Diagnosis of vascular parkinsonism: A new tool for gait hypokinesia occurring in older persons.

INTRODUCTION: Reliable diagnosis of vascular parkinsonism (VaP) in the presence of a gait hypokinesia is an issue that is encountered in geriatrics. The EVAMAR-AGEX study was focusing on the phenomenon of recurrent falls in older persons (OP) with this parkinsonian gait. The present study is focusing on the diagnosis of VaP-related parkinsonian gait by developing a diagnostic guidance model adapted to OP. METHODS: Data from baseline and the 2-year follow-up visit were used to carry out univariate analysis and calculation of odds ratios, allowing to identify relevant variables to include in the diagnostic guidance model. To evaluate the model, confusion matrices were created, evaluating true positive, false negative, false positive and true negative incidences, sensitivity and specificity, and negative and positive predictive values. RESULTS: 79 patients included 58% male; average age 81.24 years. VaP diagnosis according to Zijlmans criteria occurred in 28%; neurodegenerative parkinsonian syndromes in 72%. A 4-criteria model was established to facilitate diagnostic: lack of prior hallucinations, lack of movement disorders tremor excluded, no cognitive fluctuations, and ≥75 years of age at diagnosis. In combination of 4/4 criteria, all of them were required to disclose a specificity of 91% in the diagnosis of VaP. In combination of 3/4, in case of negative test, a negative predictive value for VaP diagnosis of 0.97 was obtained. CONCLUSION: The challenge of our tool is both to be able to rule out what is probably not a VaP and to argue what makes a VaP diagnosis probable in OP.

Older Persons Displaying Parkinsonian Gait: Prediction and Explanation of the Recurrent Falling Phenomenon and Its Related Poor Prognosis.

INTRODUCTION: Parkinsonian gait in older persons is a major risk factor for recurrent falling. This prospective, longitudinal study (named EVAMAR-AGEX) aimed to validate the threshold value of two or more falls per year for distinguishing non-recurrent (NRF) from recurrent fallers (RF), to explore predictive factors for recurrent falling, and to identify factors which underlie the transition of patients from NRF to RF. The study took place over 2 years, with an intermediate analysis at 1 year of follow-up. Herein, we report results after 2 years of follow-up. METHODS: Participants over the age of 65, diagnosed with parkinsonian gait, were followed over the course of 2 years. Induced parkinsonian syndrome and uncontrolled orthostatic hypotension were excluded. Assessments of motor, visual, and cognitive functions were carried out during visits at baseline. Between visits at 12 and 24 months of follow-up, data were collected by phone call every 2 months (falls, traumatic falls, hospitalizations, cognitive fluctuations, delirium, and mortality). Odds ratios (ORs) for a panel of predictive factors for recurrent falling were established using a Bayesian model. RESULTS: Sixty-six of the 79 initially enrolled participants progressed to the second year of the study, with a mean age of 80.57 (SD 6.3), 56% male, presenting parkinsonian gait (53% Parkinson's disease, 15% atypical neurodegenerative parkinsonism, 21% vascular parkinsonism, and 11% diffuse Lewy body disease). At 2 years of follow-up, 67% were RF. Univariate analysis revealed a previous history of falls to be the most significant predictive factor of recurrent falls (OR 13.16, credibility interval [CrI] [95%] 4.04-53.73), and this was reinforced at 2 years of follow-up compared to the intermediate 1-year analysis (OR 11.73, CrI [95%] 4.33-35.28). Multivariate analysis confirmed a previous history of falls (OR 13.20, CrI [95%] 3.29-72.08) and abnormal posture (OR 3.59, CrI [95%] 1.37-11.26) to be predictive factors for recurrent falling. Cognitive decline and fluctuating cognition were associated with the transition from NRF to RF (-3.5 MMSE points for participants transitioning from NRF to RF). CONCLUSION: Within this population of older persons presenting parkinsonian gait, a previous history of falls and abnormal posture may be used to easily identify individuals at risk of recurrent falls. Cognitive decline and fluctuations may underlie the transition of NRF to RF.

Upper and lower gastrointestinal endoscopies in patients over 85 years of age: Risk-benefit evaluation of a longitudinal cohort.

