Cyrille P. Launay

Gait variability at fast-pace walking speed: A biomarker of mild cognitive impairment?

BackgroundThe interpretation of the increase in stride-to-stride variability of stride time (STV) regarding the evolution of cognitive deficits across the dementia spectrum is matter of debate.ObjectiveThe aim of this study was to compare STV at usual and fast-pace walking speeds of MCI patients with that of cognitively healthy individuals (CHI) and Alzheimer’s disease (AD) patients with mild dementia, while considering the effects of potential confounders.MethodsSTV while walking at usual and fast-pace walking speeds was recorded with the GAITRite® system from 116 older adults (mean age 75.6±6.5 years; 55.2% female) divided into 3 groups according to their cognitive status (44 CHI, 39 MCI patients and 33 AD patients with mild dementia).ResultsThe full adjusted multiple linear regression models showed that high STV was associated with slow gait speed at usual-pace walking speed (P=0.002) and with the MCI status at fast-pace walking speed (P=0.015).ConclusionsHigh STV at fast-pace walking speed was a specific gait disturbance of MCI patients in the sample of studied participants, and thus could be used in the future as a specific biomarker of MCI patients.

Association of depressive symptoms with recurrent falls: a cross-sectional elderly population based study and a systematic review

BackgroundScreening of depressive symptoms is recommended in recurrent fallers. Compared to the 30-item and 15-item Geriatric Depression Scales (GDS), the 4-item GDS is easier to administer and quicker to perform. The association between abnormal 4-item GDS score and recurrent falls has not yet been examined, hi addition, while depressive symptoms-related gait instability is well known, the association with recurrent falls has been few studied.Objective1) To examine the association between abnormal 4-item GDS score and recurrent falls in community-dwelling older adults using original data from health examination centers (HEC) of French health insurance of Lyon, and 2) to perform a systematic review of studies that examined the association of depressive symptoms with recurrent falls among older adults.MethodsFirstly, based on a cross-sectional design, 2,594 community-dwellers (mean age 72.1±54years; 49.8% women) were recruited in HEC of Lyon, France. The 4-item GDS score (abnormal if score>l) and recurrent falls (i.e., 2 or more falls in the past year) were used as main outcomes. Secondly, a systematic English and French Medline literature search was conducted on May 28, 2012 with no limit of date using the following Medical Subject Heading (MeSH) terms “Aged OR aged, 80 and over”, “Accidental falls”, “Depressive disorder” and “Reccurence”. The search also included the reference lists of the retrieved articles.ResultsA total of 19.0% (n=494) participants were recurrent fallers in the cross-sectional study. Abnormal 4-item GDS score was more prevalent among recurrent fallers compared to non-recurrent fallers (44.7% versus 25.0%, with P<0.001), and was significantly associated with recurrent falls (Odd ratio (OR)=1.82 with P<0.001 for full model; OR=1.86 with P<0.001 for stepwise backward model). In addition to the current study, the systematic review found only four other studies on this topic, three of them examining the association of depressive symptoms with recurrent falls using 30-item or 15-item GDS. All studies showed a significant association of depressive symptoms with recurrent falls.ConclusionsThe current cross-sectional study shows an association between abnormal 4-item GDS score and recurrent falls. This association of depressive symptoms with recurrent falls was confirmed by the systematic review. Based on these results, we suggest that recurrent falls risk assessment should involve a systematic screening of depressive symptoms using the 4-item GDS.

Hippocampal volume, early cognitive decline and gait variability: Which association?

BACKGROUND In contrast to its prominent function in cognition, the involvement of the hippocampus in gait control is still a matter of debate. The present study aimed to examine the association of the hippocampal volume with mean values and coefficients of variation (CoV) of spatio-temporal gait parameters among cognitively healthy individuals (CHI) and patients with mild cognitive impairment (MCI). METHODS A total of 90 individuals (47 CHI with a mean age of 69.7±3.6years and 48.9% women, and 43 MCI individuals with a mean age of 70.2±3.7years and 62.8% women) were included in this cross-sectional study. The hippocampal volume was quantified from a three-dimensional T1-weighted MRI using semi-automated software. Mean values and CoV of stride time, swing time and stride width were measured at self-selected pace with a 10m electronic portable walkway (GAITRite®). Age, gender, body mass index, number of drugs daily taken, Mini-Mental State Examination (MMSE) score, history of falls, walking speed and white matter signal-intensity abnormality scoring with Manolio scale were used as covariates. RESULTS Patients with MCI had a lower MMSE score (P<0.001), a higher CoV of stride time (P=0.013) and a lower hippocampal volume (P=0.007) compared with CHI. Multiple linear regression models showed that CoV of stride time was specifically associated with higher hippocampal volume among CHI (P<0.05) but not among patients with MCI (P>0.650). CONCLUSIONS Our findings revealed a positive association between a greater (i.e., better morphological structure) hippocampal volume and a greater (i.e., worse performance) stride time variability among CHI, but not among MCI individuals.

