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Puisieux F, Pollez B, Deplanque D, Di Pompeo C, Pardessus V, Thevenon A, Dewailly P: Successes and setbacks of the falls consultation: report on the first 150 patients. Am J Phys Med Rehabil 2001;80:909–915. We report the results of a Falls Consultation. Data concerning the first 150 patients are reported. Each patient was assessed by a geriatrician, a neurologist, and a physiatrist, who visited him or her at home, and was reassessed by the same geriatrician 6 mo later. Of the 150 patients, 135 patients completed the initial evaluation. Most of them were frequent fallers. The population was very heterogeneous regarding the health status and the degree of disability. In most cases, falls were the result of several interacting factors. The most frequent recommendations from the staff were physical therapy, environmental changes, and medication changes. Over the following 6 mo, approximately one out of four patients had experienced new falls. However, the risk of falling was significantly reduced (5.3 ± 7.3 falls in 6 mo before vs. 0.8 ± 1.6 falls in 6 mo after the intervention). The Activities of Daily Living score was a predictor of recurrent falls, hospitalization, and institutionalization. Our results show that a multidisciplinary falls consultation can be efficient in reducing the risk of falls in nonselected elderly fallers but suggest that differential strategies are needed to manage adequately the more vigorous and the frail old person as well.

PURPOSE: Anticardiolipin antibodies may be associated with recurrent thromboembolic events in patients with myocardial infarction or stroke. We sought to determine the prevalence of anticardiolipin antibodies in patients with peripheral arterial disease and their association with subsequent thromboembolic events and mortality. METHODS: We ascertained anticardiolipin antibodies using a standardized enzyme-linked immunosorbent assay (immunoglobulin G [IgG] anticardiolipin ≥15 GPL units or IgM anticardiolipin ≥15 MPL units) in 232 patients with peripheral arterial disease and 100 control subjects. Patients were observed to determine overall and cardiovascular mortality, and incident thromboembolic events. RESULTS: IgG anticardiolipin antibodies were significantly more common in the patients with peripheral arterial disease (36 of 232 [16%]) than in the controls (7 of 100 [7%], P = 0.03). During a median follow-up of 3.5 years, 3 of the 232 patients were lost to follow-up and 56 (24%) died. Overall mortality was significantly greater in the IgG anticardiolipin–positive patients (16 of 35 [46%]) compared with those who were IgG anticardiolipin–negative (40 of 194 [21%], P = 0.0003), largely due to an increase in cardiovascular mortality among the IgG anticardiolipin–positive patients. In a multivariate proportional hazards analysis, IgG anticardiolipin antibodies were an independent risk factor for overall mortality (hazard ratio [HR] = 2.1, 95% confidence interval [CI]: 1.2 to 4.0) and cardiovascular mortality (HR = 4.4, 95% CI: 1.6 to 12). CONCLUSIONS: IgG anticardiolipin antibodies are common in patients with peripheral arterial disease and are associated with an increased risk of overall and cardiovascular mortality.

Functional alterations of barium-sensitive potassium inward rectifier (Kir) current, which is involved in the vasodilation of middle cerebral arteries (MCA) in rat brain, have been described during brain ischemiaireperfusion (I/R). The authors investigate the effects of I/R on Kir current recorded in isolated myocytes from MCA of control rats and from contralateral and ipsilateral MCA of ischemic rats by the whole-cell patch-clamp technique, and the relationship between its alteration and The severity of brain injury. The vascular smooth muscle cells exhibited similar morphologic features in all conditions, and the Kir was present in the three groups of myocytes, exhibiting a characteristic inward rectification and a normal external potassium dependence. The Kir density was significantly reduced in cell of MCA ipsilateral to occlusion with a maximum at −135 mV, whereas there was no difference between control and contralateral cells. This alteration in Kir density in occluded MCA was significantly correlated with severity of brain injury and brain edema. These results suggest that the alteration of Kir density in MCA myocytes after I/R and the consecutive impaired dilation of MCA may contribute to aggravation of the brain injury.

OBJECTIVES: To examine the influence of time of day and of meals on postural blood pressure (BP) changes in older adults. DESIGN: Prevalence study of BP changes in response to orthostasis. SETTING: A geriatric short-stay department PARTICIPANTS: A total of 126 inpatients (91 women and 35 men; mean age: 81.4 ± 7.9, range 61–95 years) were included in the study. MEASUREMENTS: Two sets of BP and heart rate measurements were obtained for each subject by one examiner using a standard mercury manometer: (1) in mid-morning (between 10:00 and 10:30 a.m.) and (2) within 30 to 60 minutes after lunch (between 1:00 and 1:30 p.m.). Orthostatic hypotension (OH) was defined as a systolic blood pressure (SBP) decline ≤ 20 mm Hg within 3 minutes after standing. RESULTS: Sixty-one participants (48%) experienced significant orthostatic BP decline on at least one reading. Among them, 46 (37%) had OH in the mid-morning, and 32 (25%) had OH after lunch (P = .05). Only 17 (13%) had OH on both readings (persistent OH). Forty-four patients (35%) had variable OH. Patients with persistent OH were more likely to exhibit symptoms of dizziness and had a lower body mass index and a higher mean basal supine SBP. There was a positive correlation between basal supine SBP and postural SBP decline. CONCLUSIONS: Because of the variability of postural BP changes, the diagnosis of OH should not be based on a single orthostatic BP measurement but requires repeated testing, at best under circumstances similar to those in which the symptoms occurred. The postprandial period is not particularly favorable to OH, suggesting that the ingestion of a meal does not worsen orthostatic BP changes in most aged patients. J Am Geriatr Soc 47:1332–1336,1999.

