IANA (International Academy on Nutrition and Aging) Expert Group: weight loss and Alzheimer's disease.

Weight loss, together with psychological and behavioural symptoms and problems of mobility, is one of the principal manifestations of Alzheimer's disease (AD). Weight loss may be associated with protein and energy malnutrition leading to severe complications (alteration of the immune system, muscular atrophy, loss of independence). Various explanations have been proposed such as atrophy of the mesial temporal cortex, biological disturbances, or feeding behaviours; however, none has been proven. Prevention of weight loss in AD is a major issue. It requires regular follow-up and must be an integral part of the care plan. The aim of this article is to review the present state of scientific knowledge on weight loss associated with AD. We will consider four points: the natural history of weight loss, its known etiological factors, its consequences and the various management options.

[Prevalence of pressure sores in a university hospital in 2003]. / L'escarre à l'hôpital en 2003: enquête de prévalence un jour donné.

BACKGROUND: To determine the prevalence of pressure sores in a university hospital and to assess the risk of developing a pressure sore. METHODS: A one-day survey was performed in all hospitalized patients, day hospital excepted. The Garches scale was used to assess the severity of pressure sores and the Braden scale was used to measure the patient's risk for the development of pressure ulcers. RESULTS: One thousand six hundred and eleven patients were included, mean age was 62+/-23 years and 53.3% were over 65 years old. In hospitalized patients, 64% were in acute care, 29% in intermediate medicine and long-term care and 7% in intensive care units. We have found 675 pressure sores in 268 patients, mean age of 76 years; 263 decubitus ulcers were acquired during hospitalization. The most frequent sites were heels (46%) and sacrum (26%). Stage 1 pressure ulcers showed 33% of the total. The total prevalence was 16.6%, 95% CI (14.9-18.6), the hospital acquired pressure sores prevalence was 7.5%, all stages included. A Braden score less than or equal to 15 was found in 29.1% of hospitalized patients. Standard mattresses were used in 37% of patients with pressure sores. Multivariate analysis showed that age and a Braden score less than or equal to 15 were significantly associated with pressure sores. CONCLUSION: Pressure sores are still an important problem in hospital; occurrence must be considered as an iatrogenic event and management requires a multidisciplinary approach.

The brain of the elderly diabetic patient.

All available estimations agree that the French population is aging and that the proportion of diabetics in the elderly population is increasing. The prevalence of diabetes could be about 10% in the over 65 y population. The fact that diabetes has an effect on brain function is widely accepted, but there are very few studies providing pertinent details. Diabetes is known to affect brain function, potential consequences including cognitive decline, dementia, depression, and stroke. These complications are frequently associated, leading to poor quality-of-life with considerable social and economic impact. While the results of different studies can be contradictory, there is an overall trend towards the conclusion that diabetes, often associated with high blood pressure, contributes to cognitive decline in elderly diabetics as well as to an increased frequency and severity of cerebral vascular events. These considerations point out the importance of proper management of diabetes in the elderly population and the need for cooperative studies to determine the role of diabetes and different cardiovascular risk factors in the development of dementia, stroke, and depressive syndromes whose consequences are probably underestimated.

Nutritional status assessment during Alzheimer's disease: results after one year (the REAL French Study Group).

OBJECTIVES: Weight loss and malnutrition are frequent and serious complications of Alzheimer's disease. The aim of the present article was to describe the cognitive and behavioural characteristics of the test population within the frame of the PHRC REAL.FR cohort (for Réseau sur la Maladie d'Alzheimer Français), depending on their nutritional state, and to consider their evolution one year after the original inclusion. METHOD: The study population' stratification was done in three groups according to their Mini Nutritional Assessment (MNA) score: malnutrition group (MNA < 17.5), at risk of malnutrition group (MNA 17.5-23.5), and normal nutritional status group (MNA > or = 23.5). 561 patients were evaluated at inclusion time, 393 at one year. The evaluation included the following scales: Mini Nutritional Assessment (MNA), Mini Mental State Examination (MMSE), Activities Daily Living (ADL), Instrumental Activities Daily Living (IADL), Neuro Psychiatric Inventory (NPI) and Zarit scale (ZARIT). Comparison and descriptive analysis for each MNA group at baseline and at one year has been performed. RESULTS: at baseline, the well-nourished and the malnutrition risk groups are significantly different concerning age, IADL and NPI; the well-nourished and undernutrition groups are different concerning MMSE, NPI and Zarit; the malnutrition risk and undernutrition groups are only different concerning NPI. At one year, the well-nourished and the malnutrition risk and undernutrition groups are different concerning one lonely variable, the NPI, in a significant way. The comparison of the three groups between baseline and one-year evaluation demonstrate for the well-nourished group an aggravation of MMSE, ADL, IADL, NPI, for the malnutrition risk group of MMSE and IADL, and for the undernutrition group of MMSE, IADL and NPI. CONCLUSION: Among the patients suffering from Alzheimer's disease, the most malnutritioned worsen highly on cognitive and functional capacities. Furthermore, the nutritional aggravation seems strongly linked to behavioural disorders aggravation. The improvement of those disorders has therefore to be part of every improvement strategy applied to the nutritional status of the demented patients.

