Telemedicine for the acute management of stroke in Burgundy, France: an evaluation of effectiveness and safety.

BACKGROUND: In the context of the development of telemedicine in France to address low thrombolysis rates and limited stroke infrastructures, a star-shaped telestroke network was implemented in Burgundy (1.6 million inhabitants). We evaluated the safety and effectiveness of this network for thrombolysis in acute ischemic stroke patients. METHODS: One hundred and thirty-two consecutive patients who received intravenous thrombolysis during a telemedicine procedure (2012-2014) and 222 consecutive patients who were treated at the stroke center of Dijon University Hospital, France (2011-2012) were included. Main outcomes were the modified Rankin scale (mRS) score and case fatality at 3 months. Comparisons between groups were made using multivariable ordinal logistic regression and logistic regression analyses, respectively. RESULTS: Baseline characteristics of telethrombolysis patients were similar to those of patients undergoing thrombolysis locally except for a higher frequency of previous cancer and pre-morbid handicap, and a trend towards greater severity at admission in the former. The distribution of mRS scores at 3 months was similar between groups, as were case-fatality rates (18.9% in the telethrombolysis group versus 16.5%, P = 0.56). In multivariable models, telethrombolysis did not independently influence functional outcomes at 3 months (odds ratio for a shift towards a worse outcome on the mRS, 1.11; 95% confidence interval, 0.74-1.66, P = 0.62) or death (odds ratio, 0.86; 95% confidence interval, 0.44-1.69, P = 0.66). CONCLUSION: The implementation of a regional telemedicine network for the management of acute ischemic stroke appeared to be effective and safe. Thanks to this network, the proportion of patients who benefit from thrombolysis will increase. Further research is needed to evaluate economic benefits.

Semantic memory assessment in 15 patients with amyotrophic lateral sclerosis.

INTRODUCTION: A total of 30 to 50% of amyotrophic lateral sclerosis patients suffer from cognitive disorders. The aim of the study is to characterize these disorders and to assess semantic memory in non-demented ALS patients. The secondary aim is to look for a link between disease type and neuropsychological characteristics. METHOD: Patients were followed in an ALS center in Dijon. The following neuropsychological tests were used in this study: Folstein test, BREF test, verbal fluency, Isaac test, GRESEM test and TOP 30 test. RESULTS: Fifteen ALS patients were included. Nine of them (60%) were suffering from a semantic memory disorder. There was no correlation between ALS characteristics and the semantic memory disorder. DISCUSSION: This is the first study to reveal a semantic memory disorder in ALS. This result accentuates the hypothesis that ALS and semantic dementia are two phenotypes of the same degenerative process linked to TDP 43 proteinopathy.

Dual effect of docosahexaenoic acid (attenuation or amplification) on C22:0-, C24:0-, and C26:0-induced mitochondrial dysfunctions and oxidative stress on human neuronal SK-N-BE cells.

Increased levels of C22:0, C24:0 and C26:0 were found in cortical lesions of patients with Alzheimer's disease (AD). So, it was of interest to precise the cytotoxic effects of these fatty acids, and to determine whether docosahexaenoic acid (DHA), described to prevent AD, can attenuate their eventual side effects. Human neuronal SK-N-BE cells were cultured in the absence or presence of C22:0, C24:0 or C26:0 (0.1-20 µM) without or with DHA (50-150 µM). C22:0, C24:0 and C26:0 induce an inhibition of cell growth, a loss of Δψm, an overproduction of reactive oxygen species (ROS), a decrease of reduced glutathione, and a lipid peroxidation. DHA attenuates C22:0, C24:0 and C26:0 induced-mitochondrial dysfunctions and/or cell growth inhibition measured with MTT whatever the concentrations considered, whereas it can either decrease or amplify (especially at 150 µM) ROS overproduction. C22:0, C24:0 and C26:0 have neurotoxic activities, and depending on its concentration, DHA attenuates or not fatty acid-induced side effects.

Impact of a premature menopause on cognitive function in later life.

