Showing papers by "Joël Belmin published in 2002"

Degenerative and vascular lesions of the brain have synergistic effects in dementia of the elderly.

Abstract: The relative importance of vascular and Alzheimer's disease (AD) lesions, their interaction in the development of cognitive impairment and the very existence of mixed dementia induced by the potentiation of both mechanisms remain controversial The aim of this study was to assess whether the patients with infarcts and lacunes have fewer plaques and tangles than those without vascular lesions, for similar severity of clinical dementia We performed a prospective clinicopathological study in elderly patients of a long-stay care unit The severity of clinical dementia was assessed by psychometry performed according to standardized methods less than 6 months before death A volumetric study of cerebral vascular lesions was performed at post-mortem study of the brain The density of neuritic plaques (SP), Amyloid β focal deposits (Aβ FD), and neurofibrillary tangles (NFT) in the temporal and frontal isocortex was quantified According to DSM III criteria, 28 of the 33 patients for whom autopsies were performed had dementia Twenty-four of the included patients had degenerative or vascular lesions, or both The volume of infarcts and lacunes was significantly correlated with the severity of cognitive impairment The density of SP, Aβ FD and NFT in the temporal and frontal isocortex was significantly lower when vascular lesions were present For similar clinical severity of dementia, there were fewer AD lesions in patients with vascular lesions than in those without vascular lesions

Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone.

Abstract: OBJECTIVES: To compare the efficacy of a sequential strategy combining calcium alginate and hydrocolloid dressings treatment of grade III or IV pressure ulcers (PUs) and the efficacy of nonsequential strategy with hydrocolloids alone. DESIGN: An open, randomized, multicenter parallel-group trial. SETTING: Twenty geriatrics hospital wards. PARTICIPANTS: One hundred ten older patients with grade III or IV PUs. INTERVENTION: The control strategy consisted of applying hydrocolloid dressings (DuodermE) for 8 weeks; the sequential strategy consisted of applying combined calcium alginate dressings (UrgoSorb) for the first 4 weeks and hydrocolloid dressings (Algoplaque) for the next 4 weeks. MEASUREMENTS: PU surface areas were measured weekly by ulcer tracing. The endpoints were the mean absolute surface area reduction (SAR) during the 8-week study period and the number of patients achieving a 40% or more SAR (SAR 40 ). RESULTS: Fifty-seven and 53 patients were randomly allocated to sequential and control strategies respectively. Baseline patient characteristics and PU ulcer features at inclusion were similar in the two groups. Mean ± standard deviation SAR was significantly larger in the sequential treatment group (5.4 ± 5.7 cm 2 and 7.6 ± 7.1 cm 2 at 4 and 8 weeks) than in the control group (1.6 ± 4.9 cm 2 and 3.1 ± 7.2 cm 2 , P <.001). In the sequential treatment group, 68.4% of the patients reached SAR 40 at 4 weeks and 75.4% at 8 weeks, proportions significantly larger than in the control group (22.6% and 58.5%, respectively, P < .0001). Dressing tolerance was good in both strategies. CONCLUSIONS: In grade III or IV PUs, treatment using first calcium alginate dressings and then hydrocolloid dressings promotes faster healing than treatment with hydrocolloid dressings alone.

Complaints of informal caregivers providing home care for dementia patients: the Pixel study.

Abstract: Context Prospective study of the complaints, problems and requirements of the main caregiver providing home care for dementia patients. Objectives To determine the complaints of home caregivers, how they are interrelated and what causes them. Resources Self-administered questionnaire of 42 questions on the patient and caregiver, including a list of complaints, given to the main caregiver. Medical questionnaire on the patient filled in by the attending physician, usually a specialist, freelance or salaried doctor. Results 408 sets of records were compiled, concerning 236 demented women (77.1 ± 0.47 years) and 172 demented men (75.7 ± 0.57 years). In two-thirds of cases, the main caregiver was a woman aged 60.6 ± 0.79 years. Female caregivers were more vulnerable than male caregivers. The most frequent caregiver complaint, regardless of the stage of the disease, concerned loss of motivation and withdrawal. The patient's awareness of the disorder was accompanied by a reduction in motor dysfunction and aggressiveness, but associated with a higher frequency of the complaint regarding loss of motivation reported by the caregiver. The caregivers' problems concerned mainly the absence of relief and the impossibility of having any time to themselves. Caregivers' requests for information concerned medical information, care structures and day care facilities. Discussion The attending physician comes into close contact with the patient, but must take into account the patient's environment. The physician can provides a separate analysis to the caregiver and does not completely answer to certain family questions or needs. He or she is not the family's prime source of information. The caregivers' requirements relate to the areas that are the attending physician's responsibility: the development and characteristics of the disease. The caregiver is anxious about the patient's future and is trapped by his or her involvement in the care, suffering greatly from the lack of relief. Conclusions It is necessary to change the focus of home care for dementia patients to fit the context in which they live and to allow for periods of relief for home caregivers. Copyright © 2002 John Wiley & Sons, Ltd.

