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Type 2 diabetes, whose prevalence has increased among elderly aged over 75 years, has a number of specific features which differ from that in young people: heterogeneous population, association with other cardiovascular risk factors and several comorbidities, different therapeutic constraints and risks, and lower life expectancy. By using a standardized geriatric assessment it is possible to determine therapeutic and glycemic goals for each patient. In the elderly, main complications of diabetes are hypoglycemia and foot lesions. In order to avoid malnutrition, lifestyle and dietary rules should not be too strict. Recommendations for the prescription of oral antidiabetic agents are the same for both elderly and young subjects, but with increased monitoring in the elderly because of the high risk of complications including iatrogenic hypoglycemia. Insulin therapy should be preferred., (Copyright © 2012 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Introduction: Cytomegalovirus ileitis occurs rarely in immunocompetent subjects., Case Report: An 88-year-old woman presented with severe pain located in right iliac fossa. Biological tests showed an increase in C-reactive protein and neutrophils. Colonoscopy revealed a severely ulcerated and inflamed terminal ileal mucosa. Histopathological analysis of biopsies showed a typical cytopathic effect with ballooned cells and intranuclear inclusions, confirmed by positive immunological marking with anti-cytomegalovirus antibodies. Cytomegalovirus polymerase chain reaction in the plasma showed positive activity. The patient was successfully treated with valganciclovir., Conclusion: The predominant or isolated ileal location of cytomegalovirus infection should be known, especially in the elderly because aging could be a risk factor., (Copyright © 2012 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Only few studies have investigated the use of HA in elderly subjects and there are no data in very elderly subjects. We assessed the prescription of HA and analyzed the relationship between such prescriptions and frailty markers among persons aged 80 and more in an observational study. We recorded the prescriptions for 13,211 patients aged 80-109 years and affiliated to the "Mutualité-Sociale-Agricole (MSA)" of Burgundy over a 1-month period. The prescription of a HA among all included patients, and the existence of serious long-term disease(s) (LTD), polypharmacy or a prescription of cardiovascular drugs among patients receiving a HA were recorder. Among the 13,211 patients, 3412 aged 80-98 years were treated with an HA. The main HA were statins (70.4%), and fibrates were used in 27.3% of cases. Of these 3412 patients, 2250 had one or several LTD mainly coronaropathy, hypertension, diabetes mellitus or peripheral artery disease. The mean number of drugs per prescription was 6.37. Among subjects treated with HA, 40% also received antiplatelets, 35.6% β-blockers and 30% inhibitors of the renin-angiotensin system. For 99% of the patients, the prescription of HA was a renewal. Prescribers were mainly general practitioners (96.8%). Statins are the most widely prescribed HA even among very elderly subjects. However, after 80 years the prescription of HA, mainly statins, decreases with aging. This could be explained by polypathology, polypharmacy and the deterioration in metabolic functions which are markers of frailty. This study should encourage research into the use of statins in very elderly subjects., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives: Studies have shown the importance of vascular risk factors in the pathogenesis and evolution of cognitive disorders and dementia especially among the very elderly. The aim of the present longitudinal 1-year cohort analysis was to evaluate the influence of arterial stiffness on cognitive decline in institutionalized subjects older than 80 years., Design: Longitudinal study., Setting: Nursing homes in France and Italy., Participants: A total of 873 subjects (79% women), aged 87 ± 5 years were included in this longitudinal analysis from the PARTAGE cohort., Measurements: All completed the Mini-Mental Status Examination (MMSE) on the 2 visits over 1 year and underwent a measurement of carotid-femoral pulse wave velocity (PWV), an indicator of aortic stiffness. Clinical and 3-day self-measurements of blood pressure (BP) and activities of daily living (ADL) were evaluated at baseline visit., Results: According to PWV tertiles and after adjustment for baseline MMSE, mean BP (MBP), age, education level, and ADL, Δ MMSE was -1.42 ± 3.60 in the first tertile, -1.78 ± 4.08 in the second tertile, and -2.20 ± 3.98 in the third tertile (P < .03). Similar analyses with self-measured MBP failed to show any association between BP on MMSE decline., Conclusion: This 1-year longitudinal study in institutionalized patients older than 80 years shows that the higher the aortic stiffness, the more pronounced the decline in cognitive function. These results point out the interest of measuring PWV, a simple noninvasive and validated method for arterial stiffness assessment, to detect high-risk patients for cognitive decline., (Copyright © 2012 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Achromobacter xylosoxidans (AX) is a non-fermentative aerobic gram-negative bacillus. It is an opportunistic pathogen and the causative agent of various infections. We report an original case of late posttraumatic meningitis due to AX denitrificans., Case Report: An 83-year-old man was hospitalized for acute headache, nausea and vomiting. The emergency brain computer tomography (CT) scan did not reveal any anomaly. In his medical history, there was an auditory injury due to a cranial trauma incurred in a skiing accident 60 years earlier. Cytobiochemical analysis of the cerebrospinal fluid (CSF) revealed increased levels of neutrophils and proteins. The CSF bacterial culture was positive: the Gram stain showed a gram-negative bacillus, oxidase + and catalase +, and the biochemical pattern using the API 20 NE strip revealed AX dentrificans. Late posttraumatic meningitis on a possible osteomeningeal breach was diagnosed even though the breach was not confirmed because the patient declined a second brain CT scan. The patient was successfully treated with meropenem., Conclusions: This report demonstrates the importance of searching for unusual or atypical organisms when the clinician encounters meningitis in a particular context, as well as the importance of adequate follow-up of craniofacial traumas.

