Are migraine and non-migrainous headache risk factors for stroke in the elderly? Findings from a 12-year cohort follow-up.

BACKGROUND AND PURPOSE: There is evidence that migraine is a risk factor for stroke but little is known about this association in elderly people. Furthermore, non-migrainous headache (NMH) has received little attention despite being the most frequently reported type of headache. Late-life migraine and NMH were examined as candidate risk factors for stroke in a community-dwelling elderly sample over a 12-year follow-up. METHODS: One thousand nine hundred and nineteen non-institutionalized subjects aged 65+, without dementia (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, DSM-IV criteria) and with no stroke history at baseline, were drawn from the Three-City Montpellier cohort (recruitment 1999-2001) for longitudinal analysis. Ischaemic and haemorrhagic stroke was reported at baseline and at each of the five follow-ups, with cases validated by a panel of experts, according to ICD-10 criteria (International Classification of Diseases, 10th revision). Migraine and NMH were determined at baseline during a neurological interview and examination using 1988 International Headache Society criteria. RESULTS: A total of 110 (5.4%) cases of migraine and 179 (8.9%) cases of NMH were identified at baseline. During the median 8.8-year follow-up, incident stroke was observed in 1.9% of baseline migrainers, 6.2% of NMH and 3.6% of those with no lifetime history of headache. Cox proportional hazard models indicated that migraine was not a risk factor for stroke; however, NMH sufferers were twice as likely to have a stroke (hazard ratio 2.00, 95% confidence interval 1.00-3.93, P = 0.049). CONCLUSIONS: This study is one of the first to suggest that late-life NMH rather than migraine could be an independent risk factor for stroke and a warning sign. The incidence of stroke in elderly migrainers, seldom reported, is particularly low.

[Cutaneous necrosis at apomorphine injection points]. / Nécroses cutanées localisées aux points d'injection d'apomorphine.

BACKGROUND: Apomorphine is a specific dopaminergic agonist used in the treatment of severe fluctuations of Parkinson's disease, particularly in patients on L-dopa. The drug is usually given subcutaneously, either as several daily injections or via a continuous subcutaneous delivery system. We describe two cases of localized cutaneous necrosis at the points of subcutaneous apomorphine injection. OBSERVATIONS: Two male patients presenting Parkinson's disease were treated by subcutaneous injection of apomorphine. One month later, asymptomatic necrotic lesions measuring from 2 to 5 mm appeared at the injection sites. Complete blood count, standard and advanced coagulation studies and screening tests were normal. One patient had taken acetylsalicylic acid. A skin biopsy showed normal epidermis, oedema of the papillary dermis with perivascular lymphocytic infiltrates, reticular dermal infiltrate with neutrophils, and necrosis of the reticular dermis and hypodermis in one patient, and in the other, necrosis in the epidermis, dermis, hypodermis and skin appendages, with dermal leucocytoclastic vasculitis and cytosteatonecrosis. Due to the severity of necrosis, apomorphine was stopped, resulting in improvement of skin lesions in one patient. In the second, due to the localized nature of the lesions and the improvement in the patient's quality of life since the introduction of apomorphine, the drug was continued, resulting in the appearance of new lesions, which continued to be limited to the injection sites. COMMENTS: To our knowledge, this is the first description of biopsy-proven apomorphine-induced localized skin necrosis. Reported cutaneous side effects of the drug include pruritic subcutaneous nodules corresponding to panniculitis with large numbers of eosinophils, allergic contact dermatitis, pigmented nodules resulting from oxidation of apomorphine, and nonspecific rashes. Cutaneous necrosis at injection sites could arise through various mechanisms: localized vasoconstriction ("dopamine necrosis"), direct toxicity of the injected drug, local manifestations of pre-existent coagulation disorders, immunological mechanisms or poor administration technique involving intravascular injection. The specific pharmacodynamic properties of apomorphine rule out vasomotor phenomena in the aetiology of such necrosis. Screening tests for thrombophilia were negative in the first patient. Although the underlying mechanism of this form of necrosis remains unknown, an immunological mechanism of the immune complex type could be considered aetiologically relevant on histological grounds due to the presence of vasculitis in one of the two patients.

Effect of music therapy on anxiety and depression in patients with Alzheimer's type dementia: randomised, controlled study.

