Effect of a multi-domain intervention on the quality of life in older adults with major neurocognitive disorder: A pilot study.

PURPOSE: Major neurocognitive disorders (MND) have multiple negative consequences on patients' lives and on their caregivers' health. Occupational therapy and cognitive stimulation have failed to show any significant efficacy on quality of life (QoL), cognitive functioning and behavioural symptoms. Bretonneau Hospital's Day Care Unit offers personalized and structured multi-domain interventions to cognitively impaired older patients on a weekly basis, for a 3-month period. OBJECTIVES: Our objective was to determine whether a specific rehabilitation day care unit (RDCU) could influence the QoL of cognitively impaired community-dwelling elderly patients. We also aimed to better understand the characteristics of patients who had the most benefited from the RDCU. METHODS: Retrospective study based on a sample of outpatients participating in RDCU during three months. All patients underwent a cognitive (MMS), functional (IADl, ADL) and behavioral (NPI) assessment. We compared QoL using the QoL-Alzheimer's Disease (QoL-AD) scale before and after RDCU. RESULTS: Overall, we included 60 outpatients in our study (mean age 83.3±5.8; women=70%). We found a statistically significant improvement of QoL-AD scores after RDCU (31.8±4.9 to 32.9±5.2, P=0.008). Patients who benefitted the most from RDCU were older (P=0.01) and had lower baseline QoL (P=0.04). We did not find any other characteristics associated with QoL-AD score improvement in our population. CONCLUSION: RDCU showed positive effects on QoL in this uncontrolled pilot study of older adults with MND. These findings should be confirmed in a future randomized controlled trial to corroborate the potential benefits of RDCU on QoL in older cognitively impaired patients.

Ethical dilemma for healthcare professionals facing elderly dementia patients during the COVID-19 pandemic.

The management of elderly patients with dementia and COVID-19 infections without access to an intensive care unit gives rise to serious ethical conflicts. Therapeutic decisions have been made in psychogeriatric units, leaving a heavy moral burden on staff. They had to deal with the most difficult patients without the support of appropriate guidelines. The gap between established rules and hospital reality led to psychological distress and burnout. Managing uncertainty in medical decisions is a skill that doctors and staff learn through experience. However, with the COVID-19 pandemic, uncertainty about patient outcomes seems no longer acceptable. Geriatric triage has challenged professional conscience, emotions and values. The principle of distributive justice, which consists of giving each person in society what is rightfully his or hers, is not being respected during this pandemic. Charity has been reduced to patient survival. Staffs need to make decisions together, and it is important to allow all carers access to a space for reflection. In our unit, the involvement of nurses and care assistants in the decision-making process for patient care is crucial especially for refusal of care. Their view of the patient's condition is different from that of the doctors, as they provide daily care to the patient and stay in the wards for several hours with them. By including as many people as possible in the reflection, we could avoid moral or personal prejudices related to these difficult decisions. The current pandemic can give new meaning to team thinking, giving everyone a voice without hierarchical barriers. With these new waves of COVID-19, we need to rethink our therapeutic conduct for elderly patients with dementia to avoid ethical failure.

Hemorrhagic transformation after stroke: inter- and intrarater agreement.

BACKGROUND AND PURPOSE: Hemorrhagic transformation (HT) is a complication of stroke that can occur spontaneously or after treatment. We aimed to assess the inter- and intrarater reliability of HT diagnosis. METHODS: Studies assessing the reliability of the European Cooperative Acute Stroke Study (ECASS) classification of HT or of the presence (yes/no) of HT were systematically reviewed. A total of 18 raters independently examined 30 post-thrombectomy computed tomography scans selected from the Aspiration versus STEnt-Retriever (ASTER) trial. They were asked whether there was HT (yes/no), what the ECASS classification of the particular scan (0/HI1/HI2/PH1/PH2) (HI indicates hemorrhagic infarctions and PH indicates parenchymal hematomas) was and whether they would prescribe an antiplatelet agent if it was otherwise indicated. Agreement was measured with Fleiss' and Cohen's κ statistics. RESULTS: The systematic review yielded four studies involving few (≤3) raters with heterogeneous results. In our 18-rater study, agreement for the presence of HT was moderate [κ = 0.55; 95% confidence interval (CI), 0.41-0.68]. Agreement for ECASS classification was only fair for all five categories, but agreement improved to substantial (κ = 0.72; 95% CI, 0.69-0.75) after dichotomizing the ECASS classification into 0/HI1/HI2/PH1 versus PH2. The inter-rater agreement for the decision to reintroduce antiplatelet therapy was moderate for all raters, but substantial among vascular neurologists (κ = 0.70; 95% CI, 0.57-0.84). CONCLUSION: The ECASS classification may involve too many categories and the diagnosis of HT may not be easily replicable, except in the presence of a large parenchymal hematoma.