One-year longitudinal evaluation of neuropsychiatric symptoms in Alzheimer's disease. The REAL.FR Study.

Behavioral and Psychological Symptoms are major and frequent manifestations of Alzheimer's Disease (AD). The aim of the present study was to evaluate neuropsychiatric symptoms in the PHRC REAL.FR cohort (for Réseau sur la maladie d'Alzheimer Français) after one year of evolution. Four hundred and eighty two patients with mild and moderate AD were assessed. A majority of them had significant symptoms at inclusion (85.3 % of subjects with mild AD, 89.7% of patients with a moderate AD). Patients with mild AD had a significant increase of the Neuropsychiatric Inventory (NPI) frequency x severity scores for apathy and aberrant motor behavior. Patients with moderate AD had a significant increase of NPI disinhibition, aberrant motor behavior and sleep disorders scores. The variation of NPI total score at one year correlated positively with change in Zarit's caregiver burden score, independently of global cognitive evolution. After one year, a group of 54 patients were institutionalized in nursing home or long term care unit. When compared to non institutionalized patients, the institutionalized group was characterized at base line by a lower MMSE score, a higher Zarit caregiver burden score, and a higher NPI agitation and disinhibition scores.

[Behavioral and psychological symptoms in dementia: description and management]. / Les symptômes psychologiques et comportementaux de la démence: description et prise en charge.

Behavioral and Psychological Symptoms in Dementia (BPSD) are, beside cognitive disorders, major features of Alzheimer's disease and related disorders. Diagnosis is important to enhance our knowledge of the pathophysiology of dementia and of their functional consequences for patients and caregivers. Pharmacological and non-pharmacological management of dementia depends to a large extent on the presence of BPSD. A committee of geriatricians, neurologists and psychiatrists specialized in dementia (THEMA 2) has promoted an epidemiological, diagnostic and therapeutic update in this field. This work was based on the BPSD Consensus Conference Report edited in 2000 by the International Psychogeriatric Association. This report was updated with the most recent literature reports, and was adapted to the French environment. This paper is a synthesis of this meeting, validated and corrected by the entire Thema 2 group.

Cobalamin deficiency in the elderly: aetiology and management: a study of 125 patients in a geriatric hospital.

INTRODUCTION: Cobalamin deficiency is frequent in elderly patients and the main aetiologies are food-cobalamin malabsorption and pernicious anaemia. The aim of our retrospective study was to identify the causes and methods of management of cobalamin deficiency at Nice geriatric university hospital. METHODS: A retrospective monocentric study was conducted over 14 months at Nice geriatric hospital, which included patients with cobalamin deficiency having received supplementation. The clinical and paraclinical data, etiological diagnosis, treatment and follow-up modalities were analyzed retrospectively. RESULTS: We studied 125 elderly patients whose median age was 85.5 ± 7 years. The etiological diagnosis was food-cobalamin malabsorption for 72 patients (57.6 %), nutritional cobalamin deficiency for 15 patients (12 %), pernicious anaemia for 12 patients (9.6 %) and there was no etiological diagnosis for 26 patients (20.8 %). Concerning cobalamin therapy, 111 patients (88.8 %) received oral therapy and 14 (11.2 %) intramuscular therapy. Vitamin B12 levels increased significantly after supplementation (p<0.001) but cobalamin administration varied according to the diagnoses (p<0.001) and was less effective in patients with dementia (p=0.04) and food-cobalamin malabsorption. CONCLUSION: Our study showed the importance of food-cobalamin malabsorption in etiological diagnosis in accordance with the literature, but also the non-negligible share of nutritional cobalamin deficiency. Mainly oral cobalamin supplementation was used in our study with a significant increase in vitamin B12 levels. An oral cobalamin regimen is proposed for elderly patients with cobalamin deficiency but with no severe neurological signs.