BACKGROUND/AIMS: Numerous studies have indicated the value of music therapy in the management of patients with Alzheimer's disease. A recent pilot study demonstrated the feasibility and usefulness of a new music therapy technique. The aim of this controlled, randomised study was to assess the effects of this new music therapy technique on anxiety and depression in patients with mild to moderate Alzheimer-type dementia. METHODS: This was a single-centre, comparative, controlled, randomised study, with blinded assessment of its results. The duration of follow-up was 24 weeks. The treated group (n = 15) participated in weekly sessions of individual, receptive music therapy. The musical style of the session was chosen by the patient. The validated 'U' technique was employed. The control group (n = 15) participated under the same conditions in reading sessions. The principal endpoint, measured at weeks 1, 4, 8, 16 and 24, was the level of anxiety (Hamilton Scale). Changes in the depression score (Geriatric Depression Scale) were also analyzed as a secondary endpoint. RESULTS: Significant improvements in anxiety (p < 0.01) and depression (p < 0.01) were observed in the music therapy group as from week 4 and until week 16. The effect of music therapy was sustained for up to 8 weeks after the discontinuation of sessions between weeks 16 and 24 (p < 0.01). CONCLUSION: These results confirm the valuable effect of music therapy on anxiety and depression in patients with mild to moderate Alzheimer's disease. This new music therapy technique is simple to implement and can easily be integrated in a multidisciplinary programme for the management of Alzheimer's disease.

[Impact of music therapy on anxiety and depression for patients with Alzheimer's disease and on the burden felt by the main caregiver (feasibility study)]. / Intérêts de la musicothérapie sur l'anxiété, la dépression des patients atteints de la maladie d'Alzheimer et sur la charge ressentie par l'accompagnant principal (étude de faisabilité).

INTRODUCTION: The impact of music therapy on dementia care for patients with Alzheimer's disease (AD) is well-recognized. Music alters the different components of the disease through sensory, cognitive, emotional, behavioral and social impacts. The academic aspect of music therapy in this area was based on the fact that music can alter the various components of the overall evolution of this disease. We found around 10 case studies presenting various results from receptive music therapy sessions on patients with Alzheimer's disease. The results of these studies point out the interest of music therapy in the multidisciplinary care of Alzheimer's disease and its related syndromes. It has been deemed useful for significantly reducing the medication given to AD patients. A music therapy protocol, specifically tailored to the patient's needs has been shown to significantly reduce anxiety, depression and aggressiveness in patients suffering from Alzheimer's disease. This technique has also demonstrated its impact on helping AD patients recall their previous life experience. OBJECTIVE: To demonstrate the feasibility and to evaluate the impact of music therapy on anxiety and depression at the early to moderate stage of Alzheimer's disease and on the main caregiver burden. METHOD: Five outpatients suffering from early stage of Alzheimer's disease (MMS: 18-26) were prospectively included. They were living in Montpellier with a reliable caregiver. A weekly receptive music therapy session was delivered to patients over a 10-week period, according to the U method standardized protocol. This technique was based on the recommendations made by Gardner and Good relating to the importance given to an individualized choice of music. Instrumental tracks were selected from various music styles (classic, jazz, world music...) and were tailored to the patient's requirements. This individual session was always followed by an interview with the music therapist in order to allow the patient to express the emotions felt during the session and to stimulate the patient's cognitive functions by recalling memories and images from his past life experience. The main evaluation criterion was regular session attendance at the hospital. Secondary criteria were: anxiety score (Hamilton scale), depression score (Cornell scale) and the burden score felt by the main caregiver (Zarit scale). Evaluations took place at W1, W4 and W10. The score evolution on the Hamilton, Cornell and Zarit scales were tested using the Wilcoxon test on paired data. The significance threshold has conventionally been set at 5% for all tests used. The statistical analysis was done using the SAS software (8th version) (SAS Institute, Cary, N.C.; proc npar1way, proc univariate, proc freq). Alzheimer's disease is a recognized indication for music therapy. A simple oral consent was collected prior to the study inclusion. RESULTS: Five patients were included for a total of 44 sessions. The patients' regular attendance at the music therapy sessions showed its feasibility. Thanks to oral feedback, we were able to see that music therapy was very well-accepted both by patients and caregivers. After the sessions, all patients expressed a sensation of well-being and pleasure, such as: "Music made me feel better, I feel more relaxed", "I feel better", "I didn't know that music could have such an impact on me"... Other verbal comments were collected regarding the patients' previous life experience: "This music reminds me of my childhood", "I imagined myself dancing just like I used to in the old days", "This reminds me of my trip to Italy with my children"... The level of anxiety (Hamilton scale) dropped significantly from 9.4 (+/-2.2) to 3.4 (+/-2.6) between the first session and the fourth session (P<0.004). The differences observed between W4-W10 and W1-W10 were close to the threshold of significance due to a major drop in the anxiety level starting at W4 (P=NS). On the Cornell scale, the depression level dropped significantly from 10.8 (+/-5.3) to 2.2 (+/-1.9) between the first session and the fourth session (P<0.01). The differences observed between W4-W10 and W1-W10 were not significant (P=NS). The weight of the physical and emotional burden experienced by the main caregiver (Zarit scale) fell significantly from 30.2 (+/-11.7) to 15.6 (+/-10.4) between W1-W4 (P<0.002). The differences observed between W4-W10 and W1-W10 were not significant (P=NS). DISCUSSION/CONCLUSION: This preliminary study demonstrates the feasibility as well as the initial efficacy of music therapy in terms of its impact on the overall care for patients suffering from Alzheimer's disease. This easily applicable technique can be useful in treating anxiety and depression in a patient with Alzheimer's disease and also in relieving the emotional and physical burden experienced by the main caregiver.

