Parkinsonian gait in elderly people: Significance of the threshold value of two and more falls per year.

OBJECTIVES: Parkinsonism in the elderly presents a major risk factor for recurrent falls (2 and more falls per year), which is associated with increased morbidity. The main objective was to investigate explanatory variables relating to the risk of being recurrent fallers (RF) in persons with parkinsonian gait. METHODS: Seventy-nine among 172 eligible persons were enrolled in this prospective study, the findings of which were analyzed at 12 months. Motor and non-motor features, as well as follow-up interviews to identify falls, loss of ability to walk, fluctuating cognition, traumatic falls, all-cause hospitalizations and deaths were collated and results compared between non RF (zero and one fall per year) and RF. Bayesian model averaging was used to predict the probability of patients being RF from their medical history as well as from cognitive assessment, gait velocity, vision and posture. RESULTS: N=79, 0.58 men, 50% had Parkinson's disease, 14% other neurodegenerative parkinsonian syndrome, 23% vascular parkinsonism and 13% Lewy body disease, 58% were RF. Median age 81.2 years and median MMSE 25/30. A history of falls and of hallucinations, median odds ratio respectively 9.06 (CI 2.34-38.22), 4.21 (CI 1.04-18.67) were associated with the highest odds ratios along with fluctuating cognition and abnormal posture. Two or more falls a year was a relevant threshold to distinguish a population with a high risk of comorbidity. CONCLUSION: The whole history of falls, hallucinations and fluctuating cognition can be considered predictive of recurrent falls in elderly people with parkinsonian gait and provide a tracking tool for patient management.

Health benefits of multicomponent training programmes in seniors: a systematic review.

BACKGROUND: The ageing process is intrinsically associated with decline in physical endurance, muscle strength and gait ability and balance, which all contribute to functional disability. Regular physical training, and more particularly multicomponent training (MCT), has demonstrated many health benefits. OBJECTIVE: To evaluate the evidence of the health benefits of MCT including endurance training, muscle strengthening, balance exercises, and/or stretching (i.e. flexibility training) and/or coordination training in adults aged 65 years or over. METHODS: A comprehensive, systematic database search for manuscripts was performed in CINAHL Plus, Embase, Medline, PubMed Central, ScienceDirect, Scopus, Sport Discus and Web of Science using key words. For potential inclusion, two reviewers independently assessed all intervention studies published in English language from 1 January 2000 to 30 April 2015. RESULTS: Of 2525 articles initially identified, 27 studies were finally included in this systematic review. They were all divided into five categories according to their main outcome measurements (cardio-respiratory fitness, metabolic outcomes, functional and cognitive functions and quality of life, QoL). These studies reported that MCT has a significant beneficial effect on cardio-respiratory fitness and on metabolic outcomes. Substantial improvement in functional and cognitive performance was also measured and a slighter but positive effect on QoL. CONCLUSION: Overall, this review demonstrates a positive effect of MCT with functional benefits and positive health outcomes for seniors. Based on this evidence, clinicians should encourage all adults aged 65 or over to engage in MCT programmes to favour healthy ageing and keeping older members of our society autonomous and independent.

[The use of the new direct oral anticoagulants among older subjects: The limits of the evidence-based medicine?]. / L'utilisation des anticoagulants oraux directs chez les patients âgés: les limites de la médecine fondée sur les preuves ?

The growing use of direct oral anticoagulants, in particular among older subjects, raises questions about the limits of the evidence-based medicine. The phase III studies that have validated the efficacy and the safety profile of these molecules (dabigatran, rivaroxaban, apixaban, edoxaban) in their both indications, the venous thromboembolic disease and the non-valvular atrial fibrillation raise concerns in four major fields: the financial support of pharmaceutical companies, the links of interest for many authors with the industry, the study design (exclusively non-inferiority studies), and the poor representativeness of the older subjects included. All these points are discussed, using data of sub-groups studies, post-marketing studies and recent meta-analysis. The lack of data for the very old subjects, with frailty or comorbidities, remains the main concern from these phase III studies.

Health benefits of endurance training alone or combined with diet for obese patients over 60: a review.