OBJECTIVE: To determine whether premature menopause (≤40 years) can have long-lasting effects on later-life cognition and investigate whether this association varies depending on the type of menopause and use of hormone treatment (HT). DESIGN: Population-based cohort study. SETTING: The French Three-City Study. POPULATION: Four thousand eight hundred and sixty-eight women aged at least 65 years. METHODS: Multivariable-adjusted logistic regression models were used to determine the association between age at menopause, type of menopause (surgical, natural), and the use of menopausal HT and later-life cognitive function. MAIN OUTCOME MEASURES: Performance on a cognitive test battery (at baseline and over 7 years) and clinical dementia diagnosis. RESULTS: Menopause at or before the age of 40 years, both premature bilateral ovariectomy and premature ovarian failure (non-surgical loss of ovarian function), was associated with worse verbal fluency (OR 1.56, 95%CI 1.12-1.87, P=0.004) and visual memory (OR 1.39, 95%CI 1.09-1.77, P=0.007) in later life. HT at the time of premature menopause appeared beneficial for later-life visual memory but increased the risk of poor verbal fluency. Type of menopause was not significantly associated with cognitive function. Premature menopause was associated with a 30% increased risk of decline in psychomotor speed and global cognitive function over 7 years. CONCLUSION: Both premature surgical menopause and premature ovarian failure were associated with long-term negative effects on cognitive function, which are not entirely offset by menopausal HT. In terms of surgical menopause, these results suggest that the potential long-term effects on cognitive function should form part of the risk/benefit ratio when considering ovariectomy in younger women.

Vascular aphasia outcome after intravenous recombinant tissue plasminogen activator thrombolysis for ischemic stroke.

INTRODUCTION: No data about the specific outcome of aphasia after thrombolysis are available. Our aim was to describe the severity and type of aphasia after stroke thrombolysis. METHODS: This retrospective cohort study included consecutive aphasic patients hospitalized in the Stroke Unit of Dijon (University Hospital, France) between 2004 and 2009 for a first-ever ischemic stroke of the left middle cerebral artery. Aphasic syndromes and their severity (French version of the Boston Diagnostic Aphasia Examination) were evaluated during the first week and 3 months after stroke. RESULTS: In multivariate analyses, the severity of aphasia in the 37 thrombolysed patients was milder than in the 38 nonthrombolysed patients during the first week (adjusted OR = 10.13, 95% CI: 2.43-42.28, p = 0.002) and at 3 months (adjusted OR = 8.44, 95% CI: 2.76-25.80, p = 0.001). The frequency of mild aphasia (conduction or atypical) was not significantly higher in thrombolysed patients during the first week after stroke (adjusted OR = 5.80, 95% CI: 0.82-41.16, p = 0.079). CONCLUSION: The severity of aphasia during the first week and 3 months after stroke is milder in thrombolysed than in nonthrombolysed patients, perhaps because of a greater frequency of conduction and mild atypical aphasia.

The association between caffeine and cognitive decline: examining alternative causal hypotheses.

BACKGROUND: Numerous studies suggest that higher coffee consumption may reduce the rate of aging-related cognitive decline in women. It is thus potentially a cheap and widely available candidate for prevention programs provided its mechanism may be adequately understood. The assumed effect is that of reduced amyloid deposition, however, alternative pathways notably by reducing depression and diabetes type 2 risk have not been considered. METHODS: A population study of 1,193 elderly persons examining depressive symptomatology, caffeine consumption, fasting glucose levels, type 2 diabetes onset, serum amyloid, and factors known to affect cognitive performance was used to explore alternative causal models. RESULTS: Higher caffeine consumption was found to be associated with decreased risk of incident diabetes in men (HR = 0.64; 95% CI 0.42-0.97) and increased risk in women (HR = 1.51; 95% CI 1.08-2.11). No association was found with incident depression. While in the total sample lower ratio Aß42/Aß40 levels (OR = 1.36, 95% CI 1.05-1.77, p = 0.02) were found in high caffeine consumers, this failed to reach significance when the analyses were stratified by gender. CONCLUSIONS: We found no evidence that reduced risk of cognitive decline in women with high caffeine consumption is moderated or confounded by diabetes or depression. The evidence of an association with plasma beta amyloid could not be clearly demonstrated. Insufficient proof of causal mechanisms currently precludes the recommendation of coffee consumption as a public health measure. Further research should focus on the high estrogen content of coffee as a plausible alternative explanation.

