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The purpose of this study was to assess the effect of nutritional supplementation on dietary intake and on pressure ulcer development in critically ill older patients. The multi-center trial involved 19 wards stratified according to specialty and recruitment for critically ill older patients; 9 wards were randomly selected for nutritional intervention (nutritional intervention group), consisting of the daily distribution of two oral supplements, with each supplement containg 200 kcal, for 15 d. Pressure ulcer incidence was prospectively recorded for grades I (erythema), II (superficial broken skin), and III (subcutaneous lesion) for 15 d. Nutritional intake was monitored by using estimates in units of quarters validated by comparison with weight measurement. There were 672 subjects older than 65 y, and 295 were in the nutritional intervention group versus 377 in the control group. The patients were similar for age, sex ratio, and C-reactive protein. In comparison with the control group, the nutritional intervention group included more patients with stroke, heart failure, and dyspnea and fewer with antecedent falls, delirium, lower limb fractures, and digestive disease. The nutritional intervention group had a lower risk of pressure ulcers according to the Norton score but was less dependent (Kuntzman score) and had a lower serum albumin level. During the trial, energy and protein intakes were higher in the nutritional intervention group (day 2: 1081 +/- 595 kcal versus 957 +/- 530 kcal, P = 0.006; 45.9 +/- 27.8 g protein versus 38.3 +/- 23.8 g protein in the control group, P < 0.001). At 15 d, the cumulative incidence of pressure ulcers was 40.6% in the nutritional intervention group versus 47.2% in the control group. The proportion of grade I cases relative to the total number of cases was 90%. Multivariate analysis, taking into account all diagnoses, potential risk factors, and the intra-ward correlation, indicated that the independent risk factors of developing a pressure ulcer during this period were: serum albumin level at baseline, for 1 g/L decrease: 1.05 (95% confidence interval: 1.02 to 1.07, P < 0.001); Kuntzmann score at baseline, for 1-point increase: 1.22 (0.32 to 4.58, P = 0.003); lower limb fracture: 2.68 (1.75 to 4.11, P < 0.001); Norton score < 10 versus > 14: 1.28 (1.01 to 1.62, P = 0.04); and belonging to the control group: 1.57 (1.03 to 2.38, P = 0.04). In conclusion, it was possible to increase the dietary intake of critically ill elderly subjects by systematic use of oral supplements. This intervention was associated with a decreased risk of pressure ulcer incidence.

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The authors discuss law and ethics when medical decisions are to be taken by patients who are unable in any valid sense to express their own wishes. The main problem in legal terms is to protect an individual's free will as far as possible and ensure that his or her wishes, if known, are respected. If a patient's independent wishes cannot be known, then we must at least ensure that nothing is imposed which is not in his interest. Legal measures, however, are far from adequate in resolving all the concrete problems that emerge. The field of ethics does bring some better adapted solutions, but none is laid down in law. One such approach, involving a multidisciplinary advisory group in a department of geriatrics, is discussed.

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OBJECTIVES: To evaluate the prevalence of diabetes mellitus in older French subjects and to examine the different aspects of quality of life in an older diabetic population. DESIGN: From a random sample of 2792 people older than age 65 living in the community, a diabetic sample was selected using three items from a questionnaire: Are you diabetic? Are you on a diabetic diet? What kind of medications do you take daily? Validation of the questionnaire was carried out previously to correct the observed prevalence. MEASUREMENTS: The questionnaire assessed social and demographic aspects, physical, mental, and subjective health, and functional disabilities. Because quality of life assessment was mainly subjective, demented subjects were excluded. RESULTS: The diabetic group consisted of 237 subjects from the older sample of 2792 (8.5%). No age difference was demonstrated between the two groups (mean, distribution), but the male/female ratio was significantly higher in those with diabetes (49.4% vs 39.3%, P = .003). Corrected prevalence of diabetes was 10.3%. After exclusion of demented subjects, 230/2726 people were investigated. Diabetic subjects were heavier (P < .001), had higher systolic blood pressure (P < .001), and had more frequent symptoms of ischemic heart disease (P < .001) and painful peripheral arterial disease (P < .001) and dyspnea (P < .001), but antecedents of stroke were similar in both groups. Diabetics were more often lacking in autonomy according to the IADL Lawton scale (P < .001), Rosow and Breslow scale (P < .001), and Mobility scale (P = .043), but not according to the Katz ADL scale. They more often exhibited symptoms of depression on the CES-D self-rating scale (21.3% vs 12.7%, P < .001), but evaluation of cognitive function was similar in both groups. Thirteen percent of diabetics, compared with 7.6% of non-diabetics, were unsatisfied with their own situation (P = .002). Health was rated as fair, bad, or very bad by 67.8% of diabetics compared with 49% of non-diabetics (P < .001). Diabetics rated themselves as feeling worse than others (15.3% vs 9.2%, P < < .001) and worried more about their health status (78% vs 63%, P < < .001). CONCLUSION: The observed prevalence of diabetes in older French people living in the community was 8.5%. Quality of life in older diabetics was poorer than that of other people of the same age.

