CSF in Epileptic Prodromal Alzheimer's Disease: No Diagnostic Contribution but a Pathophysiological One

Objective: To study whether cerebrospinal fluid (CSF) analysis may serve as a diagnostic test for the screening of epilepsy in sporadic prodromal Alzheimer's disease (AD).

Methods: A total of 29 patients with epileptic prodromal sporadic AD patients (epADs) were included and were retrospectively compared with 38 non-epileptic prodromal AD patients (nepADs) for demographics, clinical features, Mini-Mental Status Examination (MMSE) results, CSF biomarkers, and electro-radiological features.

Results: Our study did not show any significant differences in CSF biomarkers regarding neurodegeneration, albumin levels, and inflammation between epADs and nepADs. The epADs were significantly older at diagnosis (p = 0.001), more hypertensive (p = 0.01), and displayed larger white matter hyperintensities on brain magnetic resonance imaging (MRI; p = 0.05). There was a significant correlation between the CSF Aβ-42 and Aβ-40 levels with interictal epileptiform discharges and delta slowing on EEGs recordings, respectively (p = 0.03).

Conclusions: Our study suggests that CSF may not serve as a surrogate marker of epilepsy in prodromal AD and cannot circumvent the operator-dependent and time-consuming interpretation of EEG recordings. In humans, AD-related epileptogenesis appears to involve the Aβ peptides but likely also additional non-amyloid factors such as small-vessel disease (i.e., white matter hyperintensities).

Association of cerebral microbleeds with cerebrospinal fluid Alzheimer-biomarkers and clinical symptoms in early dementia with Lewy bodies

OBJECTIVES

To determine the prevalence, localization and associations of cerebral microbleeds (CMB) in dementia with Lewy bodies (DLB) with its core clinical symptoms and cerebrospinal fluid (CSF) biomarkers of Alzheimer's disease (AD). We hypothesize DLB patients with CMB have increased amyloid burden compared to those without CMB, which could also translate into clinical differences.

METHODS

Retrospective cross-sectional analysis from the AlphaLewyMA study (https://clinicaltrials.gov/ct2/show/NCT01876459). Patients underwent a standardized protocol of brain MRI including 3D T1, 3D FLAIR and T2* sequences, and CSF analysis of AD biomarkers. CMB and white matter hyperintensities (WMHs) were visually assessed in prodromal and mild demented (DLB, N = 91) and AD (AD, N = 67) patients.

RESULTS

CMB prevalence did not differ among DLB and AD (24.2% vs. 37.3%; p = 0.081). CMB were mainly distributed in lobar topographies in both DLB (74%) and AD (89%). CMB in DLB was not associated with global cognitive performance, executive functioning, speed of information processing, or AD CSF biomarkers. Similarly, there was no difference regarding specific clinical symptoms: fluctuations, psychotic phenomena, sleep behavior disorder and Parkinsonism between DLB patients with and without CMB. AD patients with CMB had increased burden of WMH compared to those without (2.1 ± 0.86 vs. 1.4 ± 0.89; p = 0.005), according to Fazekas scale, whereas no significant difference was observed in DLB patients (1.68 ± 0.95 vs. 1.42 ± 0.91; p = 0.25).

CONCLUSION

CMB were equally prevalent with similar topographic distribution in both DLB and AD patients. CMB was not associated with CSF AD biomarkers or core clinical symptoms in DLB.

Differential diagnostic value of total alpha-synuclein assay in the cerebrospinal fluid between Alzheimer's disease and dementia with Lewy bodies from the prodromal stage

Background

Several studies have investigated the value of alpha-synuclein assay in the cerebrospinal fluid (CSF) of Alzheimer’s disease (AD) and dementia with Lewy bodies (DLB) patients in the differential diagnosis of these two pathologies. However, very few studies have focused on this assay in AD and DLB patients at the MCI stage.

Methods

All patients were enrolled under a hospital clinical research protocol from the tertiary Memory Clinic (CM2R) of Alsace, France, by an experienced team of clinicians. A total of 166 patients were included in this study: 21 control subjects (CS), 51 patients with DLB at the prodromal stage (pro-DLB), 16 patients with DLB at the demented stage (DLB-d), 33 AD patients at the prodromal stage (pro-AD), 32 AD patients at the demented stage (AD-d), and 13 patients with mixed pathology (AD+DLB). CSF levels of total alpha-synuclein were assessed using a commercial enzyme-linked immunosorbent assay (ELISA) for alpha-synuclein (AJ Roboscreen). Alzheimer’s biomarkers (t-Tau, P-Tau, Aβ42, and Aβ40) were also measured.

