Pierre Pfitzenmeyer

End stage dementia is a particularly difficult aspect of care for patients with Alzheimer's disease and related dementias. In care institutions, caregivers and family are concerned by treatment decision-making for an acute life threatening complication occurring in Alzheimer patients at the end of life. How should the best treatment pathway be decided: to treat or not to treat? Which arguments are used for decision-making? These are mainly ethical questions which are currently difficult to express and investigate.

Background. This study investigated the hypothesis that postural abnormalities might increase energy expenditure during a clinical functional test in frail elderly persons. Methods. Two groups of hospitalized women (aged 73 to 100 years) were recruited. Women who showed postural and gait abnormalities as described in the psychomotor disadaptation syndrome (PDS) were compared with control participants. The authors measured energy expenditure during the timed “up and go” test. For each participant, oxygen uptake, carbon dioxide output, expiratory minute ventilation, breathing frequency, heart rate, and alveolar ventilation were recorded 10 minutes before, during, and 10 minutes after exercise. The arterial pressure of carbon dioxide was estimated from expired gases. Results. The mean oxygen uptake values were significantly higher in women with PDS than in the control group during exercise and recovery periods (4.89 ± 1.68 vs 3.75 ± 1.25 ml · kg⁻¹ · min⁻¹ and 4.69 ± 1.45 vs 3.76 ± 0.97 ml · kg⁻¹ · min⁻¹, respectively [p <.05]). Expiratory minute ventilation was always higher in women with PDS than in controls regardless of the period of the test (p <.05), and alveolar ventilation was higher in women with PDS only during the exercise period (p <.05). The estimated arterial pressure of carbon dioxide did not change significantly between the different phases of the test but was always lower (p <.05) in women with PDS compared with the control group. Conclusions. The significant increase in oxygen uptake during the exercise and recovery periods in women with PDS compared with controls suggests that postural abnormalities that characterize PDS may be associated with an increase in energy expenditure. In clinical practice, the low capacity to tolerate even moderate exercise must be considered when specific rehabilitation programs are offered to women with PDS.

Background: Frontal-subcortical clinical syndrome (FSCS) is frequently described in elderly patients and consists of specific alterations in cognition and motor functions. This clinical picture may be associated with a high level of dependence and a high mortality risk. Objective: We report the risks of institutionalization and death during a follow-up of 4 years in patients showing FSCS. Methods: The study was initiated in 1998 to compare FSCS patients showing postural and gait abnormalities with Alzheimer’s disease (AD) patients. Follow-up was conducted by means of telephone interviews with the patient’s general practitioner over a 4-year period (1998–2002). Results: Both institutionalization and mortality rates were significantly higher (p < 0.05) in the FSCS group compared to the AD group. Conclusions: The high risk of disability and death in FSCS patients suggests that they might require specific care programs that include stimulation in daily living activities in order to reduce the risk of institutionalization and to improve quality of life.

Psychomotor Disadaptation Syndrome (PDS) is characterized by backward disequilibrium in a sitting and standing position, reactional hypertonia, an alteration of postural reactions, gait modifications, and fear of falling. PDS may be the result of a loss of postural reserves, reaching a frailty threshold that does not allow subjects to maintain an adequate functional level. This clinical picture may be associated with frontal-subcortical dysfunction in which microangiopathy could play a key role. PDS may be triggered by numerous factors, such as cardiovascular and metabolic diseases, falls, and bed rest. In addition to medical and neurological evaluations, a specific rehabilitation program is one of the most important aspects of the management of patients showing PDS.

To assess, in a population of elderly patients, the circumstances clinical and progressive characteristics and form of management of an acute colonic pseudo-obstruction (ACPO). Retrospective study of the files of 40 patients aged 70 and more having presented an acute colonic pseudo-obstruction and hospitalised in the university hospital in Dijon from January 1995 to June 2000. The population was composed of 24 men (60%) and 16 women (40%) with a mean age of 80.8 years. The reasons for hospitalisation were varied: only 15 patients had been referred for an occlusive syndrome. 39 patients presented with abdominal distension, 30 suffered from abdominal pain. In this population, 17 patients exhibited reduced or clearly limited mobility, 20 patients had altered cognitive capacity with an MMS < 20. Thirty-eight patients suffered from a progressive heart disease and 8 patients presented with advanced dementia. The usual treatment of these patients to help the intestinal transit included diuretics in 25 cases and agents slowing the transit in 19 cases. Biologically speaking, hypokalaemia was observed in 21 cases and increased thyroid stimulating hormone (TSH) in 3 cases. An image was obtained of the abdomen without preparation in all patients: the mean caecum diameter was of 9.8 cm. A colon aspiration was performed in 20 patients and molecules to improve peristaltism were administered in 21 cases, with neostigmine prescribed for 9 patients. Surgery was required for 7 patients and 3 of them subsequently died. In terms of progression, 20 patients were cured after treatment, 13 relapsed and 7 patients worsened. Unfortunately, 10 patients died in our series. In our study, the clinical profiles of acute colonic pseudo-obstruction were similar to those described in the literature: they occurred in varying circumstances, in medical or surgical settings ina predominantly male population of elderly, heavily dependent,patients. Treatment of this affection is not clearly codified for fragile patients with multiple diseases and the mortality rate observed should stimulate further studies, notably on pharmacological level.

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.