We investigated the effect of aging on the ability to mentally simulate/plan a complex sequential action of the whole body, namely "rising from the floor". Forty-four non-demented elderly people (mean age: 85.2±5.5 years) and 20 young people (mean age: 26.6±4.9 years) were included in the study. They were required to put in order six images representing the main movements necessary to get up from a sitting position on the floor. We showed that older subjects had poorer performance-both in terms of proportion of success and response time-than their younger counterparts. These results are in line with previous findings showing age-related alterations in action simulation/action planning processes, and highlight the fact that elderly people have particular difficulties when the action to mentally simulate is complex., (Copyright © 2009 Elsevier Ireland Ltd. All rights reserved.)

PDS is a geriatric affliction, described in 1999, characterized by postural impairments, including backward disequilibrium, freezing, a deterioration in the ability to anticipate postural adjustments, anxiety and fear of falling, inducing loss of autonomy. This study compared 10 subjects suffering from PDS, aged 87.3+/-4.9 years, with 10 control subjects, aged 85.4+/-7.9 years concerning postural control (body sway amplitude). In all participants, postural control was assessed using the SwayStar system in natural (spontaneous) and standardized stances, eyes open and eyes closed over a period of 40 s. It was found that: (1) with eyes open, subjects with PDS showed greater body sway amplitude than did controls whatever the position (natural or standardized) and the plane (sagittal or frontal) considered (F(1,16)=6.05; p=0.026), (2) with eyes closed, subjects with PDS showed greater body sway amplitude than did controls in the natural stance whatever the plane (F(1,18)=7.65; p=0.013). In conclusion, PDS has a negative effect on postural control. This data must be taken into account during the rehabilitation of patients with this syndrome., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Background: For several years, the burden of stroke in very old patients has been increasing in western countries. Nevertheless, we have little information about this new challenge in individuals >or=80., Methods: We ascertained all first-ever strokes in the population of Dijon, France (150,000 inhabitants), from 1985 to 2006. The incidence of stroke, risk factors, clinical presentation, resource mobilization and 1-month outcome were evaluated in individuals >or=80 and compared to the data obtained in younger patients., Results: We collected 1,410 first-ever strokes in people >or=80 years (39%) versus 2,130 in those <80 years. The incidence was 997/100,000, and 68/100,000, respectively. Over the 22 years, the incidence of stroke in individuals >or=80 years rose significantly. A lower prevalence of diabetes, hypercholesterolemia and alcohol intake, as well as a higher prevalence of hypertension, atrial fibrillation, previous myocardial infarction and use of prestroke antiplatelet agents were noted in patients >or=80 years. The clinical presentation was severer and the 1-month outcome in terms of case fatality and handicap was worse, despite improvements observed over time. Finally, in patients >or=80 years, the use of CT scan, MRI, cervical Doppler, angiography and carotid surgery were significantly lower than for younger patients. Length of stay >30 days was more frequent, and discharge to prestroke residence was less common. However, all these improved between the first and the last study periods., Conclusions: Our findings have important implications not only for clinical management but also for initiating preventive strategies and health policy., ((c) 2009 S. Karger AG, Basel.)