BACKGROUND: The prevalence of obesity is rapidly increasing in older patients and it is ubiquitous in many developed countries. Obesity is related to various negative health outcomes, making it a major public health target for intervention. PURPOSE: The aim of this study was to explore and summarise the literature that addresses endurance training alone or combined with nutrition interventions to combat obesity in obese patients over age 60. METHODS: We searched online electronic databases up to September 2014 for original observational and intervention studies published between 1995 and 2014 on the relationship between endurance training alone or combined with a diet in obese patients over 60 regarding health outcomes. RESULTS: Twenty-six studies examined interventions aimed specifically at promoting endurance training alone or combined with diet for older obese patients over 60. These studies demonstrated a positive effect of this intervention on the primary prevention of cardiovascular disease, and a significant beneficial effect on the lipid profile. Improvement of body composition and insulin sensitivity, and a reduction in blood pressure were also well established. CONCLUSIONS: Overall, this review demonstrates a positive effect of endurance training alone or combined with diet on health outcomes and metabolic benefits in older adults. Clinicians can now use this evidence to formulate actions to encourage the older obese to profit from the health benefits of endurance training and diet. This will not only help reduce the dramatic increase in the number of older obese but also help prevent sarcopenic obesity, which is a complex challenge for healthcare professionals.

[Anticoagulation in atrial fibrillation in the elderly: the geriatrician point of view with a focus on the direct oral anticoagulants]. / L'anticoagulation dans la fibrillation atriale du sujet âgé : point de vue du gériatre avec un focus sur les anticoagulants oraux directs.

Prescribing anticoagulant therapy when the CHA2DS2-VASc score is ≥ 1 prevents strokes secondary to non-valvular atrial fibrillation (AF). However, it is important to remember that whether the aged population has the highest risk of stroke in case of AF, under anticoagulant therapy this population is also at the highest risk of bleeding. Vitamin K antagonists were for decades the molecules of reference with benefits even after 75 years of age. The direct oral anticoagulants have overcome the biological constraints inherent to monitoring vitamin K antagonists and provide a more stable pharmacological action with a limited number of drug-drug interactions. However, the widespread use of these molecules in the older population remains controversial. In this review article, indications and modalities of administration of anticoagulant therapy in the elderly will be detailed and discussed on the basis of the most recent recommendations proposed in particular by the European Society of Cardiology. Particular attention will be paid to new oral anticoagulant therapies compared with vitamin K antagonists and antiplatelet agents.

Effect of a short-term intermittent exercise-training programme on the pulse wave velocity and arterial pressure: a prospective study among 71 healthy older subjects.

AIMS OF THE STUDY: Stiffening of large arteries has been associated with increased cardiovascular outcomes among older subjects. Endurance exercises might attenuate artery stiffness, but little is known about the effects of intermittent training programme. We evaluate the effect of a short Intermittent Work Exercise Training Program (IWEP) on arterial stiffness estimated by the measure of the pulse wave velocity (PWV). METHODS AND SUBJECTS: Seventy-one healthy volunteers (mean age: 64.6 years) free of symptomatic cardiac and pulmonary disease performed a 9-week IWEP that consisted of a 30-min cycling twice a week over a 9-week period. Each session involved six 5-min bouts of exercise, each of the latter separated into 4-min cycling at the first ventilatory threshold alternated with 1-min cycling at 90% of the pretraining maximal tolerated power. Before and after the IWEP, the following measurements were made: carotid-radial PWV and carotid-femoral PWV with a tonometer and systolic and diastolic blood pressure. RESULTS: Training resulted in a non-significant decrease of the carotid-radial PWV, a significant decrease of the carotid-femoral PWV from 10.2 to 9.6 m/s (p < 0.001) (that was no longer significant after adjustment for mean arterial pressure) and a significant decrease in both systolic and diastolic blood pressure, respectively, from 129.6 ± 14.9 mmHg to 120.1 ± 14.1 mmHg (p < 0.001) and from 77.2 ± 8.8 mmHg to 71.4 ± 10.1 mmHg (p < 0.001). CONCLUSION: The present results support the idea that a short-term intermittent aerobic exercise programme may be an effective lifestyle intervention for reducing rapidly blood pressure and probably central arterial stiffness among older healthy subjects.

Effects of a short-term personalized Intermittent Work Exercise Program (IWEP) on maximal cardio-respiratory function and endurance parameters among healthy young and older seniors.