Derivation and validation of a Short Form of the Mini-Mental State Examination for the screening of dementia in older adults with a memory complaint

To validate a Short Form of the Mini‐Mental State Examination (SMMSE) as a screening test for dementia in older ambulatory individuals followed in a memory clinic for a memory complaint.

Development of a short form of Mini-Mental State Examination for the screening of dementia in older adults with a memory complaint: a case control study

BackgroundPrimary care physicians need a brief and accurate screening test of dementia. The objective of this study was to determine whether a short form of Mini-Mental State Examination (SMMSE) was as accurate as the Mini-Mental State Examination (MMSE) in screening dementia.MethodsBased on case control design study, SMMSE and MMSE were assessed in 184 community-dwelling older adults (mean age 81.3 ± 6.5 years, 71.7% women) with memory complaint sent by their primary care physician to a memory clinic. Included participants were separated into two groups: cognitively healthy individuals and demented individuals.ResultsThe trade-off between sensitivity and specificity of the SMMSE for clinically diagnosed dementia was 4. Based on the cut-off value ≤ 4 for SMMSE and a cut-off value ≤ 24 for MMSE, the sensitivity of both tests was similar (89.5% for SMMSE versus 90.0% for MMSE), whereas the specificity, the positive predictive values (PPV) and the negative predictive values (NPV) were higher for SMMSE compared to MMSE (85.4 versus 75.5% for specificity; 95.5% versus 92.8% for PPV; 70.0 versus 68.9 for NPV). The positive and negative Likehood Ratio (LR) of SMMSE were higher than those of MMSE (respectively, 6.1 versus 3.7; 8.1 versus 7.7). In addition, odds ratio (OR) for dementia was higher for the SMMSE compared to the MMSE (OR = 49.8 with 95% confident interval (CI) [18.0; 137.8] versus OR = 28.6 with 95% CI [11.6; 70.3]).ConclusionsSMMSE seems to be an efficient short screening test for dementia among community-dwelling older adults with a memory complaint. Further research is needed to confirm its predictive values among unselected primary care older patients.

Do not resuscitate orders and aging: impact of multimorbidity on the decision-making process.

BackgroundThe “Do Not Resuscitate” orders (DNR) are defined as advance medical directives to withhold cardiopulmonary resuscitation during cardiac arrest. Age-related multimorbidity may influence the DNR decision-making process. Our objective was to perform a systematic review and meta-analysis of published data examining the relationship between DNR orders and multimorbidity in older patients.MethodsA systematic Medline and Cochrane literature search limited to human studies published in English and French was conducted on August 2012, with no date limits, using the following Medical Subject Heading terms: “resuscitation orders” OR “do-not-resuscitate” combined with “aged, 80 and over” combined with “comorbidities” OR “chronic diseases”.ResultsOf the 65 selected studies, 22 met the selection criteria for inclusion in the qualitative analysis. DNR orders were positively associated with multimorbidity in 21 studies (95%). The meta-analysis included 7 studies with a total of 27,707 participants and 5065 DNR orders. It confirmed that multimorbidity were associated with DNR orders (summary OR = 1.25 [95% CI: 1.19–1.33]). The relationship between DNR orders and multimorbidity differed according to the nature of morbidities; the summary OR for DNR orders was 1.15 (95% CI: 1.07–1.23) for cognitive impairment, OR=2.58 (95% CI: 2.08–3.20) for cancer, OR=1.07 (95% CI: 0.92–1.24) for heart diseases (i.e., coronary heart disease or congestive heart failure), and OR=1.97 (95% CI: 1.61–2.40) for stroke.ConclusionsThis systematic review and metaanalysis showed that DNR orders are positively associated with multimorbidity, and especially with three morbidities, which are cognitive impairment, cancer and stroke.

