients referred for EEG over a 30-month period, IGE were identified in 10 cases. Eight patients began seizures in childhood or adulthood (3 childhood absence epilepsies, 2 juvenile/adult myoclonic epilepsies and 3 epilepsies with-generalized-tonic-clonic-seizures alone (EGTCS)) and 2 very late in life with EGTCS. The early-onset IGE cases had usually experienced a quiescent long period in adulthood before relapsing late in life. This relapse, mostly severe, consisted of absence status, myoclonic status or repeated generalized tonic clonic seizures and was often not-situation related. Absence status and myoclonic status were stopped by Clonazepam. The two late-onset IGE cases had familial history of epilepsy. Inappropriate antiepileptic drugs (AED) previously given in four patients with two worsenings were corrected. CONCLUSIONS: In this study, the non-negligible number of elderly cases observed over a short period of time suggests that IGE are frequent in the elderly but underestimated until recently. IGE may be lifelong with late severe exacerbations. A few very late-onset IGE cases exist. EEG remains useful in contributing to diagnose IGE and AED adjustment continues to be beneficial at extreme age.

Because of a lack of efficacy of influenza vaccination in elderly population, there are still numerous outbreaks in geriatric health care settings. The health care workers (HCW) flu vaccination is known to get herd immunity and decrease the impact of influenza in elderly population living in geriatric health care settings. However, the rates of vaccinated HCWs are still low in France. The French Geriatric Infection Risk Institute (ORIG) performed the VESTA study, a three-phase multicentre to identify factors limiting vaccination in HCWs, and to develop and implement active programs promoting HCWs influenza vaccination. To implement multicenter programs to enhance HCW influenza vaccination. It was a cluster randomised interventional studies. 43 geriatric health care settings (GHCSs), long term care and rehabilitation care settings in France. 1814 Health care workers from 20 GHCSs in the interventional group and 2,435 health care workers in 23 GHCSs in the control group. After the failure of a first educational program giving scientific information and. tested during the 2005–06 flu season in 43 HCSs, a second program was designed with the help of marketing experts, one year after Program 1. The objectives were to involve HCWs in the creation of “safety zones”, and to give personal satisfaction. Program 2 was tested during the 2006–07 season. 20 of the 24 HCSs from the Program 1 cluster were included in the Program 2 cluster (1,814 HCWs), and 16 of the 19 HCSs from the Control 1 cluster, plus 7 new HCSs with interest in participating, were included in the Control 2 cluster (23 HCSs; 2,435 HCWs). The efficacy of each program was assessed by calculating and comparing the percentage of vaccinated HCWs, from all HCSs taken together, in the program and control clusters. Program 1 failed to increase the HCW vaccination coverage rate (VCR) (Program 1: 34%; Control 1: 32%; p>0.05),). Program 2 increased the VCR in HCWs (Program 2: 44%; Control 2: 27%; Chi2 test, p

Chronic obstructive pulmonary disease (COPD) is a chronic disease characterized by incompletely reversible airflow limitation, measured by a decrease of FEV(1)/FVC ratio. International consensus does not agree on a single threshold for this ratio, which can define airflow obstruction. Although the prevalence of COPD in the elderly population varies according to the definition used, it definitely increases with age and could reach 15% in those over 65 years of age. Therefore, ageing of the population should result in increased prevalence and socioeconomical costs of COPD during coming years. In France, diagnosis of COPD in the elderly is difficult, late and insufficient. Management, which has the same goals as in younger populations, has to be global and coordinated. Some points should be considered with particular attention considering the cumulative risks related on the one hand to COPD and on the other to ageing: pharmacological side-effects, decreased physical and social autonomy, nutritional impairment, comorbidities. Given the lack of specific data in elderly populations, pharmacological indications are generally considered to be the same as in younger populations, but some additional precautionary measures are necessary. Pulmonary rehabilitation seems to be beneficial at any age. Palliative care comes up against important difficulties: an indefinite beginning of the palliative stage in COPD; insufficient palliative care resources; insufficient communication; insufficient utilization of palliative care resources. Global COPD management in elderly requires coordination, best reached in health care network organizations involving medical and/or social professionals.

In Europe, 60% of all cancers and 75% of all deaths from cancer occur in patients older than 65 years. The incidence of many cancers (prostate, colorectal, and hematological) either increases with age or remains high (breast and lungs). The two principal characteristics of cancer in the elderly are late diagnosis and comorbidity that requires specific geriatric assessment and cooperation between the oncologist and the geriatrician. Academic and pharmaceutical industry research must focus on the specificities of cancers in the elderly and of response to treatment according to functional abilities and comorbidity. Equal access to high quality medical care and procedures must be ensured, regardless of age; this is not currently the case everywhere.