Objective: The aim of the longitudinal study PARTAGE (predictive values of blood pressure and arterial stiffness in institutionalized very aged population) was to determine the predictive value of blood pressure (BP) and arterial stiffness for overall mortality, major cardiovascular events and cognitive decline in a large population of institutionalized patients aged 80 and over. In the study herein, we present the baseline data values of this study., Methods: A total of 1130 patients were recruited (878 women), living in French and Italian nursing homes. Clinical and 3-day self-measurements of BP were conducted. Aortic and upper limb pulse wave velocity were obtained using a PulsePen tonometer., Results: Of this population, 76% of women and 60% of men had a known hypertension and over 91% of the patients were under antihypertensive treatment; 51% of the treated hypertensive patients were well controlled (systolic BP <140 mmHg). No significant differences were found between clinical and self-measured BP. With age, there was an increase in pulse pressure (P < 0.001) due to a decrease in diastolic BP (P < 0.001), without any increase in systolic BP. Aortic but not peripheral pulse wave velocity significantly increased with age (P < 0.005)., Conclusion: Baseline values obtained herein demonstrate that elderly patients living in nursing homes present hemodynamic characteristics which are different to those described in community-living elderly populations, and indicate the interest of assessing, in longitudinal studies, the role of BP and arterial stiffness in morbidity and mortality in this population.

Rheumatoid arthritis (RA) may include rare extra-articular manifestations, and particularly cardiopulmonary involvement. We report a 83-year-old woman, with RA, who presented with both pulmonary and heart failures that were related to the RA, resulting from the presence of mediastinal and axillary lymph nodes, and pleural and pericardial effusions. This was confirmed by the dramatic improvement after a specific treatment of RA.

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.

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.

Objectives: The aim of this paper was to describe gait disorders and their consequences in primary dementias, and to prove the positive impact of their prevention and rehabilitation., Method: The most relevant articles on gait and dementias available on Medline were analyzed., Results: The prevalence of gait and balance disorders is between 9 and 52% in Alzheimer-type dementia in which frontal gait and apraxic gait are described. Gait disorders, appearing with a prevalence of over 71% in vascular dementia, seem to be an early indicator of this dementia in which hemiparetic gait, frontal gait and unsteady gait are commonly described. As clinical practice shows, gait disorders appear to be frequent in dementia with Lewy bodies and Parkinson's dementia, both being characterized by Parkinsonian gait; however, there are very few prevalence studies concerning gait disturbances in these two dementias. The balance and gait assessment in demented subjects is based on the analysis of sit-to-stand/back-to-sit and one-leg balance, the measurement of gait speed, the Timed-Up-and-Go and the dual task tests. Although there are few studies on the topic, the benefit of the motor rehabilitation on functional independency in demented subjects is now recognized. The programs used for motor rehabilitation of demented people must be individual with targeted objectives, and associate strength and balance exercises, attentional tasks, immediate and working memories and praxis, in the context of multidisciplinary intervention. However, there is no consensus on a standard rehabilitation program of demented subjects., Conclusion: Future studies have to analyse gait disorders in demented subjects in order to clarify their pathophysiology. Besides, they may confirm the benefit of rehabilitation and suggest consensual programs.

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.

In addition to the usual adverse effects, the chronic use of the valproic acid can entail dementia syndrome. We describe the case of a 68-year-old woman who had presented a dementia syndrome due to the use of valproic acid for one year. This drug was prescribed in order to prevent a potential convulsive crisis after an ischemic stroke in a patient who did not have a history of epilepsy. This case shows that each clinician must be careful about all medications consumed by the patient in the face of cognitive disorders.

We assessed the role of clinical and biological parameters on performance in four balance tests in elderly subjects. An observational study was conducted in the Center for Preventive Medicine of Nancy (France) in 2368 community-living elderly subjects aged 60 and older. Body mass index (BMI), Mini-Mental State Examination (MMSE), clock test, "Health score" and use of psychotropic drugs (UPD) were assessed. Participants performed four balance tests: "one-leg-stand" (OLS), "timed-up-and-go" (TUG), "rise-from-the-floor" (RFF) and "sit-to-stand" (STS). The statistical analysis showed that women were almost twice as likely to fail balance tests as men. In both women and men, the following determinant factors of the performance in balance tests were found: for OLS: age, BMI and health score; for TUG: age, BMI, clock test and health score; for RFF: BMI and health score. In addition, in women other determinant factors were: MMSE for OLS, UPD for TUG, age and clock test for RFF. In men, the clock test and the UPD were also significant determinant factors for OLS. Similar results were found for STS. In conclusion, female sex, overweight, low cognitive status, low self-perception of health and UPD were associated with a higher risk of failure in balance tests.