Quantified Self and Comprehensive Geriatric Assessment: Older Adults Are Able to Evaluate Their Own Health and Functional Status

Background There is an increased interest of individuals in quantifying their own health and functional status. The aim of this study was to examine the concordance of answers to a self-administered questionnaire exploring health and functional status with information collected during a full clinical examination performed by a physician among cognitively healthy adults (CHI) and older patients with mild cognitive impairment (MCI) or mild-to-moderate Alzheimer disease (AD). Methods Based on cross-sectional design, a total of 60 older adults (20 CHI, 20 patients with MCI, and 20 patients with mild-to-moderate AD) were recruited in the memory clinic of Angers, France. All participants completed a self-administered questionnaire in paper format composed of 33 items exploring age, gender, nutrition, place of living, social resources, drugs daily taken, memory complaint, mood and general feeling, fatigue, activities of daily living, physical activity and history of falls. Participants then underwent a full clinical examination by a physician exploring the same domains. Results High concordance between the self-administered questionnaire and physicians clinical examination was showed. The few divergences were related to cognitive status, answers of AD and MCI patients to the self-administered questionnaire being less reliable than those of CHI. Conclusion Older adults are able to evaluate their own health and functional status, regardless of their cognitive status. This result needs to be confirmed and opens new perspectives for the quantified self-trend and could be helpful in daily clinical practice of primary care.

Motor imagery of gait: a new way to detect mild cognitive impairment?

Objectives1) To measure and compare the time required to perform (pTUG) and the time required to imagine (iTUG) the Timed Up & Go (TUG), and the time difference between these two tasks (i.e., TUG delta time) in older adults with cognitive decline (i.e., mild cognitive impairment (MCI) and mild-to-moderate Alzheimer disease and related disorders (ADRD)) and in cognitively healthy individuals (CHI); and 2) to examine any association between the TUG delta time and a cognitive status.MethodsSixty-six participants (24 CHI, 23 individuals with MCI, and 19 individuals with ADRD) were recruited in this cross-sectional study. The mean and standard deviation of the pTUG and iTUG completion times and the TUG delta time, as well as age, gender, and Mini-Mental State Examination (MMSE) scores were used as outcomes. Participants were separated into three groups based on the tertilization of TUG delta time: lowest (<13.6%; n = 22; best performance), intermediate (13.6-52.2%; n = 22), and highest tertile (>52.2%; n = 22, worst performance).ResultsFewer CHI were in the group exhibiting the highest tertile of TUG delta time compared to individuals with lowest and intermediate TUG delta times (p = 0.013). Being in the highest tertile of the TUG delta time was associated with cognitive decline in the unadjusted model (p = 0.012 for MCI, and p = 0.021 for mild-to-moderate ADRD). In the multivariate models, this association remained significant only for individuals with MCI (p = 0.019 while adjusting for age and gender; p = 0.047 while adjusting for age, gender, and MMSE score; p = 0.012 for the stepwise backward model).ConclusionsOur results provide the first evidence that motor imagery of gait may be used as a biomarker of MCI in older adults.

Who is at risk of long hospital stay among patients admitted to geriatric acute care unit? Results from a prospective cohort study

Objective1) To confirm that vitamin D deficiency, defined as serum 25-hydroxyvitamin D (25OHD) concentration < 25nmol/L, was associated with long length-of-stay (LOS) among older inpatients admitted to geriatric acute care unit; and 2) to examine which combination of risk factors of longer LOS including vitamin D deficiency best predicted longer LOS.Study design and settingBased on a prospective cohort study with a 25-day follow-up on average, 531 consecutive older inpatients (mean age 85.0±7.2 years, 59.1% women) admitted to the geriatric acute care unit of Angers University Hospital, France, were included.ResultsLinear regression models showed that male gender (P<0.025), delirium (P<0.015) and vitamin D deficiency (P<0.001) were independently associated with a longer LOS. The highest risk of a longer LOS was shown while combining vitamin D deficiency with male gender (Odds ratio (OR)=3.70 with P<0.001). The risk increased significantly while delirium was associated with these two baseline characteristics (OR=4.76 with P=0.001). Kaplan-Meier distributions of discharge differed significantly between participants who had or not the combination of the 3 criteria (P<0.007).ConclusionsVitamin D deficiency, delirium and male gender were significant risk factors for a longer LOS in the studied sample of older inpatients.

