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

Objectif Estimation de la dependance, description des conditions de vie (aides apportees par des professionnels et l’entourage non professionnel, equipement technique et amenagement du logement), des besoins non combles et des perspectives de maintien a domicile des personnes âgees vivant a domicile en Alsace. Methode Realisee en 1996-97 en Alsace, cette enquete se compose de deux parties. Une enquete postale sur un echantillon de 15 600 personnes âgees de 75 ans et plus, tire au sort a partir des listes d’affiliation des caisses de retraites. Cette enquete apporte une image fiable de la population en terme de desavantage selon la classification de Colvez. Dans un second temps, une enquete a domicile aupres de 1 259 personnes selectionnees essentiellement parmi les plus desavantagees au sein de l’echantillon initial, a ete realisee afin de decrire leurs conditions de vie et leur dependance. La situation des differents groupes de dependance (GIR) a ete comparee en matiere d’aides humaines, d’equipements techniques et de conditions de logement. Resultats On a estime la population des 75 ans ou plus vivant a domicile a pres de 71 000 individus en Alsace. Selon l’enquete postale, la grande majorite (68 %) vit sans desavantage. Mais 6 000 personnes (8 %) ont besoin d’une aide pour la toilette et l’habillage dont 1 500 (2 %) restent confinees au lit ou au fauteuil. Selon l’enquete a domicile, entre 4 350 et 5 400 appartiennent aux groupes iso-ressources (GIR) 1 a 3. Dans notre enquete, la dependance est liee a l’âge et au sexe. L’aide apportee par l’entourage familial et/ou les proches est systematique et concerne l’ensemble des activites de la vie quotidienne, meme les plus intimes. Les professionnels n’interviennent le plus souvent qu’en complement et pour des activites techniques. Les services de gardes a domicile et en soins infirmiers ne concernent que les plus dependants. Chez ceux-ci, l’aide de l’entourage est trois fois plus important que l’aide des professionnels en terme de nombre d’activites prises en charge. Seuls 11 % des personnes GIR 1 a 3 considerent etre insuffisamment aides. L’equipement technique des logements est correcte, exclusion faite de la telealarme. Dans ce cas, l’absence d’equipement correspond soit a un manque d’information soit a un refus d’amenagement. Plus de 80 % des personnes âgees sont satisfaites de cette situation et n’envisagent pas d’entree en institution. Conclusion Cette etude confirme l’importante solidarite des familles et des proches envers leurs aines.

Resume Introduction. – Les candidemies, qui affectent principalement les patients neutropeniques d’oncohematologie et les malades fragilises de reanimation, peuvent egalement etre diagnostiquees chez des personnes âgees fragiles en geriatrie. Exegese. – Les auteurs rapportent quatre observations de candidemies mises en evidence chez des patients âges, polypathologiques et dependants, devant une fievre persistante ou recidivante apres une antibiotherapie a large spectre. Ces patients ont ete traites par fluconazole avec sterilisation des hemocultures sur milieu fongique en quelques jours. Trois des quatre malades sont decedes dans les semaines qui ont suivi le traitement antifongique en raison de la gravite des maladies associees. Conclusion. – ces observations montrent qu’il faut penser a une candidemie en cas de fievre persistante chez une personne âgee fragile. Le fluconazole, qui est aussi efficace que l’amphotericine B et bien tolere par le sujet âge, represente le traitement de premiere intention des candidemies des patients non neutropeniques.