After age 85, upper and lower gastrointestinal (GI) endoscopy may be indicated in 5% to 10% of inpatients, but the risk-benefit ratio is unknown. We studied patients older than 85 years undergoing upper and lower GI endoscopy.We analyzed a retrospective cohort of inpatients older than 85 years between 2004 and 2012, all explored by upper and complete lower GI endoscopy. Initial indications, including iron deficiency anemia (IDA), other anemias, GI bleeding, weight loss, and GI symptoms, were noted, as were endoscopy or anesthesia complications, immediate endoscopic diagnosis, and the ability to modify the patients' therapeutics. Deaths and final diagnosis for initial endoscopic indication were analyzed after at least 12 months.We included 55 patients, 78% women, with a median age, reticulocyte count, hemoglobin, and ferritin levels of 87 (85-99), 56 (24-214) g/L, 8.6 (4.8-12.9) g/dL, and 56 (3-799) µg/L, respectively. IDA was the most frequent indication for endoscopy (60%; n = 33). Immediate diagnoses were found in 64% of the patients (n = 35), including 25% with GI cancers (n = 14) and 22% with gastroduodenal ulcers or erosions (n = 12). Cancer diagnosis was associated with lower reticulocyte count (45 vs. 60 G/L; P = .02). Among the 35 diagnoses, 94% (n = 33) led to modifications of the patients' therapeutics, with 29% of the patients deciding on palliative care (n = 10). No endoscopic complications lead to death. Follow-up of >12 months was available in 82% (n = 45) of the patients; among these patients, 40% (n = 27) died after an average 24 ±â€Š18 months. Cancer diagnosis was significantly associated with less ulterior red cell transfusion (0% vs. 28%; P = .02) and fewer further investigations (6.7% vs. 40%; P = .02).Upper and complete lower GI endoscopy in patients older than 85 years appears to be safe, and enables a high rate of immediate diagnosis, with significant modifications of therapeutics. GI cancers represented more than one-third of the endoscopic diagnoses.

The Movement Disorders Society criteria for the diagnosis of Parkinson's disease dementia: their usefulness and limitations in elderly patients.

The aim of this study was to assess the performance of the Movement Disorders Society (MDS) criteria for the diagnosis of Parkinson's disease dementia (PDD) in the elderly, and also to evaluate the relevance of applying other tests in this patient population. The MDS criteria include a first short part in checklist form, and a second part which is used as a basis for reference and consists of an in-depth neuropsychological examination. Forty consecutive PD patients presenting with cognitive complaints were enrolled. An assessment was made of the performances of the MDS checklist compared with the MDS exhaustive cognitive examination which was used as a basis for reference, and with other cognitive tests including the Mattis Dementia Rating Scale (MDRS), the French version of the Grober and Buschke test, the verbal fluency test, the Rey-Osterreith complex figure and the paced auditory serial addition test. Out of a total of 40 PD subjects (mean age: 80.5 ± 4.9 years), 20 were diagnosed with PDD according to the checklist and 31 on the basis of the exhaustive examination, i.e. with 11 more patients diagnosed via the latter. The sensitivity of the checklist for the diagnosis of PDD was 0.64, with a specificity of 1.00. The use of the MDRS for PDD diagnosis with a cut-off at ≤ 120 showed a sensitivity of 0.80 and a specificity of 1.00, while at ≤ 132 it displayed a sensitivity of 1.00 and a specificity of 0.444. The specificity of the checklist for the diagnosis of PDD in the elderly was confirmed, but it was lacking in sensitivity. It was also found that the MDRS could be helpful in the diagnosis and screening of PDD.

TDP43-positive intraneuronal inclusions in a patient with motor neuron disease and Parkinson's disease.

BACKGROUND: The role of the 43-kDa transactivation-responsive DNA-binding protein (TDP43) in neurodegenerative diseases is not yet clearly established. OBJECTIVE: To assess for the first time the presence of TDP43 in a patient with motor neuron disease (MND) and Parkinson's disease (PD). METHODS: A 78-year-old woman developed poorly dopa-responsive parkinsonism without cognitive alteration. Three years later, MND appeared and led to death in less than a year. Neuropathologic examination was performed. RESULTS: We observed the presence of PD and MND lesions with TDP43-positive cytoplasmic inclusions in the spinal cord and bulbar nuclei but not in the dentate gyrus and neocortex. The MND was characterized by a severe degeneration of bulbar and cervical lower motor neurons. Numerous senile plaques and topographically limited neurofibrillary tangles were also observed. CONCLUSION: The mechanisms underlying the rare co-occurrence of PD and MND are still unclear. The assessment of an abnormal reactivity for TDP43 in our case might gain more insight into the pathophysiology of this association of two diseases. Further studies are needed to confirm these findings and to understand the role of TDP43 in neurodegenerative diseases.