Background: Balance and gait are essential to maintain physical autonomy, particularly in elderly people. Thus the detection of risk factors of balance and gait impairment appears necessary in order to prevent falls and dependency. The objective of this study was to analyze the impact of demographic, social, clinical, psychological, and biological parameters on the decline in balance and gait assessed by the Tinetti test (TT) after a two-year follow-up., Material/methods: This prospective study was conducted among community-living, young elderly volunteers in the centre "Investigations Preventives et Cliniques" and "Observatoire De l'Age" (Paris, France). Three hundred and forty-four participants aged 63.5 on average were enrolled and performed the TT twice, once at inclusion and again two years later. After the two-year follow-up, two groups were constituted according to whether or not there was a decrease in the TT score: the "TT no-deterioration" group comprised subjects with a decrease of less than two points and the "TT deterioration" group comprised those with a decrease of two points or more. Selected demographic, social, clinical, psychological, and biological parameters for the two groups were then compared., Results: Statistical analysis showed that female sex, advanced age, high body mass index, osteoarticular pain, and a high level of anxiety all have a negative impact on TT score., Conclusions: Knowledge of predictive factors of the onset or worsening of balance and gait disorders could allow clinicians to detect young elderly people who should benefit from a specific prevention program.

Backward disequilibrium is observed frequently in daily clinical practice. However, there are no epidemiological data concerning this postural disorder. Defined by a posterior position of the centre of mass with respect to the base of support, backward disequilibrium is abnormal postural behavior, usually characterized by a posterior trunk tilt in standing and sitting positions, which predisposes subjects to backward falls. Many afflictions whether they are somatic (degenerative, ischemic and traumatic brain lesions), psychosomatic (psychomotor disadaptation syndrome, confinement to bed, nonuse situations) or psychological (depression) can cause backward disequilibrium. A vicious circle of falls, and loss of autonomy can arise and this is the main consequence of backward disequilibrium. Thus, in this paper, we review backward disequilibrium in elderly subjects with regard to the causes, consequences, assessment, and management.

Objective: Deep-vein thrombosis is common but not easy to diagnose. It is generally considered that the diagnosis can be ruled out in subjects with a D-Dimer level lower than a reference threshold value. We report a case where this hypothesis was misleading., Method: An 89-year-old man was hospitalized for a pain in his left lower leg, which had been persistent for 5 days., Results: The venous duplex ultrasound found two recent deep-vein thrombi in this leg while the D-Dimer level was lower than 220 UI/ml at admission., Conclusion: This case illustrates the importance of prudent interpretation of the serum D-Dimer level.

Purpose: Although there is currently no epidemiological data on backward disequilibrium, this disturbance of posture does not seem to be rare in frail elderly., Actualities and Strong Points: Backward disequilibrium is characterized by the following criteria: the location of buttocks on the anterior side of the seat while the trunk rested at the back of the armchair in the sitting position; an inadequate forward of the trunk and a backward projection of the trunk outside the base of support during sit-to-stand; and a posterior projection of the center of mass outside the base of support in the standing position. Several pathological situations either somatic (degenerative, ischemic and traumatic brain lesions), psycho-somatic (psychomotor disadaptation syndrome, extended bed confining, non-use) or psychological (depression) affections can entail backward disequilibrium. Falls, loss of autonomy and the risk of the vicious circle with its causes are the main consequences of backward disequilibrium., Prospects and Projects: Although the geriatrician is familiarized with backward disequilibrium, there is no scale to quantify it. In this paper we review causes, consequences and management of backward disequilibrium, and in order to assess it, we propose a semi-quantitative scale, based on some activities of everyday living which are sitting position, sit-to-stand, back-to-sit and standing position. So, a backward disequilibrium score could be determined.

Objective: We hypothesised that backward disequilibrium (BD), defined by a posterior position of the centre of mass with respect to the base of support, could be caused by a backward tilt in the perception of verticality., Methods: The relationship between BD, the perception of verticality, and the history of falls in 25 subjects aged 84.5+/-7.4 years was analysed. An original ordinal scale, the BD scale (BDS), was used to quantify BD. Postural (PV) and haptic verticals (HV) were measured in sagittal plane., Results: BDS scores closely correlated with the number of falls (r = 0.81, p =10(-5)). The more the PV was tilted backward, the greater the BDS scores (r = -0.95, p<10(-6)), with a huge backward tilt of about 15 degrees in 4 subjects with severe BD. In these subjects, the tilt in perception of verticality was transmodal since a severe backward HV tilt was also found., Conclusions: This transmodality suggested high-order cognitive disruption in the construction of the subjective vertical used in postural control by subjects showing BD, which confirmed our hypothesis., Significance: This study clearly shows that perception and action with respect to gravity are closely related and brings a new insight about fall mechanisms in the elderly.