OBJECTIVE: The aim of this study was to evaluate the efficiency of a short-term Intermittent Work Exercise Program (IWEP) among healthy elderly subjects. STUDY DESIGN AND SETTING: This longitudinal prospective study took place at the Strasbourg University Hospital geriatric department. STUDY PARTICIPANTS: One hundred and fifty older volunteers, previously determined as being free from cardiac and pulmonary disease, were separated into two age groups: the "young senior" (60.2 ± 3.1 yr) and the "older senior" groups (70.8 ± 5.2 yr). These groups were then subdivided by gender into the "young female senior", "young male senior" "older female senior" and "older male senior" groups. INTERVENTION: Before and after the IWEP, all subjects were asked to perform an incremental cycle exercise to obtain their first ventilatory threshold (VT1), maximal tolerated power (MTP), peak oxygen uptake (VO2peak) and maximal minute ventilation (MMV). The IWEP consisted of a 30-min cycling exercise which took place twice a week, and was divided into six 5-min stages consisting of 4 min at VT1 intensity and 1 min at 90% MTP. MEASUREMENTS: An assessment was made of the effects of the IWEP on maximal cardio-respiratory function (MTP, VO2peak, MMV) and endurance parameters (VT1, heart rate [HR] measured at pretraining VT1 and lactate concentrations at pre-training MTP). RESULTS: This short-term training program resulted in a significant increase of MTP (from 13.2% to 20.6%), VO2peak (from 8.9% to 16.6%) and MMV (from 11.1% to 21.8%) in all groups (p<0.05). VT1 improved from 21% at pretraining to 27%, while HR at pre-training VT1 as well as lactate concentrations at pre-training MTP decreased significantly in all groups (p<0.05). The post-training values for VO2peak and MMV of the "older seniors" were not significantly different (p>0.05) from the "young seniors" pre-training values for the same parameters. CONCLUSION: The most striking finding in this study is that after only 9 weeks, our short-term "individually-tailored" IWEP significantly improved both maximal cardio-respiratory function and endurance parameters in healthy, previously untrained seniors.

[Management of a scabies epidemic in the Strasbourg teaching hospital, France]. / Gestion d'une épidémie de gale aux Hôpitaux universitaires de Strasbourg.

CONTEXT: An outbreak of scabies occurred in the geriatric department of the Strasbourg University Hospital in September 2005. The index case presented with hyperkeratosic scabies, an extremely contagious form. The epidemic spread to several wards and pavilions and also contaminated healthcare staff and patient's families. OBJECTIVE: Our objective was to describe the outbreak, its progression, and the measures taken to eradicate it. METHODOLOGY: All healthcare workers, patients, and families affected in the outbreak were retrospectively studied, using medical prescriptions recorded by the hospital pharmacy, listings established by the occupational health department, and patient files. RESULTS: Two epidemic waves were recorded, between August 31 and December 16, 2005, affecting 51 patients and staff members in the geriatric department, with a total of 58 episodes of scabies, seven of which were recurrences. Three main measures were taken to eradicate the epidemic: setting up of "contact" isolation precautions, information for the affected individuals, and treatment of the infected patients associated to mass treatment of contact cases. The mass treatment was widely applied, involving 490 patients and 592 caregivers. All of these measures successfully curtailed the outbreak in 3 months. CONCLUSION: Rapid and radical action is essential to prevent extension of scabies within a community.

[Parkinson's disease dementia: correlations between clinical, neuropsychological and neuropathological features]. / Corrélats anatomocliniques au cours de la démence de la maladie de Parkinson.

INTRODUCTION: Cognitive disorders such as deficit of attention and executive and visuoconstructive dysfunctions occur in Parkinson's disease dementia (PDD). Memory impairment is not an early feature and statement not well delimited. CASE REPORT: A 78-year-old man with PDD underwent neuropsychological assessment and moreover demonstrated memory decline. After death, pathology examination of the brain and immunohistochemy analysis confirmed PD and showed Lewy body pathology (LBP) in the insula, limbic and especially in CA3 hippocampus areas. Hippocampus and gyrus parahippocampic also exhibited neurofibrillary tangles. Lack of senile plaque and lack of beta A4 amyloid deposition were noticeable in the whole brain examination. CONCLUSION: Severe executive dysfunctions are probably related to LBP and dysfunction in memory process may be related to DNF lesions in medial temporal area.

Impact of short-term aerobic interval training on maximal exercise in sedentary aged subjects.

BACKGROUND: Ageing is known to be associated with a decrease in peak oxygen consumption (VO2peak) and maximal tolerated power (MTP). Regular physical exercise is the most appropriate to improve aerobic capacity, but its effect still remained discussed in old people. DESIGN: The aim of this study was to determine whether a short interval training session would be associated with improvements in exercise efficiency in aged subjects in both genders. METHODS: In all, 19 women and 16 men (65.4 +/- 4.9 years) performed a cycle incremental exercise test before and after a 9-week period of aerobic interval training (twice a week, 30 min session where 6 x 4-min at the first ventilatory threshold alternated with 1-min at the second ventilatory threshold) with cycle ergometer. Minute ventilation (MV), O(2) uptake (VO(2)) and CO(2) output (VCO(2)) were measured breath-by-breath and by an open-circuit metabolic cart. RESULTS: Before training, maximal values of MV (MMV), VO2peak, heart rate, systolic blood pressure, MTP, blood lactate at MTP recovery and the power at the first (pVT(1)) and second ventilatory thresholds (pVT(2)) were higher in men compared with women. Nine weeks of interval training induced a significant increase in MMV, VO2peak, MTP, pVT(1) and pVT(2) and decrease in systolic blood pressure in the same way in men than in women, without any significant effect on their maximal heart rate values. CONCLUSIONS: These findings suggest that the age-related declines in aerobic index are attenuated by a short exercise interval training sessions in women and men.