Results

The alpha-synuclein assays showed a significant difference between the AD and DLB groups. Total alpha-synuclein levels were significantly higher in AD patients than in DLB patients. However, the ROC curves show a moderate discriminating power between AD and DLB (AUC = 0.78) which does not improve the discriminating power of the combination of Alzheimer biomarkers (AUC = 0.95 with or without alpha-synuclein). Interestingly, the levels appeared to be altered from the prodromal stage in both AD and DLB.

Conclusions

The modification of total alpha-synuclein levels in the CSF of patients occurs early, from the prodromal stage. The adding of alpha-synuclein total to the combination of Alzheimer’s biomarker does not improve the differential diagnosis between AD and DLB.

Trial registration

ClinicalTrials.gov, NCT01876459 (AlphaLewyMa)

Environmental exposure to phthalates and dementia with Lewy bodies: contribution of metabolomics

BACKGROUND

In neurodegenerative diseases, alongside genetic factors, the possible intervention of environmental factors in the pathogenesis is increasingly being considered. In particular, recent evidence suggests the intervention of a pesticide-like xenobiotic in the initiation of disease with Lewy bodies (DLB).

OBJECTIVES

To test for the presence of pesticides or other xenobiotics in the cerebrospinal fluid (CSF) of patients with DLB.

METHODS

A total of 45 patients were included in this study: 16 patients with DLB at the prodromal stage, 8 patients with DLB at the demented stage, 8 patients with Alzheimer's disease (AD) at the prodromal stage and 13 patients with AD at the demented stage. CSF was obtained by lumbar puncture and analysed by liquid chromatography-mass spectrometry.

RESULTS

Among the compounds detected in greater abundance in the CSF of patients with DLB compared with patients with AD, only one had a xenobiotic profile potentially related to the pathophysiology of DLB. After normalisation and scaling, bis(2-ethylhexyl) phthalate was more abundant in the CSF of patients with DLB (whole cohort: 2.7-fold abundant in DLB, p=0.031; patients with dementia: 3.8-fold abundant in DLB, p=0.001).

CONCLUSIONS

This study is the first reported presence of a phthalate in the CSF of patients with DLB. This molecule, which is widely distributed in the environment and enters the body orally, nasally and transdermally, was first introduced in the 1920s as a plasticizer. Thereafter, the first cases of DLB were described in the 1960s and 1970s. These observations suggest that phthalates may be involved in the pathophysiology of DLB.

Changes in gray matter volume and functional connectivity in dementia with Lewy bodies compared to Alzheimer's disease and normal aging: implications for fluctuations

BACKGROUND

Fluctuations are one of the core clinical features characterizing dementia with Lewy bodies (DLB). They represent a determining factor for its diagnosis and strongly impact the quality of life of patients and their caregivers. However, the neural correlates of this complex symptom remain poorly understood. This study aimed to investigate the structural and functional changes in DLB patients, compared to Alzheimer's disease (AD) patients and healthy elderly subjects, and their potential links with fluctuations.

METHODS

Structural and resting-state functional MRI data were collected from 92 DLB patients, 70 AD patients, and 22 control subjects, who also underwent a detailed clinical examination including the Mayo Clinic Fluctuation Scale. Gray matter volume changes were analyzed using whole-brain voxel-based morphometry, and resting-state functional connectivity was investigated using a seed-based analysis, with regions of interest corresponding to the main nodes of the salience network (SN), frontoparietal network (FPN), dorsal attention network (DAN), and default mode network (DMN).

RESULTS

At the structural level, fluctuation scores in DLB patients did not relate to the atrophy of insular, temporal, and frontal regions typically found in this pathology, but instead showed a weak correlation with more subtle volume reductions in different regions of the cholinergic system. At the functional level, the DLB group was characterized by a decreased connectivity within the SN and attentional networks, while the AD group showed decreases within the SN and DMN. In addition, higher fluctuation scores in DLB patients were correlated to a greater connectivity of the SN with the DAN and left thalamus, along with a decreased connectivity between the SN and DMN, and between the right thalamus and both the FPN and DMN.

CONCLUSIONS

Functional connectivity changes, rather than significant gray matter loss, could play an important role in the emergence of fluctuations in DLB. Notably, fluctuations in DLB patients appeared to be related to a disturbed external functional connectivity of the SN, which may lead to less relevant transitions between different cognitive states in response to internal and environmental stimuli. Our results also suggest that the thalamus could be a key region for the occurrence of this symptom.