Purpose: We describe the psychomotor disadaptation syndrome and report the last findings on its physiopathology and therapeutic. This syndrome was first described by Pr Gaudet's team in 1986 and named "psychomotor regression syndrome". This name has been recently changed into "psychomotor disadaptation syndrome"., Actualities and Strong Points: The psychomotor disadaptation syndrome is a decompensation of postural function, gait and psychomotor automatisms due to the alteration of the posture and motor programming. That alteration is linked to subcortical-frontal lesions. Clinically, the psychomotor disadaptation syndrome is characterized by postural impairments (retro-propulsion or backward disequilibrium), non-specific gait disorders, neurological signs (akinesia, reactional hypertonia, alteration of both reactive postural responses and protective reactions) and psychological troubles. Psychological troubles include fear of standing and gait in its acute feature or slowness of cognitive processing and anhedonia in its chronic feature. The psychomotor disadaptation syndrome occurs as a failure to compensate for the effects of the following three factors which entail the reduction of motor functional reserves because of their impact on frontal subcortex: 1) aging, 2) chronic illness named predisposing factors (degenerative or vascular disorders) and both 3) functional and organic acute factors. The latter factors cause a reduction of cerebral blood perfusion. The psychomotor disadaptation syndrome requires multidisciplinary management including medical, physiotherapeutic and psychological approaches., Prospects and Projects: In the next years we have to determine the frequency of psychomotor disadaptation syndrome and its physiopathology needs to be further explored.

We determined whether management including medical, psychological, and physiotherapeutic approaches, over a period of 6 weeks, has a beneficial effect on motor abilities, psychological status, and independence of elderly fallers with psychomotor disadaptation syndrome (PDS). We included 28 subjects (mean age 81.4 years). They were assessed from a medical, motor, and psychological point of view at both the inclusion and the end of the multidisciplinary intervention. A follow-up was conducted with multidisciplinary assessment at 6 and 9 months after the beginning of the study in order to evaluate duration of benefits of the management. The statistical analysis concerned only subjects who took part in the total multidisciplinary program, i.e., 14 subjects. The multidisciplinary intervention had an overall positive impact on motor abilities as shown by the increase in the mini-motor test scores, the rate of success in rising from the floor and decrease of time for the dual task. This study also showed a reduction in the fear of falling and a decrease in the rate of fallers. This positive effect on motor abilities, fear of falling and rate of fallers was sustained until 9 months after the beginning of the multidisciplinary management. This study shows the importance of a multidisciplinary management of elderly fallers with PDS.

The aims of this study were to analyze the effects of cognitive task on static posture in Alzheimer's disease (AD) and in healthy elderly (HE) subjects and to evaluate whether those effects were greater in AD subjects than in HE subjects. We performed a posturographic analysis on 13 subjects with mild AD (mean age, 79.7+/-5.1 years, Mini-Mental State Examination scores between 18 and 23) and on 17 HE subjects (mean age, 78.5+/-4.4 years). After watching a video sequence, the subjects were asked to maintain a stable upright posture while standing on a force platform. Then, the postural sway was measured during the following two conditions: (1) quiet standing and (2) both standing and answering questions about the video sequence. We were interested in the center of pressure (CoP) area and path. For each group, the single task was compared to the dual task for the CoP area and path. We also compared the variability of both CoP area (variation of the CoP area between the single and the dual task) and path (variation of the CoP path between the single and the dual task) between the two groups. We showed that there was no significant difference between the single and the dual task in HE subjects concerning the CoP area and path, in contrast to the AD group, and that variability of both the CoP area and path were significantly greater in the AD subjects than in the HE subjects. This finding may contribute to the risk of falls in AD patients., (Copyright (c) 2005 Movement Disorder Society.)

We studied the kinematics of shoulder displacement during sit-to-stand and back-to-sit in 6 healthy elderly subjects and six elderly subjects with mild to moderate Alzheimer's disease in order to elucidate the impact of Alzheimer's disease on motor planning and control processes. During sit-to-stand, Alzheimer's disease subjects reduced their forward displacement and started their upward displacement earlier than healthy elderly subjects. Furthermore, shoulder path curvatures were more pronounced for upward compared with downward displacement in healthy elderly group, in contrast with Alzheimer's disease group. Temporal analysis found that: 1) for both groups, profiles of velocity of sit-to-stand and back-to-sit showed two peaks corresponding respectively to forward/upward and to downward/backward displacements, 2) peaks of velocity were almost comparable between the two groups, 3) duration of sit-to-stand was shorter than duration of back-to-sit in the two groups and 4) duration of sit-to-stand and back-to-sit was shorter in Alzheimer's disease group than in healthy elderly group. However, dissimilarities were observed for transition and deceleration phases during sit-to-stand, and for acceleration and transition phases during back-to-sit, between the two groups. Interestingly, while sit-to-stand and back-to-sit differed in healthy elderly subjects during transition and deceleration phases, such a difference was not observed for Alzheimer's disease subjects. So, our study showed that invariant spatio-temporal movement parameters in the two groups differed, while non-invariant parameters did not, and suggests that higher level motor process of whole body motions are affected by Alzheimer's disease, while lower level motor features remain intact.