Resume Propos. – Les fractures spontanees, de fatigue ou par insuffisance osseuse, sont bien connues en milieu rhumatologique, mais peu etudiees en milieu geriatrique. Methodes. – Nous avons realise une etude clinique prospective de 30 mois dans les unites de soins de longue duree de la Societe de gerontologie de l'Est (70 etablissements, 11 495 lits). Resultats. – Sur les 30 etablissements ayant detecte des fractures spontanees (soit 3 052 lits), nous avons releve 67 fractures spontanees (cinq de fatigue au niveau des pieds et 62 par insuffisance osseuse). Chez ces patients d'âge moyen 85 ± 7 ans, le point commun est le confinement au lit ou au fauteuil. La frequence des fractures spontanees, calculee en fonction du nombre de patients admis de facon consecutive dans ces unites de soins de longue duree, est estimee a 0,34 % (calcul prenant en compte 11 495 lits) et 1,3 % (calcul prenant en compte 3 052 lits). Les fractures des os longs sont particulierement frequentes (col du femur : 15, tibia et/ou perone : 14, diaphyse femorale : 13, humerus : 11). Les fractures de la diaphyse femorale ont le plus mauvais pronostic vital avec sept deces sur 13 versus deux deces sur 15 en cas de fracture du col du femur ( p Conclusion. – Contrairement aux fractures observees en milieu rhumatologique chez des patients jeunes et valides, les fractures par insuffisance osseuse observees en unites de soins de longue duree chez les personnes âgees concernent principalement les os longs et sont de mauvais pronostic. Les moyens de prevention restent a definir.

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

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

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

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

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.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.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.This 4-year study emphasizes the limits of antibiotherapy in eradicating WSBL-producing enterobacteria and the fact that only the strict respect of hygiene by all caregivers (isolation of patients exhibiting WSBL and washing-disinfection of the hands between each patient) limits the incidence of such infections.

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

To compare the clinical, biochemical, radiological features and the outcome of elderly and young patients with tuberculosis.Between 1980 and 1997, 83 patients diagnosed as having tuberculosis were treated in two departments of Internal Medicine and Geriatrics. They were divided into 42 young (65 years) and 41 elderly (or = 65 years) patients and differences in presentation between the two groups were analysed.A past history of tuberculosis was found in 10% of young and in 18% of elderly patients (p = 0.43). Cancer was more often associated with tuberculosis in elderly patients (2% vs 15%, p = 0.09). The sites of disease were similar in both groups with 2/3 of pulmonary infection. Comparison of the presenting symptoms showed no significant difference for weight loss (52% vs 66%, p = 0.31), fever (52% vs 56%, p = 0.90) and cough (33% vs 32%, p = 1). The skin testing was positive for the majority of the young adults (84% vs 58%, p = 0.11). The commonly observed biochemical abnormalities in elderly patients were an increased erythrocyte sedimentation rate (49 vs 69 mm/h: p = 0.03) and lymphocytopenia (1724 vs 1059/microliter, p0.01). There was no significant difference in radiographic findings between both groups with miliary tuberculosis in about 10% of patients. During the first three months of treatment, the mortality was especially high (22%) for the elderly patients.Comparison of the clinical and radiological features of tuberculosis in internal medicine showed no significant difference in young and elderly patients.

Spontaneous fractures (stress and bone insufficiency fractures) are well described in young healthy patients; however, few studies were conducted in the elderly.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.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 (P0.05).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.

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.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.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.

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

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

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

The concentration of somatostatin-like immunoreactivity (SLI), the molecular forms of SLI, serotonin and dopamine metabolites in cerebrospinal fluid of patients with senile dementia of Alzheimer type (SDAT), Parkinson’s disease (PD) and age-matched control patients were determined by reverse phase HPLC and by specific radioimmunoassay. The mean SLI level in the control group was 29.5 ± 8.9 fmol/ml. In SDAT and PD the mean SLI level was significantly lower (18.6 7.9 fmol/ml, 21.4 ± 8.1 fmoI/ml). HPLC separation of SLI yielded four peaks with a preponderance of Somatostatin-14 (SST-14) and Somatostatin-28 (SST-28). In SDAT and PD changes in the molecular pattern of somatostatin indicate an altered biosynthesis and/or processing of somatostatin.

