[Causes and consequences of elderly's agitated and aggressive behavior]. / Causes et retentissements des états d'agitation et d'agressivité du sujet âgé.

Agitation and aggressiveness are frequent in the elderly and often related to dementia. As a result of the ageing of the general population this is becoming a major public health concern. No or little epidemiological data, during primary health care, about symptoms, co-morbidity, nor medical and social consequences of elderlys' disruptive behavior have been gathered or published in the French literature. Thus, in order to describe these disorders, a survey in cooperation with general practitioners (GP) was conducted. A representative sample of 212 French GP's, all with preferential geriatric activity were asked to conduct a study by including retrospectively their two most recent patients older than 65, who had exhibited agitation and/or aggressiveness. From this cross sectional study, 410 patients (female: 61%, male: 39%) were included. The mean age was 81 years (sd: 7.65). The patients suffered from change in verbal behavior (80%), verbal aggressiveness (71%), physical agitation (60%), wandering (48%), and/or physical aggressiveness (31%). The average of disruptive behavior symptoms per patient was 2.9. The symptoms appeared progressively in 81% of patients, the mean duration was two years and it was the first episode in 40% of patients. Disruptive behaviors may be explained in view of organic illness in 62% of patients (cardiovascular disease: 37%, neurologic: 12%, diabetes: 7%, dehydratation: 5%), dementia (Alzheimer disease: 20%, vascular dementia: 18%, mixed dementia: 14%). In 54% of patients disruptive behavior may be explained in view of depression: 34%, and anxiety disorder: 31%. A triggering factor was observed in 57% of cases (psychosocial stress: 39%). Somatic consequences of the symptoms were frequently identified: decrease of alimentary intake: 39%, weight loss: 27%, dehydratation: 11%, falls: 32%, and irregular medication intake: 31%. Limitation of daily life activities: 85%, and family life: 97% were also noted. Acceptability of patient's symptoms by the family was good (no discomfort or transitory and mild irritability) in 61% of cases, and very bad (reactions of exhaustion, hospitalization requirement) in 13%. This study carried out during primary care, showed that the elderly's disruptive behaviors cause severe medical consequences and familial and social distress.

[Neuropsychological testing of 5 patients with Parkinson's disease before and after neuron graft]. / Examen neuropsychologique de 5 patients Parkinsoniens avant et après greffe neuronale.

Five patients with idiopathic PD were followed by neuropsychological tests after brain fetal neuronal transplantation. The following tests were used in order to assess memory as well as visuospatial and frontal functions: MMSE, Mattis Scale, Wisconsin Card Sorting Test, Stroop task, word fluency tasks, 15-objects test, WAIS-R (Digit span, Arithmetic, Block design, Pictures completion, Pictures arrangement), learning of 15 words of Rey, WMS-R (Logical memory) and Visual memory of L. Israël. The same tests were performed before, then one year following the transplantation. Pooled data did not show any significant difference between pre and post-operative tests. Individual results varied among patients: 2 remained unchanged, 1 had a pathological deterioration which increased after one year, 1 had some frontal symptoms whereas the last patient improved. Our data confirm that this surgical procedure do not induce permanent neuropsychological deficits, but do not indicate at the present time any clear effect of dopamine reinnervation on cognitive functions.

Long-term outcome of unilaterally transplanted parkinsonian patients. I. Clinical approach.

Five patients with Parkinson's disease, unilaterally transplanted with foetal mesencephalic cells into putamen (n=1) or putamen and caudate (n=4), were followed throughout a period of 15-36 months after surgery, according to the recommendations of the core assessment programme for intracerebral transplantations (CAPIT). All these patients exhibited an increase in the fluorodopa uptake in the grafted putamen, which was most significant in the first and last patient of the series. Long-term bilateral improvement of skilled hand movements was observed, starting between the third and sixth month after grafting, and confirmed by the statistical analysis of CAPIT timed tests. A mild to moderate effect on the amount of 'off' time and 'on-off' fluctuations was observed, whereas, apart from one case, no other clear effect on gait, walking and speech was found. One patient included in the study, already suffering slight cognitive impairment, clearly exhibited progression of a dementia process after surgery. Daily living activities were clearly improved in only one of the other four patients. At the end of the study period, all patients needed L-dopa therapy at a similar or higher dose than before grafting, but, in most of them, other dopaminergic drugs were reduced or stopped. All patients exhibited bilateral dyskinesias before grafting that were greatly decreased in intensity a few months after surgery. Delayed asymmetrical dyskinesias, occurring on the side displaying the better motor improvement, i.e. contralateral to the graft, were observed in three patients. These results suggest that neural transplants may influence two central mechanisms involved in motor function and the onset of dyskinesias. These effects are likely to occur through complex interactions with the post-synaptic dopaminergic receptors. The occurrence of dyskinesias might simply reflect increased presynaptic storage and release of dopamine. Alternatively, it might, in part, represent some other long-term deleterious effect of the graft. Since PET-scan data indicate that the reinnervation obtained is sub-optimal, it will be of interest to obtain a larger and denser reinnervation of the host striatum and to try, thereafter, to reduce the dose of L-dopa.

The difficult elderly patient: curable hostile depression or personality disorder?

The aim of this article is to suggest that hostile behavior in elderly patients is often caused by a reversible mood disorder rather than by a personality disorder or dementia, even if these two last diagnoses are already well established. Sedatives, often prescribed for hostile behavior, can induce confusion, falls, and bedridden states, and can actually increase the rate of mortality. The mood disorder can be a hostile agitated depression or a mixed affective state. The hypothesis of a mood disorder calls for an antidepressant trial, possibly combined with a mood stabilizer.