Risk profiles for mild cognitive impairment and progression to dementia are gender specific.

OBJECTIVE: To examine risk factors for mild cognitive impairment (MCI) and progression to dementia in a prospective community-based study of subjects aged 65 years and over. METHODS: 6892 participants who were over 65 and without dementia were recruited from a population-based cohort in three French cities. Cognitive performance, clinical diagnosis of dementia, and clinical and environmental risk factors were evaluated at baseline and 2-year and 4-year follow-ups. RESULTS: 42% of the population were classified as having MCI at baseline. After adjustment for confounding with logistic regression models, men and women classified as having MCI were more likely to have depressive symptomatology and to be taking anticholinergic drugs. Men were also more likely to have a higher body mass index, diabetes and stroke, whereas women were more likely to have poor subjective health, to be disabled, to be socially isolated, and to suffer from insomnia. The principal adjusted risk factors for men for progression from MCI to dementia in descending order were ApoE4 allele (OR = 3.2, 95% CI 1.7 to 5.7), stroke (OR = 2.8, 95% CI 1.2 to 6.9), low level of education (OR = 2.3, 95% CI 1.3 to 4.1), loss of Instrumental Activities of Daily Living (IADL) (OR = 2.2, 95% CI 1.1 to 4.5) and age (OR = 1.2, 95% CI 1.1 to 1.2). In women, progression is best predicted by IADL loss (OR = 3.5, 95% CI 2.1 to 5.9), ApoE4 allele (OR = 2.3, 95% CI 1.4 to 4.0), low level of education (OR = 2.2, 95% CI 1.3 to 3.6), subclinical depression (OR = 2.0, 95% CI 1.1 to 3.6), use of anticholinergic drugs (OR = 1.8, 95% CI 1.0 to 3.0) and age (OR = 1.1, 95% CI 1.1 to 1.2). CONCLUSIONS: Men and women have different risk profiles for both MCI and progression to dementia. Intervention programmes should focus principally on risk of stroke in men and depressive symptomatology and use of anticholinergic medication in women.

Prevention of progression to dementia in the elderly: rationale and proposal for a health-promoting memory consultation (an IANA Task Force).

