[The COVID-19 funeral. A director of an ethical reflection space and a funeral guide look at the upheaval of funeral rites during the health crisis]. / Les funérailles à l'épreuve de la pandémie de COVID-19. Regards croisés d'un directeur d'espace de réflexion éthique et d'un guide de funérailles sur le bouleversement des rites funéraires lors de la crise sanitaire.

The pandemic has severely affected social cohesion and the traditional landmarks of our fellow citizens. In addition to suffering related to the loss of a loved one, disorganization of the funeral and the experience of confiscation of the funeral deeply affected the psychic life of the bereaved. Despite the adaptation of funeral laws during the pandemic, an anthropological discontinuity has emerged. This anthropological break prevented the dynamic of mourning and burial of COVID-19 deaths, all the while affecting the ritualization of people leaving at the end of life, the orderliness of feelings through funeral rites as well as the resilience of caregivers and families facing an unprecedented wave of deaths. This has resulted in both a pandemic-related mortality and funeral crisis and a human crisis revealed by the COVID-19 viral storm.

[EHPAD: Reintroducing relational life after the health emergency]. / Après l'urgence sanitaire, réaffirmer le droit à la vie personnelle en EHPAD avec pour horizon le respect de la dignité des anciens et de leur famille.

The health emergency linked to COVID-19 has been stressful for staff working in nursing home, doubly painful for residents faced with the risk of infection and the reality of family separation. We explore in this article some psychological consequences resulting from the experience of residents and caregivers in the waning health crisis, hoping that the experience gained will allow greater efficiency in the event of a resumption of the pandemic. At the same time, we proposed to combine this point of view with the more ethical one, taking seriously a fundamental tendency towards ageism in Western societies and what they reflect from the social ethics of care. It is now important to declare a refusal to "return to the abnormal", this medical and ethical prehistory, such as suffered by many of our elders and their caregivers during confinement.

[Negative hallucination, self-consciousness and ageing]. / Hallucination négative, conscience de soi et avancée en âge.

BACKGROUND: Negative hallucinations are characterized by a defect in perception of an object or a person, or a denial of the existence of their perception. Negative hallucinations create blank spaces, due to both an impossible representation and an incapability of investment in reality. They have a close relationship with Cotard's syndrome, delusional theme of organ denial observed in melancholic syndromes in the elderly. METHODS: Phenomenological approach. The phenomenology of negative hallucinations provides quite an amount of information on the origin of the psychotic symptoms when one is rather old. RESULTS: The connections between hallucinations, mood disorders and negative symptoms are often difficult to live with for the nearest and dearest. Negative hallucinations require a strict approach to identify their expression that is crucial because a wide heterogeneity exists within the pathological pictures, as in Cotard's syndrome. Although the negative hallucination has an anti traumatic function in elderly people fighting against mental pain, it still represents a deficiency in symbolization. The prevalence of this symptom is without doubt underestimated, although its presence often underlines thymic suffering that is more striking. These hallucinatory symptoms have an important impact on the patients' daily life, and they appear to be prisoners of a suffering, which cannot be revealed. CONCLUSIONS: We propose in this article to review the clinical symptoms of negative hallucinations in the elderly and the way to manage them. The medicinal approaches are not always effective. A greater place must be given to what is in connection with the body, aiming at a strong impact and thus to offer non-pharmacological approaches, such as somatic ones, which can be either invasive (electroconvulsive therapy) or not (transcranial magnetic stimulation).

[The legal limits and ambiguities of the role of the family caregivers]. / Limites et ambiguïtés juridiques du rôle des aidants familiaux.

INTRODUCTION: While living in a period easily characterized by the self-actualization of the patient as the support of a non-professional valuation, it seems useful to evaluate the situation concerning the limits of the involvement of the non-professional caregivers who take care of dependent or disabled persons. They become involved in the course of care in order to protect their relative the best way they can. This involvement has an influence on the evolution of the care, particularly from a psychic point of view, as well as in the way any medical act will be conducted. OBJECTIVES: This work analyses the French legal context, reflecting the practical experience of the gerontopsychiatric teams. A legal point is established on the outlines of the voluntary help provided by the relatives and/or close friends. The approach, aiming at recognizing the family caregivers as such and bearing in mind that they can almost become the persons' guardians if need be, cannot but provoke several ethical issues as well as difficulties concerning the way of taking care of the patient. The difficulties the caregivers may have are in a way related to the lack of clear legal definitions of the medical act, as well as to the lack of definitions of the tasks one may expect from the family caregiver. CONCLUSIONS: This lack also shows the difficulties the law-maker is confronted with when defining what concerns the natural family care and what concerns the collective solidarity. The evolution of the role of caregivers in our society, which must face the pandemic of chronic diseases, thus means an evolution in the substantive law in the field of family care.