[Prospective study of oral anticoagulation control in 110 very elderly hospitalized patients and of risk factors for poor control]. / Difficultés pour équilibrer les antivitamines K chez des personnes très âgées hospitalisées: étude prospective chez 110 patients avec recherche de facteurs de risque de déséquilibre.

OBJECTIVES: The primary aim of this study was to analyze the quality of oral anticoagulation management in the real-life practice of hospital geriatric departments, in the absence of a formal dose-adjustment protocol. The secondary objective was to identify factors associated with international normalized ratios (INR) outside the target range. METHODS: This prospective study was conducted between November 2004 and August 2005 in our hospital's acute geriatric care and geriatric rehabilitation units. It included 110 subjects older than 65 years, all taking fluindione (target INR range of 2 to 3). Indications for oral anticoagulation were atrial fibrillation, venous thromboembolism, and pulmonary embolism. Patients were eligible for inclusion if they had at least 4 INR measurements, and we assessed a maximum of 20 such measures per patient. RESULTS: The study included 74 patients in the acute geriatric unit and 36 subjects in rehabilitation units (mean age: 85 years [65-97 years]), who had 1079 INR tests during the study period (mean per patient: 9.8 (+/-5.5)). Overall, 333 patients (31%) were in the target range of 2-3, 48% below 2, 21% above 3, and 3.6% above 5. The time interval between INR tests did not vary when INR was below 2, but we noted a nonsignificant trend towards a reduction in the average testing interval when INR was above 3 (p=0.079). No bleeding or thrombotic complications were reported during the study. Of the 11 predefined variables, only cancer (history or current) was significantly associated with elevated INR. CONCLUSION: This study confirms the difficulty of controlling INR in anticoagulation therapy of elderly subjects. Only 31% of tests showed INR in the target range of 2 to 3, a rate lower than in other cohorts. These results may be explained by the high rate of comorbidities in this very old study population.

[Risk factors for Alzheimer: towards prevention?]. / Facteurs de risque de la maladie d'Alzheimer: vers une prévention?

Recent longitudinal studies have highlighted associations between Alzheimer's disease (AD) and several factors, especially some cardiovascular risk factors, including hypertension, diabetes, diet, obesity, and elevated levels of homocysteine and lipids in the blood. The strongest associations are with hypertension and diabetes. Moderate alcohol consumption also appears to be associated with a decreased risk of incident AD. Studies of the effect of interventions to control these risk factors on the onset and course of dementia report encouraging results about antihypertensive agents and statins. Benefits from other drug therapies such as nonsteroidal antiinflammatory drugs and antioxidants remain uncertain, and initial hopes for hormonal replacement therapy for postmenopausal women have not been confirmed. Physical, cognitive and leisure activities seem to provide protection against incident AD. Cautious interpretation is necessary in view of the possible biases in these studies (confounding factors as well as survival, regression dilution, and indication biases). These epidemiologic data raise questions about the diagnostic boundaries between AD and vascular dementia. Additional studies are needed to validate these concepts and to confirm the possible benefits of preventive measures.

Intracerebral aneurysms: a review with special attention to geriatric aspects.

Rupture of an intracranial aneurysm (ICA) remains a devastating complication associated with a high degree of morbidity and mortality. In the past 2 decades, older people were often excluded from active treatment on the unique basis of their chronological age. Recent developments of less-invasive techniques for the diagnosis and treatment of ruptured and unruptured ICAs suggest that this fatalistic attitude toward older patients should be reconsidered. Furthermore, taking into account the heterogeneity of the elderly population, the use of a comprehensive geriatric assessment approach, based on a multidisciplinary evaluation, appears particularly helpful in proposing the optimal treatment strategy for each older patient. This article reviews the geriatric features of epidemiological, physiopathological, as well as clinical and therapeutic aspects of ruptured and unruptured ICAs.