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INTRODUCTION: Dementia is now a frequent disease in elderly and may be a major risk of falling. Usually these falls are multiple and serious, but their consequences are not specific. All types of dementia (Alzheimer's disease, dementia with Lewy bodies, dementia in Parkinson's disease, fronto-temporal dementia, vascular dementiaellipsis) and all stages of evolution are concerned. DISCUSSION: These falls result from cognitive and behavioural disorders, visual and motor problems, gait and balance disturbances, malnutrition, adverse effects of medication and fear of falling. CONCLUSION: Prevention is possible. Attention must be given on the patient himself (keeping in good health, limitation in sedative treatment and mechanical restraintsellipsis) and on his environment (lighting, obstacles on the ground, stress levelellipsis). After a fall, especially after a complicated fall, rehabilitation modalities and aims must be adapted but caring must not be defeatist. Randomized studies need to be realized.

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THE PREVALENCE: The exact prevalence of deglutition disorders in the elderly is not known. It appears frequent in very old patients and in those suffering from polypathological symptoms, affecting 50% of the populations in long-term care units. THE EFFECTS OF AGING: Physiological aging alters various parameters of swallowing, however it seems that these modifications related to age have little effect on healthy subjects. However, they may increase vulnerability in those presenting with intercurrent pathologies. CONCOMITANT DISORDERS: Other than the decrease in efficient mastication and the existence of xerostomia, frequently observed contributing factors, many diseases may be responsible for dysphagia in the elderly. Neurological disorders, particularly cerebral vascular diseases, central nervous system degenerative disorders and neuro-motor diseases predominate. In the aging, muscular disorders and after effects of various diseases can set-in. Modifications in oropharyngeal anatomy generally results from cancerous lesions of the aero-digestive junction, but also, occasionally from extrinsic compression that does not necessarily reflect a neoplastic etiology. Zenker's diverticulitis represents a cause of dysphagia specific to the elderly. Problems in swallowing of iatrogenic origin are also frequent, following cervical radiotherapy or after oropharyngeal surgery, during tracheal intubation or when using feeding tubes and also during various medical treatments. UNDERRATED CONSEQUENCES: Dysphagia leads to multiple morbid after effects, primarily alteration in quality of life, dehydration, undernutrition, asphyxia and congestion and recurrent infections of the respiratory tract. The responsibility of deglutition disorders in the occurrence of these complications is difficult to assess in weak elderly subjects because of the frequent concomitance with multiple deficiencies and incapacities.

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FROM DISCOVERY TO CLINICAL DIAGNOSIS: Dysphagia is easy to diagnose in its acute stage and when complicating a known neurological disease. However diagnosis may be greatly delayed when expressed by respiratory or nutritional symptoms, or when the patient presents cognitive disorders, as is frequent in the elderly. In such instances, simple tests such as the water test are clearly indicated. However, although they are reliable for diagnosing dysphagia, they are not precise in diagnosis of inhalation. Clinical examination is essential for diagnosing the etiology of the disorder. In the absence of clinical orientation, a nasofibroscopy is mandatory and digestive endoscopy debatable. SPECIALIZED EXAMINATIONS: The first-line supplementary examination is a videoradiography. It consists in the patient swallowing a liquid or solid barium sulfate bolus. This detects any anatomical or functional abnormalities. It is the examination of choice for the diagnosis of inhalation and its mechanism. Videoendoscopy is complementary to videoradiography. It can be conducted in first intention in patients who cannot be transported to the radiology unit. It provides precise information on glottal closing and pharyngeal contraction. IMPACT ON MANAGEMENT: In a restricted number of patients, the precise knowledge of the mechanism of dysphagia can help to orientate specific treatment. In others, such examinations will orient re-education, postural adaptation and the modification of food texture. In many patients, precise diagnosis of the mechanism at the origin of dysphagia has no impact on the management of dysphagia.

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GENERAL PRINCIPLES: The management of dysphagia requires multi-disciplinary interventions, implying various procedures, the choice of which depends on the results of the global prior assessment of the patient. General measures for oral hygiene, dental care and the organization of conditions in which meals are taken are essential, particularly for dependent patients. A change in food texture or in viscosity of liquids is a strategy commonly used. However, such changes must depend on objective bases and not unnecessarily penalize patients or expose them to further risks of complications. COMPENSATION AND RE-EDUCATION TECHNIQUES: Various strategies can help to counteract deficient deglutition mechanisms. Among these, adopting a particular position while swallowing is helpful in many dysphagic patients, but may be limited by severe cervical stiffness. The swallow reflex can be enhanced by sensorial stimulation techniques, although they are only effective short-term. Execution of voluntary maneuvers improves efficacy and safety when swallowing, but learning these maneuvers can be difficult or even impossible, even when accepted by the patients and compliance is inconsistent. Re-education techniques are intended to lastingly improve swallowing, but it is difficult to obtain the active participation of many elderly patients. Furthermore, these commonly used techniques lack seriousness and require validation. MISCELLANEOUS PROCEDURES: The efficacy of pharmacological intervention is not clear, other than in certain particular etiological contexts and, as with procedures enhancing the stimulating properties of food and liquids, will obviously be developed in the future. Surgery, or related techniques, provides help in certain specific conditions, notably when an anatomical disorder is responsible for the disorder. Gastrostomy is still controversial, not only with regard to its optimal practical use and its capacity to decrease respiratory infection risks and improve nutritional prognosis, but also with regard to its impact on patients' survival and quality of life.