Introduction: Owing to the very great age and the polypathology of the patients in geriatrics, we are often confronted to the palliative care decision., Purpose: The purposes of this retrospective study were both to define the criteria leading to palliative care and to analyse the evolution of patients., Method: We analysed 40 files of patients hospitalised in Geriatric internal medicine or Geriatric rehabilitation departments over 11 months., Results: Mean age was 85.4 years and 62.5% of patients were females. Infections, heart failure, general weakness, orthopaedic affections, strokes and cancers were the main causes of hospitalisation. Patients had 3 medical or surgical histories of chronic or cured serious diseases and a MMSE average value of 17.7. The rate of malnutrition was 92% and 90% of patients were very dependent. Severe infections, cancers, heart failure and severe pressure ulcers were the main affections for decision of palliative care. The latter was always decided by the staff with patients or families taking part in 8 cases and being informed in other cases. The palliative care lasted 7 days on average. Morphine was used in 31 cases. No artificial nutrition was introduced., Conclusion: The decision of palliative care is very complex since great age, polypathology, great dependence and high prevalence of cognitive disorders are frequent in this population.

Objective: To analyse the clinical usefulness and metrological properties of the main techniques and indices used to assess balance disorders., Methods: More than 4000 abstracts referenced in MEDLINE and dealing with postural control and postural disorders (wide screening) were reviewed to determine the main postural techniques and indices used in a clinical context. We retained abstracts with a high citation frequency and those with interesting findings. Corresponding key words were identified for a specific search of articles that we analysed., Results: Postural assessment tools can be classified as scales of ordinal items, tests based on metric or chronometric measurement, posturography, and verticality perception. These techniques are complementary, and their association is recommended in a clinical context. Regarding generic tools, the Falls-related Efficacy Scale (FES) and the Activities-specific Balance Confidence scale (ABC scale) would be enhanced if comparatively analysed and reworked to allow for a feasible and reliable assessment of the fear of falling. Despite a wide diffusion in numerous postural fields worldwide, the Berg Balance Scale (BBS) and the Functional Reach Test (FRT) do not have the required criteria to remain the gold standards they were in the 1990s. Static posturography should be normalised and yield more reliable indices. The clinical relevance of the subjective assessment of visual, haptic, and postural verticals are questionable, especially to explain postural disability. Regarding specific tools, the Tinetti test (TT) and the Time Up and Go test (TUG) are the most suited to assess postural capacities in very elderly people, in whom the predictive validity of the postural assessment of falls is still modest. In stroke patients, the Postural Assessment Scale for Stroke (PASS), posturography, lateropulsion assessment, and vertically perception are interesting and complementary techniques. Postural assessment relies mainly upon the 5 postural items of the Unified Parkinson Disease Rating Scale (UPDRS) in people with Parkinson disease and upon the Romberg test and posturography in patients with cerebellar or proprioceptive ataxia. Some novel postural scales for patients with multiple sclerosis or spinal cord injury are also emerging., Conclusion: Among numerous tools that contribute to the assessment of postural disorders, only the most recent ones (developed in the last 10 years) have undergone complete validation. It is now crucial to compare these tools, not only in terms of reproducibility and internal consistency, but also overall, in terms of feasibility, responsiveness, and predictive validity for a given population.

Background and Purpose: Trunk motion plays an important role in achieving both sit-to-stand and stand-to-sit transfers. However, these 2 body transfers depend on different postural and mechanical constraints. Although the effects of aging on sit-to-stand transfers have been widely studied, there is a lack of information concerning stand-to-sit transfers. The aim of this study was to determine how angular displacements of the trunk and shank are affected by aging during sit-to-stand and stand-to-sit transfers., Subjects: Ten community-dwelling older adults (mean age=75.9 years, SD=3.2) and 9 young adults (mean age=26.8 years, SD=4.7) volunteered to participate., Methods: Maximal angular displacements of the trunk and shank with respect to the vertical (ie, orientation angles) were measured, during standing up and sitting down, using an optoelectronic movement analyzer., Results: For standing up, there was no difference between the young and older adults with regard to both maximal orientation angles. During sitting down, the maximal shank orientation angle was not affected by age, whereas the older adults had a smaller trunk motion compared with the young adults (approximately 10 degrees less)., Discussion and Conclusion: The results showed that older adults tended to minimize the forward body displacement during sitting down. This strategy could be seen as an adaptive mechanism to decrease the risk of anterior disequilibrium. The authors suggest that this feature could be used as an early marker of aging on postural control.

