Association between Vitamin D Deficiency and Prognosis after Hip Fracture Surgery in Older Patients in a Dedicated Orthogeriatric Care Pathway.

OBJECTIVES: Vitamin D deficiency is common in patients undergoing hip fracture surgery (HFS) and has been found to be associated with poor post-operative outcome in other settings. This study aimed to analyze the association between vitamin D status and prognosis after HFS. DESIGN: Observational, prospective, single-center study. SETTING AND PARTICIPANTS: All patients admitted in a peri-operative geriatric unit between 2009 and 2020 for HFS were included. MEASUREMENTS: A moderate vitamin D deficiency was defined by a vitamin D level between 25 and 75 nmol/l and a severe deficiency by a vitamin D level <25 nmol/l. Primary endpoint was mortality 6 months after surgery. Secondary endpoints were bacterial infections and delirium during hospitalization. Odds ratio (OR) and 95% confidence interval (95%CI) were computed using logistic regression models with adjustment for confounders. RESULTS: 1197 patients were included (median age 87 years, IQR [82-91]). Median vitamin D level was 55 nmol/l (IQR [30-75 nmol/l]). Moderate and severe vitamin D deficiencies were reported in 53% and 21% of patients, respectively. There was no significant association between moderate or severe vitamin D deficiencies and 6-month mortality (OR 0.91, 95%CI [0.59-1.39], and OR 1.31, 95%CI [0.77-2.22], respectively), bacterial infection (OR 0.89, 95%CI [0.60-1.31] and OR 1.55, 95%CI [0.99-2.41], respectively), nor delirium (OR 1.03, 95%CI [0.75-1.40], and OR 1.05, 95%CI [0.70-1.57], respectively). CONCLUSION: Vitamin D deficiency was not associated with mortality, bacterial infection or delirium after HFS. Our results suggest that comorbidities, functional status and post-operative complications are the main determinants of post-operative outcome after HFS.

Cognitive deficit, and neuropathological correlates, in the oldest-old.

Several disorders are usually involved in the cognitive deficit of the oldest old. Alzheimer disease is the commonest. It is usually characterized by progressive memory impairment - neocortical symptoms occurring much later in the course of the disease. Alzheimer disease should not be considered any more as the single cause of a cognitive deficit in a very old patient. Vascular alterations, possibly causing microinfarcts, are commonly associated, especially in cerebral amyloid angiopathy. A slowly progressive memory deficit with negative CSF biomarkers of Alzheimer's disease may be due to hippocampal sclerosis that may be the consequence of multiple causes: in most of the cases, it is associated with neuronal TDP-43 inclusions. Recently, a distribution of these inclusions to a territory more extensive than the hippocampus has been reported and attributed to a new entity, called Limbic-predominant Age-related TDP-43 Encephalopathy (LATE) with or without hippocampal sclerosis. The presence of cortical Lewy bodies may cause an intellectual deficit or contribute to it. The prevalence of dementia with cortical Lewy bodies in the oldest old is discussed. Tau inclusions in cortical glia have also been shown to participate to the intellectual deficit. Association of neurodegenerative and vascular changes is the most frequent situation in the very old patients. Systemic diseases such as diabetes or heart failure, prescription drugs (when misused), or toxic such as alcohol may also contribute to the cognitive impairment and be amenable to treatment.

GREFON recommendations for assessment of instrumental activities of daily living in memory clinics.

Following a review of the available assessment scales and current practices of evaluation of instrumental activities of daily living (IADL) in French memory centres by GREFON (Groupe de réflexion sur l'évaluation fonctionnelle; Working Group on Functional Assessment), the main aim of this position paper was to provide good clinical practice (GCP) guidelines for the assessment of IADL. Another aim was to highlight the need for innovative tools adapted to the present and future evolution of such activities in real life, including the use of new technologies, the need for earlier detection of IADL impairment during the diagnostic process of mild neurocognitive disorders, and greater sensitivity to IADL changes during follow-up to allow adaptation of clinical management and evaluation of the impact of therapeutic interventions.

Perception of Alzheimer's disease in the French population.

