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.

[Lung cancer in the elderly subject]. / Cancer bronchique du sujet âgé.

INTRODUCTION: In France, the average age for the diagnosis of bronchial carcinoma is 64. It is 76 in the population of over 70. In fact, its incidence increases with age linked intrinsic risk of developing a cancer and with general ageing of the population. Diagnosis tools are the same for elderlies than for younger patients, and positive diagnosis mainly depends on fibreoptic bronchoscopy, complications of which being comparable to those observed in younger patients. STATE OF THE ART: The assessment of dissemination has been modified in recent years by the availability of PET scanning which is increasingly becoming the examination of choice for preventing unnecessary surgical intervention, a fortiori in elderly subjects. Cerebral imaging by tomodensitometry and nuclear magnetic resonance should systematically be obtained before proposing chirurgical treatment. An assessment of the general state of health of the elderly subject is an essential step before the therapeutic decision is made. This depends on the concept of geriatric evaluation: Geriatric Multidimensional Assessment, and the Comprehensive Geriatric Assessment which concerns overall competence of the elderly. PERSPECTIVES: This is a global approach that allows precise definition and ranking of the patient's problems and their impact on daily life and social environment. Certain geriatric variables (IADL, BADL, MMSE, IMC etc) may be predictive of survival rates after chemotherapy or the incidence of complications following thoracic surgery. The main therapeutic principles for the management of bronchial carcinoma are applicable to the elderly subject; long term survival without relapse after surgical resection is independent of age. Whether the oncological strategy is curative or palliative, the elderly patient with bronchial carcinoma should receive supportive treatments. They should be integrated into a palliative programme if such is the case. In fact, age alone is not a factor that should detract from optimal oncological management. CONCLUSIONS: The development of an individual management programme for an elderly patient suffering from bronchial carcinoma should be based on the combination of oncological investigation and comprehensive geriatric assessment.

[Consensus statement on severe dementia]. / Consensus sur la démence de type Alzheimer au stade sévère.

Under the auspices of the French Society of Gerontology and Geriatrics, a multidisciplinary team including geriatritians, neurologists, epidemiologists, psychiatrists, pharmacologists and public health specialists developed a consensus on care for patients with severe dementia. They defined 21 recommendations for general practitioners, long-term care physicians and specialists based on knowledge available in 2005. At all stages of the disease, the objective of care is to improve as much as possible quality-of-life for the patient and his/her family, including a life project until the end of life. It is always possible to do something for these patients and their family: nutritional status, behavior disorders, and incapacities to deal with basic activities of daily life have to be taken in consideration. Resource allocation and proximity care have to be targeted. Research areas necessary to improve the care of patients with severe dementia has been selected.

[Consensus statement on severe dementia]. / Consensus sur la démence de type Alzheimer au stade sévère.

Under the auspices of the French Society of Gerontology and Geriatrics, a multidisciplinary group of experts, including geriatricians, neurologists, epidemiologists, psychiatrists, pharmacologists, and public health specialists developed consensus recommendations about care for patients with severe dementia. They defined 21 recommendations for general practitioners, long-term care physicians, and specialists, based on the knowledge currently available (2005). The aim of care at all stages is to mitigate the quality-of-life of patient, caregiver, and family insofar as possible, combining care and future planning until the end of life. Management, to take into account problems including nutritional status, behavior disorders, and ability (or inability) to perform activities of daily living, must be global, multidisciplinary, and coordinated and must optimize use of local medical and social resources. The group also stressed the importance of clinical research to improve knowledge of disease course and assess management strategies and recommended specific area for research.

Comparison of single-dose pharmacokinetics of imipramine and maprotiline in the elderly.

Pharmacokinetic profiles of imipramine and a newer tetracyclic antidepressant, maprotiline, were studied in elderly (75-83 years of age) subjects who were given a single oral dose of 125 and 175 mg, respectively, of these drugs. The apparent elimination half-life of imipramine was 20.8-34.9h (means 26.4h), its biovailability (F) was 40-64% (means 57%), and the apparent plasma clearance was from 0.27-0.57h/kg (mean 0.41h/kg). Maprotiline had a longer half-life (mean 31.5h range 20.6-51.8h, but its bioavailability (mean 50%) and plasma clearance (mean 0.49h/kg) values were in the range similar to those seen after imipramine. It appears that the elimination half-life of imipramine is longer and its plasma clearance is markedly reduced in elderly subjects when compared to values reported in young adults. Subjective clinical side effects were minimal with the two drugs. However, alterations in heart rate, blood pressure, or electrocardiogram occurred in all subjects. This suggests that caution should be exercised before initiating and during the treatment of elderly patients with these antidepressant drugs.