MAPT STUDY: A MULTIDOMAIN APPROACH FOR PREVENTING ALZHEIMER'S DISEASE: DESIGN AND BASELINE DATA.

OBJECTIVE: The Multidomain Alzheimer Preventive Trial (MAPT study) was designed to assess the efficacy of isolated supplementation with omega-3 fatty acid, an isolated multidomain intervention (consisting of nutritional counseling, physical exercise, cognitive stimulation) or a combination of the two interventions on the change of cognitive functions in frail subjects aged 70 years and older for a period of 3 years. Ancillary neuroimaging studies were additionally implemented to evaluate the impact of interventions on cerebral metabolism (FDG PET scans) and atrophy rate (MRIs), as well as brain amyloïd deposit (AV45 PET scans). DESIGN PATIENTS: 1680 subjects (mean age: 75.3 years; female: 64.8 %), enrolled by 13 memory clinics, were randomized into one of the following four groups: omega-3 supplementation alone, multidomain intervention alone, omega-3 plus multidomain intervention, or placebo. Participants underwent cognitive, functional and biological assessments at M6, M12, M24 and M36 visits. The primary endpoint is a change of memory function at 3 years, as assessed by the Free and Cued Selective Reminding test. All participants will be followed for 2 additional years after the 3-years intervention (MAPT PLUS extension study). INTERVENTIONS: 1/Omega-3 supplementation: two soft capsules daily as a single dose, containing a total of 400 mg docosahexaenoic acid (DHA), i.e., 800 mg docosahexaenoic acid per day, for 3 years. 2/ Multidomain intervention: collective training sessions conducted in small groups (6-8 participants) in twelve 120-minute sessions over the first 2 months (two sessions a week for the first month, and one session a week the second month) then a 60-minute session per month in the following three areas: nutrition, physical activity, and cognition until the end of the 3 years. In addition to the collective sessions, individualized preventive outpatient visits exploring possible risk factors for cognitive decline are performed at baseline, M12 and M24. BASELINE POPULATION: For cognition, the mean MMSE at baseline was 28.1 (± 1.6). About 58% and 42% of participants had a CDR score equal to 0 and 0.5, respectively. Regarding mobility status, 200 (11.9%) had a 4-m gait speed lower or equal to 0.8 m/s. According to the Fried criteria, 673 (42.1%) participants were considered pre frail, and 51 (3.2%) frail. The red blood cell DHA content was 26.1 ± 8.1 µg/g. Five hundred and three participants underwent baseline MRI. AV45 PET scans were performed in 271 individuals and preliminary results showed that 38.0% had a cortical SUVR > 1.17, which gave an indication of significant brain amyloïd deposit. DISCUSSION: The MAPT trial is presently the first largest and longest multidomain preventive trial relevant to cognitive decline in older adults with subjective memory complaints. The multidomain intervention designed for the MAPT trial is likely to be easily implemented within the general population.

Prestroke antiplatelet therapy and early prognosis in stroke patients: the Dijon Stroke Registry.

BACKGROUND AND PURPOSE: Previous antiplatelet therapy (APT) in cardiovascular prevention is common in patients with first-ever stroke. We aimed to evaluate the prognostic value of APT on early outcome in stroke patients. METHODS: All first-ever strokes from 1985 to 2011 were identified from the population-based Stroke Registry of Dijon, France. Demographic features, risk factors, prestroke treatments and clinical information were recorded. Multivariate analyses were performed to evaluate the associations between pre-admission APT and both severe handicap at discharge, and mortality at 1 month and 1 year. RESULTS: Among the 4275 patients, 870 (20.4%) were previously treated with APT. Severe handicap at discharge was noted in 233 (26.8%) APT users and in 974 (28.7%) non-users. Prestroke APT use was associated with lower odds of severe handicap at discharge [adjusted odds ratio (OR): 0.79; 95% confidence interval (CI): 063-1.00; P = 0.046], non-significant better survival at 1 month [adjusted hazard ratio (HR): 0.87; 95% CI: 0.70-1.09; P = 0.222] and no effect on 1-year mortality (HR: 0.94; 95% CI 0.80-1.10; P = 0.429). In stratum-specific analyses, APT was associated with a lower risk of 1-month mortality in patients with cardioembolic ischaemic stroke (HR: 0.65; 95% CI: 0.43-0.98; P = 0.040). CONCLUSIONS: APT before stroke was associated with less severe handicap at discharge, with no significant protective effect for mortality at 1 month except in patients with cardioembolic stroke. No protective effect of APT was observed for mortality at 1 year. Further studies are needed to understand the mechanisms underlying the distinct effects of prior APT observed across the ischaemic stroke subtypes.