The evaluation of the cardiac safety of newly developed drugs by electrophysiological studies are today mandatory in several countries. A number of experimental models performed either on multicellular preparations or on native or cloned ionic channels have been used but the predictivity of the results remains a matter of debate, particularly if a drug exerts mixed ionic channel-blocking effects. The present study was designed to scrutinize the repercussions of selectively decreasing the main ionic currents which play a role in the repolarization process. Using conventional microelectrodes, action potentials were recorded from rabbit Purkinje fibers stimulated at 1 Hz and 0.2 Hz and exposed to a broad range of cumulative and increasing concentrations. The compounds used were 1) potassium channel blockers (4-aminopyridine, dofetilide, terikalant, and indapamide), 2) chloride current blocker (4,4′-diisothiocyanatostilbene-2,2′-disulfonic acid), and 3) calcium channel antagonists (nifedipine, verapamil, and cadmium). It appears from our results that the modifications observed in the repolarization phase and in the spike-and-dome aspect showed that the antagonists evaluated were not as specific as one would expected and that they affected action potential profiles as a result of additional nonspecific effects which may influence the incidence of proarrhythmic events. In conclusion, we propose the use of rabbit Purkinje fibers as an in vitro model adequate for the evaluation of the cardiac safety of newly developed drugs. Drug Dev. Res. 47:63–76, 1999. © 1999 Wiley-Liss, Inc.

Resume Entre 1985 et 1995, 47 patients ont ete hospitalises en medecine interne pour une periarterite noueuse. Pour 39 d'entre eux, le diagnostic reposait sur des arguments cliniques et histologiques ou arteriographiques. Pour huit patients, il reposait seulement sur des criteres cliniques. Vingt-cinq patients (53 %) avaient moins de 65 ans au moment du diagnostic (groupe A) et 22 patients (47 %) avaient plus de 65 ans (groupe B). En dehors d'une plus grande frequence de l'alteration de l'etat general dans le groupe B et des signes cutanes (purpura et nodules) dans le groupe A, les signes cliniques et biologiques au debut de la maladie n'etaient pas significativement differents dans les deux groupes. Le suivi moyen a ete de 46,9 ± 36,5 mois. Le nombre de deces a ete significativement plus grand parmi les malades âges (dix deces dans le groupe B versus deux dans le groupe A).

The purposes of this study were (1) to assess the prevalence of antiphospholipid (aPL) antibodies in patients with non-specific heart valve disease referred for valve replacement and (2) to determine whether the presence of aPL antibodies carries a risk for thrombotic events during a postoperative follow-up in a prospective cohort. The sera of 89 consecutive patients and 80 matched control subjects were tested for antibodies to cardiolipin (immunoglobulin G and immunoglobulin M) and for lupus anticoagulant. The prevalence of aPL antibodies was significantly higher in patients (19 [21%] of 89) than in control subjects (7 [9%] of 80) (p0.05). Patients were divided into two subgroups according to the presence (subgroup A) or the absence (subgroup B) of aPL antibodies. No significant difference in age or sex ratio was observed between the two subgroups. A history of arterial thrombosis was more frequent in subgroup A (8 [42%] of 19) than in subgroup B (8 [11%] of 70) (p0.01). No significant difference with respect to the occurrence of thrombotic events was observed during a median follow-up period of 8.7 months. Thus a high prevalence of aPL antibodies was found in patients referred for heart valve replacement compared with matched control subjects. No increased risk has been demonstrated in the patients with aPL antibodies.

Resume Cinquante-huit personnes âgees (sept hommes et 51 femmes, moyenne d'âge de 84 ± 6 ans), consecutivement hospitalisees pour insuffisance cardiaque congestive, ont ete explorees de facon prospective par echodoppler cardiaque afin de determiner la prevalence des insuffisances cardiaques a fonction systolique conservee, de juger du role des anomalies du remplissage ventriculaire gauche (dysfonction diastolique), d'evaluer les parametres echographiques utilises pour apprecier la fonction diastolique: rapport du pic de vitesse de remplissage precoce sur le pic de vitesse de remplissage telediastolique (E/A), temps de deceleration mitrale (TDM), temps de relaxation isovolumetrique (TRI). Sur les 58 patients de l'etude, 32 (55%) avaient une fonction systolique ventriculaire gauche normale et 26 (45%) une dysfonction systolique. Pour les 32 malades avec fonction systolique conservee, la fonction diastolique ne pouvait etre etudiee chez neuf patients, elle etait consideree comme anormale chez 16 patients et normale chez sept. L'insuffisance cardiaque congestive a fonction systolique normale est donc tres frequente chez le sujet âge. Les donnees cliniques etant trop peu sensibles, l'echodoppler cardiaque apparait comme le moyen d'etude le plus simple pour la distinguer de celle a fonction systolique alteree. Chez le sujet âge, le TDM et le TRI sont des parametres echocardiographiques plus sensibles que le rapport E/A pour le diagnostic de dysfonction diastolique.