[Sleep disturbances in home caregivers of persons with dementia]. / Troubles du sommeil chez les aidants à domicile de patients atteints de démence.

BACKGROUND: Estimates suggest that there are more than 700,000 adult caregivers of persons with dementia in this country, a large number of whom experience some form of sleep disturbance during the course of their caregiving career. Health care professionals are in the best position to detect and address this significant public health problem. OBJECTIVES: Prospective study of sleep with the main caregivers providing home-care for demented patients. METHODS: This study was performed on elderly persons living at home. Two populations were concerned. The control group concerned 86 old persons living in the area of Limoges (France) and was contacted to join by the senior clubs of this city. The other group concerned caregivers to persons with dementia, living with them at home, and the assessments were done during the patient assessment. Each group had a cognitive evaluation by a Folstein's test and answered a questionnaire to describe their possible sleep difficulties. RESULTS: Sixty-eight caregivers face sleep disturbance versus 25 non-caregiver controls. Caregiver sleep-problems are often linked to sleep disturbances in the care-recipient. Night-time awakenings by persons with dementia are a common precipitating cause of sleep/wake disturbances in vulnerable caregivers. Caregivers awake 2.3 times during the night versus 1.2 for control persons. Caregivers awake earlier (around 6:20) than non-caregivers (around 7:05) and their sleep time is shorter by one hour. Caregivers are more often depressed (28 in 98 versus 13 in 86) and have more often high blood pressure (56 in 98 versus 24 in 86). They received more medications and used more often self-medication. DISCUSSION: Three major contributors to caregiver sleep-disturbance are pointed in this paper: the apparition of caregiver disrupted sleep routines, caregiver burden and depression and the caregiver's physical health status. Successful treatment of a caregiver's sleep disturbance requires careful consideration of each of these contributors. Non-pharmacological options are generally recommended as a first line of treatment for managing sleep disturbances in older adults, including caregivers of persons with dementia.

[Depression and frontal dysfunction: risks for the elderly?]. / Dépression et syndrome frontal: quels risques pour la personne âgée?