Dermatoglyphic patterns in dementia of the Alzheimer type: a case-control study.

STUDY OBJECTIVE: The aim was to compare digital and palmar dermatoglyphics in subjects with dementia of Alzheimer type and in mentally healthy elderly controls. DESIGN: This design was a case-control study. SETTING: The study was carried out in geriatric units and retirement communities in the Paris area. PARTICIPANTS: Cases were women with clinically diagnosed Alzheimer type dementia according to DSM III-R criteria (n = 82), mainly with late onset of the disease. Controls were women aged 85 years or older without cognitive deterioration (n = 76). MEASUREMENTS AND MAIN RESULTS: Finger and palm prints obtained from both hands by the classical ink method were examined. Fingerprints were classified into four types of figures. On palms, palmar flexion creases, palmar axial triradii, true patterns of the hypothenar area, and main line terminations were described. Examinations were performed by two examiners blind to the subjects's diagnostic category. For the different patterns studied, no major differences between dementia patients and elderly controls were found. Nor was there evidence of high frequencies of features commonly observed in Down's syndrome (trisomy 21), which have previously, though sporadically, been reported. CONCLUSIONS: On one of the largest samples of Alzheimer dementia patients studied, and with evaluation blind to diagnosis, no evidence has been found that particular dermatoglyphic patterns occur like those observed in Down's syndrome, a disease which is related to dementia of the Alzheimer type.

[Treatment of arterial hypertension in the aged with a calcium antagonist: nicardipine]. / Traitement de l'hypertension artérielle du sujet âgé par un inhibiteur calcique: la nicardipine.

The purpose of this study was to test in double-blind trial the tolerance and antihypertensive effect of nicardipine versus placebo in 32 elderly patients (mean age: 84 years). Nicardipine was given three times a day (mean dose: 69.4 mg per day). After four weeks, nicardipine lowered blood pressure (BP) from 186 +/- 4 mmHg/99.5 +/- 3 mmHg to 150 +/- 6/84 +/- 3 mmHg (p less than 0.001). 10 out of 16 patients were normalized (BP less than 160-95 mmHg). The placebo group remained hypertensive: 181 +/- 7/96 +/- 4 mmHg versus 183 +/- 4/101 +/- 3 mmHg (NS). 3 placebo treated patients were nevertheless normalized. The changes in systolic BP and diastolic BP were significantly greater in the Nicardipine group: respectively -36 +/- 4 versus -2 +/- 6 mmHg (p less than 0.001), -16 +/- 3 versus -5 +/- 4 mmHg (p less than 0.05). Treatment was very well tolerated. Orthostatic hypotension, change in heart rate, variation in biological parameters were never observed. These data agree with Buhler's statement suggesting that calcium channel inhibitors can represent an interesting alternative to diuretics as first line monotherapy in the treatment of hypertension in the elderly.

[Significance of inhibitors of conversion enzymes in elderly subjects. The example of perindopril]. / Intérêt des inhibiteurs de l'enzyme de conversion chez le sujet âgé. L'exemple du perindopril.

The effectiveness and safety of perindopril in elderly hypertensive patients has clearly been demonstrated. In a randomized, double-blind drug versus placebo study involving 34 such patients of mean age 84 years, we observed a 10 p. 100 fall in systolic arterial pressure (p less than 0.01) and a 9 p. 100 fall in diastolic arterial pressure (p less than 0.01) in the perindopril group. The corresponding figures in the placebo group were 5 p. 100 and 4 p. 100 respectively, the difference between the two groups not being significant. The drug was well tolerated, both clinically and biochemically. However, a significant (p less than 0.01) increase in blood potassium level (albeit within normal limits) was observed in the treated group. An open trial conducted in 91 patients (mean age 79.1 years) followed up for 6 years confirmed the acceptability of the drug despite a transient decrease of creatinine clearance recorded in one patient. The effectiveness of perindopril, evaluated less unquestionably in this open trial, was excellent, the hypertension being controlled at the end of treatment in 92.5 p. 100 of the patients. In a trial performed on healthy volunteers, Reid found that perindopril had a greater effect of arterial pressure in elderly subjects, probably due in part to their high blood pressure and to an earlier and more prolonged inhibition of the angiotensin-converting enzyme (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

[Nosologic framework of mental deterioration in aged subjects. From clinical practice to epidemiology]. / Cadre nosologique des détériorations mentales du sujet âgé. De la clinique à l'épidémiologie.