Purpose: Fifty percents of cancer arise in people older than 65-year-old. Most clinical trials in cancer treatment are limited in patients younger than 65-year-old. We review literature-describing particularity of cancer treatment in elderly patients., Current Knowledge and Key Points: Therapeutic decisions should be based on an estimation of the patient's life expectancy, and risks and benefits should be weighted up accordingly. Geriatric oncology is made of a geriatric evaluation of patient and of knowledge of clinical trial about elderly patients., Future Prospects and Projects: We present in this issue the principle of geriatric evaluation and the results of recent clinical trial on elderly cancer patients.

Purpose: Fifty percent of cancer arise in people older than 65 year-old. Most clinical trials in cancer treatment are limited in patients younger than 65 year-old. We review literature describing particularity of cancer treatment in elderly patients., Current Knowledge and Key Points: Therapeutic decisions should be based on an estimation of the patient's life expectancy, and risks and benefits should be weighted up accordingly. Geriatric oncology is made of a geriatric evaluation of patient and of knowledge of clinical trial about elderly patients., Future Prospects and Projects: We present in this issue the principle of geriatric evaluation and the results of recent clinical trial on elderly cancer patients.

Background: Frontal-subcortical clinical syndrome (FSCS) is frequently described in elderly patients and consists of specific alterations in cognition and motor functions. This clinical picture may be associated with a high level of dependence and a high mortality risk., Objective: We report the risks of institutionalization and death during a follow-up of 4 years in patients showing FSCS., Methods: The study was initiated in 1998 to compare FSCS patients showing postural and gait abnormalities with Alzheimer's disease (AD) patients. Follow-up was conducted by means of telephone interviews with the patient's general practitioner over a 4-year period (1998-2002)., Results: Both institutionalization and mortality rates were significantly higher (p < 0.05) in the FSCS group compared to the AD group., Conclusions: The high risk of disability and death in FSCS patients suggests that they might require specific care programs that include stimulation in daily living activities in order to reduce the risk of institutionalization and to improve quality of life., (Copyright (c) 2005 S. Karger AG, Basel)

Background: Depression is one of the most common risk factors for falls, but links between falls and depression are still unclear. Few studies have examined the relationship between depression and gait alteration, which may increase the risk of fall., Objective: This study aims to assess a possible relationship between depression, postural and gait abnormalities, and falls., Methods: We conducted a 1-year prospective study on patients >/=70 years who were admitted to a geriatric unit for 'spontaneous' unexplained falls. Patients were tested for depression using the 30-item Geriatric Depression Scale (GDS). Their motor performances were assessed using the Mini Motor Test (MMT), which is an easy direct-observation test, validated in France, for assessment of frail old people who present with severe postural and gait impairment. This scale is composed of 4 categories of items: (1) abilities in bed; (2) quality of the sitting position; (3) abilities in the standing position, and (4) quality of gait., Results: Sixty-nine patients were included. Depression was found in 46 patients (66.7%). The MMT score was higher in the non-depressed fallers (NDF) group (GDS 10; p < 0.05). The 2 groups were compared for each of the 4 items of the MMT: the difference between the DF and NDF groups was mainly explained by the impairment of postural abilities in the standing position., Conclusions: Our results support the idea that depression is associated with postural abnormalities in the standing position, which may predispose to falls. In clinical practice, more attention should be given to old fallers concerning diagnosis and treatment of associated depression., (Copyright 2004 S. Karger AG, Basel)

Intravascular malignant lymphomatosis (IML) is characterized by proliferation of malignant lymphoid B cells within the lumens of small vessels. Common symptoms include general weakness and central neurological and cutaneous signs. Only histopathological analysis can confirm the diagnosis. We report on a 69-year-old man hospitalized for general weakness, inflammatory syndrome, and hemophagocytic syndrome (HS). Our observation shows that histopathological signs may be observed on a muscular biopsy without clinical or biological signs of muscular involvement.

Psychomotor Disadaptation Syndrome (PDS) is characterized by backward disequilibrium in a sitting and standing position, reactional hypertonia, an alteration of postural reactions, gait modifications, and fear of falling. PDS may be the result of a loss of postural reserves, reaching a frailty threshold that does not allow subjects to maintain an adequate functional level. This clinical picture may be associated with frontal-subcortical dysfunction in which microangiopathy could play a key role. PDS may be triggered by numerous factors, such as cardiovascular and metabolic diseases, falls, and bed rest. In addition to medical and neurological evaluations, a specific rehabilitation program is one of the most important aspects of the management of patients showing PDS.