BACKGROUND: Frontal lobe syndromes include reduced activity, particularly a diminution of spontaneous activity, lack of drive, inability to plan ahead, and induce a lack of concern. These last points constitute the executive dysfunction syndrome. That executive dysfunction could be the core defect in patients with geriatric or vascular depression, and might be related to frontal-subcortical circuit dysfunction. Sometimes frontal lobe syndromes are associated with restless, aimless, uncoordinated behavior or even disinhibition, increasing the risks of falls and of malnutrition. Some authors have distinguished between lesions of the lateral frontal cortex, most closely linked to the motor structures of the brain, which lead to disturbances of movement and action with perseveration and inertia, and lesions of the orbital and medial areas, interlinked with limbic and reticular systems, damage to which leads to disinhibition and changes of affect. The medial frontal syndrome is marked by akinesia, associated with gait disturbances, and loss of autonomy. For these reasons, it has been proposed that a subtype of depression, "depression-executive dysfunction syndrome" could occur in late life. This assertion was based on clinical, neuropathological, and neuroimaging findings suggesting that frontostriatal dysfunctions contribute to the development of both depression and executive dysfunction and influence the course of depression. Depressive symptomatology, and especially psychomotor retardation and loss of interest in activities, contributed to disability in depression-executive dysfunction syndrome patients. This study is not restricted to major depression. It examined the relationship of executive impairment to the course of depressive symptoms among a psychogeriatric population with dementia or depression in order to assess the consequences of these pathologies on disabilities of aged persons. METHODS: The study was carried out in Limoges (France) during 2006 and 2007. Three hundred and twenty one psychogeriatric outpatients were included after their written agreement. They were assessed using different scales for autonomy, cognition, depression, frontal impairment and these results were compared with the risk of fall, a possible loss of autonomy and a proteino-energical malnutrition. The statistical study was made using the Systat 11 software. The following tests were used: Student Test, Chi(2) test, and the Manova test, which was adjusted to the duration of the disease, the caregiver's age, his/her education level, and level of cognitive impairment. The regression method used was the multiple linear regression method as well as a descending step-by-step analysis. RESULTS: One hundred and thirty six males (77.3+/-7.09 years old) and 185 females (80.4+/-6.5 years old) were recruited. Patients mainly presented with Alzheimer's disease (n=123) and 65 presented an associated depression, 25 presented vascular dementia, 30 a Lewy bodies dementia, 27 a fronto-temporal dementia. Twenty-seven presented psychosis and 40 a Mild Cognitive Impairment. A control group was composed of 33 persons presumed without psychogeriatric pathologies. Depression associated with an executive dysfunction syndrome increased loss of autonomy, the risk of fall and of malnutrition, especially in the case of cognitive impairment. The multivariate regression analysis step-by-step shows an increasing risk of fall in the presence of a depression-executive dysfunction syndrome. Motivation is altered when the patient is depressed. In demented patients, depression significantly increases behavioral disorders, social and familial relationships, and instrumental acts of daily life. It precipitates the risks of falls and of malnutrition. DISCUSSION: The principal finding of this study is that geriatric depression is characterized by impaired executive functioning. In the present study, depressed patients also had a greater tendency to fall and to suffer from malnutrition. Executive processes are fundamental to the daily functioning of depressed older adults, and dysfunction may lead to a lack of compensatory strategies that would improve the outcomes of late-life depression or of increasing dependency as well. In demented patients, depression triggers loss of motivation and executive dysfunction as well. CONCLUSIONS: Depression and executive dysfunction triggers the loss of autonomy, the risk of fall and of malnutrition in elderly patients. The clinical significance of this study is that the delineation of specific executive in depressed elderly patients may facilitate the development of effective treatment interventions, including treatment for geriatric depression.

[Facilitating environment for dementia patients--the Pixel study]. / Environnement contenant chez la personne âgée démente--Etude Pixel.

UNLABELLED: Caregivers of demented outpatients can suffer from poor health, are often anguished and unable to cope with the cared patient, and this burden can generate frailty. OBJECTIVES: This survey attempted to determine the psychological parameters and effective capability influence of the caregiver's Quality of Life (QoL) and vulnerability, and measured the consequences of their alteration. METHODS: 4 categories of situations were studied, according to the angst and coping capability of caregivers. Caregiver's QoL and vulnerability were assessed in these situations. Data were related to the socio-demographic data of both patients and their principal caregivers, and to the patients' medical and therapeutic data. RESULTS: 1,410 and 10 patients diagnosed with dementia who lived at home with their principal caregivers were recruited for this survey. Angst and inability to cope with patients alter caregivers' QoL and was correlated to their vulnerability. Female caregivers were often in these situations, had a poorer QoL and were more vulnerable than men. Caregivers anguished and/or nab to cope with the cared patient were less satisfied with their own care and did not enjoy their relationships with their patients. Caregivers with psychological difficulties and failure to cope had to deal with nutritional difficulties with the demented patient. DISCUSSION: Caregivers' QoL and vulnerability, are related to angst and inability to cope with patients. We could imagine that both patients and caregivers would benefit by taking care of carers.

[Loss of motivation and frontal dysfunction. Role of the white matter change]. / Démotivation et dysfonctionnements frontaux chez le sujet âgé: place de la leucoaraïose.