The difficulty of defining a precise nosologic framework for mental decline is linked, on the one hand, to the contradictions surrounding the term normalcy as age increases, and, on the other, to the fact that mental decline has been mired for years under a term that must be definitively proscribed: "psycho-compartmental disorders of senescence". In this catch-all++ proscribed: "psycho-compartmental disorders of senescence". In this catch++-all it is, in fact, essential to identify diseases whose nature, prognosis and, above all, therapeutic approaches differ fundamentally one from the other; to confuse them is to risk dramatic consequences. Standardization of diagnostic criteria through the combined use of clinical data, the DSM III classification, scored tests (MMS, Hachinsky, etc.), as well as scannography, presently makes it possible to arrive at the diagnosis of dementia with reasonable accuracy. This standardization++ has its limits and is not necessarily useful in atypical cases. It is nevertheless an indispensable tool for epidemiological studies and therapeutic trials.

[Arterial hypertension in the elderly. Double-blind study versus placebo of the efficacy and tolerability of an alpha-beta blocker: labetalol]. / Hypertension artérielle du sujet âgé. Etude en double-insu contre placebo de l'efficacité et de la tolérance d'un alpha-bêtabloquant: le labétalol.

The purpose of this study was to investigate the efficacy and safety of labetalol, an alpha and beta-adrenergic receptor blocking agent in 32 patients aged from 72 to 97 years (mean = 85 years) with blood pressure (B.P.) greater than or equal to 160/95 mmHg. This study was carried out in a double-blind, randomized, placebo-controlled design. After 6 weeks of treatment with labetalol (mean dose = 235 +/- 47.5 mg/day), the systolic pressure was lowered from 187 +/- 24 to 145 +/- 28 mmHg (p less than 0.001) and the diastolic pressure from 98 +/- 10 to 82 +/- 9 mmHg (p less than 0.001). Likewise, in the placebo group, both systolic and diastolic pressures were significantly reduced but the changes were significantly greater in the labetalol group, -33 +/- 26 versus -13 +/- 20 mmHg and -14 +/- 10 versus -8 +/- 14 mmHg respectively. Labetalol achieved B.P. control (160/95 mmHg) in 64% of the treated patients, compared to 40% in the placebo group. Two patients on labetalol discontinued their treatment due to side-effects (one bradycardia and one cutaneous reaction) compared with one patient on placebo (cardiac failure). Two other cases in the labetalol group had side-effects (one fatigue and one dizziness) which prevented increasing the treatment as necessary.

[Risk of cerebrovascular accident in the aged hypertensive subject. Results of a 10-year longitudinal survey]. / Risque d'accident vasculaire cérébral chez le sujet âgé hypertendu. Résultats d'une surveillance longitudinale de 10 ans.

A ten year longitudinal survey of 191 female elderly subjects (mean age 80 - Range 61 to 101 years) was set up to demonstrate that even a moderate isolated systolic hypertension is a powerful contributor to the incidence of cerebrovascular complications in the elderly. The incidence of cerebrovascular events was carefully recorded and was correlated with a number of parameters registered at entry into the study. The results show that isolated systolic hypertension as well as diastolic hypertension is significantly correlated to the incidence of strokes independently of other parameters (Blood Cholesterol, Blood Sugar) which do not appear in this population as risk factors of cardiovascular morbidity. This underlines the high interest of controlled therapeutic studies run in this field in elderly patients.

[Treatment of arterial hypertension in the aged subject with a converting enzyme inhibitor: enalapril]. / Traitement de l'hypertension artérielle du sujet âgé par un inhibiteur de l'enzyme de conversion: l'énalapril.