References 1 Cros D, Gamby R, Serratrice G. Acne rheumatism. Report of a case. I RheumatoI1981;8:336-339. 2 Rosner lA, Richter DE, Huettner TL et al. Spondylarthropathy associated with hydradenitis suppurativa and acne conglobata. Ann Intern Med 1982;97:520-525. 3 Lindroth Y, Hansen B, Holst R. Sakroiliit och missbruk av anabola steroider. Liikartidningen 1989;86:3369-3370. 4 McCarty DI, Arthritis and allied conditions. Philadelphia: Lea and Febiger, 1985;820-82l. 5 liirvholm U, Bergmann BR, Elgefors B. Bakteriell infektion i sakroiliakleden. Liikartidningen 1984;81:2278-2279. 6 Traupe H, von Muhlendahl KE, Briimswig I, Happie R. Acne of the fulminans type following testosterone therapy in three excessively tall boys. Arch DerrnatoI1988;124:414-417. 7 Marynick SP, Chakmakjian ZH, McCaffree DL, Herndon IH. Androgen excess in cystic acne. N Engl I Med 1983;308:981-986. 8 Davis DE, Viozzi FI, Miller OF, Blodgett RC. The musculoskeletal manifestations of acne fulminans. I Rheumatol 1981;8:317-320. 9 Williamson DM, Cunliff WI, Gatecliff M, Scott DG. Acute ulcerative acne conglobata (acne fulminans) with erythema nodosum. Clin Exp DermatoI1977;2:351-354. 10 Goldschmidt H, Leyden I. Stein K~ Acne fulminans. Arch DermatoI1977;113;444-449. 11 Edlund E. Iohnsson U, Lidgren L et al. Palmoplantar pustulosis and sternoclavicular arthro-osteitis. Ann Rheum Dis 1988;47:809-815.

It is essential that patients' age, as well as period of hospitalisation and pathologies, be taken into account when assessing a departmental activity. The older the inpatients in internal medicine departments, the greater their need for care

The concentrations of somatostatin-like immunoreactivity (SLI) and substance-P-like immunoreactivity (SPLI) in lumbar spinal fluid of patients with senile dementia of the Alzheimer type (SDAT), multi-infarct syndrome, communicating hydrocephalus and control patients were determined by specific radio-immunoassay. Mean SLI and SPLI levels were significantly lower in an aged control patient group (mean age 83.5 +/- 5.6 years) than in an adult control patient group (mean age 30.8 +/- 10 years). In the latter group SPLI levels correlated negatively with age. Mean SLI levels decreased with deterioration in SDAT patients by up to 33% in late dementia. SPLI correlated with SLI in SDAT patients but was decreased significantly only in late dementia patients. Moderate and insignificant decreases of SLI were observed in patients with multi-infarct syndrome or communicating hydrocephalus. Analysis of SLI by gel-permeation chromatography revealed molecular heterogeneity of SLI. At least four peaks of SLI were eluted, two of which had apparent molecular weights of about 10,000 and 15,500, possibly representing somatostatin precursors. The ratio of SRIF to SLI of higher molecular weight was increased in patients with dementia compared to control patients.

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

Since there are divergencies in the thyrotropin (TSH) response to thyrotropin-releasing hormone (TRH) in old age, and since a hypothalamopituitary dysfunction has been suggested in the elderly, we have studied the thyroid function and the TRH responsiveness of TSH and prolactin (PRL) in 56 euthyroid patients over 70 years old, grouped according to age (70-79, 80-89, 90 or more years) and sex. Results were compared to those of 15 postmenopausal women and 11 men. In the elderly patients there was a decrease in plasma tri-iodothyronine (T3) and an increase in reverse T3 (rT3) levels while thyroxine (T4), basal TSH and PRL levels remained normal. The mean TSH and PRL responses to TRH (250 micrograms i.v.) were reduced but there was no age effect within the elderly. Only a sex effect was detected, TSH and PRL responses being appreciably lowered in men. In eight patients without severe disease or malnutrition, the response of TSH was not significant. We conclude that despite an apparent euthyroid status, TSH and PRL responses are blunted in elderly patients, and more in men than in women. These data, consistent with a hypothetical hypothalamopituitary dysfunction, indicate the difficulties of thyroid status assessment in the elderly.

The authors analyse the frequency of arterial calcifications in the lower limbs in diabetics. These calcifications were found in the thighs and legs and also in the feet. They were more frequent in diabetics than in normal subjects and occurred earlier in life. Their presence showed the existence of a severe microangiopathic process.