Since the recognition of white matter changes on computed tomography, researches were done to investigate a possible relation with ageing and cognition. This study examined whether computed tomography evidence of cerebrovascular disease in the form of white matter changes was associated with decreased implicit performance of frontal tests and with a loss of motivation in a group of 10 elderly volunteers with a mild cognitive impairment and in a group of 29 demented patients; 39 old patients (28 females: 82.4 +/- 7.1; 10 males: 75.5 +/- 11.3) cared in a psycho-geriatric day care hospital were enrolled for this essay. Motivation was evaluated with a specific scale: EAD. Patients were tested during the same period with MMSE for cognition, Cornell's scale for depression, Marin's scale for apathy. There were also assessed with a battery of frontal tests: BREF test. A brain scan was used to determinate the presence of leukoaraïosis. Table 1 give a description of the population according to the pathology. Cognitive disorder, but also apathy and loss motivation, frontal evaluation significantly differ in the two studied groups. The presence of a leukoaraïosis is associated with older people, a weaker cognitive status, a more important apathy or loss of motivation, and weaker results with frontal evaluation (table 2). Similar results were obtained considering only the frontal lesions (table 3). Age related changes of the white matter observed on computed tomography were associated with a decreased cognitive status. Leukoaraïosis is associated with loss of motivation and related with a poor results on frontal assessment. Loss of motivation is associated with certain frontal dysfunctions and with brain abnormal scan anomalies.

Influence of antidepressant therapies on weight and appetite in the elderly.

OBJECTIVE: Determine the nutritional impact of antidepressant drugs in elderly. METHODS: The study included 139 independently mobile out-patients managed by the Poitiers geriatric day hospital for problems of loss of home support, rehabilitation and medical or psychological care, with a stable treatment for 3 months at the time of inclusion and over the 3 months of the study. The study addressed the time course of nutritional parameters from baseline to 3 months post-inclusion. The physical examination included monthly weighing of the patients, 3-monthly evaluation of nutritional status using the Mini Nutritional Assessment (MNA) instrument and serum albumin. RESULTS: 52 men (76.3 +/- 6.7 years [62-87]) and 87 women (81.0 +/- 7.2 years [65-100]) were included. Seventy-nine patients presented with dementia. Seventy-four patients were receiving an antidepressant, of which 54 serotonin reuptake inhibitors. The patients free from dementia and not receiving antidepressants had nutritional indices that did not vary over the study period. The dementia-free patients receiving antidepressants gained weight (1.44 kg) - 1.87 kg on serotonin reuptake inhibitors - showed an improvement in MNA of 0.76/30 and showed a significant improvement in serum albumin of 1.78 g/L. The demented patients not receiving antidepressants lost weight (-1.01 kg), MNA score fell and serum albumin significantly decreased. On antidepressants, the demented patients significantly gained weight (0.73 kg) while no deterioration in the other parameters reflecting undernutrition was observed. Conclusions. In the middle term, in elderly subjects, antidepressants do not induce undernutrition or weight loss. Irrespective of antidepressant type, those agents seem to prevent weight loss in elderly subjects presenting with dementia.

[Loss of motivation and frontal dysfunctions in old patients]. / Démotivation et dysfonctionnements frontaux chez le sujet âgé

UNLABELLED: Loss of motivation and frontal dysfunction are frequent in old people. Motivation refers to what drives acts and relationships. The loss of motivation has some spécific characteristics from depression: loss of sens of meaning, loss of commitment for others, disinterest for daily activities. The frontal function is related to speed of acting, emotional system, anticipating of the future. All these points are altered in demotivated patients. For these reasons we assayed to analyse the possible links between loss of motivation and frontal dysfunctions. METHODS: The focus of this assay was to determine and to precise the functional links between frontal brain and loss of motivation in old people; 45 old patients cared in a day care hospital were proposed to participate to neuropsychologic evaluation. After their agreement and their family acceptation if they were demented, they were assessed by a practitioner, then by 2 different psychologists. They were evaluated for cognition (MMS), depression (Cornell's scale), apathy (Marin's scale), age and scholarships level. In a other time, they were tested with different frontal tests: Trail making A and B, Wisconsin, BREF (frontal battery of psychological tests) ana-lyse concerned speeds, number and natures of errors, habilities for matching categories. Loss of demotivation was scored on EAD scale. Statistical analysis was done with Systat 10 and Statview software. RESULTS: It could be notice the significant negative links between EAD scores and the BREF scales, or with the number of categories found with the Wisconsin test. The more motivated the patients are the best results they have with their frontal tests. There are positive and significant links between EAD score and the number of errors at the Wisconsin test, and especially with repetitive errors either with this test or with BREF test. Repetitive errors and the number of errors, pointing some frontal dysfunctions are associated with a loss of motivation. Considering BREF sub-items, it could be shown the negative links between EAD scores and programmation or inhibition sub-items. All these points persist in a statistical model including pathology, cognitive levels, depression level at the Cornell's scale, age or scholarship level. We do not find a link between EAD scores and the time obtained with the Trail making test. CONCLUSION: Loss of motivation is associated with some frontal impairment responsible for numerous errors in tasks. A good motivation of old people is associated with good frontal habilities especially in complex tasks or in programming capacities of old patients. There is no links between the speeds of tasks and the level of motivation. Motivation could be so related with orbito-frontal brain activities.