Nursing home residents are very old, with multiple comorbidities and disabled for activities of daily living (ADLs). Therefore, they have a higher risk of accidents as falls or fractures or acute diseases as infections, which require hospitalization. Care's coordination and sharing of informations between hospitals and nursing homes are often insufficient even with agreements. Thus, discharge to nursing homes after hospitalization may be difficult for old patients because of incomplete oral or written transmissions.To examine both protocols and the quality of the return to the nursing homes after an hospitalization for old residents.A prospective multicenter study done by collecting data about consecutive returns into their nursing home after an hospitalization of more than 24 hours of nursing home residents aged 65 years and more.Twenty-eight nursing homes of the North of France were enrolled in the study. During the 3 months period of the study, 246 discharges after an hospitalization of 24 hours or more were registered. 225 residents (165 women and 60 men), mean age 85.0 ± 7.2, were concerned. Most of them were ADLs disabled, with a dementia for 47.1% of them. The average length of hospitalization was 11.6 days. At the end of hospitalization, the notification of return, which was made only in 82% of cases, was announced in average 1.3 days before the discharge. Unfortunately, in 32% of cases, the notification was made the day of the discharge. Residents went back home indifferently any day of the week but more often the Friday and less often the weekend. The day and the hour of the planned discharge were respected in 79.1% of cases. In most cases, nursing home caregivers have considered that the clinical status was stable or improved compared to the previous one. However in 28% of cases, a loss of autonomy was found. Medical doctors wrote a letter of discharge in 85.8% of cases. Nurses gave written transmissions only in 41.9% of cases.Many points concerning discharge from hospital, about old people living in nursing home, have to be improved: oral transmissions about patient's status, notification of the return, discharge's letter, nurse's transmissions and assessment of the loss of autonomy.

Resume Les auteurs rapportent trois observations de syndrome de Gougerot-Sjogren primitif chez des mineurs de charbon atteints d'anthracosilicose. Tous les patients remplissaient les criteres diagnostiques du syndrome de Gougerot-Sjogren primitif recemment etablis par le groupe d'etude de la Communaute europeenne. Ils avaient une xerostomie et une xerophtalmie severes. Un patient avait une cryoglobulinemie et une polynevrite. Un autre avait un phenomene de Raynaud, des arthralgies, un purpura et une polynevrite. La capillaroscopie etait normale dans les trois cas, des anticorps antinucleaires etaient detectes chez un seul patient (anticorps anti-SSA et anti-SSB). La prevalence de la sclerodermie systemique, de la polyarthrite rhumatoide et probablement du lupus erythemateux dissemine est significativement plus elevee apres exposition professionnelle prolongee a la silice. En revanche, aucun cas de syndrome de Gougerot-Sjogren primitif associe a une silicose pulmonaire n'a encore ete rapporte. Les mecanismes physiopathologiques de ces associations sont mal connus.

Objectives To assess the clinical significance of unsuspected rise in cardiac troponin I (cTnI) levels in elderly patients who have fallen. Design Monocentre prospective observational pilot study Participants Consecutive elderly patients (age >65 years) referred to the emergency department after being immobilised on the ground after a fall. Measurements Clinical, laboratory and Doppler echocardiography data were collected on admission to assess the cardiac correlates of increased cTnI. The survival endpoint was a composite of death or cardiovascular event. Results 60 patients were included in this study. Mean age was 81±8 years. Cardiac TnI was ≥0.05 ng/ml in at least one blood sample in 40 patients (67%). New diagnosis of cardiac disease was performed in 14 patients, 13 of them had cTnI ≥0.05 ng/ml. Transient apical ballooning was diagnosed in six patients. During a median follow-up of 92 (49–131) days death occurred in six patients, myocardial infarction in three, stroke in one and acute heart failure in five. Cardiac TnI ≥0.05 ng/ml was a predictor of these events (p=0.034). Conclusion An unsuspected rise in cTnI correlates with new diagnosis of cardiac disease and is a potential marker of stress induced cardiomyopathy in elderly patients who fall. Cardiac TnI might be a strong predictor of outcome in these patients.

International audience; Seizures are frequent in the elderly, but their diagnosis can be challenging. The objective of this work was to develop and validate an expert-based algorithm for the diagnosis of seizures in elderly people. A multidisciplinary group of neurologists and geriatricians developed a diagnostic algorithm using a combination of selected clinical, electroencephalographical and radiological criteria. The algorithm was validated by multicentre retrospective analysis of data of patients referred for specific symptoms and classified by the experts as epileptic patients or not. The algorithm was applied to all the patients, and the diagnosis provided by the algorithm was compared to the clinical diagnosis of the experts. Twenty-nine clinical, electroencephalographical and radiological criteria were selected for the algorithm. According to criteria combination, seizures were classified in four levels of diagnosis: certain, highly probable, possible or improbable. To validate the algorithm, the medical records of 269 elderly patients were analyzed (138 with epileptic seizures, 131 with non-epileptic manifestations). Patients were mainly referred for a transient focal deficit (40%), confusion (38%), unconsciousness (27%). The algorithm best classified certain and probable seizures versus possible and improbable seizures, with 86.2% sensitivity and 67.2% specificity. Using logistical regression, 2 simplified models were developed, the first with 13 criteria (Se 85.5%, Sp 90.1%), and the second with 7 criteria only (Se 84.8%, Sp 88.6%). In conclusion, the present study validated the use of a revised diagnostic algorithm to help diagnosis epileptic seizures in the elderly. A prospective study is planned to further validate this algorithm.

