One hundred unrelated patients with type IIa hyperlipoproteinemia have been investigated for their HLA-A and B antigens and compared to 171 normal controls. This study does not support the significant increase of HLA-B17 and Bw35 previously reported by others.

Cognitive disorders and falls: experience of the Lille multidisciplinary falls service. E. Maeker, S. Bombois, V. Pardessus, F. Tiberghien, C. DiPompeo, A. Thevenon, P. Dewailly, F Puisieux, Rev Neurol (Paris) 2005; 161:4,419-426 Background. Falls and dementia are two major public health problems which concern the elderly population. Cognitive impairment, as a result of Alzheimer's disease or non-Alzheimer dementia, is recognized as a risk factor for falling. Through the experience of the Multidisciplinary Falls Consultation, our aims were first, to evaluate the prevalence of a cognitive decline among outpatients who consult for falls, and second, to determine whether the cognitive impairment was known and diagnosed before the consultation or not. Methods. Data concerning the first 300 out patients who completed the initial evaluation are reported. Each patient was assessed by a geriatrician, a neurologist, and a physiatrist, who visited him or her at home. Cognitive impairment was defined as a Mini-Mental State Examination (MMSE) score < 24. Results. Of the 300 patients, 228 patients completed the initial evaluation. Among them, 97 (42.5 percent) had a MMSE score < 24; 55 had mild stage dementia (MMSE score between 23 and 18) and 42 were at a moderate or severe stage (MMSE score : 17130). The cognitive decline was not diagnosed before the consultation in 80 of the 97 patients (82 percent). Conclusion. The findings show that a large proportion of old persons presenting with gait disturbance at the Multidisciplinary Falls Consultation have an underlying cognitive decline. Assessment of cognitive functions is required in every elderly faller.

Falls and dementia are two major public health problems which concern the elderly population. Cognitive impairment, as a result of Alzheimer's disease or non-Alzheimer dementia, is recognized as a risk factor for falling. Through the experience of the Multidisciplinary Falls Consultation, our aims were first, to evaluate the prevalence of a cognitive decline among outpatients who consult for falls, and second, to determine whether the cognitive impairment was known and diagnosed before the consultation or not.Data concerning the first 300 outpatients who completed the initial evaluation are reported. Each patient was assessed by a geriatrician, a neurologist, and a physiatrist, who visited him or her at home. Cognitive impairment was defined as a Mini-Mental State Examination (MMSE) score<24.Of the 300 patients, 228 patients completed the initial evaluation. Among them, 97 (42.5 percent) had a MMSE score<24; 55 had mild stage dementia (MMSE score between 23 and 18) and 42 were at a moderate or severe stage (MMSE score< or =17/30). The cognitive decline was not diagnosed before the consultation in 80 of the 97 patients (82 percent).The findings show that a large proportion of old persons presenting with gait disturbance at the Multidisciplinary Falls Consultation have an underlying cognitive decline. Assessment of cognitive functions is required in every elderly faller.

OBJECTIVE:We developed a prescribing guideline containing recommendations for the initial empirical antibiotic therapy in community or nosocomial pneumonia. The aim of the present study was to examine the impact of this measure.METHOD:The prescribing guideline was implemented in May 1999. We retrospectively reviewed the charts of all patients>65 years with community-, or nursing home- or hospital-acquired pneumonia hospitalised in our department of acute geriatric care between May 1999 and November 2000. The criteria assessed were: consistence with the guideline, clinical effectiveness within 72 hours, adequation with the isolated germs and intra-hospital mortality.RESULTS:Data were collected on 112 patients (63 women et 49 men; mean age=80 +/- 8 Years). The pneumonia was community-acquired in 52 cases (46%), nursing home acquired in 25 cases (22%) and hospital-acquired in 35 cases (31%). Antibiotic prescription was consistent with the guideline in 64 cases (57%). When the antibiotic therapy was consistent, the patients were more likely to improve within 72 hours (45/64 versus 23/48; p=0.01). Despite a tendency, the number of antimicrobial treatments adapted to the isolated microorganisms was not significantly higher in the consistent group (22/36 adapted treatments versus 10/20). The intra-hospital mortality (25%) was similar in the two groups consistent and not consistent with the guideline. SARM was the most frequent multiresistant bacteria that was isolated.CONCLUSION:The use of a prescribing guideline might improve the efficiency of empirical probabilistic antibiotic therapies. The impact of the guideline use on overall antibiotic costs and microbiological flora remains to be determined.