The purpose of this study was to investigate the effectiveness and safety of enalapril in elderly people. A double-blind, randomized, placebo-controlled trial was carried out in 32 subjects aged from 75 to 97 years (mean: 86 years) with blood pressure values equal or superior to 160/90 mmHg. After 8 weeks of treatment with enalapril in doses of 20 to 40 mg/day, the systolic pressure was lowered from 190 +/- 16 to 151 +/- 19 mmHg (P less than 0.0001) and the diastolic pressure from 102 +/- 7 to 85 +/- 11 mmHg (P less than 0.0001). Systolic and diastolic pressures were also significantly reduced in subjects under placebo (from 183 +/- 16 to 165 +/- 21 mmHg, P less than 0.001; and from 101 +/- 9 to 91 +/- 13 mmHg, P less than 0.001, respectively), but the degree of reduction was significantly superior with enalapril (systolic: 39 +/- 25 vs 18 +/- 19 mmHg, P less than 0.005; diastolic: 17 +/- 13 vs 11 +/- 12, P less than 0.001); blood pressure was inferior to 160/90 mmHg in 67% of the subjects treated, as against 35% of those under placebo. Two patients under enalapril died: one on the 27th, the other on the 47th day of treatment. No relation could be established between these deaths and the drug, and this figure of 2 is not significantly different for the number of deaths expected over the same period in a population of that age-group. Among the patients under placebo, one had pulmonary embolism on the 34th day and another had a sudden increase in blood pressure on the 6th day, requiring discontinuation of treatment. It is concluded that enalapril administered alone is effective and well tolerated. Long-term studies are needed to find out whether this angiotensin-converting enzyme inhibitor is superior to a diuretic as initial treatment of arterial hypertension.

[A new instrument to measure quality of life in older people: The French version of the WHOQOL-OLD]. / Un nouvel instrument destiné à mesurer la qualité de vie des personnes âgées : le WHOQOL-OLD version française.

PURPOSE: We present the validation data of the French version of a new quality of life questionnaire, specifically developed for use with older adults (>60 years old): the WHOQOL-OLD module. This questionnaire, which contains 24 items in six domains, is a complementary module of the WHOQOL-BREF quality of life questionnaire. It was internationally developed by a World Health Organization (WHO) group. METHODS: The first development and pilot studies led to a first questionnaire applied in field studies in 20 centers all over the world. They were done in 5566 subjects and allowed the validation of the final form of the WHOQOL-OLD questionnaire. For its French version, 281 subjects, with a mean age of 74 years, were recruited in three centers (Paris, Nancy and Geneva). RESULTS: The results of the psychometric properties of the questionnaire, particularly the multitrait analysis, are compatible with the assumptions underlying the construction of scores. Otherwise, scores present a sufficient accuracy to use this instrument in group comparisons. CONCLUSION: The WHOQOL-OLD questionnaire can be used in older people in health services, clinical research and epidemiologic studies.

Nicardipine in elderly patients with hypertension: a review of experience in France.

A double-blind, placebo-controlled clinical trial in France has studied the efficacy and safety of nicardipine in 31 elderly patients, aged 57 to 95 years (mean age 84 years), 16 of whom were actively treated with nicardipine, 10 to 30 mg three times a day (mean dose 69.4 mg/day). After 4 weeks, nicardipine lowered mean blood pressure (186/99 to 150/83 mm Hg; p less than 0.001), and the changes in systolic and diastolic blood pressure were significantly greater in the nicardipine group than in the placebo group. Nicardipine was well tolerated; orthostatic hypotension was not observed and there was no change in heart rate. Plasma renin activity (PRA) was measured in eight patients, but there was no correlation between PRA and the antihypertensive effect of nicardipine. Results of a pharmacokinetic study performed in 15 elderly patients showed a rapid rate of absorption and higher plasma levels than those observed in younger patients with hypertension (mean age 54 years). The results support those of the major French multicenter open study of 29, 104 elderly patients with hypertension (mean age 64 +/- 12 years) treated with nicardipine. The findings of this trial are reviewed and discussed, and recommendations made on the directions for future research in cardiovascular medicine with calcium channel blockers. Results of the trials discussed in this article show that nicardipine is an effective and well-tolerated drug in elderly patients and has wide-ranging effects on the cardiovascular system.

[Treatment of arterial hypertension in the elderly with an alpha-blocker: nicergoline (author's transl)]. / Traitement de l'hypertension artérielle du sujet âgé par un alpha-bloquant: la nicergoline.

The tolerance and anti-hypertensive activity of nicergoline, an alpha-adrenoceptor blocking agent, were studied in 28 hypertensive subjects older than 65 years (mean age: 84 years). The trial was conducted double-blind: 14 subjects were given nicergoline 30 mg/day divided into 6 doses ("lyocs"), and 14 subjects received a placebo identical in appearance with the drug. A mean decrease of 34 mm Hg in systolic arterial pressure (p < 0.001) and of 16 mm Hg in diastolic arterial pressure (p < 0.001) was observed in subjects under nicergoline. The corresponding changes in blood pressure (-12 and -7.9 mm Hg respectively) in subjects under placebo were not significant. No side-effect requiring discontinuation of treatment was encountered. The remarkable effectiveness and tolerance of nicergoline make it a highly suitable agent for the treatment of hypertension in elderly people.