Although the role of inflammation has been studied in specific diseases or in community living elderly, data in hospitalized acute care elderly patients are scarce. The present study was designed to determine the predictive value of sociodemographic, clinical and biological factors for mortality in acute care geriatric wards. Retrospective study was conducted in two acute care wards in a university-based geriatric hospital with elderly patients (n=224) consecutively admitted to acute care wards with available medical files. Sociodemographic variables, primary medical diagnosis and number of associated conditions, dementia, depression, pressure sores, functional status (measure by the activities of daily living=ADL scale), weight, and plasma levels of albumin, transthyretin, C-reactive protein (CRP) and orosomucoid were recorded at admission. Patients who died in the acute care wards were compared to those who survived. The mean length of stay was 16+/-13 days; mortality was 12%. Univariate analysis revealed that disability, no anti-depressant drug, pressure ulcers, a higher number of associated conditions, living with another person, and biological markers of malnutrition (albumin35g/l, transthyretin200mg/l) and inflammation (CRPor =30mg/l, orosomucoidor =1.25g/l) were significantly associated with an increase in the risk of death. The logistic regression model retained CRPor =30mg/l (odds ratio (OR)=3.72, 95% confidence interval (CI)=1.34-10.31; p=0.009) and disability for at least one ADL item (OR=2.16, 95% CI=1.55-2.99; p0.001) as independent risk factors for death. We conclude that CRP and disability are strong independent risk factors for death in this population, and special attention should be paid to these patients in an integrated therapeutic approach to geriatric care.

International audience; Background: Age and short leukocyte telomeres have been associated with a higher risk of Alzheimer's disease (AD). Inflammation is involved in AD and it is suggested that anti-inflammatory interleukin-10 (IL-10) may partly antagonize these processes. Objective: The aim is to correlate telomere length (TL) in peripheral blood mononuclear cells (PBMC) from patients with AD to disease progression rate. Moreover, we evaluated whether TL was associated with IL-10 production by unstimulated or amyloid-beta (A beta)-stimulated PBMC. Methods: We enrolled 31 late-onset AD and 20 age-matched healthy elderly (HE). After a two-year follow-up period, patients were retrospectively evaluated as slow-progressing (ADS) (Mini Mental State Examination (MMSE) decline over the two years of follow-up = 5 points). TL was measured by flow cytometry and in vitro IL-10 production by enzyme-linked immunosorbent assay. Results: TL (mean +/- SD) for HE, ADS, and ADFwas 2.3 +/- 0.1, 2.0 +/- 0.1, and 2.5 +/- 0.1 Kb, respectively. ADS showed a shorter TL compared to HE (p = 0.034) and to ADF (p = 0.005). MMSE decline correlated with TL in AD (R-2 = 0.284; p = 0.008). We found a significant difference in IL-10 production between unstimulated and A beta-stimulated PBMC from ADS (40.7 +/- 13.7 versus 59.0 +/- 27.0; p = 0.004) but not from ADF (39.7 +/- 14.4 versus 42.2 +/- 22.4). HE showed a trend toward significance (47.1 +/- 25.4 versus 55.3 +/- 27.9; p = 0.10). Conclusion: PBMC from ADF may be characterized by an impaired response induced by A beta and by a reduced proliferative response responsible for the longer telomeres. TL might be a contributing factor in predicting the rate of AD progression.

International audience; It is well known that both falls and epileptic seizures are very frequent and harmful in the elderly. Moreover, although seizures may cause falls, their relationship is poorly documented in this population. We report four women (mean age: 84.5 years) who presented falls with: late-onset focal seizures of possible parietal (Case 1) or frontal localisation (Case 2), early onset with late aggravation of juvenile myoclonic epilepsy (Case 3), and generalised situation-related myoclonic seizures (Case 4). Falls were presumably associated with tonic posturing of left (Case 1) or right (Case 2) hemibody, to bilateral and massive myoclonic jerks (Cases 3 and 4) with a loss of consciousness (Case 3). The diagnosis of seizures was difficult and routine EEG was unremarkable in Cases 1 and 2, requiring video-EEG monitoring to capture the clinical events. Adequate treatment offered recovery from seizures and falls in all patients. Other mechanisms of seizure-induced falls in older patients and their management are discussed. In conclusion, falls may be caused by different seizure types and appear to be underestimated due to difficulties in seizure diagnosis in the elderly. Recognizing falls related to seizures is important in geriatric practice, as it facilitates adequate management.