Ageing of the population leads to an increase of cognitive disorders and chronic renal failure incidence. Compared to the general population, prevalence of cognitive impairment is more important in renal failure patients, especially in dialyzed patients. No direct link has been established between renal failure and cognitive impairment. The care of older and older patients and the high frequency of vascular risk factors, in particular hypertension and diabetes, partially explain the prevalence of vascular dementia and Alzheimer disease in this population. Other factors as the anemia, phosphocalcic metabolism disorders facilitate the cognitive impairment. The present work reviews the links existing between chronic renal failure and cognitive impairment.

Although frail elderly people are particularly vulnerable to the adverse effects of alcohol, very little work on alcohol consumption patterns in older people living in nursing homes has been undertaken.To determine alcohol consumption patterns among the residents of 8 nursing homes of the Nord Pas-de-Calais in France, and the characteristics associated with heavy drinking (≥ 3 glasses of wine or equivalent/day).All residents were invited to participate in the study on condition that they satisfied the inclusion criteria (age ≥ 60 years, Mini Mental State of Folstein (MMSE)15, agreement) and the exclusion criteria (no oral communication, end of life). Two questionnaires were used, one for the residents and the other for the personnel nursing.Three hundred and sixty-eight residents [242 females (65.8%) and 126 males (34.2%); mean age, 80.5 ± 8.9 years] participated in the study. Among them, 98 (26.6%) reported no consumption of alcohol and 21 (5.7%) reported occasional consumption. The 249 (67.7%) others reported every-day consumption, principally in the restaurant at the time of the meals. Sixty-seven (18.2%), were heavy drinkers with an early-onset alcoholism for two out of three. Compared with the other residents participating in the study, the at-risk alcohol drinkers were younger and more likely to be a man.The study confirms that the prevalence of chronic at risk consumption is high in nursing homes. More efforts are needed to identify and improve management of alcohol disorders in this particular setting.

Renal failure in the elderly is currently underestimated and presents a real challenge for the public health system. Kidney function must be routinely assessed by creatinine clearance, estimated with either the Cockcroft and Gault formula or the simplified MDRD formula, which appears especially appropriate for the elderly. Normal kidney aging is related to tissue and functional changes that make older patients very vulnerable to environmental modifications. Numerous factors can accelerate the impairment of rental function during aging. Some of them cannot be modified: sex, genome, and initial kidney disease. Most of them can be managed or treated: hypertension, diabetes mellitus, obesity, smoking, dyslipidemia, proteinuria, and the presence of oxidation and glycation products. Chronic renal failure in the elderly must be managed early with strict treatment targets to avoid the development of end-stage renal disease. Inhibitors of the renin-angiotensin-aldosterone system play an essential role in optimizing nephroprotection: control of hypertension, diabetes complications, and proteinuria. They should be prescribed very carefully in older patients. Age is not a prerequisite for consultations with nephrologists, which should take place early so that nephroprotection can still be useful.

The development of the geriatrics portion of the third national health plan in the Nord-Pas de Calais presented an interesting opportunity to analyse the management of health care for an ageing population in one of France's youngest regions. This work served as a means to establish recommendations for the improvement of the organisation and planning of health care services for this particular population group in the region. In this article reporting on the study's outcomes, the authors present the results on the management of health care for elderly people in hospitals and other short term medical care facilities.

Dementia and cognitive impairment are known as a major risk for falls and subsequent adverse events in the elderly. In addition to result in serious injury, including fractures, falls lead to functional decline due to fear of falling again and self limitation of activity in older adults. All types of dementia and all degrees of severity are involved. Rather than resulting from a single cause, falls are the result of a combination of intrinsic, situational, and environmental factors. The most common risk factors for falls in patients with cognitive impairment and dementia are gait and balance disturbances, behavioral disorders, visual problems, malnutrition, adverse effects of drugs, fear of falling, neurocardiovascular instability (particularly orthostatic hypotension), and environmental hazards. Based on data from studies in cognitively normal people who fall, a multifaceted intervention, including a physical exercise programme and modification of the risk factors may prevent falls in older people with cognitive impairment and dementia. Preliminary research suggests that physiotherapy may have a role for falls prevention in these patients. However, randomized studies need to be performed.

Cisapride, a gastrointestinal prokinetic agent, has been associated with cases of Torsades de Pointes but its effects on the cardiac action potential have not been described. We investigated its electrophysiological effects on rabbit isolated Purkinje fibres. The results demonstrated that cisapride (0.01-10 microM) lengthened concentration-dependently the action potential duration without modifying other parameters and induced early after depolarizations and subsequent triggered activity. This typical class III antiarrhythmic effect, that showed "reverse" rate-dependence and was reduced by increasing external K concentration, can account for clinical arrhythmogenesis.