Alzheimer's disease (AD) is the most frequent form of dementia and according to the most recent estimation it affects nearly 27 million people in the world. The onset of the disease is generally insidious. It is becoming increasingly evident that the underlying pathophysiological mechanisms are active long before the appearance of the clinical symptoms of the disease. In the current context, it is important to develop strategies to delay the onset of cognitive decline. Delaying the onset by 5 years would reduce the prevalence by half at term, and a delay of 10 years would reduce it by three-quarters. The effectiveness of currently suggested preventive approaches remains to be confirmed, but certain strategies could be applied straight away to at-risk subjects. We propose that a health-promoting memory consultation should be set up for elderly persons who have attended a specialized memory consultation and in whom the diagnosis of dementia and of AD in particular, has not been established by standardized tools. Through this consultation, they would be offered full multidimensional investigation of all aspects of their health status, follow-up could be organized, general practitioners in private practice could be made more conscious of this population and the elderly could be made more aware of the risk factors to which they are exposed. The development of an information policy for the elderly would meet a present need. In our reflection, we must take into account the question of how to give this preventive consultation its due place in the healthcare pathway of the elderly person in order to ensure coordinated follow-up with all the other health professionals involved. The principle of the health-promoting memory consultation is undergoing validation in a large French multicentre preventive trial in 1200 frail elderly persons aged 70 years followed for three years, the Multidomain Alzheimer Preventive Trial (MAPT).

Six and 18-month changes in mild to moderate Alzheimer's patients treated with acetylcholinesterase inhibitors: what can we learn for clinical outcomes of therapeutic trials?

BACKGROUND: Clinical trials in Alzheimer's disease (AD) include patients benefiting from recent improvements in AD management. OBJECTIVE: To observe the progression of Alzheimer's disease (AD) after 6 and 18 months in patients treated with acetylcholinesterase inhibitors (AChEI) in order to determine the best duration of follow-up necessary to demonstrate the impact of new drugs. METHODS: Six hundred and eleven patients included in the REAL.FR cohort were treated with AChEI at baseline. We describe the cognitive, functional, behavioural, nutritional and global changes in the 509 and 364 patients who completed 6 and 18 months of follow-up, respectively, and who did not discontinue treatment. RESULTS: After 6 and 18 months, we observed a statistically significant change in the MMSE (-0.54 +/- 3.13 at 6 months and -2.90 +/- 4.10 at 18 months), ADAS-cog (1.58 +/- 5.23 and 4.02 +/- 6.83), ADL (-0.30 +/- 0.79 and -0.84 +/- 1.20), IADL (-0.31 +/- 0.95 and -0.94 +/- 1.20), CDR sum of boxes (0.75 +/- 2.03 and 2.65 +/- 3.18) and MNA scores (-0.42 +/- 2.89 and -0.95 +/- 3.57), demonstrating the progression of AD. But on examining these changes, it appears that even if they were statistically significant at 6 months, they do not appear to be clinically relevant or sufficient to allow the observation of the effect of a new drug at this time, whereas such observation would be possible after 18 months. Similar results were obtained in a subgroup of patients who answer to the inclusion criteria of disease modifying trials which confirms the need for having 18 months of follow-up. CONCLUSION: Changes in AD in patients under AChEI treatment are not sufficient to demonstrate the effect of a new treatment at 6 months. However, 18-month trials appear to have the potential to demonstrate clearly the effect of a new drug.

IANA task force on nutrition and cognitive decline with aging.

Cognitive impairment can be influenced by a number of factors. The potential effect of nutrition has become a topic of increasing scientific and public interest. In particular, there are arguments that nutrients (food and/or supplements) such as vitamins, trace minerals, lipids, can affect the risk of cognitive decline and dementia, especially in frail elderly people at risk of deficiencies. Our objective in this paper is to review data relating diet to risk of cognitive decline and dementia, especially Alzheimer's disease (AD). We chose to focus our statements on homocysteine-related vitamins (B-vitamins), antioxidant nutrients (vitamins E and C, carotenoids, flavonoids, enzymatic cofactors) and dietary lipids. Results of epidemiological studies may sometimes appeared conflicting; however, certain associations are frequently found. High intake of saturated and trans-unsaturated (hydrogenated) fats were positively associated with increased risk of AD, whereas intake of polyunsaturated and monounsaturated fats were protective against cognitive decline in the elderly in prospective studies. Fish consumption has been associated with lower risk of AD in longitudinal cohort studies. Moreover, epidemiologic data suggest a protective role of the B-vitamins, especially vitamins B9 and B12, on cognitive decline and dementia. Finally, the results on antioxidant nutrients may suggest the importance of having a balanced combination of several antioxidant nutrients to exert a significant effect on the prevention of cognitive decline and dementia, while taking into account the potential adverse effects of these nutrients. There is no lack of attractive hypotheses to support research on the relationships between nutrition and cognitive decline. It is important to stress the need to develop further prospective studies of sufficiently long duration, including subjects whose diet is monitored at a sufficiently early stage or at least before disease or cognitive decline exist. Meta analyses should be developed, and on the basis of their results the most appropriate interventional studies can be planned. These studies must control for the greatest number of known confounding factors and take into account the impact of the standard social determinants of food habits, such as the regional cultures, social status, and educational level.