There is no single universally accepted biochemical marker of nutritional status in the elderly. Many markers are affected by non-nutritional factors.The purpose of this study was to determine the biological parameters best related to anthropometric markers of malnutrition in an elderly polypathological population, and determine cutoff values for these potential parameters to diagnose malnutrition.This prospective study enrolled 116 elderly hospitalized patients and 76 elderly outpatients. Nutritional status (albumin, transthyretin, body mass index (BMI), skinfold thickness) and biological parameters (leptin, insulin-like growth factor-1 (IGF-1), IGF binding protein-1 (IGFBP-1), IGFBP-3, C-reactive protein (CRP), orosomucoid) were assessed. We defined malnutrition according to the lowest quartile of BMI and skinfold thickness measured in a large healthy elderly French sample population.In this sample of elderly patients (age: 85+/-7 years old), leptin concentration was the only biological parameter significantly related to nutrition status. Independent correlations were found between leptin concentration and BMI, skinfold thickness and sex. The relationship between nutritional status and leptin concentration is significantly different in each sex: the more the patients are undernourished, the lower the leptin concentration in both sexes. The optimal leptin cutoff value for the diagnosis of malnutrition in this population was 4 microg/l in men (sensitivity 0.89, specificity 0.82) and 6.48 microg/l in women (sensitivity 0.90, specificity 0.83).Leptin concentration is highly correlated with anthropometric data whereas albumin or transthyretin are known to be also influenced by morbidity and inflammatory conditions. Serum leptin concentration could be used for nutritional assessment in elderly patients with acute diseases.

International audience; We investigated IL-10 and IL-6 production in amyloid-beta (A beta) stimulated peripheral blood mononuclear cells (PBMCs) in twenty Alzheimer's disease (AD) patients with slow progression, eleven with fast progression, and twenty age-matched controls. Promoter polymorphisms in IL-10 (position -592, -819, -1082), IL-6 (-174), transforming growth factor-beta 1 (TGF-beta 1) (-10, -25), interferon-beta (IFN-gamma) (-874), and tumor necrosis factor-alpha (TNF-alpha) (-308) genes were analyzed. IL-10 production after A beta stimulation was high in PBMCs from slow decliners and almost completely abrogated in fast decliners. Association between AA IFN-gamma low-producing genotype and fast progression was demonstrated. Investigations in a larger sample will clarify these findings.

We compared the densities of lesions immunolabeled with ubiquitin, tau and beta A4 antibodies and stained by various silver impregnations, with the intellectual status. The densities of senile plaques and neurofibrillary tangles labelled by anti-ubiquitin antibody were correlated with the Blessed test score. Ubiquitin-positive neurofibrillary tangles were less numerous than those labelled by Gallyas, anti-tau, Bodian's and Bielschowsky's methods. There were five times more beta A4 deposits than ubiquitin positive plaques. beta A4 deposits could be numerous in cases in which ubiquitin immunolabelling was entirely negative. Bielschowsky's method, silver methenamine and thioflavin S revealed more senile plaques than anti-ubiquitin, whereas anti-tau, Gallyas', Bodian's and Cross' techniques revealed similar numbers. Anti-ubiquitin positive lesions were correlated with the severity of dementia. Compared with other staining methods, sensitivity of anti-ubiquitin was weaker for neurofibrillary tangles than for senile plaques. These findings suggest that ubiquitin epitopes are linked to the neurofibrillary changes (in the perikaryon or within the senile plaques), and are absent from beta A4 deposits, either diffuse or compact.

Cholinergic neurons were studied by immunohistochemistry, with an antiserum against choline acetyltransferase (ChAT), in the basal forebrain (Ch1 to Ch4) of four patients with Alzheimer's disease (AD) and four control subjects. ChAT-positive cell bodies were mapped and counted in Ch1 (medial septal nucleus), Ch2 (vertical nucleus of the diagonal band), Ch3 (horizontal nucleus of the diagonal band) and Ch4 (nucleus basalis of Meynert). Compared to controls, the number of cholinergic neurons in AD patients was reduced by 50% on average. The interindividual variations in cholinergic cell loss were high, neuronal loss ranging from moderate (27%) to severe (63%). Despite the small number of brains studied, a significant correlation was found between the cholinergic cell loss and the degree of intellectual impairment. To determine the selectivity of cholinergic neuronal loss in the basal forebrain of AD patients, NPY-immunoreactive neurons were also investigated. The number of NPY-positive cell bodies was the same in controls and AD patients. The results (1) confirm cholinergic neuron degeneration in the basal forebrain in AD and the relative sparing of these neurons in some patients, (2) indicate that degeneration of cholinergic neurons in the basal forebrain contributes to intellectual decline, and (3) show that, in AD, such cholinergic cell loss is selective, since NPY-positive neurons are preserved in the basal forebrain.