Homocysteine, vitamin B12, folate and cognitive functions: a systematic and critical review of the literature.

Elevated serum homocysteine, decreased folate and low vitamin B(12) serum levels are associated with poor cognitive function, cognitive decline and dementia. Despite evidence of an epidemiological association, randomised controlled trials did not provide any clear evidence so far that supplementation with vitamin B(12) and/or folate improves dementia or slows cognitive decline, even though it might normalise homocysteine levels. In this report, we review the current knowledge on the relationship between homocysteine, folate and vitamin B(12) levels and the way their disruption influences cognitive function in adults.

Health benefits of physical activity in older patients: a review.

As the number of elderly persons in our country increases, more attention is being given to geriatric healthcare needs and successful ageing is becoming an important topic in medical literature. Concept of successful ageing is in first line on a preventive approach of care for older people. Promotion of regular physical activity is one of the main non-pharmaceutical measures proposed to older subjects as low rate of physical activity is frequently noticed in this age group. Moderate but regular physical activity is associated with a reduction in total mortality among older people, a positive effect on primary prevention of coronary heart disease and a significant benefit on the lipid profile. Improving body composition with a reduction in fat mass, reducing blood pressure and prevention of stroke, as well as type 2 diabetes, are also well established. Prevention of some cancers (especially that of breast and colon), increasing bone density and prevention of falls are also reported. Moreover, some longitudinal studies suggest that physical activity is linked to a reduced risk of developing dementia and Alzheimer's disease in particular.

[Microbial description of bacteriuria in long-term care facilities: a prospective study in the French Teaching Hospital of Strasbourg]. / Description de la flore bactérienne responsable des bactériuries symptomatiques en unité de soins de longue durée: étude prospective au CHRU de Strasbourg.

OBJECTIVE: The authors had for aim to assess, the incidence of symptomatic bacteriuria and the level of antibiotic resistance in bacteria identified in long-term care facilities (LTC). DESIGN: Symptomatic bacteriuria cases were prospectively collected, during 9 months in the two LTC of the Strasbourg French Teaching Hospital (196 beds). RESULTS: One hundred and eleven bacteriuria cases were included. They concerned 67 of the 274 residents (cumulative incidence: 2.07/1,000 patients-day). A gram-negative bacillus was identified in 85% of the symptomatic bacteriuria cases, and Escherichia coli in 40%. Sixty percent of the identified bacterial strain was resistant to amoxicillin (Amx-R) and 42% to the clavulanic acid combination (AmC-R). Third generation cephalosporins (3GC) were effective in 90% of Urinary tract infections (UTIs) and fluoroquinolones in 65% (Fq). Four bacterias with broad beta-lactamase spectrum were identified (0.04%) including 3 Enterobacter aerogenes. No yeast infection was diagnosed. E. coli strains were 65% Amx-R and 50% AmC-R. Concerning the Fq-R strains (15%), 50% were cotrimoxazole resistant (Stx-R) and 70% Amx-R; 3GC remained effective (82%). CONCLUSION: In LTC, multi-drug resistance bacteria are rare and 3GCs seem to be the best first line treatment. Nevertheless, Fq-R is increasing (15 vs 8%), and attention must be paid to the antibiotic therapy used.

Hematological response to short-term oral cyanocobalamin therapy for the treatment of cobalamin deficiencies in elderly patients.

OBJECTIVES: The aim of this trial was to demonstrate the efficacy of one month of oral cobalamin (vitamin B12) therapy in elderly patients with cobalamin deficiency related to food-cobalamin malabsorption (FCM). PATIENTS AND METHOD: Twenty elderly patients (mean age: 78+/-17 years) with established cobalamin deficiency related to FCM were included in an open-label, non-randomized, non-placebo trial. They were treated with a maximum of 1,000 microgram per day of oral crystalline cyanocobalamin for at least 1 month. Serum cobalamin levels (primary endpoint), blood count abnormalities and reticulocytes count (secondary endpoints) were determined at baseline and during the first month of treatment. RESULTS: 85% of the patients normalized their serum cobalamin levels with a mean increase of+167 pg/ml (p<0.001 compared with baseline). 100% of the patients corrected their initial macrocytosis and 25% their anemia; 100% of the patients had medullar regeneration with a mean increase of reticulocytes count of 32+/-11.3 x 106/l (p=0.03 compared with baseline). CONCLUSIONS: Our findings support the view that one month of oral crystalline cyanocobalamin is effective to correct serum vitamin B12 levels and to obtain hematological responses in elderly patients with cobalamin deficiency related to FCM.