Inertial sensors as measurement tools of elbow range of motion in gerontology.

BACKGROUND AND PURPOSE: Musculoskeletal system deterioration among the aging is a major reason for loss of autonomy and directly affects the quality of life of the elderly. Articular evaluation is part of physiotherapeutic assessment and helps in establishing a precise diagnosis and deciding appropriate therapy. Reference instruments are valid but not easy to use for some joints. The main goal of our study was to determine reliability and intertester reproducibility of the MP-BV, an inertial sensor (the MotionPod(®) [MP]) combined with specific software (BioVal [BV]), for elbow passive range-of-motion measurements in geriatrics. METHODS: This open, monocentric, randomized study compared inertial sensor to inclinometer in patients hospitalized in an acute, post-acute, and long-term-care gerontology unit. RESULTS: Seventy-seven patients (mean age 83.5±6.4 years, sex ratio 1.08 [male/female]) were analyzed. The MP-BV was reliable for each of the three measurements (flexion, pronation, and supination) for 24.3% (CI 95% 13.9-32.8) of the patients. Separately, the percentages of reliable measures were 59.7% (49.2-70.5) for flexion, 68.8% (58.4-79.5) for pronation, and 62.3% (51.2-73.1) for supination. The intraclass correlation coefficients were 0.15 (0.07-0.73), 0.46 (0.27-0.98), and 0.50 (0.31-40 0.98) for flexion, pronation, and supination, respectively. CONCLUSION: This study shows the convenience of the MP-BV in terms of ease of use and of export of measured data. However, this instrument seems less reliable and valuable compared to the reference instruments used to measure elbow range of motion in gerontology.

[Prevalence of anal incontinence in adults]. / Etude de la prévalence de l'incontinence anale chez l'adulte.

Inquiries were conducted to determine the prevalence of anal incontinence in a) the general population over 45 by a gallup poll studying 1,100 persons (A); b) 3,914 patients seen by their general practitioner or their gastroenterologist during the same week (B); c) 500 patients consulting for urinary stress incontinence (C1); d) 1,136 neurological patients suffering from micturation disorders (C2); and e) 10,157 elderly persons living in retirement homes or in hospital (D). In the general community (A), the prevalence of anal incontinence, including gas and stool incontinence, was 11 percent, the prevalence of fecal incontinence, 6 percent, the prevalence of daily or weekly fecal incontinence, 2 percent; prevalences were respectively 15.5 percent, 7.9 percent, and 3.2 percent in group B, and 27 percent, 9 percent and 3.8 percent in group C1. The prevalence of fecal incontinence was 18 percent in group C2 and 33 percent in group D. Prevalence did not depend on age in group A and C1, but was twofold higher in group C1 than in group A. The prevalence increased with age in groups B and D.

[Nutritional status and Alzheimer's disease: preliminary results of the REAL.FR study]. / Etat nutritionnel et maladie d'Alzheimer: résultats préliminaires de l'étude REAL.FR.

Weight loss is common in elderly people with dementia, particularly those with Alzheimer' disease (AD), and feeding difficulties are major issues in their care in the later stages of the disease. In this study (REAL FR for Réseau sur la maladie d'Alzheimer Français) we prospectively used the Mini Nutritional Assessment (MNA) to examine the nutritional status of 479 subjects. Three groups of patients were studied: group 1 = 22 patients with undernutrition (MNA = 17), group 2 = 166 patients with risk of undernutrition (17 < MNA < 24), and group 3 = 291 patients without undernutrition (MNA = 24). Correlations with behavioral and psychological signs and symptoms of dementia (Neuropsychiatric Inventory NPI), with caregiver distress (Zarit), and with the Mini Mental State Examination (MMSE) were studied. Undernutrition is more frequently associated with low MMSE (p < 0.001), high behavioural disturbances (p < 0.001) and high distress of caregivers (p < 0.001). Risk of undernutrition is also associated with NPI (p < 0.001) and Zarit (p < 0.001). These first results in a French cohort of patients with AD underline the importance of the evaluation of nutritional status and finally the follow-up of eating behavior, cognitive status and the quality of life of the caregivers.

[Behavioral and psychologic symptoms in Alzheimer's disease: results of the REAL.FR study]. / Symptômes comportementaux et psychologiques dans la maladie d'Alzheimer: résultats de l'étude REAL.FR.