Elderly patients represent a heterogeneous population in which decisions on cancer treatment are often difficult. The present study aims to report a 2-year period of the activity of geriatric assessment consultations and the impact on treatment decisions. Since January 2007, we have systematically carried out geriatric consultations, using well-known international scales, for elderly patients in whom treatment decisions appear complex to oncologists. From January 2007 to November 2008, 161 patients (57 men, 104 women; median age 82.4 years, range 73-97) were seen at geriatric consultations. Most of the patients (134/161) were undergoing first-line treatment and cancer was metastatic in 86 patients (53%). Geriatric assessment found severe comorbidities (grade 3 or 4 in CIRS-G scale) in 75 patients, dependence for at least one activity of daily living (ADL) in 52 patients, cognitive impairment in 42 patients, malnutrition in 104 patients (65%) and depression in 39 patients. According to the oncologists' prior decisions, there were no changes in treatment decisions in only 29 patients. Cancer treatment was changed in 79 patients (49%), including delayed therapy in 5 patients, less intensive therapy in 29 patients and more intensive therapy in 45 patients. Patients for whom the final decision was delayed or who underwent less intensive therapy had significantly more frequent severe comorbidities (23/34, p

beta A4 immunoreactivity was studied in temporal neocortex, area 22, of 26 cases with graded intellectual status. Sampling was performed in psychometrically assessed women over 75 years, either intellectually normal or affected by senile dementia of Alzheimer type of various degrees of severity. beta A4 antibodies labelled various types of beta A4 deposits in 22/26 cases: (1) small, stellate deposits; (2) diffuse deposits, (3) primitive, (4) classic and (5) compact, or burn-out, plaques. The densities of the stellate deposits, primitive and classic plaques were always positively linked with the severity of the intellectual status, whereas those of the diffuse deposits were not. This was due to a single case with normal mental status and numerous beta A4 deposits. Densities of stellate and diffuse deposits were higher in layers I, III and IV, whereas densities of primitive, classic, and neuritic plaques observed with Bodian's technique were higher in layers II and III. Topographical distribution of each subtype did not vary as a function of the severity of the intellectual status. These data suggest that deposits of beta A4 protein appear a necessary but not a sufficient condition for inducing neuritic plaque formation, in the neocortex as in other brain areas. beta A4 proteins could accumulate either as diffuse deposits, which do not cause an intellectual deficit, or as dense deposits, associated with argyrophilic neurites, i.e., classic neuritic plaques, highly correlated to the intellectual impairment. This evolution could depend on factors which are laminarily distributed in the neocortex.

Objective: The aim of this review of the literature is to report the factors which both contribute to the frailty syndrome and increase hip fracture risk in the elderly. This work is the fruit of common reflection by geriatricians, endocrinologists, gynecologists and rheumatologists, and seeks to stress the importance of detection and management of the various components of frailty in elderly subjects who are followed and treated for osteoporosis. It also sets out to heighten awareness of the need for management of osteoporosis in the frail elderly.Design: The current literature on frailty and its links with hip fracture was reviewed and discussed by the group.Results: The factors and mechanisms which are common to both osteoporosis and frailty (falls, weight loss, sarcopenia, low physical activity, cognitive decline, depression, hormones such as testosterone, estrogens, insulin-like growth factor-I (IGF-I), growth hormone (GH), vitamin D and pro-inflammatory cytokines) were identified. The obstacles to access to diagnosis and treatment of osteoporosis in the frail elderly population and common therapeutic pathways for osteoporosis and frailty were discussed.Conclusion: Future research including frail subjects would improve our understanding of how management of frailty can can contribute to lower the incidence of fractures. In parallel, more systematic management of osteoporosis should reduce the risk of becoming frail in the elderly population.

Protein–energy malnutrition and nosocomial infection (NI) are frequent in elderly patients, and a causal link between the two has often been suggested. The aim of the present study was to identify the nutritional parameters predictive of NI in elderly patients. We assessed on admission 101 patients (sixty-six women, thirty-five men, aged over 65 years) admitted to an acute care of the elderly department. Sarcopenia was detected by dual-energy X-ray absorptiometry, with appendicular skeletal muscle mass expressed with respect to body area. Weight, BMI, albuminaemia, serum transthyretin and C-reactive protein values were also determined on admission, and known risk factors, such as functional dependence and invasive biomedical material, were also evaluated. After up to 3 weeks of hospitalisation, patients were classified according to whether they had developed an NI. After 3 weeks of hospitalisation, we found that twenty-nine patients had suffered an NI, occurring after a mean of 16·1 d. Patients who were sarcopenic on admission had a significantly higher risk of contracting an NI (relative risk 2·1, 95 % CI 1·1, 3·8). None of the other morphometric or biological parameters differed significantly between the two groups of patients on admission. Patients who experienced an NI were also more likely, on admission, to have a medical device (P=0·02 to P=0·001 depending on the device), to have swallowing problems (P=0·002) or to have restricted autonomy (P