Factors influencing time between onset of signs/symptoms and referral for dementia in elderly outpatients.

BACKGROUND: The few studies that have focused on Time between Onset of Signs and Symptoms and Referral (TOSR) for dementia to a memory center suggest a substantial delay of 1-3 years. This delay has a negative impact on both patients' and their caregivers' quality of life. OBJECTIVE: This study aimed to evaluate this delay and the factors associated with it in a cohort of community-dwelling elderly people attending a memory clinic, as well as assess the impact of the Third French National Alzheimer Plan (2008-2012). METHODS: All patients referred to the Bretonneau Memory Clinic for the first time between January 2006 (the clinic has maintained a specific database since then) and March 2016 were included in the study. RESULTS: Of the 8543 patients attending our Memory Clinic during the study period, 3353 attending for the first time and with complete data were included. Briefly, their ages were 82±7 years, and 67.2% were female; MMSE score was 21.2±6.6, IADL was 4.06±0.78 and the social-needs category of the Groupes Iso Ressources (GIR); Iso-Resource Group (IRG) scale was 4.04±0.37. The TOSR was, on average, 35.4±30.24 months, and increased after implementation of the Third French National Alzheimer Plan, from 26.68±26.28 months before 2009 to 40.08±31.2 months after 2009. Age and MMSE were associated with TOSR, but not the type of dementia, household composition and social characteristics. Also, there was a shorter TOSR for mild cognitive impairment than for dementia patients. CONCLUSION: Our results emphasize the need for more education and information among the general public about the early signs of cognitive impairment, especially in elderly people.

Effectiveness of multidisciplinary consultation for older adults with Alzheimer's disease in response to acute situations.

BACKGROUND: To avoid emergency hospitalisation of elderly people with dementia, which often has negative consequences, there are two main approaches: consultation and day care hospitalisation. However, it usually takes some time to arrange a consultation, and geriatric day hospital facilities are over-subscribed and costly. In 2014, we created a "consultation de crise" (CMC) programme in our sector of Paris, with several special features: a short wait for an appointment, a consultation involving an interdisciplinary team, a weekly multi-disciplinary meeting to reassess complex patients, and the possibility of a rapid referral to a social worker. METHODS: To determine whether the CMC programme is a useful way to minimise hospitalization among elderly community-dwelling populations, and to examine its design criteria. Retrospective review of all CMC requests from April 2014 to January 2017 in comparison with consultation at the Memory Center and geriatric day hospital. CMC patients were followed up at one month after their assessment. RESULTS: Mini Mental Status and Neuro Psychiatric Inventory vary significantly different between the 3 groups. The CMC group had the lowest score on the MMSE scale and the highest for NPI. After one month, 60% of CMC patients were still at home (33 patients) or in the same nursing home (6 patients) and about 23% were hospitalized during the follow-up period. CONCLUSION: Our study showed the potential value of a less expensive multidisciplinary consultation, and confirmed that collaborative care resulted in a significant improvement in the quality of care.

Usefulness of colour Doppler flow imaging in the management of lacrimal gland lesions.