Bilateral motor improvement and alteration of L-dopa effect in two patients with Parkinson's disease following intrastriatal transplantation of foetal ventral mesencephalon.

Several recent reports have suggested that foetal ventral mesencephalic transplants could alleviate motor symptoms in patients with Parkinson's disease. Expectations of future success must be clarified by precise analysis of the extent and limitation of recovery associated with an assessment of function of the graft using [18F]fluorodopa (18F-dopa) PET. Two patients with idiopathic Parkinson's disease, severely impaired despite optimal medication, have been followed 10 and 17 months after stereotaxic unilateral intrastriatal transplantation of neural cells dissociated from human foetal ventral mesencephalon. Analysis of the clinical evolution complied with the protocol established in the 'Core Assessment Program for Intracerebral Transplantation'. Both patients have benefited from the transplantation in their daily activities and in motor timed tests, although they still exhibit parkinsonian symptoms and require L-dopa therapy. This is associated with a gradual increase in 18F-dopa uptake at the site of grafting. There are two major clinical changes: (i) a bilateral motor improvement for the speed of movements (the quality of movements improved almost exclusively on the side contralateral to the graft); (ii) a change in the outcome of the L-dopa treatment as exemplified by a postoperative transient period of heavy dyskinesias and subsequent additive actions of the two treatments. These results confirm that neural transplantation may be useful for patients with Parkinson's disease. The improvement recorded on the side ipsilateral to the graft does not match that observed on the contralateral side and it is proposed that bilateral transplantation may be necessary. The existence of a transient postoperative period of heavy dyskinesias suggests that the patients may benefit from a controlled decrease of L-dopa intake after grafting.

[Aggressivity in the elderly: when and how to treat?]. / Agressivité du sujet âgé: quand et comment faut-il la traiter?

Aggressivity in the elderly subject is often attributed to a personality that could be termed "difficult". This diagnosis risks over-looking required pharmacological therapy, which can ultimately lead to abrupt institution of emergency treatment, in the absence of previous diagnostic steps, of a high-dose sedative that can result in confusion and prolonged decubitus. Our experience with elderly persons who display aggressivity favors the hypothesis of a mood disorder, an anxiety-depressional state of hostility. Using an anti-depressant, sedative or not, as a therapeutic test has the interest of provoking a high response. Aggressive behaviour disappears or is better tolerated by the patient's family. Suicide can be considered as a form of aggressivity turned against oneself, and the second interest of antidepression treatment is the decreased risk of suicide.

[Alcohol, sleep and biological rhythms]. / Alcool, sommeil et rythmes biologiques.

Alcohol reduces sleep latency but notably alters sleep structure: sleep is fragmented, particularly at the end of the night. Slow wave sleep duration is enhanced in the first part of the night and REM sleep duration and density are diminished. Alcohol withdrawal provokes inverse effects in alcoholic patients: sleep onset is delayed, slow wave sleep durations diminished and REM sleep duration is enhanced. REM sleep is associated with motor inhibition failure. Sleep remains disturbed in long term evaluations. Alcohol promotes the occurrence of sleep apneas and hypopneas. This effect persists in alcoholics after alcohol withdrawal. Sleep disturbances in alcoholism can be partly understood as the expression of amplitude diminution and phase advance of biological rhythms. Thus, the chronobiologic characteristics of alcoholics resemble those of depressives or the elderly.

[Automatic actions with amnesia induced by taking hypnotic drugs. Association with personal and familial history of somnambulism and epilepsy]. / Activités automatiques avec amnésie induites par la prise de médicaments hypnotiques. Association à un passé personnel et familial de somnambulisme et d'épilepsie.

A family which combined sleep-walking drug-induced sleep-walking and epilepsy is reported. This co-morbidity suggest various mechanisms which could explain drug induced sleep-walking. We stated the hypothesis that these behaviors were epileptic states due to a mini-withdrawal syndrome. This mini-withdrawal including of course a rebound of anxiety and insomnia during the day, but also a pro-convulsivant effect.

[Misleading symptoms of cerebral thrombophlebitis in pregnancy and the puerperium]. / Symptomatologie trompeuse des thrombophlébites cérébrales au cours de la grossesse et du post-partum.

Four cases of cerebral thrombophlebitis, 3 of which occurred during post-partum and 1 during the first trimester of pregnancy, are reported. The symptoms were misleading, being predominantly psychiatric, with secondary appearance of an epileptic attack or motor deficit. The value of cerebral angiography is stressed in the literature.

Degeneration of noradrenergic and serotonergic but not dopaminergic neurones in the lumbar spinal cord of parkinsonian patients.

To investigate the possible alterations of spinal cord monoaminergic pathways in Parkinson's disease, the levels of dopamine, homovanillic acid, noradrenaline, serotonin and 5-hydroxyindoleacetic acid have been measured in different subregions of the lumbar spinal cord in control subjects and parkinsonian patients. Substantial amounts of these compounds were found in the dorsal, intermediate and ventral grey matter portions and in the white matter of the spinal cord; the levels of serotonin and its metabolite being the highest. In parkinsonian patients, lumbar spinal cord dopamine and homovanillic acid levels were similar to those in the control subjects, whereas the concentrations of noradrenaline, serotonin and its metabolites were clearly subnormal in the different parts of the cord, the depletion of noradrenaline being the most pronounced. These data suggest that lumbar spinal cord noradrenergic and serotonergic, but not dopaminergic, systems are damaged in Parkinson's disease.