OBJECTIVE: The aim of this study was to investigate the perception, knowledge, opinions and beliefs about AD in the French population to improve care for patients with Alzheimer's disease. DESIGN: A cross-sectional telephone survey in 2008. SETTING: French "Alzheimer Plan 2008-2012". PARTICIPANTS: 2013 respondents, representative of the French population. MEASUREMENTS: The respondents answered a questionnaire in which they were presented with a series of attitudinal statements about health in general and AD. RESULTS: Main results are summarized as followed: (a) Respondents think that AD can be devastating for a family (93%). This devastating feeling prevails in the population >75 years old and in people who know patient with AD. (b) General population has a reasonable knowledge about AD, but is still unable to recognize early stages: 95% of respondents considered that difficulties to manage administrative papers and find their way back home suggest early AD. (c) 91% of the population would like to know the diagnosis if they had AD. (d) 38% of the population know or have known at least one patient within their social circle. People think that the care of AD's patient can be better but they trust in the French government to improve it. CONCLUSION: General representation of AD is changing in a positive way and, even though AD is perceived as a calamity, people are confident that solutions will be found in the future.

Utility of 123I-FP-CIT SPECT for dementia diagnoses and therapeutic strategies in elderly patients.

OBJECTIVES: Evaluation of the influence of single photon emission computed tomography (SPECT) of the dopamine transporter (123I-FP-CIT) on diagnosis and treatment strategies in elderly patients with mild dementia. DESIGN: Retrospective study. SETTING: Geriatrics memory clinic. PARTICIPANTS: Consecutive ambulatory patients who had 123I-FP-CIT SPECT for a suspicion of DLB. MEASUREMENTS: Clinical diagnoses before SPECT were compared with imaging results. RESULTS: 46 patients were included. Pre imaging clinical hypotheses were probable DLB in 14, possible DLB in 21 and alternate diagnoses in 11. Rates of abnormal imaging in these groups were respectively 71%, 43% and 18%. Overall, diagnoses were revised in 37% of the cases. Four patients with probable DLB had normal imaging. Their number of core criteria did not differ from the remainder (2.75 ± 0.5 vs. 2.1 ± 0.6), but hallucinations in 2 patients were not well formed and detailed as usual in DLB. Among 38 patients free of antipsychotics, rates of abnormal scans were 36% in patients with questionable parkinsonism, 57% in definite parkinsonism, 67% in patients with no parkinsonism. Among 9 patients on Levodopa, 6 had normal scans and Levodopa was stopped. CONCLUSION: We show a significant impact of 123I-FP-CIT SPECT on diagnoses, even in cases of definite parkinsonism or probable DLB. In the latter, scarcity of hallucinations, especially if there are not well formed and detailed, should prompt 123I-FP-CIT SPECT.

Neuropsychiatric symptoms in elderly inpatients: a multicenter cross-sectional study.

BACKGROUND/AIMS: We determined the prevalence of neuropsychiatric symptoms in geriatric rehabilitation patients to compare neuropsychiatric symptoms between patients with and without dementia, and to evaluate associations linking severity of cognitive impairment and neuropsychiatric symptoms. METHODS: In February 2009, we studied patients aged 75 years or older who had been admitted to four geriatric rehabilitation units in the Paris area. The twelve Neuropsychiatric Inventory items and four neuropsychiatric subsyndromes defined by the European Alzheimer's Disease Consortium were evaluated. RESULTS: Of the 194 patients, 149 (76.8%) had dementia, and 154 (79.4%) had exhibited at least one neuropsychiatric symptom during the past week. Agitation was the most common neuropsychiatric symptom in the group with dementia (36.9%) and depression in the group without dementia (35.6%). The dementia group had significantly higher prevalences of hyperactivity (p < 0.001) and delusions (p = 0.01) than the non-dementia group. In the dementia group, severity of cognitive impairment was associated with hyperactivity (p = 0.01) and psychosis (p = 0.02). CONCLUSION: The prevalence of neuropsychiatric symptoms among geriatric rehabilitation patients was high but not higher than in elderly outpatients.

Scurvy in hospitalized elderly patients.