Serum 25-hydroxyvitamin D predicts severity and prognosis in stroke patients.

BACKGROUND AND PURPOSE: We aimed to evaluate the association between 25-hydroxyvitamin D (25(OH)D) levels and both clinical severity at admission and outcome at discharge in stroke patients. METHODS: From February 2010 to December 2010, consecutive stroke patients admitted to the Department of Neurology of Dijon, France, were identified. Clinical information was collected. Serum concentration of 25(OH)D was measured at baseline. Stroke severity was assessed at admission using the NIHSS score. Functional impairment was evaluated at discharge using the modified Rankin scale (m-Rankin). Multivariate analyses were performed using logistic regression models. RESULTS: Of the 386 recorded patients, serum 25(OH)D levels were obtained in 382 (median value = 35.1 nM; IQR = 21-57.8). At admission, 208 patients had a NIHSS ≤5, with a higher mean 25(OH)D level than that observed in patients with moderate-to-high severity (45.9 vs. 38.6 nM, P < 0.001). In multivariate analyses, a 25(OH)D level in the lowest tertile (<25.7 nM) was a predictor of a NIHSS ≥6 (OR = 1.67; 95% CI = 1.05-2.68; P = 0.03). The mean 25(OH)D level was lower in patients with moderate-to-severe handicap at discharge (m-Rankin 3-6) than in patients with no or mild handicap (35.0 vs. 47.5 nM, P < 0.001). In multivariate analyses, the lowest tertile of 25(OH)D level (<25.7 nM) was associated with a higher risk of moderate-to-severe handicap (OR = 2.06; 95% CI = 1.06-3.94; P = 0.03). CONCLUSION: A low serum 25(OH)D level is a predictor of both severity at admission and poor early functional outcome in stroke patients. The underlying mechanisms of these associations remain to be investigated.

Recruitment strategies for preventive trials. The MAPT study (MultiDomain Alzheimer Preventive Trial).

1680 participants were randomized over the recruitment period in MAPT study. A total of 1290 participants were recruited in the 7 University Hospital centers, and 390 participants in the 6 memory clinics around Toulouse Gerontopole / Alzheimer Disease research clinical center. The first randomization was on May 30, 2008, and the targeted number of randomized participants was reached on February 24, 2011; 2595 subjects were finally screened, of which 1680 fulfilled the eligibility criteria which represents 64.8%. Approximately, one quarter of screened people refused to participate after the detailed presentation of the study and 4.3% were still interested in participating but missed for unknown reasons the baseline visit even after repeated contacts. Of the 1810 subjects who signed the consent for participating to the study at the baseline visit, 130 (7.1%) were excluded because one of the eligibility criteria was not satisfied. Interestingly, the higher percentage of randomizations compared to screened participants is the personal contact source; almost 85 % of screened participants entered in the study. In an equivalent way, Medias and conferences are efficient recruiting sources to enrol volunteers in the study. Unexpectedly, only about 60% of screened participants from the hospital and GP sources were randomized and 33.2% from health care services. Almost a quarter of the randomized participants come from the hospital outpatients clinics and approximately 20% from public conferences. A total of 1128 contacts yielded to 556 screened volunteers and 345 randomized participants in the coordinating center of Toulouse. Thus, 30 % of contacts were recruited.

One-year survival of demented stroke patients: data from the Dijon Stroke Registry, France (1985-2008).