The present work examined the hypothesis that brain ischemic tolerance induced by ischemic preconditioning (IPC) is triggered by an initial oxidative stress and is associated with an increase in antioxidant enzyme activities as one end-effector of the neuroprotection. Wistar rats were preconditioned by a single 3-min occlusion of the middle cerebral artery. After a various duration of reperfusion (30 min, 24, 72 or 168 h), rats were subjected to a 60-min focal ischemia and sacrificed 24 h later. Cerebral infarcts were significantly reduced when performed during the 24- to 72-h time window after IPC. The pretreatment with the protein synthesis inhibitor, cycloheximide (1 mg/kg, i.p., 30 min prior to IPC), completely suppressed the neuroprotection. The free radical scavenger, dimethylthiourea (DMTU; 300 mg/kg, i.p., 30 min prior to IPC) and the antioxidant ebselen (10 mg/kg, oral cramming, 2 h before and 12 h after IPC) also abolished the IPC-induced protection of the brain. Nevertheless, IPC did not induce any delayed changes in antioxidant enzyme (superoxide dismutase, glutathion peroxidase) activities nor in the neuronal expression of Mn and Cu/Zn superoxide dismutase. These results indicate that an initial oxidative stress could be involved as a trigger of IPC, while antioxidant enzymes do not play a key role as end-effectors in such a neuroprotection.

We developed a prescribing guideline containing recommendations for the initial empirical antibiotic therapy in community or nosocomial pneumonia. The aim of the present study was to examine the impact of this measure.The prescribing guideline was implemented in May 1999. We retrospectively reviewed the charts of all patients65 years with community-, or nursing home- or hospital-acquired pneumonia hospitalised in our department of acute geriatric care between May 1999 and November 2000. The criteria assessed were: consistence with the guideline, clinical effectiveness within 72 hours, adequation with the isolated germs and intra-hospital mortality.Data were collected on 112 patients (63 women et 49 men; mean age=80 +/- 8 Years). The pneumonia was community-acquired in 52 cases (46%), nursing home acquired in 25 cases (22%) and hospital-acquired in 35 cases (31%). Antibiotic prescription was consistent with the guideline in 64 cases (57%). When the antibiotic therapy was consistent, the patients were more likely to improve within 72 hours (45/64 versus 23/48; p=0.01). Despite a tendency, the number of antimicrobial treatments adapted to the isolated microorganisms was not significantly higher in the consistent group (22/36 adapted treatments versus 10/20). The intra-hospital mortality (25%) was similar in the two groups consistent and not consistent with the guideline. SARM was the most frequent multiresistant bacteria that was isolated.The use of a prescribing guideline might improve the efficiency of empirical probabilistic antibiotic therapies. The impact of the guideline use on overall antibiotic costs and microbiological flora remains to be determined.

A FREQUENT BLOOD PRESSURE DISORDER: Falls and syncope are frequent accidents in the elderly and may be caused by a large variety of disorders. Over the past decade, postprandial hypotension (PPH), which is defined as a decrease in systolic blood pressure of 20 mmHg or more within two hours of ingestion of the meal, has been recognised as a common cause of syncope and falls in this population. It should therefore be searched for systematically in any assessment of syncope and falls. The PPH mechanism is not fully understood, but PPH is probably the consequence of an alteration in the compensatory mechanisms for meal-induced splanchnic blood pooling and the lowering of peripheral vascular resistance following ingestion of food. REGARDING TREATMENT: Treatment of PPH, which may be non pharmacologic and pharmacologic, is not well codified, because too few rigorous studies has been conducted on symptomatic patients.

Objectives. To evaluate spinal curvature changes over a 3-year period in postmenopausal women who had had an osteoporotic vertebral fracture within the last 3 months. Methods. Thoracic kyphosis and lumbar lordosis were measured using a curviscope at baseline and after 1, 3, 6, 12, and 36 months. Anteroposterior and lateral radiographs of the thoracolumbar spine were obtained after 1 and 3 years. Results. Sixty-one patients were included. At baseline, a significant increase in thoracic curvature was found in the subgroup with thoracic fractures as compared to the subgroups with thoracolumbar or lumbar fractures (64° ± 9°, 56° ± 10 , and 56° ± 13 , respectively; P

Although leuko-araiosis is a common finding on computed tomographic (CT) scans of the brain, its pathogenesis remains uncertain. To investigate the association between blood pressure (BP) disturbances and leuko-araiosis, we retrospectively reviewed CT scans and 24-hour ambulatory blood pressure monitorings of 79 elderly patients (57 women and 22 men; mean age: 83.3 ± 6.4 years). Of the 79 patients, 50 were demented (30 had Alzheimer’s disease and 18 vascular dementia) and 29 were not demented. The leuko-araiosis score (LA score) was determined by using Rezek’s scale. To evaluate short-term variation of BP, we determined (1) the variability of systolic and diastolic BPs (SBP, DBP; within-subject standard deviation of all readings over a 24-hour period), (2) the coefficient of variability (variability of BP/mean BP) and (3) the maximal variation of BP (difference between the maximum and minimum 24-hour BPs). Higher LA scores were associated with higher SBPs in 24-hour, diurnal and nocturnal periods, higher maximal variation of SBP, greater variability of SBP during 24-hour, diurnal and nocturnal periods and greater coefficient of variability of SBP during sleep. Our study suggests that elevations and short-term variations of SBP may contribute to the pathogenesis of white matter lesions in elderly persons.