Mild cognitive impairment (MCI) in medical practice: a critical review of the concept and new diagnostic procedure. Report of the MCI Working Group of the European Consortium on Alzheimer's Disease.

Mild cognitive impairment (MCI) was proposed as a nosological entity referring to elderly people with mild cognitive deficit but no dementia. MCI is a heterogeneous clinical entity with multiple sources of heterogeneity. The concept of MCI was reviewed and a diagnostic procedure with three different stages was proposed by the European Consortium on Alzheimer's Disease Working Group on MCI. Firstly, MCI should correspond to cognitive complaints coming from the patients or their families; the reporting of a relative decline in cognitive functioning during the past year by a patient or informant; cognitive disorders as evidenced by clinical evaluation; absence of major repercussions on daily life; and absence of dementia. These criteria, similar to those defined during an international workshop in Stockholm, make it possible to identify an MCI syndrome, which is the first stage of the diagnostic procedure. Secondly, subtypes of MCI had to be recognised. Finally, the aetiopathogenic subtype could be identified. Identifying patients at a high risk for progression to dementia and establishing more specific and adapted therapeutic strategies at an early stage, together with more structured overall management, is made possible by the diagnostic procedure proposed.

Evaluation of real-time QRS detection algorithms in variable contexts.

A method is presented to evaluate the detection performance of real-time QRS detection algorithms to propose a strategy for the adaptive selection of ORS detectors, in variable signal contexts. Signal contexts are defined as different combinations of QRS morphologies and clinical noise. Four QRS detectors are compared in these contexts by means of a multivariate analysis. This evaluation strategy is general and can be easily extended to a larger number of detectors. A set of morphology contexts, corresponding to eight QRS morphologies (normal, PVC, premature atrial beat, paced beat, LBBB, fusion, RBBB, junctional premature beat), was extracted from 17 standard ECG records. For each morphology context, the set of extracted beats, ranging from 30 to 23000, was resampled to generate 50 realisations of 20 concatenated beats. These realisations were then used as input to the QRS detectors, without noise, and with three different types of additive clinical noise (electrode motion artifact, muscle artifact, baseline wander) at three signal-to-noise ratios (5 dB, -5 dB, -15 dB). Performance was assessed by the number of errors, which reflected both false alarms and missed beats. The results show that the evaluated detectors are indeed complementary. For example, the Pan-Tompkins detector is the best in most contexts but the Okada detector generates fewer errors in the presence of electrode motion artifact. These results will be particularly useful to the development of a real-time system that will be able to choose the best ORS detector according to the current context.

[Behavioral and psychological symptoms in dementia: description and management]. / Les symptômes psychologiques et comportementaux de la démence: description et prise en charge.

Behavioral and Psychological Symptoms in Dementia (BPSD) are, beside cognitive disorders, major features of Alzheimer's disease and related disorders. Diagnosis is important to enhance our knowledge of the pathophysiology of dementia and of their functional consequences for patients and caregivers. Pharmacological and non-pharmacological management of dementia depends to a large extent on the presence of BPSD. A committee of geriatricians, neurologists and psychiatrists specialized in dementia (THEMA 2) has promoted an epidemiological, diagnostic and therapeutic update in this field. This work was based on the BPSD Consensus Conference Report edited in 2000 by the International Psychogeriatric Association. This report was updated with the most recent literature reports, and was adapted to the French environment. This paper is a synthesis of this meeting, validated and corrected by the entire Thema 2 group.

Simultaneous quantitative trace analysis of anionic and nonionic surfactant mixtures by reversed-phase liquid chromatography.