OBJECTIVE: To assess the role of colour Doppler flow imaging (CDFI) in the diagnosis and management of lacrimal fossa lesions. METHODS: Institutional ethical committee approval was obtained. Fifty-one patients with 62 lacrimal fossa lesions were retrospectively included from 2003-2015. All patients underwent conventional ultrasonography and CDFI, with a qualitative and quantitative analysis of the vascularization. All patients had lacrimal gland surgery. Definitive diagnosis was based on pathological examination. RESULTS: The study included 47 non-epithelial lesions (NEL) and 15 epithelial lesions (EL), with 24 (39 %) malignant lesions and 38 (61 %) benign lesions. NEL were significantly more likely to present with septa (p < 0.001), hypoechogenicity (p < 0.001), high vascular intensity (p < 0.001), both central and peripheral vascularization (p < 0.001), tree-shape vascularization (p < 0.05) and a low resistance index (RI) (p < 0.0001). EL were significantly more likely to present with the presence of cysts (p < 0.001), and a higher RI. Receiver operating characteristic curves identified a RI value of 0.72 as the best cut-off to differentiate NEL from EL, with a sensitivity and specificity of 100 %. CONCLUSION: CDFI is a valuable tool in the differential diagnosis of lacrimal fossa lesions. Resistance index measurement enables substantial distinction between EL and NEL, thus providing crucial data for surgical management. KEY POINTS: • CDFI is a valuable tool in lacrimal fossa lesions. • Resistance Index measurement enables substantial distinction between epithelial and non-epithelial lesions. • Management of patients becomes more appropriate.

Evaluation of visual recognition memory for the early diagnosis of Alzheimer's disease in patients over 75 years.

INTRODUCTION: Current diagnostic criteria of Alzheimer Disease (AD) are mainly based on clinical definition. In France, the Delayed Matching Sample (DMS48) test, a recently introduced test that explores visual object recognition, is recommended for the early diagnosis of AD. However, little is known on the DMS48 performances of older subjects over 75 years. Therefore, our aim was to assess its specific clinical value for early detection of AD in older patients. METHOD: We studied 93 consecutive patients over 75 years from an expert memory clinic in a geriatric hospital. This population included 31 patients with single domain amnestic Mild Cognitive Impairment (aMCI), 31 AD patients and 31 controls subjects. RESULTS AND DISCUSSION: The aMCI and AD performances on the DMS48 were significantly lower than those of the control subjects (set 1 and set 2, P<10(-7)). The DMS48 performances in the healthy group appeared closely related to the previously published normative data. However, the DMS48 performances appeared unexpectedly high in these older patients, especially in the AD subgroup (set 1, 82.2±12.1 and set 2, 75.2±16.2). Moreover, there was an unexpected frequent discordance between the results on the DMS48 and the Free and Cued Selective Reminding tests (FCSR). The DMS test appears useful for highlighting the heterogeneity of the syndromes of aMCI and AD in old-old people aged 75+: our results also underline the need for further characterization of cognitive impairment in this fastest growing subgroup of patients.

[Behavioral and psychological symptoms of dementia in a pilot psychogeriatric unit: management and outcomes]. / Expérience d'une unité pilote (unité cognitivocomportementale) spécialisée dans la prise en charge des symptômes comportementaux et psychologiques de la démence.

BACKGROUND: Behavioral and psychological symptoms in dementia (BPSD) are a major concern. The French government gave a consensual definition of reinforced intermediate-term care units for BPSD within the project "Plan Alzheimer 2008/2012". OBJECTIVE: Our aim was to report one of the first experiences of this unit in France. RESULTS: Fifty-two patients (38 females, 14 males) were included, mean age 82.07±7.84 (73-97). About 80% of patients were improved and there was a high discharge rate to home of about 30%. Night-time behaviors, aberrant motor behaviors and agitation were the most frequent symptoms. CONCLUSION: Our study confirms that demented elderly patients greatly benefit from a specific BPSD care unit in agreement with the objective of Plan Alzheimer 2008/2012.

[Gait analysis with simple and dual-task paradigm in community-dwelling old people attending a geriatric outpatient clinic]. / Analyse clinique au cours d'une marche simple et avec une double tâche chez une population de sujets âgés ambulatoires consultant en gériatrie.

