Thierry Constans

Epilepsy and Dementia in the Elderly

Epilepsy is a frequent condition in the elderly; however, it remains a relatively understudied condition in older adults with dementia. The diagnosis of a seizure is particularly difficult and is most often based on questions to the caregiver. Epilepsy in dementia has significant consequences on the prognosis of the underlying dementia: it can result in a worsening of cognitive performance, particularly in language, as well as a reduction in autonomy, a greater risk of injury and a higher mortality rate. In this review, management strategies are recommended for the clinician. The presence of pre-existing Alzheimer’s disease does not exempt the clinician from ruling out other symptomatic causes of seizures. Anti-epileptic drugs (AED) should be started only after the diagnosis has been clearly established, when the risk of recurrence is high, and with monotherapy whenever possible. Although few data are available, the more recent AED offer significant advantages over the older medications in this context.

Outcome of older patients requiring ventilatory support in intensive care: impact of nutritional status.

OBJECTIVES: To determine predictors of mortality in the intensive care unit (ICU) and at 6 months after discharge; to assess the lifestyles of survivors 6 months after discharge.

Subcutaneous infusion or hypodermoclysis: a practical approach.

The aim of this practical review was to revalidate subcutaneous infusion or hypodermoclysis in the older subject and to set out its indications and limitations, its contraindications, and its techniques and methods of surveillance. Hypodermoclysis is an effective technique for the prevention or cure of moderate dehydration, although it cannot be used in place of intravenous infusion in cases of severe dehydration. Hypodermoclysis is simple and safe. It is the least aggressive of infusion techniques and thus avoids hospital, admission and reduces health costs. Infusion of a solution of amino acids can also limit the consequences of low protein intake for a short period of time, but it will not cure severe malnutrition. The many advantages and the few disadvantages of this technique should encourage its wider use in geriatrics.

Review of Cerebral Microangiopathy and Alzheimer’s Disease: Relation between White Matter Hyperintensities and Microbleeds

Although Alzheimer’s disease (AD) is basically considered to be a neurodegenerative disorder, cerebrovascular disease is also involved. The role of vascular risk factors and vascular disease in the progression of AD remains incompletely understood. With the development of brain MRI, it is now possible to detect small-vessel disease, whose prevalence and severity increase with age. The first types of small-vessel disease to be described were white matter hyperintensities (WMHs). More recently, small areas of signal loss on T2*-weighted images, also called microbleeds (MBs), have been reported. Cerebral MBs are focal deposits of hemosiderin that indicate prior microhemorrhages around small vessels, related to either ruptured atherosclerotic microvessels or amyloid angiopathy. Consequently, using brain MRI for the detection of microangiopathy may prove useful to improve our understanding of the impact of the vascular burden in AD pathology. The relationship between microangiopathy and the clinical course of AD or the conversion of mild cognitive impairment to AD remains questionable in terms of cognitive or affective symptoms, particularly if we consider MBs.

Comparison of Subcutaneous and Intravenous Administration of a Solution of Aminoacids in Older Patients

OBJECTIVE: To compare the plasma amino acid (AA) concentrations obtained by the infusion of an AA solution (660 mOsm/L, pH 7) using the subcutaneous (SC) with that using the intravenous (IV) route in older patients.

Outcome of elderly patients requiring ventilatory support in intensive care

The objectives of the study were: 1) to evaluate mortality in elderly patients requiring ventilatory support in Intensive Care Unit (ICU) and at 6, 12 and 18 months after discharge from ICU; 2) (main objective) to determine predictors of mortality in ICU and after discharge; and 3) to assess the life- style of survivors. One hundred and ten consecutive hospitalized patients ⩾70 years were included in this retrospective study. Follow- up evaluation was conducted by telephone interview. Mortality in ICU and after discharge was the outcome variable. Fifteen parameters were recorded at admission and during hospitalization. Residence, health status, and self- sufficiency were evaluated after discharge. 1) Mortality in ICU and at 6, 12 and 18 months after discharge was 38%, 60%, 63% and 67% respectively. 2) The predictors of mortality in ICU were admission in shock, and use of major therapeutic interventions. Predictors of mortality at 6 months were admission in shock, previous impaired health status and marital status. 3) Eighteen months after discharge 92% of the surviving patients (N=33) had the same residence, 75% had the same health status, and 78% had the same autonomy compared with pre- admission status. We concluded that shock and previous health status but not age are predictors of short- and long- term prognoses in elderly patients hospitalized in ICU for mechanical ventilation. (Aging Clin. Exp. Res. 7: 221–227, 1995)

Emergence of community-acquired Clostridium difficile infection: the experience of a French hospital and review of the literature

BACKGROUND Clostridium difficile infection (CDI) is a common cause of nosocomial diarrhoea. People in the general community are not usually considered to be at risk of CDI. CDI is associated with a high risk of morbidity and mortality. The risk of severity is defined by the Clostridium Severity Index (CSI). METHODS The cases of 136 adult patients with CDI treated at the University Hospital of Tours, France between 2008 and 2012 are described. This was a retrospective study. RESULTS Among the 136 patients included, 62 were men and 74 were women. Their median age was 64.4 years (range 18-97 years). Twenty-six of the 136 (19%) cases were community-acquired (CA) and 110 (81%) were healthcare-acquired (HCA). The major risk factors for both groups were long-term treatment with proton pump inhibitors (54% of CA, 53% of HCA patients) and antibiotic treatment within the 2.5 months preceding the CDI (50% of CA, 91% of HCA). The CSI was higher in the CA-CDI group (1.56) than in the HCA-CDI group (1.39). Intensive care was required for 8% of CA-CDI and 16.5% of HCA-CDI patients. CONCLUSIONS CDI can cause community-acquired diarrhoea, and CA-CDI may be more severe than HCA-CDI. Prospective studies of CDI involving people from the general community without risk factors are required to confirm this observation.