Behavioral and Psychological Signs and Symptoms of Dementia (BPSD) are important manifestations of Alzheimer's Disease (AD) and other forms of dementia, because they are associate with care-giver distress, increase the likelihood of institutionalization, and may be associated with more rapid cognitive decline In this study (REAL.FR for Réseau sur la maladie d'Alzheimer Français) we prospectively used the Neuropsychiatric Inventory NPI to examine BPSD. 255 AD patients with a Mini-Mental State Examination (MMSE) score between 11 and 20 and 244 AD patients with a MMSE between 21 and 30 were examined. Factor analysis was carried out leading to three different syndromes according to the level of cognitive impairment. BPSD were detected in 92.5% of the patients with a MMSE between 11 and 20, and in 84% of the patients with a MMSE between 21 and 30. Apathy was the most common abnormality, followed by anxiety and dysphoria. These results in a French cohort of patients with AD underline the importance of the evaluation and finally of the treatment of BPSD.

Key priorities in managing glucose control in older people with diabetes.

Older people with diabetes represent a major and increasing proportion of our elderly population and their care requires better organisation. Targets for risk factor control and pathways of care must be adjusted to the subject's general health status. It is thus advisable to screen for frailty. We have carried out a detailed literature review of the studies published on diabetes in older people since 1990. Studies were considered if they included groups or subgroups of diabetic patients > 65 years old. This review discusses the elaboration of general targets for care, the approach to risk factor control, the screening and the specific prevention or management of complications, the integration of geriatric concepts in diabetes care and the specificity of education with respect to frailty status.

A two-centre, randomized, double-blind trial of ornithine oxoglutarate in 194 elderly, ambulatory, convalescent subjects.

In a double-blind trial, 194 ambulatory elderly patients (mean age, 74 +/- 8 years) recovering from acute illnesses were randomly assigned to receive either ornithine oxoglutarate (OGO) or a placebo. Nine subjects withdrew during the study, six in the OGO group and three in the placebo group. OGO and the placebo were administered once daily at a dose of 10 g after lunch for 2 months; the patients were monitored for a total of 4 months. Efficacy was evaluated in terms of nutritional variables, quality of life and total cost of medical treatment. The analysis involved a total of 185 patients (93 in the placebo group and 92 in the OGO group). The two groups were comparable at inclusion. After 30 and 60 days of treatment, there was a significant improvement in the following variables in the OGO group relative to the placebo group: appetite (p < 0.001), body weight (p < 0.001) and independence (p < 0.01). Two months after the end of treatment, there was still a significant improvement in the quality-of-life index (p < 0.001) and the medical-cost index (p < 0.03) in the OGO group, with an overall cost saving of 37%. We conclude that OGO seems to be a cost-effective nutritional supplement for elderly convalescent patients.

The apathy inventory: assessment of apathy and awareness in Alzheimer's disease, Parkinson's disease and mild cognitive impairment.

OBJECTIVE: This study was designed to establish the validity and reliability of the apathy inventory (IA), a rating scale for global assessment of apathy and separate assessment of emotional blunting, lack of initiative, and lack of interest. METHOD: Information for the IA can be obtained from the patient or from a caregiver. We evaluated 115 subjects using the IA, consisting of 19 healthy elderly subjects, 24 patients with Mild Cognitive Impairment (MCI), 12 subjects with Parkinson's disease (PD) and 60 subjects with Alzheimer's disease (AD). RESULTS: Internal consistency, item reliability, and between-rater reliability were high. A test-retest reliability study demonstrated that caregiver responses to IA questions were stable over short intervals. A concurrent validity study showed that the IA assesses apathy as effectively as the Neuro Psychiatric Inventory apathy domain. In the caregiver-based evaluation, AD subjects had significantly higher scores than controls, both for global apathy score and for the lack of interest dimension. When the AD patients were subdivided according to diagnostic criteria for apathy, apathetic patients had significantly higher scores than non apathetic patients. With the patient-based evaluations, no differences were found among the AD, MCI and control groups. The scores in the patient-based evaluations were only higher for the PD group versus the control subjects. The results also indicated that AD patients had poor awareness of their emotional blunting and lack of initiative. CONCLUSIONS: The IA is a reliable method for assessing in demented and non-demented elderly subjects several dimensions of the apathetic syndrome, and also the subject's awareness of these symptoms.