INTRODUCTION: Gait and balance often change with age. Few studies are available on gait analysis in the elderly. In our work, we have focused on slow walking and variation in pace. Since first introduced by Lundlin, the dual-task paradigm has been largely used to test for the risk of falls and to better understand the link between mild cognitive decline and variation in gait. To our knowledge, very few clinical data are available on the gait changes observed in the elderly in the dual-task situation. In this study, we compared changes in gait and balance between the simple task and the dual-task situation in a 10-m walk test conducted in community-dwelling old people. METHODS: Eighty-nine subjects attending a geriatric outpatient clinic (age 80.76+/-2.82 years) were included in our protocol. Gait, balance and posture were systematically evaluated during a simple and dual-task 10-m walk using a specific 11-item clinical scale. Gait speed was noted. RESULTS: Few differences were found in the dual-task walk, only reduced speed, more stops during the walk and less compliance with instructions. These results were correlated with the Mini Mental Status (MMS) score. Systematic clinical analysis failed to identify any links with age, the MMS, the UPDRS, the Tinetti scale or gait speed except for the variables freezing, increased sustention polygon and ataxia. DISCUSSION: This kind of study appears to offer an attractive analytical approach but would require a more pertinent choice of variables for cognitive evaluation and a more exhaustive set of MRI criteria. Nonetheless, clinical gait analysis could improve our understanding of the consequences of mild cognitive impairment and aging.

[Clinical and EEG approach to the diagnosis of epilepsy in a population of old people with delusion]. / Apport d'une démarche électroclinique dans le diagnostic de l'épilepsie chez une population de sujets âgés confus.

BACKGROUND: Delusion symptoms often occur in old people; epilepsy is one of the main reasons behind these acute episodes. Current guidelines and recommendations from the Academy of Medicine have proposed a double clinical and electroencephalographic approach. Recently, a working group of French experts has issued an electro-clinical scale. The aim of our study was to compare the usual approach with the new one based on the electro-clinical score. METHOD: All EEG requests performed since December 2008 in Bretonneau Hospital for elderly people aged over 75 years for delusion syndromes were retained for this study. RESULTS: One hundred and fifteen old patients from a geriatric-hospital (age 83.5+/-6.06 years) were included in this protocol. The classical diagnostic process yielded the diagnosis of epilepsy for 50 subjects. The electro-clinical scale confirmed the diagnosis of epilepsy in 30 patients and ruled it out in 29 patients. CONCLUSION: This study underscores the importance of evidence-based medicine for the diagnosis of epilepsy in old people and points out the underuse of the new technical tool, EEG-monitoring, for the management of these patients.

Improving Detection of Multiple Sclerosis Lesions in the Posterior Fossa Using an Optimized 3D-FLAIR Sequence at 3T.

BACKGROUND AND PURPOSE: There is no consensus regarding the best MR imaging sequence for detecting MS lesions. The aim of our study was to assess the diagnostic value of optimized 3D-FLAIR in the detection of infratentorial MS lesions compared with an axial T2-weighted imaging, a 3D-FLAIR with factory settings, and a 3D double inversion recovery sequence. MATERIALS AND METHODS: In this prospective study, 27 patients with confirmed MS were included. Two radiologists blinded to clinical data independently read the following sequences: axial T2WI, 3D double inversion recovery, standard 3D-FLAIR with factory settings, and optimized 3D-FLAIR. The main judgment criterion was the overall number of high-signal-intensity lesions in the posterior fossa; secondary objectives were the assessment of the reading confidence and the measurement of the contrast. A nonparametric Wilcoxon test was used to compare the MR images. RESULTS: Twenty-two patients had at least 1 lesion in the posterior fossa. The optimized FLAIR sequence detected significantly more posterior fossa lesions than any other sequence: 7.5 versus 5.8, 4.8, and 4.1 (P values of .04, .03, and .03) with the T2WI, the double inversion recovery, and the standard FLAIR, respectively. The reading confidence index was significantly higher with the optimized FLAIR, and the contrast was significantly higher with the optimized FLAIR than with the standard FLAIR and the double inversion recovery. CONCLUSIONS: An optimized 3D-FLAIR sequence improved posterior fossa lesion detection in patients with MS.

[Interests of the ultrasound-guidance in the treatment of drooling through botulinum toxin injections, our experience over 10 years]. / Intérêt de l'échoguidage dans le traitement du bavage par injections de toxine botulique, notre expérience sur 10 ans.