How well the motor symptoms assessed by the motor section of the Unified Parkinson Disease Rating Scale (UPDRS3) reflect the neuronal loss observed in the substantia nigra is not known.To study the relationships among the motor symptoms assessed by the UPDRS3, Lewy body-associated neuronal loss in the substantia nigra, and duration of disease.Longitudinal, prospective, clinicopathological study.Long-term care facility of a university hospital.Eighteen elderly patients with a parkinsonian syndrome, studied prospectively but selected post mortem on the basis of the presence of Lewy bodies, and 5 age-matched control subjects.One map of a section of the substantia nigra, indicating the location of all the nucleolated neuronal profiles, was drawn for each case. Neuronal density was estimated using a tessellation method. The relationship between time and neuronal loss and between neuronal loss and motor symptoms (assessed by the UPDRS3) was studied by means of regression analysis, using linear and exponential models.The neuronal density was linearly linked with the UPDRS3 score (r = -0.83 [P.001]). Each point added to the UPDRS3 score corresponded to an estimated loss of 25 neurons/mm(3). The density of neuronal profiles in the substantia nigra decreased exponentially with time (r = -0.73 [P.001]). Extrapolation of the curve suggested a presymptomatic phase of 5 years.The UPDRS3 score is linearly linked to neuronal density, which, in Lewy body diseases, decreases exponentially with time at a similar pace in this series of elderly patients and in the younger patients described in the literature.

To evaluate routine use of access sites in the arm for percutaneous caval filter placement (PCFP) in elderly patients. Neck arthritis, patient anxiety, access site thrombosis or fecal/urinary incontinence complicating jugular or femoral access may require alternative access sites in this population.Access via the right arm was chosen for PCFP (VenaTech LP). The indication for PCFP was deep vein thrombosis, a history of pulmonary embolism, and a contraindication to anticoagulant therapy. Ultrasound-guided puncture was performed after diameter measurement of the arm veins (ØAV). The filter was inserted with standard imaging procedures. Procedural difficulty was graded and compared with ØAV and the angle from the arm vein to the superior vena cava (alphaAV/SVC).Over 2 years, 16 patients (14 women, 2 men) with an average age of 90 years (range 79-97 years) were included in the study. The average ØAV value of the basilic or brachial veins was 4.2 mm (range 3.0-5.1 mm). The minimal ØAV for successful access was determined after the first 15 patients. No hematoma occurred at the puncture sites. The average alphaAV/SVC value was 62 degrees (range 29 degrees -90 degrees ). Arm access was possible in 12 of 16 patients (75%) with ØAVor= 3.5 mm and alphaAV/SVCor= 29 degrees . Every procedure via the arm was graded "easy" by the operator, regardless of angulation values. Femoral access was used in one case due to the impossibility of traversing the heart (patient no. 2), and jugular access was used in 3 of 16 (19%) patients due to puncture failure (patient no. 4), small ØAV (3 mm) (patient no. 6), and stenosis of the distal right subclavian vein (patient no.16), respectively.PCFP via the arm can be routinely accomplished in patients older than 75 years, provided ØAVor= 3.5 mm, and alphaAV/SVCor= 29 degrees .

Little is known of the influence of nutritional status on cytochrome P450 (CYP) 1A2 activity in elderly patients. Thirty elderly institutionalised patients with malnutrition (group A, aged 88 +/- 5 years) and 24 without (group B, aged 81 +/- 9 years) were included. Malnutrition was defined as weight loss of >10% over the previous 6 months and/or a body mass index (BMI)

Senile plaques and neurofibrillary tangles are the markers of Alzheimer’s disease. They are also found in old patients who have been considered to be intellectually normal throughout their life, a situation referred to as “physiological aging”. The neurofibrillary tangles are made of abnormally phosphorylated tau. The anti-tau antibody labels not only the neurofibrillary tangles, but also the crown of the senile plaques and the neuropil threads interspersed between the cell bodies and the plaques. The senile plaque comprises a core made of Aβ peptide surrounded by a neuritic crown. The anti-Aβ antibody also labels “diffuse deposits”, i.e. ill limited areas of immunoreactivity which lacks the characteristics of the amyloid substance. The intellectual deficit appears to be statistically linked with the density of the tau-positive alterations -tangles, threads and plaque crowns — which usually appear simultaneously in a given cortical area. In the entorhinal area, their density increases proportionally to the intellectual deficit without threshold, suggesting that ageing and disease are a continuum. In the isocortex, the progression of the tau positive alterations is, on the contrary, stepwise — in a “all or none” fashion — from the hippocampus to the primary cortices, through the associative multimodal areas. The tau positive lesions probably progress through connections: they indeed disappear from areas, that have been disconnected by additional lesions (such as infarcts).

