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Resume Introduction Les confusions sont particulierement frequentes chez les sujets âges et elles peuvent etre liees a une epilepsie. Les differentes recommandations soulignent l’importance d’une approche electroclinique et de facon recente un score specifique a ete propose par un consensus d’expert. L’objectif de ce travail est d’evaluer sur une population de sujets âges de plus de 75 ans hospitalises en geriatrie et presentant une confusion recente, une approche clinique et EEG habituelle (procedure 1) et l’utilisation du score electroradioclinique (procedure 2). Patients et methodes Depuis decembre 2006, nous disposons d’un appareil d’EEG numerique (Micromed ® ) a l’hopital Bretonneau (Paris) et toutes les demandes d’examens de l’etablissement sont centralisees. Nous avons retenu toutes les demandes concernant des patients de plus de 75 ans et comportant la notion d’une confusion recente. Resultats Cent quinze sujets ont ete inclus dans cette etude (83,5 ± 6,06 ans). La procedure 1 a conduit a un diagnostic suppose d’epilepsie pour 50 sujets et la procedure 2 a retenu 30 diagnostics et en a elimine 29. Conclusion Ce travail montre l’importance pour les medecins de terrain de disposer d’arguments leur permettant d’appliquer le concept de medecine reposant sur la preuve. Il souligne aussi la necessite de pratiquer des examens plus sophistiques (EEG de longue duree et video EEG) sur ce terrain.

Resume Objectif Le but de ce travail est de determiner l’interet de l’analyse semiologique de la marche et de la vitesse de marche dans l’evaluation du risque de chute chez les sujets âges. Methode 78 patients (56 femmes, 22 hommes) entre 65 et 90 ans (moyenne 79,32, ecart type 5,46), ambulatoires, consultant en hopital de jour geriatrique durant les six premiers mois de l’annee 2005, ont ete inclus dans ce protocole comportant un recueil systematise de la semiologie de marche sur un parcours de 10 metres et une mesure de leur vitesse de marche sans consigne puis avec une double tâche sur cette distance. Le risque de chute a ete defini en en fonction des recommandations de l’INPES : au moins une chute les six derniers mois, un score pathologique a l’echelle de Tinetti statique (inferieur a 14), un appui unipodal inferieur a 5 secondes. Resultats Les traits semiologiques associes de facon significative (analyse ANOVA, p Conclusion Ces elements nous semblent utiles a prendre en consideration dans la pratique quotidienne a la fois pour le depistage des sujets âges a risque de chute, pour l’elaboration d’une reeducation adaptee de leur schema de marche et un amenagement de leur environnement. Ils permettent une approche complementaire des echelles utilisees habituellement dans l’evaluation du risque de chute.

Resume Propos Les inhibiteurs de l'acetylcholinesterase (IAChEs) ont demontre leur efficacite chez les patients atteints de maladie d'Alzheimer (MA) vivant au domicile. La pertinence de prolonger ces traitements en institution est controversee et releve du « cas par cas ». Cette etude a pour objectif de faire le point sur les strategies actuelles d'utilisation de ces traitements en hebergement de soins de longue duree (SLD). Methodes Il s'agit d'une etude multicentrique, observationnelle, retrospective, sur l'utilisation en SLD des trois IAChEs commercialises (donepezil, rivastigmine, galantamine). L'observation des dossiers a porte sur trois points principaux : l'indication, le suivi et la justification de la poursuite du traitement. Resultats Parmi les 1373 patients institutionnalises, 6 % recevaient un IAChEs (n = 81). Tous les stades de gravite de la maladie etaient representes, du declin fonctionnel et cognitif severe (18 %) au trouble cognitif tres leger (10 %). Vingt-neuf pour cent des patients ne repondaient a aucune recommandation d'indication officielle ou consensus professionnel. Les evaluations a l'admission etaient de qualite : 90 % prenaient en compte les differents aspects de la maladie (fonctionnelle, cognitive et comportementale). Les evaluations ulterieures etaient moins bonnes, avec 40 % jugees incompletes. Le traitement etait poursuivi alors que pres d'un patient sur deux s'etait deteriore quant a l'ensemble des domaines evalues. Conclusion Cette etude met en evidence des insuffisances de suivi des patients sous IAchEs en SLD et des ordonnances qui se perennisent sans justification evidente. Les defis economiques, medicaux et ethiques que pose l'utilisation de ces traitements en institution rendent urgente la mise en place d'une reflexion sur les modalites de leur arret.