OBJECTIVES: To report about our 10 years' experience about the treatment of drooling by ultrasound guided botulinum toxin injections. MATERIAL AND METHODS: Retrospective monocentric study including all the patients suffering from drooling and treated by ultrasound-guided botulinum toxin injections into the salivary glands between 2004 and 2015. The etiology of r drooling, the doses of toxin, the injected glands, the size of the glands measured by ultrasonography, the effectiveness of the treatment and the side effects were assessed. RESULTS: Two hundred and ninety-two injections sessions were performed in 61 patients. Exactly 70.5 % of patients reported an improvement after the first session. Parkinson's disease was the main etiology of drooling (43 % of the patients). Eleven patients reported side effects. The salivary gland volume reduced after treatment in 46 % of the patients. DISCUSSION: The interest of ultrasound-guidance is to make sure about the intraglandular injection, to lower the risk for extraglandular diffusion of the toxin responsible for swallowing disorders and to allow for an adaptation of the doses to the volume of the salivary glands, which may vary during treatment.

[Sonography of the eye and orbit with a multipurpose ultrasound unit]. / Echographie de l'oeil et de l'orbite avec un échographe polyvalent.

Our goal is to help echographists and radiologists become familiar with the various possibilities indications, technique and results of ophtalmic ultrasonography. We used a multipurpose ultrasound unit. The frequency of the transducer has to be equal or superior to 7.5 MHz. Color Doppler allowing the study of low flows is useful. The study must be standardized: the first step is to obtain measurements of both eyes. Then the entire globe is systematically evaluated. Finally, the orbital structures and vessels of the eye and orbit are analized. After a review of the anatomy and the normal sonographic features, the main indications are described as well as the main pathologies. Special attention is paid to intravitreal hemorrhage, retinal and choroidal detachments, intraocular tumors and orbital space occupying lesions.

[Vascular tumours and malformation of the orbit]. / Les lésions vasculaires de l'orbite.

Vascular diseases are an important part of orbital pathology. We describe vascular tumours of the orbit and vascular diseases with repercussion on the orbit, from intra or extra orbital origin. The classification of these abnormalities is difficult and several terms are used to describe the same histological entity. The objective of this work is, using the current classification, to illustrate the different imaging aspects of the most frequent vascular diseases of the orbit.

[Orbito-palpebral vascular pathology]. / Pathologie vasculaire orbito-palpébrale.

Orbito-palpebral vascular pathology represents 10% of all the diseases of this area. The lesion may be discovered during a brain CT scan or MRI, or because it causes clinical symptoms such as orbital mass, visual or oculomotor alteration, pain, proptosis, or acute bleeding due to a complication of the lesion (hemorrhage, thrombosis). We present these lesions using an anatomical, clinical, imaging and therapeutic approach. We distinguish four different entities. Vascular tumors have common imaging characteristics (hypersignal on T2 sequence, contrast enhancement, abnormal vascularization well depicted with ultrasound and Doppler, and possible bleeding). The main lesions are cavernous hemangiomas, the most frequent lesion of that type during adulthood; infantile hemangiomas, the most frequent vascular tumor in children; and more seldomly, hemangioperitcytomas. True vascular malformations are divided according to their flow. Low flow lesions are venous (orbital varix), capillarovenous or lymphatic (lymphangioma). High flow malformations, more rare, are either arteriovenous or arterial malformations (aneurisms). Complex malformations include both low and high flow elements. Lesions leading to modifications of the orbito-palpebral blood flow are mainly due to cavernous sinus abnormalities, either direct carotid-cavernous fistula affecting young adults after severe head trauma, or dural fistula, more insidious, found in older adults. The last section is devoted to congenital syndromic vascular malformations (Sturge-Weber, Rendu-Olser…). This classification allows for a better understanding of these pathologies and their specific imaging features.

Internet-based questionnaire to self-assess autonomy and obtain a life-at-home services enforcement plan: a retrospective validation study.