Contexte : La contention physique de la personne âgee demeure une pratique a risque. Objectif : Etablir un etat des lieux en matiere de contention physique et une grille d'auto-evaluation concernant cette pratique utilisable par les structures d'accueil de personnes âgees. Methodes : Une etude prospective est realisee un jour donne aupres de patients sous contention physique hospitalises en unites de soins geriatriques. Un questionnaire est complete avec l'equipe soignante et medicale. Les criteres analyses sont etablis selon le referentiel de l'ANAES d'octobre 2000. Resultats : Parmi les 367 patients hospitalises, 267 (72,7%) avaient une contention physique en tenant compte des barrieres de lit ; 56 (15,2%) avaient une contention sans tenir compte de ce dispositif ; 43 patients sont de sexe feminin. La moyenne d'âge etait de 82,74 ans. Le motif initial principal justifiant la contention est lie a la pathologie que presente le patient pour 52 patients (92,9%). La decision de sa mise en place revient a l'equipe soignante pour 19 patients (51,8%). La prescription medicale de la contention est ecrite dans le dossier pour 7 patients (12,5%), elle est reevaluee par 24 heures pour un patient (1,8%). 49 des patients (87,4%) sous contention avaient un traitement psychotrope associe. La principale consequence de cette pratique est la chute retrouvee pour 8 patients (14,2%). Conclusion : Le referentiel de l'ANAES est encore peu utilise. La formation des equipes et la conduite d'une politique de reduction de la contention apparait indispensable. La sensibilisation des equipes commence necessairement par un audit des pratiques actuelles.

L’hypophosphatasie est une erreur innée du métabolisme, caractérisée par une diminution de l’activité des phosphatases alcalines non spécifiques, à l’origine d’un défaut de minéralisation (rachitisme, fracture, troubles dentaires) et d’une augmentation des substrats de l’enzyme : phospho-étanol-amine, pyridoxal-5’phosphate, pyrophosphates inorganiques, ces derniers favorisant la survenue d’une chondrocalcinose articulaire. Il existe différentes formes de la maladie avec une grande variabilité de la sévérité. Nous rapportons l’observation d’un homme de 53 ans qui a le tableau typique d’une forme modérée de l’âge adulte. L’enquête familiale a permis de trouver d’autres cas (une sœur et deux enfants), confirmés par l’étude génétique qui révèle une double mutation chez le propositus, et une transmission autosomique récessive. Différentes mutations du gène de la phosphatase alcaline ont été mises en évidence : certaines sont associées aux formes sévères, d’autres aux formes mineures de la maladie, avec une corrélation génotype–phénotype.Hypophosphatasia is an inborn metabolic disorder in which abnormally low levels of the enzyme nonspecific alkaline phosphatase result in defective skeletal and dental mineralization (rickets, fractures, dental abnormalities) and in accumulation of the enzyme substrates (phosphoethanolamine, pyridoxal-5'phosphate and inorganic pyrophosphate). The build-up of inorganic pyrophosphate promotes the development of articular chondrocalcinosis. There are several forms of hypophosphatasia, with wide variations in severity. We report the case of a 53-year-old man with typical manifestations of moderate adulthood hypophosphatasia. Investigations in his family found the disease in a sister and two children. He had two autosomal mutations, which were transmitted recessively. Several mutations of the alkaline phosphatase gene have been identified. The genotype is correlated with the phenotype: some mutations are associated with milder forms and others with more severe forms of the disease.

Pardessus V, Puisieux F, Di Pompeo C, Gaudefroy C, Thevenon A, Dewailly P: Benefits of home visits for falls and autonomy in the elderly: A randomized trial study. Am J Phys Med Rehabil 2002;81:247–252. Objective To investigate whether home visits by a occupational therapist reduces the risk of falling and improves the autonomy of older patients hospitalized for falling. Design In this randomized, controlled trial set in a geriatric hospital, 60 patients (mean age, 83.5 yr) who were hospitalized for falling were recruited from the acute medicine department. A home visit from an occupational therapist and an ergotherapist assessed patients’ homes for environmental hazards and recommended modifications. The outcomes measured were falls, autonomy, hospitalization for falling, institutionalization, and death. Results During the follow-up period, the rate of falls, hospitalization for falls, institutionalization, and death were not significantly different between the two groups. Both groups had a loss of dependence at 12 mo. This loss of dependence was significant in the control group but not in the intervention group. Conclusions Home visits from occupational therapists during hospitalization of older patients at risk for falling can help to preserve the patient’s autonomy.