BACKGROUND Postprandial hypotension (PPH) is increasingly recognized as a common cause of falls and syncope in elderly persons. Noninvasive ambulatory blood pressure monitoring (ABPM) has been recommended for detecting PPH. This study investigates postprandial blood pressure (BP) changes by means of ABPM in elderly patients experiencing falls or syncopes. METHODS Twenty-four-hour ABPM was performed in 156 inpatients (111 women, mean age 80.4 +/- 8.1 years). Among them, 45 had been admitted for falls and 75 for syncope; 36 with no history of falls or syncope served as controls. Postprandial change in systolic blood pressure (deltaSBP) was calculated by subtracting the mean SBP within the 2 hours following the meal from the mean SBP within the 2 hours preceding the meal. PPH was defined by a deltaSBP > or = 20 mm Hg. RESULTS For the entire group, mean SBP decreased after the three meals. On average, the decline in SBP was greater after breakfast than after lunch or dinner, and the number of patients experiencing PPH was greater after breakfast. Average maximal deltaSBP was significantly larger in the syncope group than in the other groups ( p < .05). Moreover, the number of patients experiencing PPH was significantly higher in the syncope/fall group than in the control group (23% vs 9%; p = .03). Compared with patients without PPH, patients with PPH were more likely to have a history of diabetes mellitus (p < .01) or to use more than three different drugs daily ( p = .04), and they showed greater daytime SBP variability (p < .0001). Furthermore, there was a strong positive correlation between preprandial SBP and deltaSBP after breakfast. CONCLUSIONS About one out of four elderly patients with falls or syncope experiences PPH, usually after breakfast. Postprandial decline in BP contributes to BP variability. deltaSBP and preprandial SBP are positively correlated.

The purposes of this study were to investigate the role of nitric oxide (NO), nitric oxide synthase (NOS), and 70 kDa heat shock protein in brain ischemic tolerance induced by ischemic preconditioning and lipopolysaccharide. Focal cerebral ischemia was induced in rats by intraluminal middle cerebral artery occlusion. Infarct volume was significantly reduced (1) in rats subjected to 3 min ischemia 72 h prior to 60 min ischemia; (2) in rats administered lipopolysaccharide (0.5 mg/kg; i.p.) 72 h prior to 60 min ischemia compared with controls. The beneficial effect of ischemic preconditioning was unchanged despite prior administration of nitro-L-arginine methyl ester (L-NAME), a NOS inhibitor. Conversely, the protective effect of lipopolysaccharide was nullified by L-NAME. Using immunohistochemical techniques, we observed that (1) ischemic preconditioning but not lipopolysaccharide induces the expression of 70 kDa heat shock protein in cerebral cortex and (2) lipopolysaccharide induces early increased expression of endothelial NOS in cerebral blood vessels. The results suggest that (1) endothelium-derived NO plays a role of a trigger in the brain tolerance induced by lipopolysaccharide, and (2) 70 kDa heat shock protein is involved in the protection afforded by ischemic preconditioning but not by lipopolysaccharide.

Delayed effect on vascular reactivity of isolated aorta was studied after injection of a single low dose of lipopolysaccharide (0.5 mg/kg i.p.). The maximal vascular effect was observed 72 h after lipopolysaccharide administration with an increase in maximal endothelium-dependent relaxing response to acetylcholine and parallelly a decrease in contractile response to phenylephrine. The change in contractile response was nullified by endothelium removal as well by in vitro aortic rings incubation with Nω-monomethyl- l -arginine but not with indomethacin. A low dose of lipopolysaccharide induces a delayed enhanced nitric oxide-mediated vascular relaxation which could contribute to its delayed anti-ischemic properties in ischemic tolerance phenomenon.

Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly Intergroupe PneumoGeriatrie SPLF-SFGG place sous l’egide de la Societe de Pneumologie de Langue Francaise (SPLF) et de la Societe Francaise de Geriatrie et Gerontologie (SFGG) : F. Puisieux, C d’Andrea, P. Baconnier, D. Bui-Dinh, S. Castaings-Pelet, B. Crestani, B. Desrues, C. Ferron, A. Franco, J. Gaillat, H. Guenard, B. Housset, C. Jeandel, G. Jebrak, A. Leymarie-Selles, E. Orvoen-Frija, F. Piette, G. Pinganaud, J.-Y. Salle, D. Strubel, J.-M. Vernejoux, B. de Wazieres, S. Weil-Engerer Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient’s oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).