BACKGROUND: In France, a specially-designed care plan for the elderly is generally based on an interdisciplinary, complex and time-consuming process. The health system assigns care throughout the social and health care services using multiple providers and sites. OBJECTIVE: The free website www.jesuisautonome.fr offers senior citizens and their families an opportunity to assess their own independence at home using a questionnaire in order to obtain a personal, life-at-home, enforcement plan. We aim to examine the correlation between the specially-designed care plan obtained by the usual assessment method and through self-evaluation via the website. METHODS: Community-dwelling subjects, consulting for the first time from December 2012 to July 2014, were under consideration. Patients were assessed using the Comprehensive Geriatric Assessment (CGA) and also independently during the first consultation; patients and their caregivers were then asked to fill out the questionnaire on the website. The two methods were compared using the Bland-Altman analysis for quantitative values and Kappa values for qualitative values. RESULTS: 73 patients completed the study. Correlation was excellent between parameters that did not include error due to risk to the patient (assistance with bathing and dressing, a nurse for drug distribution, measure of legal protection). Correlation was good with housekeeper hours that involved a financial cost to state social services and families. The GIR (Iso Ressource Groupe), which in France serves as a reference to determine social disability of the elderly, was similar. CONCLUSION: Our study confirms the potential of the website www.jesuisautonome.fr. to improve the delivery of health and social care services.

Open-angle glaucoma and paraoptic cyst: first description of a series of 11 patients.

We report 11 patients who were referred to our institution for severe open-angle glaucoma who had a paraoptic cyst on MR imaging. All cysts were extraoptic and retrolaminar; most were deforming the adjacent optic nerve. Cysts had a high signal on T2 and FLAIR sequences, and a variable signal on T1 and variable echogenicity, suggesting different proteinaceous content. Arterial vascularization of the optic nerve was normal. Cyst volumes were inversely correlated with the severity of glaucoma on the same eye (P < .01-.05, Spearman correlation coefficient). We hypothesized that such cysts may reflect a valve mechanism, which would allow preservation of the translamina cribrosa pressure and thus could preserve visual function. The rarity of this association, together with the frequent mass effect of the cyst on the optic nerve, stresses the necessity of long-term follow-up in these patients.

Hot-water epilepsy in an adult: ictal EEG, MRI and SPECT features.

Reflex epilepsy constitutes a rare form of epileptic seizures. We observed a 20-year-old man who presented with seizures induced by immersion in hot water. The trigger stimulus was specific. Contrast CT scan and MRI were all normal, not revealing any structural lesion. Ictal EEG recorded during a hot bath showed focal epileptic discharges in the left temporo-occipital area. Interictal SPECT showed a hypometabolism in the same cerebral region. Neuroimaging studies were rarely performed in this uncommon type of epilepsy. Nevertheless, in our case the result of the SPECT suggests a localized functional disturbance in the emergence of the disorder.

[Left pseudothalamic cortical syndrome and pain asymbolia]. / Syndrome cortical pseudothalamique gauche et asymbolie à la douleur.

We report a case of left pseudothalamic cortical syndrome associated with asymbolia for pain in a right-handed male patient. The responsible lesion, detected at both CT and MRI, was infarction of the superficial territory of the middle cerebral artery, restricted to the posterior insula, the superior aspect of T1, the parietal operculum and the supramarginal gyrus. The ascending parietal gyrus and the thalamus were spared. This case, together with data from the literature, suggest that the somatosensory area II was responsible for the pseudothalamic syndrome. This interpretation is concordant with the hypothesis that S II plays the principal role in passive somatosensory discrimination, whereas S I plays the principal role in active discrimination implying stimulus exploration. The location of lesions that were responsible for asymbolia for pain is discussed. This case and those reported by Berthier et al. (1988), provide arguments in favour of Geschwind's hypothesis which attributes asymbolia for pain to sensory-limbic disconnection due to damage of the insula.

[Recurrent acute dyskinesia as the sole manifestation of phenytoin poisoning]. / Dyskinésies aigues récidivantes seules manifestations d'un surdosage en phénytoine.

A 20 year-old epileptic female patient was admitted because of recurrent dyskinesias of 3 months duration. She was receiving phenobarbital, phenytoin (PHT) and clonazepam. PHT dosage had been increased 4 months earlier. Clinical examination and CT scan gave normal results. PHT plasmatic levels were 42 micrograms/ml on admission and there were no other symptoms of PHT toxicity. PHT-induced dyskinesias usually occur together with severe encephalopathy and/or clinical or paraclinical evidence of basal ganglia damage and/or other evidence of PHT toxicity, none of which were present here.