OBJECTIVES: The aim of this study was to systematically screen hospitalized elderly patients for clinical symptoms of scurvy and to confirm the diagnosis with biological measures. SETTINGS: Geriatric acute care ward. MEASUREMENTS: Scurvy symptoms (one or more among perifollicular hyperkeratosis, petechiae or bruises, haemorrhagic features caused by venous puncture, severe gingivitis). We compared associated diseases, nutritional status, need for assistance for feeding, serum albumin, transthyretin, B9 and B12 vitamins, iron status and Serum Ascorbic Acid Level (SAAL) and outcome (in-hospital mortality) between scurvy and scurvy free patients. RESULTS: 18 patients with clinical symptoms of scurvy (scurvy group) were identified out of 145 consecutive patients (12%). They were compared to 23 consecutive control patients with no clinical symptoms of scurvy (scurvy-free group). SAAL was significantly lower (1.09 +/- 1.06 vs 4.87 +/- 4.2 mg x L-1, p < .001) and vitamin C deficiency more frequent (94 vs 30 %, p < .001) in the scurvy group. Moreover, in scurvy group, coronary heart disease (39 vs 9 %, p=.028), need for assistance for feeding (56 vs 13 %, p=.006) and in-hospital deaths (44 vs 9 %, p=.012) were more frequent. CONCLUSION: Ninety-four percent of patients with clinical symptoms of scurvy had vitamin C deficiency. Our results suggest that in hospitalized elderly patients, clinical symptoms allow scurvy diagnosis. Scurvy could be a frequent disease in elderly patients admitted to acute geriatric ward.

Sporadic Creutzfeldt-Jakob disease mimicking nonconvulsive status epilepticus.

BACKGROUND: Nonconvulsive status epilepticus (NCSE) in patients with confusion may be difficult to distinguish from nonepileptic (metabolic/toxic, postanoxic, and spongiform) encephalopathies. This study aimed to describe the misleading presentation of patients with sporadic Creutzfeldt-Jakob disease (sCJD) who were initially diagnosed with a refractory NCSE (rNCSE). METHODS: We retrospectively reviewed the clinical characteristics, EEG records, brain MRI scans, 14-3-3 protein detection in CSF, genotype of the prion protein gene, and neuropathologic data of patients referred to our neurologic intensive care unit (NICU) with this presentation. RESULTS: Ten patients with a final diagnosis of definite (n = 7) or probable (n = 3) sCJD were referred to our NICU with an initial diagnosis of rNCSE. Reanalysis of the EEG ruled out ictal rhythmic activities, but showed diffuse, periodic, or semiperiodic sharp-wave complexes (PSWC) with short period. PSWC were briefly attenuated by auditory (n = 5) or painful (n = 3) stimuli and by IV injection of antiepileptic drugs (n = 5) but without clinical improvement. In addition, PSWC showed fluctuations according to the vigilance level (n = 5). Brain MRI showed hyperintensities in basal ganglia (n = 9/10) and in cortical areas (n = 7/10). 14-3-3 Protein was detected in CSF (n = 10). Only 2 sCJD subtypes were found (MM1 5/7, MV1 2/7). CONCLUSIONS: This series of patients suggests that sporadic Creutzfeldt-Jakob disease should be considered as a differential diagnosis, rather than as a cause, of apparent refractory nonconvulsive status epilepticus. Criteria for nonconvulsive status epilepticus diagnosis should rely on careful examination of both EEG parameters and clinical state so that aggressive, unnecessary treatments can be avoided.

[Transfusion in clinical practice in geriatric wards]. / Enquête transversale sur la transfusion dans les services de gériatrie.