STUDY DESIGN A prospective cross-sectional case-control study. OBJECTIVES To compare spinal curvatures in women with osteoporosis and control subjects with a new instrument, the curviscope. SUMMARY OF BACKGROUND DATA Few instruments are available for measuring spinal curvatures in the sagittal plane. Most of them have poor reproducibility, and they have been poorly investigated in osteoporosis. METHODS Ninety-eight postmenopausal women were evaluated. They were divided into two groups, according to their bone status: women with osteoporosis with at least one vertebral fracture (n = 51) and control subjects (n = 47). Women with osteoporosis were divided into two subgroups, according to the delay since the last vertebral fracture had occurred (i.e., more or less than 3 months). Quality of life was assessed by using a generic instrument, the Nottingham Health Profile, in patients with osteoporosis only. RESULTS Reproducibility of the curviscope was satisfactory. For kyphosis measurements, the coefficients of variation were 2.8% and 2.4% in control subjects and women with osteoporosis, respectively. Kyphosis values were significantly higher in women with osteoporosis than in age-matched control subjects (63 degrees +/- 13 degrees vs. 52 degrees +/- 11 degrees, respectively; P < 0.005). Nottingham Health Profile scores were significantly different (P < 0.05) in women with osteoporosis with a recently diagnosed vertebral fracture, compared with other women with osteoporosis in two aspects, physical mobility and energy. Kyphosis measurements were significantly correlated with age in the whole group (r = 0.26; P < 0.05). In the Nottingham Health Profile, physical mobility was significantly correlated with kyphosis (r = 0.35; P < 0.05). CONCLUSIONS The curviscope is a reliable tool, particularly useful in the assessment of osteoporosis. Moreover, kyphosis angles measured with the curviscope are markedly increased in women with osteoporosis, compared with control subjects. Finally, an increase of kyphosis angles is associated with decreased physical mobility.

Context: optimising care pathways for the elderly is a major challenge in view of the ageing population. The acute geriatric unit (AGU) is a "pivotal" hospital care unit in the care pathway of the elderly.Objectives: to identify the risk factors for transfer to follow-up care and rehabilitation upon admission to the AGU, to describe the association between end-of-life trajectories and transition to exclusive comfort care for patients who die in the AGU, to develop and validate a prognostic score for individual and collective risk of mortality in the medium and long term (3 and 12 months respectively) after discharge from the AGU.Method: we conducted a series of analyses on data from the DAMAGE cohort. The DAMAGE cohort is a prospective multicentre study that consecutively included 3509 subjects aged 75 years or more hospitalised in the AGU. These patients underwent a broad comprehensive geriatric assessment during their stay and a description of their care pathway was collected.Results: 1928 patients were included for the search of risk factors for transfer to post-acute hospital care facility. Significant loss of functional independence, high ADL score at home, low ADL score at admission, living alone, social isolation and delirium were risk factors for transfer to post-acute hospital care facility. Obesity, high serum albumin and community infection were associated with return home.123 (69.5%) decedents received comfort care only. The frailty-related end-of-life trajectory (with or without dementia) accounted for almost 70% of deaths. Frailty in the absence of established dementia was not associated with a more frequent transition to comfort care only (odds ratio [95% CI]: 1.44 [0.44- 4.76]).3112 frail or dependent elderly patients with a high proportion of deaths at 3 months (n=455, 14.8%) and 12 months (n=1014, 33%) were included for the mortality score. The score predicted an individual risk of mortality of between 1% and 80% at 3 months and between 5% and 93% at 12 months, with a C-statistic in the validation cohort of 0.728 at 3 months and 0.733 at 12 months.Conclusion: This series of analyses allows us to better describe and identify certain risk factors useful for optimising and planning the care pathway of elderly patients in the UGA and beyond their stay in the UGA., Contexte : l'optimisation des parcours de soins des personnes âgées est un défi majeur au vu du vieillissement de la population. L'unité de gériatrie aiguë (UGA) est une unité de soins hospitaliers « pivot » dans le parcours de soins des personnes âgées.Objectifs : identifier les facteurs de risque (FDR) de transfert en soins de suite et réadaptation (SSR) dès l'admission en UGA, décrire l'association entre trajectoires de fin de vie et transition en soins de confort exclusifs pour les patients décédés en UGA, développer et valider un score pronostique du risque individuel et du risque collectif de mortalité à moyen et long terme (respectivement 3 et 12 mois) après la sortie de l'UGA.Méthode: nous avons conduit une série d'analyses sur les données de la cohorte DAMAGE. La cohorte DAMAGE est une étude prospective multicentrique qui a inclus consécutivement 3509 sujets âgés de 75 ans ou plus hospitalisés en UGA. Ces patients ont bénéficié d'une large évaluation gériatrique standardisée au cours de leur séjour et la description de leur parcours de soins a été recueillie.Résultats : 1928 patients ont été inclus pour la recherche de FDR de transfert en SSR. Une perte d'indépendance fonctionnelle importante, un score ADL élevée à domicile, un score ADL bas à l'admission, vivre seul, d'être isolé socialement et le syndrome confusionnel étaient des FDR de transfert vers le SSR. L'obésité, un taux sérique d'albumine élevé et une infection communautaire étaient associés au retour au domicile. 123 (69,5%) décédés ont bénéficié de soins de confort exclusifs. La trajectoire de fin de vie liée à la fragilité (avec ou sans troubles neurocognitifs majeurs (TNCM)) représentait près de 70% des décès. La fragilité en l'absence de TNCM établis n'était pas associée à une transition plus fréquente vers les soins de confort exclusifs (odds ratio [IC 95%] : 1,44 [0,44- 4,76]). 3112 patients âgés et fragiles ou dépendants, avec une forte proportion de décès à 3 mois (n=455, 14,8%) et à 12 mois (n=1014, 33%) ont été inclus pour la réalisation du score de mortalité. Le score prédit un risque individuel de mortalité compris entre 1% et 80% à 3 mois et entre 5% et 93% à 12 mois, avec une statistique C dans la cohorte de validation de 0,728 à 3 mois et 0,733 à 12 mois.Conclusion : cette série d'analyses permet de mieux décrire et identifier certains FDR utiles pour l'optimisation et la planification du parcours de soins des patients âgés en UGA et au-delà de leur séjour en UGA.