Objective: A follow up of nutritional status in institutionalized patients with Alzheimer's disease., Design: Observational study., Setting: Specialized unit for patients with Alzheimer's disease in Dijon hospital, France., Subjects: Fourteen women, aged 72-92 years., Assessments: On admission of patients to the specialized unit for dementia, body weight, body mass index, arm muscle circumference (AMC) and triceps skin fold (TSF) were measured. Serum concentrations of albumin, prealbumin, homocysteine, orosomucoide, calcium, folates, vitamins B12 and B6 and C-reactive protein were recorded. The same clinical and biological measurements were repeated at day 30, 90 and 180., Results: Both mean weight and mean BMI increased throughout the study with significant differences between day 0 and day 90, and day 180 (p<0.01). The weight gain was associated with a significant increase in AMC and TSF (p<0.01 and p<0.001, respectively). There was no significant difference for values of both mean serum levels of albumin and prealbumin between day 0 and day 180. Whatever the period, serum concentrations of folates and vitamin B12 were in the normal range, while mean levels of vitamin B6 were lower than the normal range; For all these values, there was no significant difference between day 0, 30, 90, 180. Mean levels of C-reactive protein and orosomucoide and lymphocyte counts were in the normal range both at admission and day 180. No significant difference was noted between value of homocysteine at admission and at day 180., Conclusion: In this special care unit, the patients with Alzheimer's disease who take part in daily activities and particularly preparation of the meal don't lose weight. It is certain that future studies recording food intake and energy expenditure are necessary to explain the benefits in the nutritional status observed in patients showing dementia when they are institutionalized in a special unit.

Objective: To assess, in a population of elderly patients, the circumstances clinical and progressive characteristics and form of management of an acute colonic pseudo-obstruction (ACPO)., Method: Retrospective study of the files of 40 patients aged 70 and more having presented an acute colonic pseudo-obstruction and hospitalised in the university hospital in Dijon from January 1995 to June 2000., Results: The population was composed of 24 men (60%) and 16 women (40%) with a mean age of 80.8 years. The reasons for hospitalisation were varied: only 15 patients had been referred for an occlusive syndrome. 39 patients presented with abdominal distension, 30 suffered from abdominal pain. In this population, 17 patients exhibited reduced or clearly limited mobility, 20 patients had altered cognitive capacity with an MMS < 20. Thirty-eight patients suffered from a progressive heart disease and 8 patients presented with advanced dementia. The usual treatment of these patients to help the intestinal transit included diuretics in 25 cases and agents slowing the transit in 19 cases. Biologically speaking, hypokalaemia was observed in 21 cases and increased thyroid stimulating hormone (TSH) in 3 cases. An image was obtained of the abdomen without preparation in all patients: the mean caecum diameter was of 9.8 cm. A colon aspiration was performed in 20 patients and molecules to improve peristaltism were administered in 21 cases, with neostigmine prescribed for 9 patients. Surgery was required for 7 patients and 3 of them subsequently died. In terms of progression, 20 patients were cured after treatment, 13 relapsed and 7 patients worsened. Unfortunately, 10 patients died in our series., Discussion: In our study, the clinical profiles of acute colonic pseudo-obstruction were similar to those described in the literature: they occurred in varying circumstances, in medical or surgical settings ina predominantly male population of elderly, heavily dependent,patients. Treatment of this affection is not clearly codified for fragile patients with multiple diseases and the mortality rate observed should stimulate further studies, notably on pharmacological level.

Background: No previous studies have demonstrated either a nutritional improvement, or a survival benefit from tube placement in an institutionalized population., Objective: The aim of this study was to determine current indications for tube feeding in French geriatric centers and to evaluate clinical outcome and mortality rates in these frail very old patients., Design: Between November 1, 2000 and April 31, 2001, we prospectively recruited all hospitalized or institutionalized patients who received enteral nutrition (EN) in 7 Departments of Geriatric Medicine in France. Nutritional parameters and main indications of EN were recorded at the time of feeding tube placement. Pneumonia and mortality rates were observed over a period of one year., Results: 57 patients of mean age 81.6 7.8 yrs underwent placement of a feeding tube. Mean BMI value was 20.7 4.8 and mean serum albumin level 26.1 6.1 g/L. The most frequent indications for EN included stoke (39%) and other neurologic diseases (42%). Fourteen patients (25%) died within 30 days, and 27 (47%) died over the 12-month follow-up period. During the first month, an episode of pneumonia was noted in 26 cases (55%)., Conclusion: The similarity between rates of early mortality reported in our study and those reported in several previous studies involving younger, ambulatory subjects is surprising because we might expect poorer survival in our frail elderly patients. We can think that French geriatric teams have changed their attitudes toward EN in recent years, EN being less frequently used in patients with advanced dementia and at the end-stage of life.