REVERSIBLE COGNITIVE AND NEUROLOGICAL SYMPTOMS DURING VALPROIC ACID THERAPY

To the Editor: An 81-year-old man with a history of left pneumonectomy for epidermoid carcinoma of the breast in 1998, hypertension (treatment with nicardipine 100 mg/d), and endoscopic prostate resection for cancer in 1987, presented with two generalized tonic-clonic seizures between January and May 2000. Brain computed tomography (CT) scan showed vascular hypodensities in left cerebellum hemisphere and leukoaraiosis. Treatment with 250 mg valproic acid (VPA) twice daily was introduced. Two months later, he complained of a disturbance in memory and a slowing of psychomotor functions. Because he experienced three tonic-clonic seizures during the year after the introduction of VPA, the dosage was increased using progressive titration: 750 mg/d, then 1,000 mg/d, and finally 1,250 mg/d. The patient progressively complained of tremor, sleepiness, vertigo, constipation, and cognitive impairment comprising bradypsychia and difficulties in memory. The physical examination failed to reveal any focal neurological signs or extrapyramidal syndrome. VPA dosage was reduced to 1,000 mg/d. Unfortunately, the seizures recurred, and the dosage had to be increased to 1,250 mg/d once again. Although the seizures were now controlled, he presented with anorexia, gait ataxia, and an increase in postural tremor associated with cognitive slowing and a mood disorder. A new brain CT and magnetic resonance imaging showed cortical atrophy and no more vascular lesion. Blood VPA concentration was within normal limits (50–100 mg/ L). Laboratory studies were normal, including a normal blood cell count and no hepatic or renal dysfunction. There was no evidence of paraneoplastic encephalitis, and central nervous system antibodies were not detected. An electroencephalogram was normal, with no evidence suggesting encephalopathy. VPA was replaced by lamotrigine, introduced slowly over 2 months to a dosage of 50 mg twice daily. The gait disorder, tremor, and cognitive complain progressively disappeared after the withdrawal of VPA. Three months later, while taking lamotrigine 50 mg twice daily, the seizures remained controlled, and the patient had recovered his normal daily activities; he was able to go shopping, drive his car again, and take care for his wife who had sustained a vertebral fracture after falling. VPA is an antiepileptic drug widely used in children and adults with partial or secondary generalized seizures. It is generally considered to be well tolerated. However, a number of dose-dependent adverse effects have been reported including gastrointestinal symptoms, heartburn, and fine hand tremor. Recently, some authors have described cognitive and neurological symptoms in older patients treated with VPA, independent of dosage. In our case, symptoms had an insidious and progressive onset and occurred over a number of weeks to several years. There was no argument in favor of VPA overdose, and serum levels were in the therapeutic range. Improvement was obtained only after complete discontinuation of VPA, not with a reduction in dosage. The mechanism of these adverse neurological effects remains unknown, although a number of conditions, such as vascular ischemic disorder, may be suspected. Epilepsy frequently occurs in elderly people. VPA does not induce an increase in hepatic drug–metabolizing enzymes and is considered to have a good cognitive behavioral profile, but clinicians should keep in mind that elderly people are especially vulnerable to cognitive impairment. Clinicians should remain wary of cognitive or neurological symptoms, because they can erroneously be considered to be due to degenerative dementia. When cognitive or neurological symptoms develop in patients receiving VPA, discontinuation of the drug should be considered.

Epileptic seizures in clinically diagnosed Alzheimer's disease: report from a geriatric medicine population.

A diagnosis of Alzheimer’s disease (AD) is associated with an increased risk of unprovoked seizures. In this observational study, we analyzed first seizures in a sample of elderly subjects with AD hospitalized in an acute geriatric care unit. Only 2.5% of the hospitalized AD patients were admitted for a first seizure. The seizures are not necessarily symptomatic of AD. Symptomatic cause must be ruled out in order to classify the syndrome before introducing antiepileptic drugs (AEDs). In practice, only recurrent unprovoked seizures or symptomatic location-related epilepsy with a high risk of recurrence should be treated with AEDs.

Vitamin D and cognition in the elderly

The understanding of the role of vitamin D in maintaining good health has considerably increased in the recent years. There is a growing evidence that vitamin D has not only a beneficial effect to prevent osteoporosis and the risk of falls in the elderly, but also may reduce incidence of cancers, infections, autoimmune, cardiovascular and neurologic diseases, and psychiatric disorders. Laboratory studies yield a biological plausibility for a positive contribution of vitamin D to brain functions: vitamin D receptor and 1,α-hydroxylase, the terminal calcitriol-activating enzyme, are widely distributed in both the fetal and adult brain. Vitamin D may be involved in neuroprotection, control of proinflammatory cytokine induced cognitive dysfunction and synthesis of calcium-binding proteins and neurotransmitter acetylcholine. However, the observational studies conducted in humans are still inconclusive, given the various tests of the cognitive functions that have been used, the performance of the studies either in patients or in healthy subjects, and different designs and/or confounding factors. The role of the vitamin D receptor in the pathophysiology of cognitive decline, incidence of Alzheimers disease or vascular dementia and/or cognitive decline with respect to previous plasma 25OHD concentration, and the effect on cognition of vitamin D supplementation should be explored in further studies.