Alzheimer's disease and brain infarcts in the elderly. Agreement with neuropathology.

Abstract: Clarifying the etiology of dementia is one of the most difficult diagnostic challenges, especially in the elderly. We examined the accuracy of clinical criteria to distinguish Alzheimer's disease (AD) and dementia associated with infarcts of the brain, either isolated (vascular dementia) or associated with degenerative lesions (mixed dementia). We carried out a prospective clinico-neuropathological study in a selected series of hospitalized patients. We evaluated the clinical aspects of 33 patients aged over 75 years by use of the criteria and scores of DSMIII, NINCDS-ADRDA, Loeb and Gandolfo, ADDTC and NINDS-AIREN and the Hachinski Ischemic Score. The neuropathological diagnosis was considered to be the gold standard. When comparing clinical criteria and neuropathology, the agreement was moderate for Hachinski's score (0.50) and Loeb's score (0.43) and substantial for the ADDTC (0.63) and the NINDS-AIREN (0.67). When mixed dementias were excluded, the agreement between all clinical criteria and scores and the pathological diagnosis rose to 0.88. Hachinski's score was the most sensitive (0.89) and the NINDS-AIREN the most specific (0.86) for the diagnosis of vascular dementia. In conclusion, all sets of clinical criteria distinguished pure AD from vascular dementia with a high accuracy whereas mixed dementia was clinically under-recognized. The NINDS-AIREN criteria were the most discriminating for the accurate identification of patients with mixed dementia.

Arterial Wall Production of Cytokines in Giant Cell Arteritis Results of a Pilot Study Using Human Temporal Artery Cultures

Abstract: BACKGROUND Giant cell arteritis (GCA) is a subacute periarteritis predominantly affecting segments of the external carotids of elderly patients. Vasculitic lesions in GCA samples might be characterized by in situ production of cytokines mRNA, indicative of macrophage and T-cell activation. However, whether the cytokine production of vessels with arteritis differs from that of vessels exposed to inflammatory conditions that originate peripheral to the vessel remains unknown. METHODS We investigated cytokine and soluble receptor cytokine production in blood samples and cultures of human temporal arteries from 22 consecutive patients (mean age 77 +/- 6 years) further investigated for possible diagnosis of GCA: 7 patients had GCA and 15 had neither GCA nor vasculitis but had other inflammatory, infectious, or malignant diseases (controls). The production of cytokines and soluble cytokine receptors in the supernatants of cultures of 3-mm segments of temporal artery specimens, before and after lipopolysaccharide (LPS) stimulation (10 ng/ml and 10 microg/ml) and in serum, was quantified using sandwich enzyme-linked immunosorbent assay (ELISA). RESULTS Cytokine production by temporal arteries increased significantly and in a dose-dependent manner (p <.01) after LPS stimulation in all patients studied, suggesting that the system is methodologically functional. Despite a large interindividual variation, we found similar differences in cytokine production before and after stimulation by 10 ng/ml and 10 microg/ml LPS between both groups: temporal arteries of GCA patients produced more interleukin (IL)-1beta (p <.05) and IFNgamma (nonsignificant) and less tumor necrosis factor (TNF)alpha (p <.05) and IL-6 (nonsignificant) than temporal arteries of controls. The levels of TNFalpha (p <.05) and IL-6 soluble receptor (p <.05) were significantly lower in GCA patients as compared with controls in blood samples, whereas levels of cytokines in temporal artery and in blood samples were not significantly correlated at the individual level in both groups. CONCLUSIONS The present pilot study, which requires further confirmation on a larger number of well-defined patients with GCA, suggests that a specific arterial cytokine production profile might exist in GCA (high IL-1beta +/- IFNgamma and low TNFalpha), addresses the question of the mechanisms by which IL-1beta and TNFalpha might be differentially regulated at the level of the arterial cell wall, and supports the view that cultures of the temporal artery might be an interesting tool for evaluating the role of cytokines in GCA pathogenesis.