The relationship between the neurofibrillary tangles and the intellectual deficit observed in senile dementia of the Alzheimer type was studied in 27 patients over the age of 75. The presence and density of tau positive tangles were assessed in six areas including limbic, paralimbic, and isocortical cortices. In the isocortical areas, the presence [1] or absence [0] of neurofibrillary tangles was better correlated with the Blessed test score than the density of the neurofibrillary tangles profiles. Multivariate analysis showed that the number of areas containing at least one neurofibrillary tangle was the best explanatory variable of the intellectual status. The cortical areas were ranked according to the prevalence of their involvement. The presence of tangles in an area of a given rank took place only if the areas of lower ranks were also involved. It is proposed that the presence of tangles in a given area is a more significant information than the value of their density. These data may lead to new diagnostic procedures.

e18505 Background: DLBCL occurs frequently in elderly pts and recent studies demonstrated that immunochemotherapy with R-mini-CHOP could be a safe and effective treatment for selected pts over 80 years Methods: Since 2008, R-mini-CHOP has been the treatment proposed for elderly pts with DLBCL referred to our oncogeriatric unit, irrespectively of their performance status (PS). We reviewed data of elderly pts treated for DLBCL at our institution from January 2008 to June 2011. Results: 74 pts (50 women, 24 men) were treated for DLBCL. Median age was 85 years (range 71–97), 84 % of pts ≥ 80 years and 16 % of pts ≥ 90 years. 68 pts (92%) had at least one comorbidity. Median number of daily medicines was 4 (range 0 – 12), irrespectively of treatments for DLBCL. Malnutrition was diagnosed in 49 pts. 50 pts (67,5 %) had a poor PS (> 2). Age-adjusted International Pronostic Index (aaIPI) was 0-1 in 9 pts, 2 in 28 pts and 3 in 35 pts. 61 pts were treated with mini-CHOP (cyclophosphamide: 400 mg/m2 D1; doxorubicine: 25 mg/m2 D1; vincristine: 1 mg total dose D1 and prednisolone 40 mg/m2 by oral route from D1 to D5) plus rituximab (375 mg/m2 D1) every 21 days for 6 cycles. Doxorubicine was replaced by etoposide (150 mg/m2 D1) for 5 pts because of cardiac dysfunction. 8 pts received reduced dose intensity chemotherapy ( without doxorubicine) for the 2 first cycles because of high risk toxicity. Prophylaxis of neutropenia with GCSF was systematic. Median survival was 11 months. 21 pts died during treatment, because of progressive disease (13) or treatment toxicity (6). Complete response (CR) was observed in 44 pts (59,5 %). With a median follow-up of 18 months, 11 relapses were observed. In our population study, aaIPI appears highly predictive of CR, with a CR Rate of 87,5 %, 75 % and 43% respectively for pts with aaIPI 0 - 1, 2 and 3.Hematological toxicity was the most common side effect. Grade 3–4 neutropenia was observed in 28% of the pts and grade 3–4 thrombocytopenia in 12%. 14 pts (19%) experienced at least one episode of febrile neutropenia. Conclusions: In unselected elderly pts with DLBCL, immunochemotherapy with R-mini-CHOP can be effective, but with significant toxicity, even using systematic G-CSF prophylaxis. Prognosis remains poor for pts with aaIPI 3

Background Despite a surge of 15,000 deaths caused by the 2003 heat wave in France, the annual winter excess mortality rate remains a recurring phenomenon that is quantitatively greater than the isolated summer event. Methods Coefficients of Seasonal Variations in Mortality (CSVMs) were calculated using monthly mortality data from 1998 to 2007 in France. CSVM was a percentage representing the excess death rate from December to March inclusively, against average, monthly mortality from the other 8 non-winter months. Sociodemographic parameters and environmental factors were also obtained. Univariate and multivariate analyses were performed to identify risk factors of increased winter mortality. Results The data revealed an annual winter excess death of 23,836 (± 7951) (mean ± 1 standard deviation) cases. On average, CSVM in France was +14.94% (13.54 [12.03; 19.70]) (mean, median, and interquartile intervals). Multivariate analysis results revealed that several factors contributed to the CSVM: sociodemographics, such as age (CSVM higher for the population older than 75) and death location (CSVM higher in nursing homes), environmental factors, such as the severity of the winter season (per monthly minimal temperature), and estimated number of influenza-like illnesses (ILI). Correlation between observed and predicted CSVMs was extremely consistent (R2 = 0.91). Conclusion There was a fundamental belief that residents in nursing homes were well protected from cold spells and their consequences. Our results revealed this to be a mere misperception.