Survival prognostic value of serum interleukin-6 level in very old people.

OBJECTIVE: To determine the survival prognostic value of serum interleukin-6 level in very old people. DESIGN: Prospective 12-month clinical survey in a long term ward and in a day care hospital. SETTING: A long-term ward and a day care hospital for very old and dependent people, located in Poitiers (France). PARTICIPANTS: A cohort of 115 old people [Range 64-101], either in a long-term ward (n=71) or in day care hospital (n=44). MEASUREMENTS: Patients were checked for different nutritional parameters and the Interleukin-6 level in the serum at baseline and patients were followed up for one year. RESULTS: A high level of interleukin-6 (Il-6) is associated with increased Prognostic Inflammatory and Nutritional Index (PINI) value, serum CRP thereby demonstrating the inflammatory role of this molecule. It is also associated with an increased risk of death. Using a survival regression model, a high Il-6 serum level observed at the beginning of the study is a bad prognostic indicator, with other biological or nutritional parameters having no significant influence. CONCLUSION: A high level of Interleukin-6 may be a better marker of prognosis than an increased PINI score.

Family, Alzheimer's disease and negative symptoms.

BACKGROUND: The aim of this study is to look at the correlation between the presence of apathy measured by Marin's scale and family complaints related to withdrawal and the loss of motivation, or depression. The multicentre study was performed on 58 non-demented elderly people, 132 outpatients with Alzheimer's-type dementia, as well as their main caregiver. METHODS: After agreement of the patients and the family, the patients were assessed using different scales: Cornell's for depression, Marin's for apathy, MMS for cognitive disorders, and IRG for dependence. At the same time, two self-administered questionnaires were given to the patients' families: one concerning a list of complaints scored from 1 to 4 relating to various disorders and the other addressing the boundary ambiguities translated from Boss' questionnaire. The 58 non-demented people were 81.20 years old+/-13.75. One hundred and thirty-two demented patients were included: 39 men and 93 women. The mean age was 79.47 years+/-9.03. RESULTS: The first family complaint relates to the loss of motivation (65%). Apathy and depression occur more frequently in dementia, in particular when the MMS is degraded. Depression and apathy attracted a high complaint score. In our study the score of boundary ambiguity is higher among patients with a weak cognitive status. A high level of ambiguity is accompanied by a high score of family complaints. When the family complaint concerning the loss of motivation is present, apathy is significantly more common. Family complaints about withdrawal and loss of motivation are frequently present, and are congruent with the actual presence of apathy in the patient. It bears witness to the distress felt by families faced with the loss of ability noted in the demented person. The family's difficulties are increased by the patient's depression.

[Development of a scale for assessing lack of motivation in elderly persons]. / Construction d'une échelle d'appréciation de la démotivation chez la personne âgée.

