[Pyoderma gangrenosum and hemopathies in older patients]. / Pyoderma gangrenosum et hémopathies chez la personne âgée.

Pyoderma gangrenosum (PG) belongs to neutrophilic dermatoses. PG can have different clinical presentations (ulcerated, bullous, pustular), is often painful, and preferentially affects the lower limbs. The diagnosis can be challenging, and a cutaneous biopsy is often necessary, which shows an aseptic cutaneous infiltrate of neutrophils. The association with inflammatory or hematologic conditions is frequent, especially in older patients. The hematologic diseases the most frequently associated with PG are myelodysplastic syndrome, followed by monoclonal gammopathy of undetermined significance. Because of the strong impact of its treatment, recognition of PG is crucial. The treatment is based on first-line corticosteroids and topical or systemic immunosuppressive drugs and most often leads to a favourable outcome. The management of an acute hematologic disease would further improve the prognosis of PG. The singularity of geriatric patients encourages to thoroughly balance the risks and benefits of the recommended drugs and to consider associated non-drug measures. Here, we propose a review of the scientific literature about the association between PG and hematologic diseases, with a special focus on older patients, accompanied by the report of two cases in geriatric ward.

[Epilepsy in the elderly]. / Epilepsie du sujet âgé: diagnostic et prise en charge.

Epilepsy is one of the most frequent neurological diseases in the elderly. Its incidence and associated-mortality rise in old age. Distinguishing epilepsy from paroxysmal non epileptic events can be a real challenge for physicians. Diagnosis of epilepsy relies on clinical examination but routine laboratory tests and cerebral imaging are warranted, especially for first-ever event. Electroencephalogram is important for the evaluation of seizures in elderly patients but it may show non specific changes associated with age. Clinical presentation in old age is often less-specific. Partial seizures are more common than generalized. Acute symptomatic seizures are very frequent most often due to metabolic abnormalities; infections or medications. Although the international classification of epilepsy is well known, its use is not easy in the elderly We favour a geriatric model of reasoning, which takes into account the effects of aging, chronic diseases and acute precipitating factors, because it is more beneficial to the patient. Based on this model, an electro-clinical scale has been created (but not yet validated) to help practitioners with the diagnosis. When initiating the treatment, monotherapy is always preferred. The choice of a molecule must be individualized. Efficacy, but also antiepileptic drug side-effects (alertness, cognitive effects), and interactions must be taken into account in this vulnerable population.

[Geriatric approach of sleep disorders in the elderly]. / Approche gériatrique des troubles du sommeil.

Sleep complaints and disorders are frequent in geriatric patients, with a prevalence of 57%. They result in increased morbidity and mortality. In this population, the primary goal is to search for a cause of secondary insomnia, such as organic or psychiatric diseases, or medications. In those cases, sleep will improve with the treatment of the cause. In the cases of primary insomnia, behavioral and sleep hygiene therapy are essential. Hypnotics have frequent side effects and should be avoided when possible. Prescription of small doses of benzodiazepines or related drugs should only be for a short period of time. Molecules with a short half life are to be preferred. Other sleep disorders include sleep apnea syndrome, restless legs syndrome and periodic limb movements, which are the most frequent diagnoses in an elderly population. In the restless legs syndrome, diagnostic workup must include the search for a cause and treatment should favor hygienic measures. The use of dopamine agonists must be cautious, as their tolerance is poor in the elderly. Periodic limb movements are also frequent but there is no particular therapeutic recommendation.

[Diabetes mellitus and cognition: is there a link?]. / Diabète et cognition: existe-t-il un lien ?

The occurrence of diabetes and dementia is very high in older patients. The fact that both conditions are concurrent raises the question of a possible link between the two. Cognitive functions of non-demented patients with diabetes have been extensively studied. In type 1 diabetes, only a mild decrease of the speed of information processing and of the psychomotor efficiency has been shown. Cognitive decline seems to be related to poor metabolic control and not to hypoglycaemia. In older patients with type 2 diabetes, memory and executive functions have been found impaired. Longitudinal studies of the literature have shown that diabetic patients have a higher chance of developing dementia than non-diabetic patient, with a relative risk (RR) between 1.26 and 2.83. The risk of vascular dementia was increased in 3 out of 5 studies, with a RR ranging between 2 and 2.6. With regard to Alzheimer's disease, the results are conflicting. Half of the studies found an increased risk in diabetic patients (RR: 1.3-2). The possible causal mechanisms of dementia in diabetic patients remain hypothetical. MRI studies showed varying degrees of cortical atrophy, cerebral infarcts and deep white matter lesions. In neuropathological studies, senile plaques and neurofibrillary tangle were not found with higher severity in the brain of diabetic patients than in the brain of age-matched controls. Several hypotheses have been raised to explain the relationship between diabetes and cognitive decline. Micro and macrovascular changes in the brain could induce cerebral hypoxia and ischemic conditions resulting in cellular death or white matter lesions. The occurrence of vascular lesions might reduce the threshold at which dementia will occur in Alzheimer disease. The deposition of advanced glycation end products doesn't spare the brain and they have been found in senile plaques, where they can reduce the solubility of proteins such as the beta amyloid and Tau proteins. Some authors favour the hypothesis of a brain insulin resistance because, in a few small studies, insulin was found to improve memory.

[Link between non hypoxemic chronic obstructive pulmonary disease and executive functioning in oldest old]. / Étude du lien entre la broncho-pneumopathie obstructive non hypoxémiante et le fonctionnement exécutif de patients de plus de 75 ans.

COPD (chronic obstructive pulmonary disease) may result in cognitive disorders (mainly executive) even without hypoxemia. The aim of this descriptive study was to highlight a deficit in task-switching in non-hypoxemic patient with COPD and mild cognitive impairment (MCI) or Alzheimer disease (AD). The main judgment criterion was patients' performances on the TMTA and B. COPD patients were recruited via the database (CogDisCo) of the geriatric medicine department at Pitié Salpêtrière hospital in Paris. 7 patients had Alzheimer's disease (AD), and 11 mild cognitive impairment (MCI): they were matched for age, sex, MMSE, education level with controls subjects without COPD. There was no significant difference between the two groups. However, patients with COPD and MCI required, on average, an extra 13 seconds compared with patient without COPD for the TMTA and 18 seconds for the TMTB. Patients with COPD and AD needed, on average, an extra 63 seconds for TMTA and 97 seconds for TMTB. The number of errors for the TMTB was the same in the both groups. This preliminary study does not show statistically significant results but the time for achieving TMT was longer in the population with COPD whether AD or MCI. These results encourage us to continue with prospective studies on larger samples.

[Neurosyphilis and cognitive disorders]. / Neurosyphilis et troubles cognitifs.

We report the case of a 75 year old man, admitted for a delirium which was unusual by its severity and duration. Underlying disorders were an infectious disease (neurosyphilis) and prodromal Alzheimer's disease. This association was thought to be responsible for the delirium intensity. According to a literature review, we discuss the difficulties of cerebral neurosyphilis diagnosis, its cognitive and behavioural symptoms. We also discuss the cumulative effects of multi morbidities on clinical presentation, underlining a frequent problem in elderly patients in whom multiple causes of cognitive impairment often coexist.

Lactococcus garvieae endocarditis: identification by 16S rRNA and sodA sequence analysis.

Lactococcus garvieae is only rarely isolated from clinical specimens. We report a case of prosthetic valve endocarditis caused by L. garvieae in an elderly patient. Molecular methods based on the 16S rRNA and sodA(int) gene sequences confirmed the phenotypic identification of this opportunistic human pathogen.