The aim of this work was to simultaneously analyse mixtures of a polydisperse polyethylene oxide (PEO) nonionic surfactant and an anionic surfactant (sodium dodecylsulphate, SDS) in water containing sodium chloride in order to quantify trace amounts of these mixtures after their adsorption at water-solid interfaces. A fractional factorial design was then used to optimise the separation by ion-pair reversed-phase liquid chromatography as a function of six factors: the chain length of the tetraalkylammonium salt used as ion-pairing reagent which varied from methyl (C1) to n-propyl (C3); the concentration of this ion-pairing salt; the acetonitrile percentage in water used as organic modifier; the flow-rate; the temperature of analysis and also the sodium chloride concentration. The factorial design enabled in a limited number of analyses, not only to determine which factors had significant effects on retention times or on resolution between a pair of nonionic oligomers, but also to modelize and then find the interesting and rugged area where this resolution was optimal as well as the conditions where time of analysis was not prohibitive. After optimisation of HPLC analysis, we used a trace enrichment procedure to quantify very low concentrations of SDS and C12E9 polydisperse PEO in water. A C18 cartridge and a strong anionic exchange cartridge were coupled and the conditions of elution were optimised in order to obtain concentrated samples which were injected in the same eluent than the HPLC mobile phase. Under such conditions, we were able to quantify, in a single run, mixtures of anionic and nonionic surfactants at concentrations as low as 3.6 microg l(-1) for SDS and 2.5 microg l(-1) for each PEO oligomer in water.

Analytical investigation of the self-desorption of the oligomers of mixtures of a polydisperse ethoxylated surfactant with sodium dodecylsulfate from a silica/water interface.

The adsorption isotherms onto a hydrophilic silica of mixtures of sodium dodecylsulfate (SDS) and of all the oligomers of a polydisperse nonylethylene glycol n-dodecyl ether (C(12)E(9)) surfactant were determined using a high-performance liquid chromatography (HPLC) technique. Incorporation of the anionic surfactant to the negatively charged silica surface is favored by the adsorption of the nonionic surfactant. Comparison between the adsorption isotherms of mixtures of SDS with a monodisperse C(12)E(9) and a polydisperse C(12)E(9) shows that the adsorption of SDS at the silica/water interface is stronger with the latter material than with the former in a large surface coverage domain. The composition of the surface aggregates and the variation of the oligomer distribution in these aggregates were determined. The previously described phenomena called self-desorption which was observed for the global C(12)E(9) and SDS surfactant mixtures was confirmed: increasing the total concentration at a fixed surfactant ratio induces at high concentration a desorption of the anionic surfactant and all of the less polar oligomers from the solid/water interface. An interpretation scheme is proposed which assumes that the interaction of SDS is larger with the less polar oligomers than with the polar ones. The self-desorption effect could then be considered as the consequence of the polydispersity of the nonionic surfactant and to the net repulsion interaction between SDS and the silica surface as the mole fraction of SDS in the surfactant mixture increases.

[Mild cognitive impairment: imaging data]. / Mild Cognitive Impairment: données de l'imagerie.

The diagnosis of Mild Cognitive Impairment (MCI) as defined by Petersen et al. (1997), is based uniquely on clinical observations. Cerebral imaging, both morphological and functional, may in fact facilitate diagnosis, particularly with regard to the differentiation of sub-types of MCI and the identification of prodromal AD (MCI-AD). Volumetric Magnetic Resonance Imagery (MRI) examination of structures affected early in AD such as entorhinal cortex, the temporal lobe and, above all, the hippocampus, are especially useful. Hypoactivity within these regions, especially of the temporal lobe and posterior cingulate gyrus by Positon Emission Tomography, and more recently monophotonic emission tomoscintigraphy, also appears to have diagnostic utility. Studies of cholinergic system activity by functional imaging may also be of future value in MCI-AD diagnosis. MRI used in conjunction with other techniques may be of significant value, in particular the use of spectro-MRI and functional MRI. This latter technique, leading to the development of cognitive activation paradigms, is particularly promising.

[REM Sleep behavioral disorder]. / Troubles du comportement en sommeil paradoxal.

Rapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia which occurs only during REM sleep. RBD is characterized by the loss of skeletal muscle atonia, which is the principal feature of REM sleep, and by abnormal behavior representing the attempted enactment of dreaming. Clinically, it consists of abnormal behavior, frequently violent, that may lead to injuries. A polysomnographic study is necessary to assess the diagnosis showing the absence of REM sleep atonia and related abnormal behavior. RBD usually affects older men. Its exact etiological factors remain unknown. However, RBD is sometimes linked with drug use or exposure to toxic conditions. Moreover, the association with neurological disorders is frequently reported, particularly cerebrovascular, tumoral or neurodegenerative disease. Neurodegenerative disorders with parkinsonism are frequently involved. In Lewy body dementia, RBD is particularly frequent. In many cases, RBD may have a predictive value, preceding other symptoms of neurodegenerative disorders with parkinsonism. The biochemical mechanisms underlying RBD still remain unclear but could involve the dopamino-cholinergic balance and the serotoninergic pathway.

[Amyotrophic lateral sclerosis and cognitive disorders: review and analysis of the literature]. / SLA et troubles cognitifs: revue et analyse de la littérature.

In the last ten years, the syndromic nature of amyotrophic lateral sclerosis (ALS) has become more accepted. Together with upper and lower motor neuron signs, sensory or cognitive impairment are not uncommon. The frequency of a multidegenerative profile in ALS with SOD1 mutations is also an argument for this. We reviewed the literature about:

["The 5 words": a simple and sensitive test for the diagnosis of Alzheimer's disease]. / "Les 5 mots", épreuve simple et sensible pour le diagnostic de la maladie d'Alzheimer.

OBJECTIVE: Alzheimer's disease (AD) is under-diagnosed in France. Today only an estimated 50% of patients are identified. Diagnosis of AD is particularly difficult because the amnesic syndrome, characteristic of the disease, is often confused with memory dysfunction that is frequent during the process of aging. The improvement in the diagnostic conditions of AD relies on the availability of a simple and reliable tool for screening memory disorders of organic origin. METHOD: The 5-word test studies the recall of a short list, which the physician ensures the patient has registered. Its construction permits the identification of patients exhibiting objective memory disorders. A validation study has been conducted in 86 patients suffering from AD and 126 persons complaining of functional memory disorders. RESULTS: The study has shown the sensitivity (91%) and specificity (87%) of the 5-word test in identifying patients with AD. CONCLUSION: This is a rapid (2 minutes) and simple test that is easy to use in medical practice for the screening of AD.

Neurodegenerative dementia and parkinsonism.

BACKGROUND: Dementia and Parkinsonism are two major neurodegenerative disorders. Accurate diagnosis can be difficult when patients have both syndromes because of a wide range of etiologies. OBJECTIVES: To improve clinical diagnosis, we propose a disease classification based on the pathological proteins which are involved in the neuropathological disease process. DESIGN: Four neuropathological classes are proposed based on four major proteins, tau, A beta, alpha -synuclein and TDP43 : 1/ Tauopathy and amyloidopathy with possible Parkinsonism, 2/ Tauopathy with predominant Parkinsonism, 3/ Synucleinopathies with cognitive impairment/dementia and 4/ The TAR DNA binding protein 43 (TDP-43). This classification raises certain questions in clinical practice due to intriguing overlaps between clinical presentations despite the same pathological protein being involved. CONCLUSION: The development of molecular and pathological protein research in neurodegenerative disorders can help classify the clinical association of dementia and Parkinsonism and improve therapeutic strategies against proteins involved in the degenerative process.

Policy options in addressing livestock's contribution to climate change.

There is a great potential to reduce greenhouse gas (GHG) emissions related to livestock production. For achieving this potential will require new initiatives at national and international levels that include promoting research and development on new mitigation technologies; deploying, diffusing and transferring technologies to mitigate emissions; and enhancing capacities to monitor, report and verify emissions from livestock production. This study describes the sources of livestock-related GHG emissions and reviews available mitigation technologies and practices. We assess the main policy instruments available to curb emissions and promote carbon sinks, and discuss the relative merits of alternative approaches. We discuss recent experiences in countries that have enacted mitigation strategies for the livestock sector to illustrate some of the key issues and constraints in policy implementation. Finally, we explore the main issues and challenges surrounding international efforts to mitigate GHG emissions and discuss some possible ways to address these challenges in future climate agreements.