Background: Postprandial hypotension (PPH) is increasingly recognized as a common cause of falls and syncopes in the elderly. The diagnosis of PPH is based on the measurement of meal-induced blood pressure (BP) changes. Although the problem of intraindividual reproducibility of PPH is of clinical importance, it has not been extensively studied. Objective: To assess the intraindividual reproducibility of PPH. Methods: 50 patients (42 women and 8 males, 83 ± 8 years) were included in the study. To evaluate PPH, we measured the BP before and every 15 min for 2 h after the start of a standardized mixed meal. The PPH was defined as a decrease in systolic BP of 20 mm Hg or more. Three sets of BP were obtained for each subject on 2 successive days: (1) between 08.00 and 10.00 h and (2) between 16.00 and 18.00 h on the 1st day and (3) between 08.00 and 10.00 h on the 2nd day. Results: 32 participants (64%) experienced PPH on at least one test. Among them, 19 (38%) had PPH on the first test, 16 (32%) had PPH on the second test, and 21 (42%) had PPH on the third test. The intraindividual reproducibility of PPH was good when the results of the two morning tests were compared together (kappa coefficient = 0.6), but was low when the morning test results were compared with the afternoon test results of the 1st day (kappa coefficient = 0.1). Conclusions: Because of the good reproducibility of postprandial BP changes, we conclude that the diagnosis of PPH may be based on a single standardized test. However, the test must be performed under circumstances (time of the meal, medications) similar to those in which the symptoms occurred.

To the Editor: Bradyarrhythmias, both sick syndrome and complete atrioventricular block, frequently occur in older people. The main clinical symptoms are syncopes, presyncopes, and dizziness.1 It has been also suggested that patients suffering from very slow heart rate may show intellectual decline2–8 and that the treatment with an artificial pacemaker may improve their cognitive functioning. However, the studies are not all in accordance, included only small numbers of patients,4,7 were not controlled,7 or had a very short follow-up,6,7 so that the question remains unanswered. We performed a study to assess cognitive performance of consecutive old patients undergoing permanent pacemaker primoimplantation for permanent or paroxysmal bradycardia and, for comparison, in old patients undergoing replacement of permanent pacemaker. Inclusion criteria were age 65 and older, need for permanent pacemaker implantation because of permanent or paroxysmal bradycardia, and consent to participate. Exclusion criterion was implantation after myocardial infarction or cardiac arrest. The control subjects were recruited from the same department of cardiac pacing after giving informed consent. The diagnosis of dementia was made according to Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition).9 Cognitive assessments were made before pacemaker implantation, then at 5 days and 6 months later. The same investigator conducted all assessments (CB). This evaluation included Folstein's Mini-Mental State Examination (MMSE); the paired word-learning test from the Wechsler memory scale; a word fluency test with two categories of words, animals, and fruits; and cube drawing.10,11 The assessment also included the Geriatric Depression Scale,12 and the Katz assessment of activities of daily living.13 During the period of the study, of 32 eligible patients, two declined to participate and four could not be assessed before implantation; 26 patients participated in the study, and 15 patients served as controls. Patients and controls were not different with regard to age (mean ± standard deviation: 75 ± 6 vs 76 ± 6), gender, medications, cardiac diseases, or main associated disorders. Mean heart rate (beats per minute) was significantly lower (P MA2C .05) in the patient group (54 ± 18; range 20–89) than in the control group (64 ± 7, range 50–80). Patients were implanted because of atrioventricular block (n = 12), sick sinus syndrome (n = 14), or chronic atrial fibrillation (n = 2). On average, initial cognitive performances were not different between the two groups. Three patients and two controls were initially classified as demented. In the patient group, we observed an improvement of cognitive performance 6 months after implantation (Table 1). At 5 days, only the paired word-learning test score was significantly increased. Of the three patients who were classified as having dementia before implantation, two were judged clinically to have improved from a moderate to a mild degree of cognitive impairment, and one normalized his performance at 6 months. When we excluded the three demented patients, we observed a slight, nonsignificant improvement in cognitive performance at 6 months. There was no significant improvement in the control group. In particular, the two demented control subjects did not improve during the follow-up period. Our findings confirm that cognitive function may improve after pacemaker implantation in patients with permanent or transient bradycardia.3,6–8 Because the only initial significant difference between the two groups was the mean cardiac heart rate, our data support the relationship between cognitive impairment and cerebral hypoperfusion due to low heart rate. However, we failed to observe a significant correlation between heart rate on electrocardiogram and cognitive performance or between length of time that heart rate was below 40 beats per minute on 24-hour ambulatory electrocardiographic monitoring and cognitive performance. Moreover, the improvement in cognitive performance was not immediate after implantation but was progressive. Consequently, the underlying mechanisms are certainly more complicated and may involve complex cerebral neurobiological processus that require a long time to recover after cerebral perfusion restoration or may also be psychological. The favorable evolution after pacemaker implantation of the three patients who were classified as demented supports the concept of cardiogenic dementia.14,15 However, only one patient normalized his performance at 6 months. One possible explanation is that cardiac dysrhythmia contributed only one part of cognitive function impairment. Another explanation is that chronic or severe transient cerebral hypoperfusion had caused irreversible ischemic lesions of the brain, which could not recover even after good perfusion was restored.16,17 Although our results must be interpreted with caution because of the relatively small size of the study sample, there is evidence that the cognitive functioning of bradycardiac older patients may improve after pacemaker implantation. Preexisting cognitive decline should be considered as a further argument in favor of implantation, in the hope that patients will improve their cognitive status.18,19