Insular cognitive impairment at the early stage of dementia with Lewy bodies: a preliminary study

BACKGROUND

The anterior part of the insula appears atrophied in the early stage of dementia with Lewy bodies (DLB) whereas it is not the case in early Alzheimer's disease (AD).

OBJECTIVE

The objective of this study was to develop neuropsychological markers supposed to reflect insular dysfunction, which would facilitate early diagnosis of DLB, namely in comparison to AD.

METHODS

Twelve patients with DLB, 12 patients with AD, all at the stage of Mild cognitive impairment (MCI) or mild dementia, as well as 10 Controls subjects (CS) participated in the study. Cognitive functions supposedly related to the insula were evaluated with a battery of tests: a facial expression recognition test, a test assessing the feeling of disgust with images, a test evaluating idioms' comprehension, an empathy questionnaire and a questionnaire screening for disgusting behaviors.

RESULTS

Compared to AD patients and CS, DLB patients experienced less disgust when they were shown disgusting images, whereas their ability to recognize emotional expression of disgust appeared to be preserved. Furthermore, DLB patients seemed less empathetic than AD patients. Finally, compared to CS, DLB patients were less effective to provide an intuitive decision about idioms' signification since they needed significantly more time to answer.

CONCLUSION

This preliminary study suggests the existence of a potential « insular cognitive impairment » profile in DLB at the early stage. These results provide interesting leads to develop tools facilitating the differential diagnosis of DLB and AD.

Long-term cognitive outcome of Alzheimer's disease and dementia with Lewy bodies: dual disease is worse

Background

Longitudinal studies of dementia with Lewy bodies (DLB) are rare. Clinically, DLB is usually considered to worsen into Alzheimer’s disease (AD). The aim of our study was to compare the rate of the cognitive decline in DLB, AD, and the association of the two diseases (AD + DLB).

Methods

Using the Regional Network for Diagnostic Aid and Management of Patients with Cognitive Impairment database, which includes all the patients seen at all memory clinics (medical consultation and day hospitals) in four French regions, and beta regression, we compared the longitudinal the Mini-Mental State Examination scores of 1159 patients with AD (n = 1000), DLB (n = 131) and AD + DLB (association of the two) (n = 28) during follow-up of at least 4 years.

Results

The mean follow-up of the patients was 5.88 years. Using beta regression without propensity scores, the comparison of the decline of patients with AD and patients with DLB did not show a significant difference, but the decline of patients with AD + DLB was worse than that of either patients with DLB (P = 0.006) or patients with AD (P < 0.001). Using beta regression weighted by a propensity score, comparison of patients with AD and patients with DLB showed a faster decline for patients with DLB (P < 0.001). The comparison of the decline of patients with AD + DLB with that of patients with DLB (P < 0.001) and patients with AD (P < 0.001) showed that the decline was clearly worse in the patients with dual disease.

Conclusions

Whatever the analysis, the rate of decline is faster in patients with AD + DLB dual disease. The identification of such patients is important to enable clinicians to optimise treatment and care and to better inform and help patients and caregivers.

Cognitive profile in prodromal dementia with Lewy bodies

Background

Cortical and subcortical cognitive impairments have been found in dementia with Lewy bodies (DLB). Roughly, they comprise visuoconstructive and executive dysfunction, whereas memory would remain relatively spared. However, the cognitive profile of patients with prodromal DLB remains poorly illustrated to date.

Methods

We included 37 patients with prodromal DLB (age 67.2 ± 8.6 years, 18 men, Mini Mental State Examination [MMSE] score 27.4 ± 2) and 29 healthy control subjects (HCs; age 68.8 ± 7.9 years, 15 men, MMSE score 29.0 ± 0.9). They were presented with an extensive neuropsychological test battery to assess memory; speed of processing; executive function; visuoperceptual, visuospatial and visuoconstructive abilities; language; and social cognition.

Results

Compared with HCs, patients had lower scores on a visual recognition memory test (Delayed Matching to Sample-48 items; p ≤ 0.021) and lower free recall (all p ≤ 0.035), but not total recall, performance on a verbal episodic memory test (Free and Cued Selective Reminding Test). Short-term memory (p = 0.042) and working memory (p = 0.002) scores were also lower in patients. Assessment of executive function showed no slowing but overall lower performance in patients than in HCs (all p ≤ 0.049), whereas assessment of instrumental function yielded mixed results. Indeed, patients had lower scores on language tests (p ≤ 0.022), apraxia for pantomime of tool use (p = 0.002) and imitation of meaningless gesture (p = 0.005), as well as weakened visuospatial abilities (p = 0.047). Visuoconstruction was also impaired in patients. However, visuoperceptual abilities did not differ between groups. Finally, theory of mind abilities were lower in patients than in HCs (p < 0.05), but their emotion recognition abilities were similar.