Introduction : avec le vieillissement de la population, le nombre de conducteurs âgés augmente. Les pathologies liées à l’âge peuvent compromettre l’aptitude à la conduite automobile. Les médecins confrontés à ces pathologies connaissent des difficultés à évaluer l’aptitude à la conduite automobile. L’objectif principal de cette étude était de déterminer les facteurs associés à l’arrêt de la conduite automobile en HDJ mémoire.Matériels et Méthodes : les données des patients consultant en hôpital de jour mémoire d’un centre universitaire ont été analysées rétrospectivement. Les patients inclus étaient âgés de plus de 65 ans, conducteurs actifs ou ayant arrêtés récemment de conduire (moinsde 5 ans).Résultats : le groupe des conducteurs actifs était composé de 82 patients et le groupe arrêt de la conduite récente était composé de 45 patients. L’âge, les troubles cognitifs, les troubles de la marche, les pathologies articulaires, l’impossibilité de réaliser la station unipodale, un score IADL diminué et la non pratique d’activités de loisirs étaient retrouvés comme facteurs associés à l’arrêt de la conduite automobile.Conclusion : l'évaluation de l’aptitude à la conduite automobile chez les seniors doit prendre en compte non seulement les pathologies cognitives mais aussi les pathologies motrices et sensorielles. Les conséquences de l’arrêt de la conduite automobile sur la qualité de vie doivent aussi être considérées lors de cette évaluation. En France, il n’existe pas d’évaluation obligatoire systématique de la pratique de la conduite automobile chez lapersonne âgée ; la question reste posée d’une évaluation pluridisciplinaire de l’aptitude à la conduite automobile des seniors sans pour autant stigmatiser la personne âgée.

Age-associated or diabetes arterial changes such as endothelial dysfunction are involved in the significantly increased risk of cardiovascular complications. The presence of endothelial dysfunction in the coronary or peripheral circulation has been shown to constitute a risk factor for cardiovascular events independent of the development of atherosclerosis or other vascular risk factors. Therapeutic approaches capable of preventing or reversing age-related endothelial dysfunction may thus help to reduce cardiovascular risk. The aim of the study was to determine the effects of two treatments, one on age-related endothelial dysfunction, the other on diabetes endothelial dysfunction. For primary and secondary prevention, aspirin can reduce the incidence of cardiovascular events. The first part of the present work evaluated the effect of low-dose aspirin on age-related endothelial dysfunction in C57B/J6 aging mice. Age-related endothelial dysfunction was assessed by the response to acetylcholine (ACh) of phenylephrine (Phe)-induced precontracted aortic segments isolated from 12-, 36-, 60- and 84-week-old mice. The effect of low-dose aspirin was examined in mice presenting a decrease in endothelial-dependent relaxation. The effects of age and aspirin treatment on structural changes were determined in mouse aortic sections. The effect of aspirin on the oxidative stress markers malondialdehyde (MDA) and 8-hydroxy-2'-deoxyguanosine (8-OhdG) was in addition quantified. Compared to that of 12-week-old mice, the EDR was significantly reduced in 60- and 84-week-old mice (p, Les modifications artérielles liés au vieillissement ou au diabète telles que la dysfonction endothéliale contribuent à augmenter le risque de survenue d'événements cardiovasculaires. La dysfonction endothéliale, coronaire ou périphérique, est reconnue comme un facteur indépendant de survenue d'évènements cardiovasculaires indépendamment de la présence d'athérosclérose ou de facteur de risque d'athérosclérose. Des approches thérapeutiques capables de prévenir ou de restaurer la dysfonction endothéliale pourrait aider à réduire le risque de survenue d'accidents cardiovasculaires. Ce travail a pour but d'évaluer les effets de deux molécules, l'une sur la dysfonction endothéliale liée à l'âge, l'autre sur la dysfonction liée au diabète. En prévention primaire et secondaire, l'aspirine à faible dose réduit l'incidence des évènements cardiovasculaires. La première partie de ce travail étudie les effets de l'aspirine à faible dose sur la dysfonction endothéliale chez des souris C57B/J6. La dysfonction endothéliale liée à l'âge est établie par la réponse à l'acétylcholine (ACh) de segments aortiques précontractés par phenylephrine (Phe) et isolés de souris âgées de 12-, 36-, 60- et 84 semaines. Les effets de l'aspirine à faible dose sont étudiés chez des souris présentant une altération de la relaxation endothélium-dépendante. Les effets de l'âge et du traitement par aspirine sur la structure de la paroi ont été déterminés sur des coupes aortiques de souris. Les effets de l'aspirine sur des marqueurs du stress oxydants, le malondialdehyde (MDA) et l'8-hydroxy-2'-deoxyguanosine (8-OhdG) ont été étudiés. Comparée à celle des souris âgées de 12 semaines, la relaxation endothelium-dépendante était significativement réduite chez les souris âgées de 60- et 84-semaines (p