Convergences d'un groupe pluridisciplinaire d'experts français sur les Unités de Soins Alzheimer

Abstract: Un groupe pluridisciplinaire d'experts s'est reuni afin d'enoncer des convergences sur le projet de soins en unite Alzheimer. Les minutes du premier congres francais sur les Unites Alzheimer ont servi de support a leur discussion. La maladie d'Alzheimer necessite une prise en charge specifique au sein de structures adaptees : diagnostic precoce de qualite, prise en charge de la pathologie dementielle et de ses complications, gestion des pathologies aigues associees, aide aux aidants et soutien des soignants. Deux types d'unites Alzheimer sont definis : unite de soins aigus en court sejour geriatrique et unite de vie au sein d'une institution. Cinq criteres communs ont ete retenus : 1- une population ciblee ; 2- un environnement architectural adapte et dynamisant, alliant securite et liberte, permettant de minimiser les troubles du comportement et facilitant la prise en soins ; 3- un personnel forme et soutenu ; 4- un projet de soins et de vie specifique, prenant en compte l'individualite du patient dans un respect constant de sa dignite ; 5- la participation et le soutien de la famille. Les benefices apportes par ces unites et l'absence de surcout ont ete objectives. Les dernieres mesures decidees par les pouvoirs publics ne leur ont pas fait une place claire ; il faut laisser le temps aux decideurs et aux acteurs du soin d'integrer ce concept d'unite Alzheimer, dont la mise en place est necessaire et possible.

La perte de poids dans la maladie d'Alzheimer

Abstract: La perte de poids involontaire et la malnutrition proteino-energetique est une complication desormais reconnue de la maladie d'Alzheimer. Elle se manifeste precocement a un stade debutant de la maladie ou meme avant le debut des troubles cognitifs ou le diagnostic selon certaines enquete. Une denutrition franche concerne environ 40% des patients au stade modere. Plusieurs mecanismes pourraient etre impliques dans la perte de poids et leurs roles respectifs sont mal connus : augmentation des besoins energetiques, perte d'autonomie pour s'alimenter, troubles du comportement alimentaire, atrophie du cortex mesial temporal, troubles de la regulation centrale du poids corporel. La reconnaissance precoce de la malnutrition proteino-energetique est basee sur la surveillance mensuelle du poids. En l'absence de surveillance ponderale, le diagnostic peut etre base sur les criteres de malnutrition : diminution des ingesta, voire anorexie, indice de masse corporelle abaisse, score au Mini Nutritional Assessment altere, marqueurs biologiques de la denutrition abaisses. En presence de signes de malnutrition proteino-energetique, il faut une enquete clinique et paraclinique soigneuse pour rechercher les causes modifiables de perte de poids. La prise en charge comporte le traitement des facteurs etiologiques modifiables, le renforcement de l'aide pour s'alimenter, l'augmentation des apports energetiques par des collations et des supplements dietetiques. La prevention est essentielle : l'education de l'aidant familial principal s'est montree efficace pour prevenir ou ralentir la perte de poids des patients Alzheimer. La surveillance du poids permet de reconnaitre cette complication a un stade precoce et d'optimiser la prise en charge.

Proximologie: Premières études: Les aidants informels prenant en charge des déments à domicile: Etude pixel: Une enquête auprès de 569 aidants non-professionnels de patients atteints de démences séniles

Abstract: Contexte : Etude prospective sur les plaintes, les difficultes et les demandes de l'aidant principal de dements vivants a domicile. Objectifs : Determiner l'objet des plaintes des aidants a domicile, leurs interrelations et leurs causes. Moyens : Auto-questionnaire sur le malade et l'aidant, comportant une grille de plaintes, donne a l'aidant principal (42 questions). Questionnaire medical sur le malade, rempli par le medecin traitant, principalement specialiste, liberal ou salarie. Resultats : 569 dossiers ont ete colliges, concernant 355 femmes (79,5 ± 7,7 ans) et 212 hommes (76,3 ± 7,5 ans) dements. Dans les deux-tiers des cas, l'aidant principal est une femme, âgee de 60,1 ± 12,1 ans. La plainte de l'aidant la plus frequente concerne la demotivation et le repli sur soi du malade. Les difficultes propres a l'aidant concernent principalement l'absence de repit et l'impossibilite de mener des activites personnelles. La demande des aidants en matiere d'information concerne le domaine medical, et en matiere de structures de soins, l'accueil de jour. Discussion : L'aidant est inquiet pour l'avenir du malade. Il est pris au piege de son engagement dans les soins et manque cruellement de repit. Il souhaite mieux connaitre l'evolution et les caracteristiques de la maladie, pour ameliorer la prise en charge du malade et sa propre qualite de vie. Conclusions : Il est necessaire d'adapter la prise en charge des dements a domicile en prenant la mesure de l'aide informelle dont ils beneficient. Une reponse plus adequate des attentes et des besoins de l'entourage, ainsi que le developpement d'espaces de repit s'averent necessaires si l'on souhaite maintenir sur le long terme la qualite de la prise en charge a domicile des demences degeneratives, et notamment de la maladie d'Alzheimer