Conclusions

This study presents the cognitive profile in patients with prodromal DLB. In line with the literature on DLB with dementia, our results show lower performance on tests of executive function and visuoconstruction. However, we found, from a prodromal stage of DLB, memory (free recall and visual recognition) and social cognition deficits, as well as weakened visuospatial and praxic abilities.

Diagnostic Value of Cerebrospinal Fluid Biomarkers (Phospho-Tau181, total-Tau, Aβ42, and Aβ40) in Prodromal Stage of Alzheimer's Disease and Dementia with Lewy Bodies

BACKGROUND

Dementia with Lewy bodies (DLB) symptoms are close to those of Alzheimer's disease (AD), and the differential diagnosis is difficult especially early in the disease. Unfortunately, AD biomarkers in cerebrospinal fluid (CSF), and more particularly Aβ1 - 42, appear to be altered in dementia with Lewy bodies (DLB). However, the level of these biomarkers has never been studied in the prodromal stage of the disease.

OBJECTIVE

To compare these biomarkers between DLB and AD, with a particular focus on the prodromal stage.

METHODS

A total of 166 CSF samples were collected at the memory clinic of Strasbourg. They were obtained from prodromal DLB (pro-DLB), DLB dementia, prodromal AD (pro-AD), and AD dementia patients, and elderly controls. Phospho-Tau181, total-Tau, Aβ42, and Aβ40 were measured in the CSF.

RESULTS

At the prodromal stage, contrary to AD patients, DLB patients' biomarker levels in the CSF were not altered. At the demented stage of DLB, Aβ42 levels were reduced as well as Aβ40 levels. Thus, the Aβ42/Aβ40 ratio remained unchanged between the prodromal and demented stages, contrary to what was observed in AD. Tau and Phospho-Tau181 levels were unaltered in DLB patients.

CONCLUSIONS

We have shown that at the prodromal stage the DLB patients had no pathological profile. Consequently, CSF AD biomarkers are extremely useful for differentiating AD from DLB patients particularly at this stage when the clinical diagnosis is difficult. Thus, these results open up new perspectives on the interpretation of AD biomarkers in DLB.

Exploring anterograde memory: a volumetric MRI study in patients with mild cognitive impairment

BACKGROUND

The aim of this volumetric study was to explore the neuroanatomical correlates of the Free and Cued Selective Reminding Test (FCSRT) and the Delayed Matching-to-Sample-48 items (DMS-48), two tests widely used in France to assess verbal and visual anterograde memory. We wanted to determine to what extent the two tests rely on the medial temporal lobe, and could therefore be predictive of Alzheimer's disease, in which pathological changes typically start in this region.

METHODS

We analysed data from a cohort of 138 patients with mild cognitive impairment participating in a longitudinal multicentre clinical research study. Verbal memory was assessed using the FCSRT and visual recognition memory was evaluated using the DMS-48. Performances on these two tests were correlated to local grey matter atrophy via structural MRI using voxel-based morphometry.

RESULTS

Our results confirm the existence of a positive correlation between the volume of the medial temporal lobe and the performance on the FCSRT, prominently on the left, and the performance on the DMS-48, on the right, for the whole group of patients (family-wise error, P < 0.05). Interestingly, this region remained implicated only in the subgroup of patients who had deficient scores on the cued recall of the FCSRT, whereas the free recall was associated with prefrontal aspects. For the DMS-48, it was only implicated for the group of patients whose performances declined between the immediate and delayed trial. Conversely, temporo-parietal cortices were implicated when no decline was observed. Within the medial temporal lobe, the parahippocampal gyrus was prominently involved for the FCSRT and the immediate trial of the DMS-48, whereas the hippocampus was solely involved for the delayed trial of the DMS-48.

CONCLUSIONS

The two tests are able to detect an amnestic profile of the medial temporal type, under the condition that the scores remain deficient after the cued recall of the FCSRT or decline on the delayed recognition trial of the DMS-48. Strategic retrieval as well as perceptual/attentional processes, supported by prefrontal and temporo-parietal cortices, were also found to have an impact on the performances. Finally, the implication of the hippocampus appears time dependent, triggered by a longer delay than the parahippocampus, rather than determined by the sense of recollection or the encoding strength associated with the memory trace.