OBJECTIVE: Apathy is made of depression and of loss of motivation. For patients with senile dementia of Alzheimer-type, the MMS score is inversely correlated with apathy and depression. The aim of this study is to build a scale aimed at loss of motivation and validated for elderly people. METHODS: The study was performed on 44 non-demented elderly people, 54 outpatients with dementia, mainly Alzheimer's type. After agreement of the patients and the family, patients were assessed using different scales: Cornell's for depression, Marin's for apathy, MMS for cognitive disorders. At the same time, we tested with caregivers a 21 items indirect scale listing various disorders related to loss of motivation, scored from 1 to 4: very often, often, sometimes, never. Patients were retested by 7 different caregivers, and different investigators, immediately and a month later to evaluate reproducibility, temporal stability using Cohen's Kappa and Spearman coefficients. The demotivation scale was then correlated with the other scales and Cronbach's alpha coefficient was studied. RESULTS: The 44 non-demented people were 80.25 years old +/- 7.75. 54 demented patients were included: 15 men and 39 women. The mean age was 81.47 years +/- 8.03. As Cohen's Kappa and Spearman coefficients were not sufficient for 6 items, the scale was reduced to 15 items (Presented). The depression scale is strongly and significantly correlated with the Marin's apathy scale. Internal coherence is particularly significant: Cronbach's alpha coefficient = 0.91. For the 54 patients with dementia, the depression score worsens significantly as cognitive disorders worsen. In these patients Marin's scale shows a progression of apathy with the impairment observed in MMS, but the MMS is not correlated with the score at the demotivation scale. So this latter scale seems to measure something close but independent from apathy. DISCUSSION: The loss of motivation is a frequent behavioral disorder in old patients. Loss of motivation can be present in any chronic disease with asthenia. This disorder is frequent in depression, in dementia and even in endocrine disease, for instance hyperthyroidism. It triggers a loss of commitment of old people and paves the way for the loss of autonomy. Apathy is a loss of motivation associated with an affective blunting. Demotivation is congruent with the actual presence of apathy in patients as measured using Marin's scale that has been used as a standard in this study. This paper presents a methodology for an evaluation scale aimed at the loss of motivation in old people. A psychologist and seven different caregivers working in a day care hospital on 98 patients performed an indirect assessment. An estimation of specificity, sensibility, reproducibility and homogeneity was tested with appropriate techniques. The results obtained with this scale answer the preliminary methodological queries, allowing us to trigger further researches for a final validation. According to our results, demotivation does not increase with age neither in demented nor in non-demented patients. Conversely, the aggravation of cognitive disorders in dementia is associated with increasing demotivation and depression. The loss of motivation participates to the learnt and acquired helplessness. Its care is necessarily global, using pharmacological, psychological and sociotherapeutic treatment. CONCLUSION: EAD scale appears a reliable tool to assess loss of motivation in old and very old patients.

[More tolerance in management of unmotivated elderly family members]. / Mehr Toleranz bei der Betreuung demotivierter älterer Familienmitglieder.

The elderly frequently experiences demotivation as a sign of depression. Demotivation often results in failures of relationships and isolation increases confusion of the demotivated individuals who are often additionally impaired by physical illness or its sequels. The elderly exposes himself to an affective dependence on engaged services or relationships. Motivation is also threatened by consequences of physical dependence which alters self-esteem. The difficulty to adapt to new situations adds up with poor social integration in an increasingly complex environment. This often precludes loss of ability to execute personal decisions and to cope with daily activities. This all accentuates dependence and depression and promotes further withdrawal. Impairment of cognitive functions and withdrawal increase the burden of familial suffering. We propose solutions adapted to demotivated elderly people in order to reintegrate them in their family and daily life.

[Time factors and lack of motivation in the elderly]. / Temporalité et démotivation chez la personne âgée.

The time-being experienced by the elderly is analyzed through different nosologic frameworks. The older depressive person is haunted by the unpermanency of life whereas the unmotivated elder persons gives himself over to mortification. In dementia, the present time being, even unnatural seems to be the only working reference; but it is source of despair for it refers to an impossible imaginary, source of resignation for it is without pleasure and without any gratifying support for tomorrow. This insistence on the present focuses on a personal and familial will mechanism of time fixing in order to avoid the crisis and to refuse any risk in changing.

[Demotivation of the demented elderly. From recovery to repetition]. / La démotivation de la personne âgée démente. De la reprise à la répétition.

Demotivation is a compelling feeling of self erasure and a renunciation on the hold on of the moment. Demotivation is frequently found amongst the ageing, who are confronted by narcissistic wounds and who are often discouraged to make his or her decision. The periodic psychologic recovery permits to selfactualize regularly the time gone by and to give a lift to the present and the future. The memory is precociously altered by the mental disorders where the older person is imprisoned by repeated demotivating experiences. The impossibility of the repetition, to conduct real-life experiences, the dull and sterile mind obligates themselves to regress into an unchangeable pattern. The power on the familial law can be lost by the elderlies, who then regress because enable to solute an identity crisis, sometime similar to their own adolescent crisis.