Does Memantine Improve the Gait of Individuals with Alzheimer's Disease?

no. 681. 7. Simor AE. Diagnosis, management, and prevention of Clostridium difficile infection in long-term care facilities: A review. J Am Geriatr Soc 2010;58:1556–1564. DOES MEMANTINE IMPROVE THE GAIT OF INDIVIDUALS WITH ALZHEIMER’S DISEASE? To the Editor: Memantine is a drug for the treatment of individuals with moderate to severe Alzheimer’s disease (AD) that has a beneficial effect on global cognitive function. The uncompetitive moderate-affinity antagonism of the N-methyl-D-aspartate (NMDA) receptor modulating the glutamatergic transmission explains this cognitive effect. Memantine also acts as an agonist at the dopamine D2 receptor and thus may improve motor function. 1 Unlike acetylcholinesterase inhibitors (ACEIs), the effect of memantine on gait performance has not yet been examined in AD patients. It was hypothesized that memantine could improve higher levels of gait control through a combined effect on the glutamatergic and dopaminergic systems. The aim of this study was to quantify mean values and coefficients of variation (CoV) of stride time (a marker of higher levels of gait control) in people with AD before and after the use of memantine and to compare these values with those of ageand sex-matched people with AD not taking any antidementia drug. Between June 2009 and November 2010, 17 people with AD (mean age: 83.8 ± 5.8; 52.9% women) who had never taken any antidementia drug were included in this study. They received memantine 20 mg once daily in the morning (titrated in 5-mg increments over 4 weeks) for 211.0 ± 78.2 days. Thirty-two ageand sex-matched people with AD not taking any antidementia drug (mean age: 80.0 ± 6.6; 56.3% women; mean follow-up 211.0 ± 108.9 days) were prospectively included in this cohort study. All included participants were outpatients with AD followed in the memory clinic of Angers University Hospital, Angers, France. The diagnosis of AD was made according to criteria from the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition. Participants with renal failure, acute medical illness in the past month, or severe orthopedic problem, and those using walking aids or taking ACEIs were excluded. Mean (ms) and CoV of stride time (%) ((mean/standard deviation) 9 100) were measured using the GAITRite system (GAITRite Gold walkway, 972 cm long, active electronic surface area 792 x 610 cm, with a total of 29,952 pressure sensors, scanning frequency 60 Hz, software version 3.8, CIR System, Havertown, PA) according to the European guidelines for gait analysis. The local ethical committee of Angers, France, approved the study protocol. Comparisons were made using Whitney U-test, or Wilcoxon matched-pairs signed-ranks test, as appropriate. Multiple linear regressions were performed to specify the association between stride time parameters (mean value, CoV) (dependent variable) and the use of memantine (independent variable) adjusted for baseline characteristics (age, sex, Mini-Mental State Examination (MMSE) score, mean value of stride time parameter at baseline assessment). P < .05 was considered statistically significant. All analyses were performed using SPSS version 15.0 (SPSS, Inc., Chicago, IL). The CoV of stride time was lower at follow-up assessment (3.6 ± 1.3) than at baseline (6.3 ± 6.1) in the memantine group (P = .04) (Table 1). There was no other significant difference between the baseline and follow-up assessments and no significant between-group difference except for MMSE scores. The memantine group had lower MMSE scores at baseline and follow-up assessments than the control group (P < .001) (Table 1). The delay between baseline and follow-up assessment did not differ between groups (P = .59). Multiple linear regressions showed that a high mean value of stride time at follow-up assessment was associated with a high mean value of stride at baseline (b = 0.33, 95% confidence interval (CI) = 0.07–0.58, P < .01 for fully adjusted model; b = 0.27, 95% CI = 0.04–0.51, P = .02 for stepwise backward model), whereas the use of memantine was associated with low CoV of stride time at follow-up assessment (b = 5.67, 95% CI = 10.08 to 1.25, P = .01 for fully adjusted model; b = 5.44, 95% CI = 9.95 to 0.93, P = .02 for stepwise backward model). There was no other significant association between stride time parameters (mean value, CoV) and baseline characteristics (age, sex, MMSE score). JAGS NOVEMBER 2011–VOL. 59, NO. 11 LETTERS TO THE EDITOR 2181