Current hematological findings in cobalamin deficiency. A study of 201 consecutive patients with documented cobalamin deficiency.

With the introduction of automated assays for measuring serum cobalamin levels over the last decades, the hematological manifestations related to cobalamin deficiency have been changed from the description reported in 'old' studies or textbooks. We studied the hematological manifestations or abnormalities in 201 patients (median age: 67 +/- 6 years) with well-documented cobalamin deficiency (mean serum vitamin B12 levels 125 +/- 47 pg/ml) extracted from an observational cohort study (1995-2003). Assessment included clinical features, blood count and morphological review. Hematological abnormalities were reported in at least two-third of the patients: anemia (37%), leukopenia (13.9%), thrombopenia (9.9%), macrocytosis (54%) and hypegmented neutrophils (32%). The mean hemoglobin level was 10.3 +/- 0.4 g/dl and the mean erythrocyte cell volume 98.9 +/- 25.6 fl. Approximately 10% of the patients have life-threatening hematological manifestations with documented symptomatic pancytopenia (5%), 'pseudo' thrombotic microangiopathy (Moschkowitz; 2.5%), severe anemia (defined as Hb levels <6 g/dl; 2.5%) and hemolytic anemia (1.5%). Correction of the hematological abnormalities was achieved in at least two-thirds of the patients, equally well in patients treated with either intramuscular or oral crystalline cyanocobalamin. This study, based on real data from a single institution with a large number of consecutive patients with well-documented cobalamin deficiency, confirms several 'older' findings that were previously reported before the 1990s in several studies and in textbooks.

[Cobalamin deficiencies in adults: update of etiologies, clinical manifestations and treatment]. / Carences en vitamine B12 chez l'adulte: étiologies, manifestations cliniques et traitement.

PURPOSE: Update of the adult cobalamin deficiencies. CURRENT KNOWLEDGE AND KEY POINTS: More precise definitions establish the true cobalamin deficiencies and determine their real epidemiology. The current clinical data suggest the concept of food-cobalamin malabsorption as the leading etiology of cobalamin deficiency. The new features of cobalamin deficiency include neurological, gynecological and vascular manifestations. Current treatment modalities include nasal, sublingual and oral cobalamin administration. PROSPECTS AND PROJECTS: Studies are in the way to establish the relevance of the new clinical manifestations and to validate the usefulness of oral cobalamin therapy.

[Low vitamin B12 levels in elderly patients cured within one week by oral cobalamin therapy]. / Posologie de cyanocobalamine orale corrigeant en une semaine les hypovitaminoses B12 du sujet agé.

OBJECTIVE: Non-dissociation of vitamin B12 from its carrying proteins is the most frequent cause of vitamin B12 deficiency in the elderly. The aim of this study was to determine the initial dose of oral cyanocobalamin that would correct the B12 vitamin deficiency within one week. METHODS: This was an open, prospective, study on 30 elderly patients suffering from vitamin deficiency (B12 < 0.20 microg/L) induced by food-cobalamin malabsorption. Ten patients (group I) were treated with a daily dose of 1000 microg of oral cyanocobalamin (from D1 to D8), 10 (group II) with 1000 microg every other day (D1, D3, D5 and D7), 5 (group III) with 1000 microg every 4 days (D1 and D5) and 5 (group IV) with 1000 microg only on D1. The biological response was assessed by control measurement of vitamin B12 serum levels on the 8th day. RESULTS: Mean vitamin B12 serum levels had significantly increased (p < 0.01) in groups I, II and III, but not in group IV. The dose-effect, assessed by the mean increase in vitamin B12 serum levels, was significantly greater (p < 0.05) in groups I (0.25 microg/L) and II (0.18 microg/L), than in groups III and IV (0.09 microg/L). CONCLUSION: This prospective study shows that an oral dose of 1000 microg of cyanocobalamin every 4 days, which corresponds to 250 microg per day, was sufficient to correct B12 vitamin deficiency induced by food-cobalamin malabsorption within one week. However, initial doses of 1000 microg per day or every other day would be preferable because of the greater dose-effect with daily doses higher than 500 microg. A randomised study is warranted to validate these preliminary results.