Introduction et but de l’etude Les patients diabetiques sont rarement consideres comme a risque de denutrition car le diabete de type 2 survient frequemment dans un contexte d’obesite. Cependant, plus de 15 % des plus de 75 ans sont diabetiques, et pourraient etre a risque de denutrition en raison de leurs complications ou comorbidites. L’objectif de cette etude est donc de decrire la prevalence de la denutrition chez des sujets âges diabetiques dans les differentes structures de la filiere geriatrique. Materiel et methodes Au cours d’une etude transversale et multicentrique, nous avons inclus consecutivement 274 sujets diabetiques en consultation, hopital de jour (HDJ), geriatrie aigue (UGA), soins de suite et readaptation (SSR), soins de longue duree (SLD) et unite d’hebergement pour personnes âgees dependantes (UHPAD) de cinq departements de geriatrie. Les donnees recueillies comprenaient : une evaluation geriatrique standardisee, une evaluation du statut nutritionnel et du diabete. La denutrition etait definie comme une albuminemie Resultats et analyse statistique En fonction de la structure, les patients etaient âges de 83 ± 6 a 85 ± 6 ans ; l’IADL etait de 0,9 ± 1,4 a 5,0 ± 1,4 et ils prenaient 2,0 ± 3,5 a 8,3 ± 4,1 classes therapeutiques par jour. La depression etait diagnostiquee chez 50 % des patients et la demence chez 72 % des patients. Le diabete etait connu depuis 15,7 ± 13 ans et la derniere mesure de [HbA1c] etait de 7,1 ± 1,5 %. Les complications macrovasculaires etaient : cardiopathie ischemique (35 %), AOMI (18 %) et atteinte cerebrovasculaire (35 %). Les complications microvasculaires etaient : retinopathie (30 %), nephropathie (39 %) et neuropathie (17 %). Dix pour cent avaient des escarres. Les traitements du diabete etaient : aucun dans 48 % des cas, antidiabetique oral dans 37 % des cas, insuline dans 26 % des cas et 18 % des sujets avaient a la fois de l’insuline et un antidiabetique oral. La prevalence de la denutrition etait de 27 % en consultation, 23 % en HDJ, 53 % en UGA, 66 % en SSR, 21 % en SLD et 9 % en UHPAD. Conclusion La prevalence de la denutrition est elevee chez les sujets âges diabetiques surtout en SSR. Le depistage systematique de la denutrition chez les sujets âges ne doit pas ecarter les sujets diabetiques afin d’adapter au mieux la prise en charge du diabete, notamment nutritionnelle et medicamenteuse.

Current diagnostic criteria of Alzheimer Disease (AD) are mainly based on clinical definition. In France, the Delayed Matching Sample (DMS48) test, a recently introduced test that explores visual object recognition, is recommended for the early diagnosis of AD. However, little is known on the DMS48 performances of older subjects over 75 years. Therefore, our aim was to assess its specific clinical value for early detection of AD in older patients.We studied 93 consecutive patients over 75 years from an expert memory clinic in a geriatric hospital. This population included 31 patients with single domain amnestic Mild Cognitive Impairment (aMCI), 31 AD patients and 31 controls subjects.The aMCI and AD performances on the DMS48 were significantly lower than those of the control subjects (set 1 and set 2, P10(-7)). The DMS48 performances in the healthy group appeared closely related to the previously published normative data. However, the DMS48 performances appeared unexpectedly high in these older patients, especially in the AD subgroup (set 1, 82.2±12.1 and set 2, 75.2±16.2). Moreover, there was an unexpected frequent discordance between the results on the DMS48 and the Free and Cued Selective Reminding tests (FCSR). The DMS test appears useful for highlighting the heterogeneity of the syndromes of aMCI and AD in old-old people aged 75+: our results also underline the need for further characterization of cognitive impairment in this fastest growing subgroup of patients.

Delusion symptoms often occur in old people; epilepsy is one of the main reasons behind these acute episodes. Current guidelines and recommendations from the Academy of Medicine have proposed a double clinical and electroencephalographic approach. Recently, a working group of French experts has issued an electro-clinical scale. The aim of our study was to compare the usual approach with the new one based on the electro-clinical score.All EEG requests performed since December 2008 in Bretonneau Hospital for elderly people aged over 75 years for delusion syndromes were retained for this study.One hundred and fifteen old patients from a geriatric-hospital (age 83.5+/-6.06 years) were included in this protocol. The classical diagnostic process yielded the diagnosis of epilepsy for 50 subjects. The electro-clinical scale confirmed the diagnosis of epilepsy in 30 patients and ruled it out in 29 patients.This study underscores the importance of evidence-based medicine for the diagnosis of epilepsy in old people and points out the underuse of the new technical tool, EEG-monitoring, for the management of these patients.

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

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

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

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

Objectifs Un audit cible a ete mis en place afin d’evaluer la pertinence de l’antibiotherapie dans les IR chez les patients hospitalises dans un hopital geriatrique de 205 lits apres reactualisation des recommandations de traitement des IR et formation des medecins sur celles-ci. Methode Pendant 6 mois, les prescriptions antibiotiques en rapport avec une IR etaient signalees par le pharmacien au referent antibiotique (RA). Dans les 48 heures, le RA effectuait une evaluation et notait le diagnostic retenu par le medecin, le bilan biologique et l’antibiotherapie prescrite. Le radiologue a relu toutes les radiologies disponibles. Resultats 74 patients (40 femmes, 34 hommes ; âge moyen : 87 ± 7 ; 33 en unite d’aigu, 23 en SSR et 22 en SLD) ont ete inclus et ont presente 95 episodes d’IR : 12 exacerbations de BPCO, 26 pneumonies aigues (PA), 42 pneumopathies d’inhalation (PI), 11 bronchites (BR), 3 autres. Les traitements etaient majoritairement conformes au referentiel : 38/42 PI (90 %), 23/26 PA (88 %), 11/12 BPCO (92 %) et 11/11 BR. Les durees etaient aussi en adequation avec les recommandations, exceptees pour les BPCO : 9 ± 2,6, vs. 5 a 7 jours. Conclusion Apres revision et diffusion aupres des medecins, le referentiel des traitements antibiotiques est connu et applique pour les PAC et PI a l’oppose des BPCO (duree). Les actions d’amelioration sont, apres diffusion de ces resultats, de former les medecins sur la prise en charge des BPCO et l’aerosoltherapie par un referent BPCO designe, et de realiser un recueil cible prospectif sur les BPCO (indication, principe actif, duree de traitement, nature de l’aerosoltherapie). Cette etude a permis de mieux cibler les prochaines actions de formation sur le bon usage des antibiotiques tout en montrant le bon respect des recommandations locales dans la majorite des IR.

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

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

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

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