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PREVALENCE: The prevalence of pressure sores reaches 10-20% in hospitalized elderly subjects. Higher rates are observed in units providing mid-term nursing. Rates recorded in long-term units are inversely lower. The prevalence of pressure sores in the elderly population living at home is poorly known. FAVORING FACTORS: Very old age is a favoring factor due to associated diseases. Insufficient mobility, incontinence, undernutrition, mental disorders, and skin fragility increase the risk. All these factors must be taken into consideration when using risk scales to adapt preventive measures. NATURAL HISTORY: Pressure sores generally develop in the hospital, generally within one week of admission. For patients who do not die shortly thereafter, healing is generally achieved within 3 to 5 months. Pressure sores are a source of pain and infection. They also prolong the hospital stay. Overmortality is associated with pressure sores, basically resulting from the effect of comorbid states. COST: The economic impact of pressure sores is considerable but it is quite difficult to extract the individual cost of prevention, or treatment, from the overall cost of care due to the associated deficiencies and incapacities. It would be advisable to apply evidence-based protocols to reduce the incidence of pressure sores and also reduce the economic cost, both in terms of prevention and treatment.

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Three cases of nerve root compromise in elderly women with insufficiency fractures of the sacrum are reported. Neurological compromise is generally felt to be exceedingly rare in this setting. A review of 493 cases of sacral insufficiency fractures reported in the literature suggested an incidence of about 2%. The true incidence is probably higher since many case-reports provided only scant information on symptoms; furthermore, sphincter dysfunction and lower limb paresthesia were the most common symptoms and can readily be overlooked or misinterpreted in elderly patients with multiple health problems. The neurological manifestations were delayed in some cases. A full recovery was the rule. The characteristics of the sacral fracture were not consistently related with the risk of neurological compromise. In most cases there was no displacement and in many the foramina were not involved. The pathophysiology of the neurological manifestations remains unclear. We suggest that patients with sacral insufficiency fractures should be carefully monitored for neurological manifestations.

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OBJECTIVES: Fractures of the sacrum due to bone deficiency are not extremely uncommon although this cause has been overlooked for many years. We performed a meta-analysis of reported cases in order to determine the specific characteristics. METHOD: The characteristics of 493 cases of sacral fractures reported in the literature and those of 15 personal cases were studied. RESULTS: Most of the fractures occurred in women over 60 years of age. No trauma was identified in two-thirds of the cases. Clinical expression was not specific (back pain, sciatica, pelvic pain). Standard x-ray showed a fracture of the obturator frame in 38.8% of the cases but no direct or indirect signs of sacral fracture were seen in more than two-thirds of the cases. Tc99m scintigraphy had excellent sensitivity; a characteristic hyperfixation pattern for ming an "H" was observed but only in 42.7% of the cases. Computed tomography had similar sensitivity and confirmed the diagnosis in doubtful cases. Treatment was usually bed rest until satisfactory pain relief. Of particular importance were neurological complications although they were exceptional. Several factors favoring sacral fracture were found, mainly osteoporosis and prior radiotherapy of the pelvis. CONCLUSION: Clinicians should be aware of this type of fracture which still remains largely over-looked in geriatric care units.

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OBJECTIVES: Since its first description several years ago in the elderly subject, calcification of the Cooper ligament is often considered as a rare anecdotal phenomenon. We present the radiographic presentation which is often not well known. METHODS: Two experienced radiologists examined independently a series of 100 consecutive X-rays of the pelvis performed in a population of elderly subjects (mean age 84.4 +/- 9.2), looking for calcification of the Cooper ligament. RESULTS: Calcification of the Cooper ligament was observed on 7 of the 100 images of the pelvis. There was no significant difference in age, sex, or reason for ordering the examination between subjects with calcification and those without calcifications. Arterial calcifications were observed at an equal frequency. The usual aspect of the Cooper ligament was a fine opaque line following along the upper border of the iliopectinate crest. Oblique views visualized the calcification better. The line of calcification was either continuous of fragmented and was bilateral in all 7 cases. CONCLUSION: These images are apparently of no pathological significance. Clinicians should however be aware of the radiographic presentation in order to avoid confusion with visceral calcification or periosteal deposits.

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In order to specify the frequency and the potential consequences of drug interactions in the elderly, we retrospectively analysed 409 discharge prescriptions. The possibility of drug interactions was screened out for each prescription in the software version of the Vidal drug compendium. It appears that prescriptions are mainly adapted to the elderly with respect to posology and pharmacokinetics. Potentially dangerous drug interactions ('contraindicated' or 'unsuitable' associations) were found in 6 per cent of prescriptions; after careful assessment, this frequency decreased to less than 1 per cent. The most common orthoergic side effects were sedation (15 per cent) and hypotension (14.5 per cent). This study points out the multiplicity of criteria to be considered in order to prevent drug interactions, and the gaps in available software.

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