OBJECTIVE: To determine the prevalence of dementia in a population of hospitalized or institutionalized elderly patients, and that of associated diseases according to dementia type. DESIGN: Retrospective analysis of a database of diagnostic codes. SUBJECTS: All patients admitted to 1 of the 4 geriatric units participating in the study at the Charles Foix Hospital between 1980 and 1989. MEASUREMENTS: All diagnoses mentioned in the discharge summary that could cause or contribute to hospitalization were recorded for each patient. A final list of 54 different diagnoses could be recorded for each patient. Dementia was subdivided into 3 subtypes: Alzheimer dementia (DAT), vascular dementia (VD), and other types of dementia (unclassifiable dementia). MAIN RESULTS: The study involved 3447 patients aged 81.0 ± 8.3 years, of whom 27.7% were men. Dementia was the most frequent disease in this population (34.3%); Alzheimer disease was responsible for 15%, vascular dementia for 9.5%, and other types for 9.8%. The average number of associated diseases was 3.23 ± 2.10 in the Alzheimer dementia group, 4.73 ± 2.38 in the vascular dementia group, and 3.96 ± 2.26 in the nondemented group. Parkinson disease was present in 15.5% of patients with unclassifiable dementia, compared with 7.6% in the nondemented group (P < 0.001). There were significantly more diseases commonly seen in bedridden patients in the group of patients with both other types of dementia and Parkinson disease than in the group of other types of dementia patients without Parkinson disease (P < 0.01). CONCLUSION: Dementia was the most common disease observed in our elderly institutionalized population. Alzheimer patients had significantly fewer associated diseases than nondemented patients, whereas the reverse was found in the vascular dementia group. The co-existence of Parkinson disease and dementia in our population was associated with the poorest health status, as these patients were more likely to present simultaneously such conditions as pressure sores, incontinence, dehydration, or iatrogenesis.

The aim of this study was the analysis of the development of neurofibrillary tangles (NFT) and senile plaques (SP) during aging and senile dementia of the Alzheimer type. The lesions stained by ubiquitin, tau and βA4 antibodies were studied in Brodmann's area 22 (superior temporal gyrus) in 29 cases. Samples were from a group of women over 75 years of age, psychometrically assessed and either normal or affected by Alzheimer's disease at various degrees of severity. NFT were less numerous when revealed by ubiquitin than by tau antibodies, suggesting that ubiquitin immunoreactivity appeared later in the course of the disease. Ubiquitin immunoreactive (IR) SP were made of clusters of IR neurites usually organized around a central amyloid core. Two types of ubiquitin-IR SP were designated. “Globular neurite SP” contained weakly immunostained globular neurites. They were densest in the least affected cases. However, they were not seen in every normal or lightly affected case, and were always present in the most affected ones. The density of these globular neurite SP was not significantly correlated with the severity of dementia, nor with the density of the lesions stained by tau antibodies (neuritic component of SP, NFT and neuropil threads) or by βA4 antibodies (diffuse or dense deposits). The “curly neurite” type of SP contained curly neurites strongly immunostained by ubiquitin antibodies. They exhibited the highest density in the most affected cases, where they were always present. They were lacking in the least affected cases. They were always found together with the globular neurite SP. The density of these curly neurite SP was significantly correlated with the severity of dementia, and with the density of tau-IR lesions and dense amyloid βA4 deposits. It was not correlated, however, with the density of diffuse βA4 deposits. Our results suggest that the globular neurite SP and the curly neurite SP were not systematically linked. Ubiquitin immunoreactivity in the globular neurite SP could be a transient event in the course of the disease and in the formation of SP. On the contrary, ubiquitin immunoreactivity in the curly neurite SP and NFT seemed to appear after tau immunoreactivity. These ubiquitin conjugates could constitute an irreversible lesion related to dementia.

Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly Intergroupe PneumoGeriatrie SPLF-SFGG place sous l’egide de la Societe de Pneumologie de Langue Francaise (SPLF) et de la Societe Francaise de Geriatrie et Gerontologie (SFGG) : F. Puisieux, C d’Andrea, P. Baconnier, D. Bui-Dinh, S. Castaings-Pelet, B. Crestani, B. Desrues, C. Ferron, A. Franco, J. Gaillat, H. Guenard, B. Housset, C. Jeandel, G. Jebrak, A. Leymarie-Selles, E. Orvoen-Frija, F. Piette, G. Pinganaud, J.-Y. Salle, D. Strubel, J.-M. Vernejoux, B. de Wazieres, S. Weil-Engerer Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient’s oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).