Grey matter atrophy in prodromal stage of dementia with Lewy bodies and Alzheimer's disease

Background

Little is known about the patterns of brain atrophy in prodromal dementia with Lewy bodies (pro-DLB).

Methods

In this study, we used SPM8 with diffeomorphic anatomical registration through exponentiated lie algebra to measure grey matter (GM) volume and investigate patterns of GM atrophy in pro-DLB (n = 28) and prodromal Alzheimer’s disease (pro-AD) (n = 27) and compared and contrasted them with those in elderly control subjects (n = 33) (P ≤ 0.05 corrected for family-wise error).

Results

Patients with pro-DLB showed diminished GM volumes of bilateral insulae and right anterior cingulate cortex compared with control subjects. Comparison of GM volume between patients with pro-AD and control subjects showed a more extensive pattern, with volume reductions in temporal (hippocampi and superior and middle gyri), parietal and frontal structures in the former. Direct comparison of prodromal groups suggested that more atrophy was evident in the parietal lobes of patients with pro-AD than patients with pro-DLB. In patients with pro-DLB, we found that visual hallucinations were associated with relative atrophy of the left cuneus.

Conclusions

Atrophy in pro-DLB involves the insulae and anterior cingulate cortex, regions rich in von Economo neurons, which we speculate may contribute to the early clinical phenotype of pro-DLB.

Cognitive and affective theory of mind in dementia with Lewy bodies and Alzheimer's disease

Background

Theory of mind (ToM) refers to the ability to attribute mental states, thoughts (cognitive component) or feelings (affective component) to others. This function has been studied in many neurodegenerative diseases; however, to our knowledge, no studies investigating ToM in dementia with Lewy bodies (DLB) have been published. The aim of our study was to assess ToM in patients with DLB and to search for neural correlates of potential deficits.

Methods

Thirty-three patients with DLB (DLB group) and 15 patients with Alzheimer’s disease (AD group), all in the early stage of the disease, as well as 16 healthy elderly control subjects (HC group), were included in the study. After a global cognitive assessment, we used the Faux Pas Recognition (FPR) test, the Reading the Mind in the Eyes (RME) test and Ekman’s Facial Emotion Recognition test to assess cognitive and affective components of ToM. Patients underwent cerebral 3-T magnetic resonance imaging, and atrophy of grey matter was analysed using voxel-based morphometry. We performed a one-sample t test to investigate the correlation between each ToM score and grey matter volume and a two-sample t test to compare patients with DLB impaired with those non-impaired for each test.

Results

The DLB group performed significantly worse than the HC group on the FPR test (P = 0.033) and the RME test (P = 0.015). There was no significant difference between the AD group and the HC group or between the DLB group and the AD group. Some brain regions were associated with ToM impairments. The prefrontal cortex, with the inferior frontal cortex and the orbitofrontal cortex, was the main region, but we also found correlations with the temporoparietal junction, the precuneus, the fusiform gyrus and the insula.

Conclusions

This study is the first one to show early impairments of ToM in DLB. The two cognitive and affective components both appear to be affected in this disease. Among patients with ToM difficulties, we found atrophy in brain regions classically involved in ToM, which reinforces the neuronal network of ToM. Further studies are now needed to better understand the neural basis of such impairment.

Electronic supplementary material

The online version of this article (doi:10.1186/s13195-016-0179-9) contains supplementary material, which is available to authorized users.

Cortical Thickness in Dementia with Lewy Bodies and Alzheimer's Disease: A Comparison of Prodromal and Dementia Stages

Objectives

To assess and compare cortical thickness (CTh) of patients with prodromal Dementia with Lewy bodies (pro-DLB), prodromal Alzheimer's disease (pro-AD), DLB dementia (DLB-d), AD dementia (AD-d) and normal ageing.

Methods

Study participants(28 pro-DLB, 27 pro-AD, 31 DLB-d, 54 AD-d and 33 elderly controls) underwent 3Tesla T1 3D MRI and detailed clinical and cognitive assessments. We used FreeSurfer analysis package to measure CTh and investigate patterns of cortical thinning across groups.