PURPOSE: In the absence of specific recommendations on blood transfusion in elderly subjects, we carried out a survey to assess transfusion practices in geriatric medicine. METHODS: A descriptive, national, cross-sectional survey was conducted in 14 French geriatric departments (12 teaching hospitals and two general hospitals). In each department, five patients receiving transfusions were randomly selected in order to analyze their characteristics, the indications of blood transfusion, the criteria for and the methods of transfusion compared with Afssaps recommendations on transfusion thresholds. RESULTS: Data were analyzed for 70 patients (mean age 86+/-7 years, sex ratio female to male 1.8, with an average of five+/-two pathologies and six+/-three treatments). The indicators of poor tolerance included confusion (23 %), somnolence (22 %), acute heart failure (17 %) or coronary heart disease (16 %), and differed from the Afssaps criteria in the majority of cases. The transfusion threshold that were considered in the absence of poor tolerance (45 % of transfusions) differed from that recommended by Afssaps in 26 % of cases. The main adverse event in transfusion recipients was heart failure. CONCLUSION: When criteria for poor anaemia tolerance or transfusion thresholds are considered, transfusion practices in geriatric subjects have specific features. Further studies are needed to validate the appropriateness of the practices described in this survey.

[Effects of hypomagnesemia]. / Les effets de l'hypomagnésémie.

INTRODUCTION: The clinical consequences of plasmatic magnesium variations are underecognized in clinical practice. The dosage of plasmatic magnesium is underused and not reliable. Moreover, hypomagnesemia is often associated with other metabolic disorders (hypocalcemia, hypokaliemia), which are responsible for several symptoms. CASE REPORT: We report an 85-year-old man who presented with repeated bronchospasm, confusion, and abdominal and muscular pain, attributed to low magnesium serum level. We then review pathophysiology, various etiologies, clinical features, diagnostic challenge and treatment of low magnesium serum level. CONCLUSION: Hypomagnesemia is poorly known and diagnosed. Therapeutic issues have not been clearly defined.

Sleep disorders and their impacts on healthy, dependent, and frail older adults.

BACKGROUND: Sleep disorders differ widely in the heterogeneous older adult population. Older adults can be classified into three groups based upon their overall level of disability: healthy, dependent, and frail. Frailty is an emerging concept that denotes older persons at increased risk for poor outcomes. OBJECTIVE: The aim of this consensus review is to describe the sleep disorders observed in healthy and dependent older adults and to discuss the potential sleep disorders associated with frailty as well as their potential consequences on this weakened population. METHODS: A review task force was created including neurologists, geriatricians, sleep specialists and geriatric psychiatrists to discuss age related sleep disorders depending on the three categories of older adults. All published studies on sleep in older adults on Ovid Medline were reviewed and 106 articles were selected for the purpose of this consensus. RESULTS: Many healthy older adults have complains about their sleep such as waking not rested and too early, trouble falling asleep, daytime napping, and multiple nocturnal awakenings. Sleep architecture is modified by age with an increased percentage of time spent in stage one and a decreased percentage spent in stages three and four. Insomnia is frequent and its mechanisms include painful medical conditions, psychological distress, loss of physical activity and iatrogenic influences. Treatments are also involved in older adults' somnolence. The prevalence of primary sleep disorders such as restless legs syndrome, periodic limb movements and sleep disordered breathing increases with age. Potential outcomes relevant to these sleep disorders in old age include mortality, cardiovascular and neurobehavioral co-morbidities. Sleep in dependent older adults such as patients with Alzheimer Disease (AD) is disturbed. The sleep patterns observed in these patients are often similar to those observed in non-demented elderly but alterations are more severe. Nocturnal sleep disruption and daytime sleepiness are the main problems. They are the results of Sleep/wake circadian rhythm disorders, environmental, psychological and iatrogenic factors. They are worsened by other sleep disorders such as sleep disordered breathing. Sleep in frail older adults per se has not yet been formally studied but four axes of investigation should be considered: i) sleep architecture abnormalities, ii) insomnia iii) restless legs syndrome (RLS), iv) sleep disordered breathing. CONCLUSION: Our knowledge in the field of sleep disorders in older adults has increased in recent years, yet some groups within this heterogeneous population, such as frail older adults, remain to be more thoroughly studied and characterized.

[Specificity of epileptic seizures in the elderly: A proposed electro-clinical scale]. / Spécificités des crises d'épilepsie chez le sujet âgé : proposition d'un score électro-radioclinique d'orientation.