BACKGROUND AND PURPOSE: Dementia is a frequent condition after stroke that may affect the prognosis of patients. Our aim was to determine whether post-stroke dementia was a predictor of 1-year case-fatality and to evaluate factors that could influence survival in demented stroke patients. METHODS: From 1985 to 2008, all first-ever strokes were recorded in the population-based stroke registry of Dijon, France (150, 000 inhabitants). Dementia was diagnosed during the first month following stroke, according to DSM-III and DSM-IV criteria. Survival was evaluated at 1 year and multivariate analyses were performed using Cox proportional hazards to identify independent predictive factors. RESULTS: We recorded 3948 first-ever strokes. Among these stroke patients, 3201 (81%) were testable, and of these, 653 (20.4%) had post-stroke dementia (337 women and 316 men). Demented patients had lower 1-year survival than patients without dementia (82.9% vs. 86.9%, P = 0.013). However, in multivariate analysis, dementia did not appear as an independent predictor of 1-year death. In demented stroke patients, age >80 years old, severe handicap at discharge, recurrent stroke within the first year and subarachnoid haemorrhage were associated with a higher risk of 1-year death, and the risk was lower in the study period 2003-2008. CONCLUSIONS: Dementia after stroke is not independently associated with an increased risk of death at 1 year. In recent years, 1-year case-fatality decreased in demented as well as in and non-demented patients suggesting that improvements in the management of stroke also benefited the most fragile patients.

CSF biomarkers in posterior cortical atrophy.

OBJECTIVE: To describe CSF biomarker profiles in posterior cortical atrophy (PCA), which induces high-order visual deficits often associated with Alzheimer disease (AD) pathology, and relate these findings to clinical and neuropsychological assessment. METHODS: This prospective observational study included 22 patients with PCA who underwent CSF biomarker analysis of total tau (t-tau), phosphorylated tau on amino acid 181 (p-tau181), and amyloid ß (Aß(42)). At group level, the CSF profiles of patients with PCA were compared to those of patients with typical AD and patients with other dementia (OD). Individually, the clinical presentation of patients with PCA was correlated to their CSF profile to assess the predictability of clinical features for diagnosis of underlying AD pathology. RESULTS: At group level, the PCA biomarker profile was not different from that of the AD group, but very different from that of the OD group (p < 0.001). More than 90% of patients with PCA had CSF profiles consistent with AD. All patients with PCA with either isolated higher-order visual deficit (n = 8) or visual deficit associated with memory impairment (n = 11) had CSF profiles consistent with AD. Only one of the 3 patients with PCA with asymmetric motor signs fulfilled biological CSF criteria for AD. CONCLUSIONS: PCA syndrome is usually associated with CSF biomarkers suggestive of AD, as shown by previous neuropathologic studies. This does not apply in case of motor signs suggesting associated corticobasal syndrome. CSF biomarkers help to discriminate AD from non-AD processes associated with this condition.

Association of plasma amyloid beta with risk of dementia: the prospective Three-City Study.

OBJECTIVE: Several lines of evidence indicate that a decrease in the CSF concentration of amyloid beta(42) (Abeta(42)) is a potential biomarker for incident Alzheimer disease. In contrast, studies on plasma Abeta(1-40) and Abeta(1-42) peptide levels have yielded contradictory results. Here, we explored the links between incident dementia and plasma Abeta(1-40) and Abeta(1-42) peptide concentrations in the prospective, population-based Three-City (3C) Study. We also assessed the association between plasma concentrations of truncated Abeta (Abeta(n-40) and Abeta(n-42)) and the risk of dementia. METHODS: During a subsequent 4-year follow-up period, 257 individuals presented incident dementia from 8,414 participants, and a subcohort of 1,185 individuals without dementia was drawn as a control cohort. Plasma levels of Abeta(1-40), Abeta(1-42), Abeta(n-40), and Abeta(n-42) were measured using an xMAP-based assay technology. The association between plasma Abeta peptide levels and the risk of dementia was assessed using Cox proportional hazard models. RESULTS: Of the various Abeta variables analyzed, the Abeta(1-42)/Abeta(1-40) and Abeta(n-42)/Abeta(n-40) ratios presented the strongest association with the risk of dementia: people with a high Abeta(1-42)/Abeta(1-40) or Abeta(n-42)/Abeta(n-40) ratio had a lower risk of developing dementia. These associations were restricted to individuals diagnosed at 2 years of follow-up and the Abeta(n-42)/Abeta(n-40) ratio was mainly associated with the risk of mixed/vascular dementia. CONCLUSION: Plasma Abeta peptide concentrations and Abeta(1-42)/Abeta(1-40) and Abeta(n-42)/Abeta(n-40) ratios may be useful markers to indicate individuals susceptible to short-term risk of dementia.