Results

Comparison of CTh between pro-DLB and pro-AD (p<0.05, FDR corrected) showed more right anterior insula thinning in pro-DLB, and more bilateral parietal lobe and left parahippocampal gyri thinning in pro-AD. Comparison of prodromal patients to healthy elderly controls showed the involvement of the same regions. In DLB-d (p<0.05, FDR corrected) cortical thinning was found predominantly in the right temporo-parietal junction, and insula, cingulate, orbitofrontal and lateral occipital cortices. In AD-d(p<0.05, FDR corrected),the most significant areas affected included the entorhinal cortices, parahippocampal gyri and parietal lobes. The comparison of AD-d and DLB-d demonstrated more CTh in AD-d in the left entorhinal cortex (p<0.05, FDR corrected).

Conclusion

Cortical thickness is a sensitive measure for characterising patterns of grey matter atrophy in early stages of DLB distinct from AD. Right anterior insula involvement may be a key region at the prodromal stage of DLB and needs further investigation.

Subacute bacterial endocarditis presenting as polymyalgia rheumatica or giant cell arteritis

OBJECTIVE

To report on several patients with subacute bacterial endocarditis who were initially presumed, incorrectly, to have polymyalgia rheumatica or giant cell arteritis.

METHODS

We report 3 cases of subacute streptococcal endocarditis mimicking giant cell arteritis in 2 cases and polymyalgia rheumatica in one. We reviewed the literature through Medline search of French and English-language articles published between 1966 and 2005 and found 5 similar cases.

RESULTS

Shoulder and/or pelvic girdle pain was associated with neck or back pain in all patients. Scalp tenderness, bilateral jaw pain, amaurosis fugax were present in 2 patients. One patient had no fever. Two patients were treated with corticosteroids with initial good clinical response in one. Appropriate antibiotic therapy resulted in the rapid disappearance of rheumatic complaints in 2 patients and achieved a definitive cure of endocarditis in all cases.

CONCLUSION

Rheumatologic symptoms may hinder the correct diagnosis of infective endocarditis in patients who present with a clinical picture suggesting polymyalgia rheumatica or giant cell arteritis. In such cases, blood cultures should be systematically drawn.

Mini motor test: a clinical test for rehabilitation of patients showing psychomotor disadaptation syndrome (PDS)

Direct observation of postural and motor abilities appears as very important in assessment of patients showing psychomotor disadaptation syndrome (PDS). We examine feasibility and reliability of mini motor test (MMT) which has been developed in order to establish rehabilitation goals in this population. MMT is a 20-item score which assesses abilities in bed, quality of sitting position, abilities in the standing position, and quality of gait. MMT has been conducted by two different independent investigators, a physiotherapist and a physician, in four different geriatric centers. One hundred and one subjects (mean age: 84.9 +/- 6.0 years) were included in the study. The agreement between the two investigators was highly satisfying for both MMT total score and each item of MMT. Redundancy between items appeared very limited. The difference between investigators for MMT total score did not vary significantly with score of the mini-mental-state examination (MMSE). The correlation between MMT and the Katz index was found significantly negative. MMT is an easy direct-observation test which may be particularly useful in patients who present with severe postural and gait impairment. This test can be used in clinical practice by different professional actors in order to allow an interdisciplinary approach for a common rehabilitation goal in the PDS patients.

Prognostic factors of hematological recovery in life-threatening nonchemotherapy drug-induced agranulocytosis

OBJECTIVES

We studied clinical factors that may influence the duration of hematological recovery to reach neutrophil counts and thus, indirectly, the prognosis in patients with life-threatening drug-induced agranulocytosis (DIA).

METHODS

Using univariate and multivariate analyses with Cox's proportional hazard models, we determined the prognostic factors for hematological recovery, defined as neutrophil counts>0.5 and>1.5.10(9)/L, in 91 patients with established life-threatening DIA.

RESULTS

Multivariable analysis showed that neutrophil count<0.1.10(9)/L (at diagnosis) and infection profile: severe infections or septic shock, adversely influenced the neutrophil recovery (for the two neutrophil levels). Hematopoietic growth factors were significantly associated with rapid hematological recovery (for the two neutrophil levels). Documented microbial infections and antiplatelet DIA were also associated with rapid hematological recovery (for a neutrophil count>1.5.10(9)/L).

CONCLUSION

Our findings demonstrate that in life-threatening DIA, hematological recovery is mainly dependent of the neutrophil level, the type of infections and the utilization of hematopoietic growth factors.