Diagnosis of epileptic seizure may be difficult in older patients because seizure manifestations are often unusual: confusion, paresis... and because there are multiple differential diagnoses (syncope, transient ischemic attack, transient global amnesia...). To promote and facilitate the diagnosis of seizures in the elderly, neurologists and gerontologists must work together and focus their strategy on two points: firstly, the knowledge of the specific presentation of seizures in elderly patients, and secondly, the adoption of a reasoning based on seizures and not epileptic syndromes. A multidisciplinary group worked on epilepsy of the elderly to elaborate an electro-clinical score which aims to help establish the diagnosis of epilepsy in elderly patients in different clinical settings. This electro-clinical score is based on a systematic review of scientific literature and the recommendations are explicitly linked to supporting evidence. Further, clinical validation of the electro-clinical score is required.

[Transfusion in elderly patients]. / Transfusion chez les patients âgés.

The frequency of anemia is responsible of a frequent use of transfusion in elderly patients. However, transfusion in elderly patients requires several warnings. First, semiology of elderly patients is characterized with atypical clinical signs, and anemia tolerance is often difficult to appreciate. Second, numerous comorbidities make of elderly patients an heterogeneous population, in which guidelines are poorly applicable. Last, elderly patients are particularly sensitive to iatrogenic events, and the haemodynamic overload related to transfusion has to be carefully managed. All these difficulties raise the need of prospective studies on transfusion in elderly patients to validate clinical practice.

Amnestic syndrome of the medial temporal type identifies prodromal AD: a longitudinal study.

OBJECTIVE: To compare the power of tests assessing different cognitive domains for the identification of prodromal Alzheimer disease (AD) among patients with mild cognitive impairment (MCI). BACKGROUND: Given the early involvement of the medial temporal lobe, a precocious and specific pattern of memory disorders might be expected for the identification of prodromal AD. METHODS: A total of 251 patients with MCI were tested at baseline by a standardized neuropsychological battery, which included the Free and Cued Selective Recall Reminding Test (FCSRT) for verbal episodic memory; the Benton Visual Retention Test for visual memory; the Deno 100 and verbal fluency for language; a serial digit learning test and the double task of Baddeley for working memory; Wechsler Adult Intelligence Scale (WAIS) similarities for conceptual elaboration; and the Stroop test, the Trail Making test, and the WAIS digit symbol test for executive functions. The patients were followed at 6-month intervals for up to 3 years in order to identify those who converted to AD vs those who remained stable over time. Statistical analyses were based on receiver operating characteristic curve and Cox proportional hazards models. RESULTS: A total of 59 subjects converted to AD dementia. The most sensitive and specific test for diagnosis of prodromal AD was the FCSRT. Significant cutoff for the diagnosis was 17/48 for free recall, 40/48 for total recall, and below 71% for index of sensitivity of cueing (% of efficacy of semantic cues for retrieval). CONCLUSIONS: The amnestic syndrome of the medial temporal type, defined by the Free and Cued Selective Recall Reminding Test, is able to distinguish patients at an early stage of Alzheimer disease from mild cognitive impairment non-converters.

Restoration of thiamine status with white or whole wheat bread in a thiamine-depleted rat model.

Long-term thiamine deficiency has been largely documented, whilst little is known about effects of short-term depletion/repletion periods on thiamine vitamers status. Rats were submitted to short-term depletion (8 days) followed by different durations of repletion (3 or 14 days) with thiamine from bread (whole wheat bread or white bread, whole B and white B respectively) or corresponding controls. Short-term depletion drastically decreased plasma thiamine (-97%) and its urinary excretion (-77%). TDP (thiamine diphosphate) was strongly affected in liver (-67%) but less affected in cerebellum (-38%) or kidneys (-45%). Short-term repletion (3 days) with whole B diet or its control restored TDP at initial values in cerebellum and kidneys. A longer repletion (14 days) was required to restore liver TDP. Comparison of the diet groups indicates that thiamine status in tissues of rat fed whole B or white B diet was comparable to that of rats fed purified thiamine. Plasma thiamine concentration could not be restored at initial values in the bread groups or respective controls. In conclusion, thiamine in whole wheat bread appears effective in preventing marginal deficiencies and plasma thiamine is a less reliable indicator of thiamine status than tissue TDP levels.