An 88-year-old mentally normal woman (Blessed test score = 27) had very large amounts (397/mm2) of deposits stained by anti-beta A4 serum in the first temporal gyrus. Senile plaques and neurofibrillary tangles were lacking on sections stained with the Bodian's silver method, with anti-tau and anti-paired helical filament (anti-PHF) antibodies. The following beta A4 deposits were found in decreasing order of frequency: diffuse (64.8%), stellate (24.4%), primitive (10.2%), classic (0.6%) plaques. Compact plaques were not observed. Diffuse deposits predominated in layers I, III and IV. On the contrary, the rare classic plaques were located in layers II and III. No amyloid angiopathy was seen with Congo red stain although beta A 4 deposits were seen in vessel walls with immunocytochemistry. These data indicate that severe diffuse beta A4 deposits in the neocortex do not induce dementia. They suggest that the development of senile plaques composed of beta A4 amyloid and of degenerating neurites is not related solely to the density of the diffuse beta A4 deposits. Nor does it depend on the regional susceptibility of the nervous tissue since beta A4 deposits were seen in highly vulnerable cortical areas. Some other, as yet unknown, factors seem necessary. In addition, determination of beta A4 level in the neocortex is not sufficient for the diagnosis of dementia of Alzheimer type.

The distribution of lesions in Alzheimer’s disease (AD) is a much more widely debated topic today than it was a few years ago for the following reasons: (1) many epidemiological biases (lack of recognized criteria for normality in aging, frequency of associated pathologies, cohort effects) have been ignored by morphologists using retrospective data; (2) cerebral atrophy could be due mainly to loss of corticosubcortical radial columns of interconnected neurons and associated glial cells and myelin sheaths; (3) as a consequence, the measurement of neurons on histological samples deals mainly with their density and not with their actual number; (4) the density of the various types of lesions of gray matter seen in AD is different from one area to another, and global indexes could be misleading; (4) histochemistry with antibodies to proteins tau, Alz 50, and overall A4 has provided a broader range and a larger distribution of changes; and (5) the evidence concerning the extent and mechanism of white matter lesions is conflicting. The main pertinent data from the literature are critically assessed below.

A prospective longitudinal study was undertaken in a geriatric hospital on women over 75 years of age, clinically diagnosed as either intellectually normal or having senile dementia of the Alzheimer type (SDAT) of varying degrees of severity. Mental impairment was assessed prospectively. Fifteen brains from this population were studied to evaluate quantitatively the distribution of senile plaques (SP) in relation to cortical lamination. SP density in four neocortical areas (first temporal gyrus; supramarginal gyrus calcarine area; precentral gyrus) was significantly correlated with the degree of mental impairment. SP distribution in the cortical layers was evaluated by an indirect method and appeared to be fairly constant from one case to another. Significantly higher SP densities were observed in layers II and III of the temporal and occipital samples, while minimal values were noted in layer I. Lower densities of SP were found in layers V and IV of the occipital and temporal lobes. These data suggest a selective vulnerability of some areas of cortical projections in SDAT.

The mental status of 15 women over 75 years, either intellectually normal of affected by senile dementia of the Alzheimer type at various degrees of severity, was assessed prospectively by Blessed’s test score. The pattern and density of tau immunoreactivity were studied in temporal neocortex area 22, and compared with those of PHF immunoreactivity and with the density of amyloid revealed by thio-flavin S.

A prospective study was undertaken to select mentally normal old subjects and patients with senile dementia of the Alzheimer type (SDAT). The test score of Blessed et al. (1968) (BTS) was used to determine the severity of mental impairment. A pathologic study confirmed the diagnosis of either SDAT or normal brain aging at postmortem examination in 12 cases. The cortical area and the cortical perimeter of the different cerebral lobes were measured on 1-cm-thick coronal sections using a semiautomatic image analyzer. Cortical length and thickness were calculated using perimeter and area values. BTS was significantly correlated with both the area (r = 0.7695, P = 0.003) and the length (r = 0.7421, P = 0.006) of the temporal cortex. There was no significant correlation between BTS and thickness of the temporal cortex (r = 0.559, P = 0.059). These results show that reduction of length is one of the major determinants of cortical atrophy. Although this has to be confirmed by histological study, they favor the hypothesis of a column-selective atrophy in SDAT which should be considered in the interpretation of the microscopic data.