[Early response to oral cobalamin therapy in older patients with vitamin B12 deficiency]

PURPOSE

Standard treatment of vitamin B12 deficiency involves regular intramuscular cobalamin administration. The aim of this study was to determine whether oral cobalamin treatment may be an effective therapy for treating older patients with cobalamin deficiency related to nutritional deficiency and food-cobalamin malabsorption.

PATIENTS AND METHODS

We prospectively studied 20 patients older than 80 years with established cobalamin deficiency related to food-cobalamin malabsorption (n=14) and nutritional deficiency (n=6) who received 1000 micro g of oral cyanocobalamin per day. Levels of serum cobalamin and blood counts were determined at baseline and after the first week of treatment.

RESULTS

After an average of 8 days of treatment, 17 out of 20 patients normalized their serum cobalamin levels; the patients had increased their serum cobalamin level (mean increase of 0.23 micro g/L; p<0.01 compared with baseline), reticulocyte count (mean increase of 27400/mm(3); p<0.05), hemoglobin levels (mean increase of 0.7 g/dL; NS), and decreased the mean erythrocyte volume (mean decrease of 0.7 fL; NS).

CONCLUSION

Our findings suggest that cyanocobalamin given orally during one week may be an effective treatment for cobalamin deficiency related to food-cobalamin malabsorption and nutritional deficiency and may avoid painful intra-muscular injections in older patients.

[Urinary tract infections due to wide spectrum beta lactamase producing enterobacteriaceae]

OBJECTIVES

The aim of this study was to specify the characteristics of enterobacterial urinary infections producing wide spectrum beta-lactamase (WSBL) and the management strategies for these patients infected in geriatric wards.

METHODS

The prevalence, bacteriological characteristics and treatment regimens of enterobacterial urinary infections producing WSBL, diagnosed in a geriatric department of internal medicine from May 1977 to April 2001, were studied retrospectively.

RESULTS

Sixty-six enterobacterial urinary infections producing WSBL were diagnosed, with 53 (80%) of them acquired in the ward. They represented 1.6% of admissions and concerned 24 men and 42 women (sex ratio: 0.57), with a mean age of 87 years. Their prevalence was of 20 in the 1st year, 11 in the 2nd, 9 in the third and 26 in the 4th year. The mean duration of hospitalization of infected patients was 4.5-fold longer (90 vs. 20 days) and the mortality rate 2-fold higher (32 vs. 14%). Enterobacter aerogenes were responsible for half (46%) of the WSBL urinary infections. The skin was invaded by enterobacteria in 67% and the feces in 57% of cases. More than one third of the urinary infections treated relapsed, and digestive decontamination was only efficient in half of the patients treated.

CONCLUSION

This 4-year study emphasizes the limits of antibiotherapy in eradicating WSBL-producing enterobacteria and the fact that only the strict respect of hygiene by all caregivers (isolation of patients exhibiting WSBL and washing-disinfection of the hands between each patient) limits the incidence of such infections.

Nonchemotherapy drug-induced agranulocytosis in elderly patients: the effects of granulocyte colony-stimulating factor

PURPOSE

Elderly patients with nonchemotherapy drug-induced agranulocytosis present commonly with severe infections, and have a mortality of at least 20%. We studied whether granulocyte colony-stimulating factor (G-CSF), a hematopoietic growth factor that shortens the duration of neutropenia, is useful in these patients.

SUBJECTS AND METHODS

We studied 54 patients > or =65 years of age who had drug-induced agranulocytosis, some of whom had been treated with G-CSF. We determined the times until hematologic recovery (defined as a neutrophil count >1.5 x 10(9)/L), tolerance of G-CSF, and clinical outcomes.

RESULTS

Of the 54 patients, 20 received G-CSF. Two patients who had not been treated with G-CSF died of uncontrolled septic shock and extensive pneumonia. The mean (+/- SD) time until hematologic recovery was significantly less in patients treated with G-CSF (6.6 +/- 3.9 days vs. 8.8 +/- 4.9 days, P <0.04). Compliance with G-CSF therapy was good; only mild flu-like symptoms and transient bone pain were reported in 12 patients.

CONCLUSION

Our findings suggest that G-CSF therapy may be beneficial in the management of drug-induced agranulocytosis in elderly patients.

Cardiovascular characteristics and cerebral CT findings in elderly subjects with psychomotor disadaptation syndrome

BACKGROUND AND AIMS

In previous studies, we described a clinical picture typically observed in frail old people, called "Psychomotor Disadaptation Syndrome" (PDS), but we have never studied etiopathogenic data. The aim of this study was to complete the clinical picture, record cardiovascular risk factors and provide cerebral CT scan findings in patients with PDS.