Leisure activities and the risk of dementia in the elderly: results from the Three-City Study.

OBJECTIVE: There is accumulating evidence that involvement in leisure activities may be related to risk of dementia; however, there is no consensus concerning the underlying mechanism of this association. Hypothesizing that leisure activities may contribute to cognitive reserve (CR), we examined the association between leisure activities and risk of incident dementia and its subtypes within a general population sample, categorizing leisure activity as stimulating, passive, physical, and social. The possibility that these associations may be driven by other proxies of CR was also examined. METHODS: Analyses were carried out on 5,698 dementia-free participants aged 65 and over included in the Three-City cohort study in Dijon and Montpellier (France) in 1999-2001. Hazard ratios (HR) were calculated for incident dementia and its subtypes (mixed/vascular dementia and Alzheimer disease) in relation to category of leisure activity. RESULTS: Stimulating leisure activities were found to be significantly associated with a reduced risk of dementia (n = 161, HR = 0.49, 95% confidence interval [CI]: 0.31; 0.79) and Alzheimer disease (n = 105, HR = 0.39, 95% CI: 0.21; 0.71) over the 4-year follow-up 1) independently of other proxies of CR, 2) after adjusting for vascular risk factors, depressive symptoms, and physical functioning, and 3) independently of other leisure activities. Furthermore, no significant association was found with other leisure activities and dementia after controlling for the potential confounders. CONCLUSION: Our findings support the hypothesis that cognitively stimulating leisure activities may delay the onset of dementia in community-dwelling elders.

[Should all old hypertensive subjects have Mini-Mental State Examination?]. / Faut-il réaliser un "Mini-Mental State Examination" chez tout sujet âgé hypertendu?

Hypertension constitutes a recognized risk factor of vascular dementia but also of Alzheimer-type dementia. Various longitudinal studies showed that midlife blood pressure level is one of the factors conditioning the onset of dementia syndrome in late life. The high risk of dementia is linked to leukoaraiosis, vascular rigidity, microcirculation disorders, oxidative stress, blood pressure fluctuations including orthostatic hypotension and strokes, all of those being associated with hypertension. Numerous clinical trials showed the positive effect of effective treatment of hypertension on the prevention of cognitive disorders and dementias. Thus, screening and early management of dementia and cognitive decline, in particular in the hypertensive subject, are essential. The Mini-Mental State Examination (MMSE) is a major first-intention screening test because it allows a full assessment of cognitive aptitudes. If cognitive decline is suspected and the MMSE score is considered to be abnormal, the elderly subject must be sent to a specialist or a referent memory centre; the MMSE is only a first stage in the diagnostic reasoning. MMSE should be included in the follow-up of all hypertensive elderly subjects and should be performed once a year by the general practitioner.

[What has changed for stroke at the beginning of the 21st century]. / Les accidents vasculaires cérébraux : ce qui a changé au début du xxi(e) siècle.

INTRODUCTION: Striking developments in stroke epidemiology, initially based on the results of the Framingham study, have greatly improved our neuroepidemiological knowledge of the disease. STATE OF ART: The development of stroke registries has made it possible to evaluate the descriptive epidemiology of stroke and its evolution. With the increasing use of CT-scan, MRI, and either cardiac or vascular imaging, the diagnosis of stroke and its subtypes has been made easier. Over the last 20 years, a decrease in the incidence and mortality of stroke has been observed in Western countries. In contrast, in Dijon, which has the only population-based stroke registry in France, stable incidence rates have been reported. However, over the same period, age at stroke onset has risen by five years in men and eight years in women, which is probably related to both population aging and improvements in primary prevention and general health. The reported decrease in case-fatality rates suggests better acute management of stroke patients, and explains in part the increase in the prevalence of stroke. In addition, the assessment of vascular risk factors has demonstrated that high blood pressure remains the principal risk factor for both ischemic and hemorrhagic stroke, and that antihypertensive treatment is able to reduce stroke incidence. PERSPECTIVES: Epidemiology studies could make it possible to measure the impact of new therapeutic strategies applied in both primary and secondary prevention. CONCLUSION: Prevention, diagnosis, and acute treatment of stroke have considerably improved, but cerebrovascular diseases together with myocardial infarction remain the leading cause of death. Despite the absence of a rise in the incidence of stroke, its prevalence has increased. This is due to the decrease in case-fatality rates. As a consequence, there is an urgent need to organize health networks around stroke. Moreover, the rise in stroke-free life expectancy is a positive finding that reflects improvements in prevention.