METHODS

73 patients with PDS were recruited in the Geriatric Medicine departments of the University Hospitals of Dijon (Burgundy, France) and Strasbourg (Alsace, France); this group included prospectively all hospitalized patients showing postural and gait abnormalities according to the following criteria: trend towards backward falling and gait pattern alteration characterized by hesitancy in initiation, small steps, and increase in the double support durations. General characteristics, neurological and cardiovascular information were collected for each patient. For the detection of white matter changes (WMC), we used a third-generation CT scanner (GE CT HSA) evaluating a section of 7 mm at each interval of 8 mm.

RESULTS

Neurological examination showed that "reactional hypertonia" was observed in more than 90% of the patients, and that no patient showed normal reactive postural responses. Prior history of hypertension was noted in 49% of the patients, while a current antihypertensive treatment was taken by 13% of the patients. Orthostatic hypotension was observed in 44% of patients. Severe or moderate periventricular lucencies on CT scan were found in 67% of the patients, and severe ventricular enlargement in 50.5% of the patients.

CONCLUSIONS

We advance that PDS might be associated with WMC, and that hypotension might be an important etiologic factor of WMC in causing reduction of the cerebral blood flow in subcortical areas.

[Dementia and falls]

INTRODUCTION

Dementia is now a frequent disease in elderly and may be a major risk of falling. Usually these falls are multiple and serious, but their consequences are not specific. All types of dementia (Alzheimer's disease, dementia with Lewy bodies, dementia in Parkinson's disease, fronto-temporal dementia, vascular dementiaellipsis) and all stages of evolution are concerned.

DISCUSSION

These falls result from cognitive and behavioural disorders, visual and motor problems, gait and balance disturbances, malnutrition, adverse effects of medication and fear of falling.

CONCLUSION

Prevention is possible. Attention must be given on the patient himself (keeping in good health, limitation in sedative treatment and mechanical restraintsellipsis) and on his environment (lighting, obstacles on the ground, stress levelellipsis). After a fall, especially after a complicated fall, rehabilitation modalities and aims must be adapted but caring must not be defeatist. Randomized studies need to be realized.

[Clinical and prognostic aspects of spontaneous fractures in long term care units: a thirty month prospective study. Eastern Gerontology Society]

PURPOSE

Spontaneous fractures (stress and bone insufficiency fractures) are well described in young healthy patients; however, few studies were conducted in the elderly.

METHODS

A 30-month prospective clinical and epidemiological survey including elderly patients from long-term nursing homes (LTNH) of the Société de Gérontologie de l'Est (70 centers; 11,495 elderly patients in total) was conducted.

RESULTS

Sixty-seven spontaneous fractures were encountered in 30 LTNH (3,052 elderly patients) (five stress fractures of the foot, 62 bone insufficiency fractures). The mean age of bedridden patients was 85 +/- 7 years. The prevalence of spontaneous fractures (calculated from the number of patients admitted consecutively in LTNHs) was 0.34% in the whole population (11,495 beds). When the calculation was based on LTNH reports of spontaneous fractures (3,052 elderly patients), the prevalence reached 1.3%. Fractures of long bones were common in elderly patients and included 15 fractures of the femoral neck, 14 fractures of either the tibia or fibula, 13 fractures of the femoral shaft, and 11 fractures of the humerus. Fractures of the femoral shaft were associated with the highest mortality: seven out of 13 patients died versus two out of 15 patients with regard to fractures of the femoral neck (P < 0.05).

CONCLUSION

Bone insufficiency fractures have not the same course in young healthy patients as those in elderly nursing home patients: they more often concern long bones and their prognosis is worse. Means of prevention still have to be defined.

[Extra-pyramidal syndrome induced by donepezil]

BACKGROUND

The cholinergic hypothesis of Alzheimer's disease is the basis of a new class of drugs: acetylcholinesterase inhibitors. These drugs have few side effects, mainly digestive disorders.

CASE REPORTS

Extra-pyramidal side effects with severe gait disorders were observed in 3 patients with Alzheimer's dementia treated with donepezil. This drug was associated with paroxetine or a neuroleptic. In 2 of the 3 cases, the extra-pyramidal effects disappeared when donepezil was discontinued.

DISCUSSION

Extra-pyramidal syndromes in elderly subjects with cognitive impairment are difficult to interpret. The possible causes include interactions between acetylcholinesterase inhibitors, neuroleptics and serotonine reuptake inhibitors and Lewy body dementia.