[Antidepressant use in demented elderly subjects: current data]. / Utilisation des antidépresseurs chez les sujets âgés déments: données actuelles.

Depression and behavioural and psychological symptoms of dementia (BPSD) have a significant impact on the worsening of dementia because they increase the cognitive and functional decline and they have a significant impact on the vital prognosis. Physicians should be particularly careful in the use of antidepressants in the elderly, particularly in the frail elderly. Indeed, most studies have included patients aged at least 65 years without frailty criteria, but rarely those aged over 75 years and/or frail. As they are used in clinical practice, selective serotonin reuptake inhibitors, which initially appeared to have low risks, have been associated with many and dangerous adverse effects, particularly in elderly subjects. At present, there is a lack of data to assess the benefit-risk ratio of antidepressants in the treatment of depression and BPSD in patients with Alzheimer's disease or other dementias. Among the drugs frequently used in studies in order to evaluate these indications, citalopram and moclobemide are those associated with a low risk of adverse events and a significant effectiveness on depression signs and behavioural and BPSD. It is necessary to assess the effectiveness and adverse effects of antidepressants in demented elderly subjects through several studies.

[Stroke in elderly: what have we learned from stroke epidemiology in younger people]. / Les accidents vasculaires cérébraux du sujet âgé : ce que nous a appris l'épidémiologie du sujet jeune.

Stroke in the elderly has more major differences compared to young people: it is the first complication of atherothrombosis disease associated with the following risk factors: hypertension, diabetes, hypercholesterolemia, tobacco consumption and sleep apnea syndrome; AVC is the first consequence of atrial fibrillation; from a clinical point of view, seizure at the onset of the stroke is more frequent; prognosis is characterized by a high risk of dementia (20%); primary and secondary prevention is very efficacious even in very old patients, not only on the risk of stroke, but also on the risk of dementia; time trends at Dijon show a slight decrease of incidence rates of stroke only over 85 years, while prevention of stroke has taken advantage of real progress in precocious diagnosis and innovative treatments. In contrast, we observed a decrease of case-fatality rates at any day with a delay in age of onset of stroke, reaching five years in men and eight years in women, suggesting an increase of life expectancy without stroke, reflecting a certain efficacy of prevention.

Ischaemic stroke subtypes and associated risk factors: a French population based study.

BACKGROUND: There is little reliable population based information about the distribution of risk factors among the various ischaemic stroke subtypes, even though determining risk factor profiles is of major importance to develop targeted preventive strategies. METHODS: The distribution of first ever ischaemic stroke subtypes was established in a prospective population based study conducted in Dijon, France (152,606 inhabitants). Cases were collected between January 2005 and December 2006, and were classified using TOAST classification. Vascular risk factors were recorded to determine a risk factor profile for each subtype. RESULTS: 332 patients with first ever ischaemic stroke (150 men and 182 women) were recorded. Adjusted incidence to world population was 54/100,000/year. The distribution of ischaemic stroke subtypes was as follows: 119 (35.8%) cases of large artery atherosclerosis, 89 (26.8%) small artery occlusions, 81 (24.4%) cardioembolisms and 43 (13%) other and undetermined causes. The most frequent vascular risk factor was hypertension, irrespective of the ischaemic stroke subtype, with a total prevalence of 62%. Using multivariate regression, a positive association between cardioembolism and age (OR 1.051; 95% CI 1.026 to 1.076; p<0.001) was demonstrated and between small artery occlusion and either high blood pressure (OR 1.86; 95% CI 1.06 to 3.27; p = 0.03) or hypercholesterolaemia (OR 2.23; 95% CI 1.33 to 3.76; p = 0.02). CONCLUSION: This comprehensive prospective population based study has demonstrated that vascular risk factors exhibit a particular distribution according to the ischaemic stroke subtypes. These findings, as well as the great frequency of hypertension among stroke patients, have implications for prevention strategies, the design of clinical trials and the organisation of health care services.