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This study compares plasma, red cell, and cerebrospinal fluid (CSF) folate levels in subjects with mild or moderate Alzheimer's disease (AD) of senile onset and in non-demented control subjects. Twelve subjects with mild or moderate (Folstein's Mini-Mental-State-MMS--between 10 and 23) AD (DSM3 R criteria) and 12 control subjects without dementia and with MMS above 23 were included. To avoid any change in plasma folate levels due to dehydration, all dehydrated subjects were excluded. Were also excluded all subjects obviously suffering from malnutrition or alcoholism, or taking drugs likely to interfere with folate metabolism. Changes in folate levels due to posture or prolonged venous occlusion were carefully avoided. Patients with AD were 5 males and 7 females aged (Mean +/- SD) 80.2 +/- 5.7 years, MMS 14.8 +/- 2.6; controls were 7 males and 5 females aged 78.9 +/- 7.2 y, MMS 28.3 +/- 1.5. The two groups were not statistically different for these variables, except for the MMS. Plasma folate levels were lower (p < 0.006) in patients with AD (4.5 +/- 1.5 micrograms/l) compared with controls (7 +/- 2.2 micrograms/l). Red cell folate levels were lower (p < 0.007) in patients with AD (183.7 +/- 91.1 micrograms/l) compared with controls (300.4 +/- 96.1 micrograms/l). CSF folate levels were lower in AD (18.9 +/- 9.7 micrograms/l) than in controls (21.9 +/- 8.2 micrograms/l) but the difference was not statistically significant (p > 0.05). Our results indicate poorer nutrition in patients with AD.

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Magnetic resonance spectroscopy (MRS) was used to determine the phosphorylated metabolite content in the liver of elderly patients in various nutritional states: normal, with protein deprivation, and with acute inflammatory syndrome. 31P-MRS investigations were performed at 1.5 T, and localized liver spectra were recorded using a two-dimensional chemical shift imaging sequence. Comparison to control spectra recorded on 10 healthy volunteers (age, 30.5 +/- 2.1 years) showed that the aging process does not significantly modify 31P-MRS liver spectra. Patients with protein deprivation exhibited a higher value than controls for the phosphomonoesters/nucleoside triphosphates (PME/NTP) ratio (P < .05). This increase was not due to the decrease of NTP, since the ratio of inorganic phosphate to NTP (Pi/NTP) remained constant. A decrease in the phosphodiesters to NTP (PDE/NTP) ratio (P < .04) contributed to the observed increase in the PME/PDE ratio (P < .01). In contrast, no significant difference in 31P-MRS spectra was found between elderly patients with hypoalbuminemia associated with inflammatory syndrome and the control group. We conclude that elderly patients with protein deprivation displayed changes in the level of phosphorylated metabolites in the liver that were not observed in the case of inflammatory syndrome despite lower serum albumin (Alb) concentrations.

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The aim of this study was to assess the prevalence of increased thyroid-stimulating hormone (TSH) levels (subclinical or undiagnosed hypothyroidism) in a representative sample of a community-living elderly population and to examine the relationships with cognitive functions and depressive symptoms. An epidemiological study was made of a cohort of 2792 subjects over 65 years of age. A blood sample was obtained from 425 volunteers of this cohort and assayed for TSH. Every subject participating in the study was interviewed and given a battery of neuropsychological tests by a psychologist. Three hundred and eighty-one subjects (89.7%) had normal TSH levels; 18 subjects (4.2%) had TSH lower than 0.4 microU/ml, associated in two of them with hyperthyroxinaemia. Twenty-six subjects (6.1%) had increased TSH levels, associated in 18 of them with a normal free thyroxine level and in eight with a low free thyroxine level. Increased TSH levels were significantly linked with female sex and with the presence of symptoms of depression on the CES-D scale but not with impairment of cognitive function.

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The relationship between heparin and fibrinolysis is strongly suggested. We have studied the influence on fibrinolysis of standard heparin (SH), Calciparin and low molecular weight heparin (LMWH), Fraxiparin, given preventively in an elderly population. Patients were randomized into two groups (SH, LMWH). We investigated fibrinolytic parameters (ECLT, t-PA antigen, PAI-1 activity and antigen, t-PA/PAI-1 complexes) before treatment (D0) and at D30 and D60, before and after venous occlusion (VO). Values at D0, D30 and D60 were compared within each group. A significant and marked increase in t-PA and t-PA/PAI-1 complexes at D30 and D60 before and after VO was noted only in the SH group. The mechanism and clinical relevance of this increase remains to be established.

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The pharmacokinetics of tianeptine, an antidepressant with an original serotoninergic neurochemical action, was investigated in elderly patients. Kinetic profiles were developed in 12 elderly patients (age range: 72-81 yr) after single (12.5 mg) dose and multiple oral dosages (12.5 mg tid for 17 days). Multiple dosing of tianeptine was well tolerated; no accumulation of the unchanged drug was observed. Tianeptine and its MC5 metabolite (C5 acid analogue of tianeptine) reached maximum plasma levels after 1.81 +/- .99 and 2.96 +/- 1.44 hr, respectively, with values of 353 +/- 198 and 81 +/- 20 ng/mL, respectively, after a single dose and of 405 +/- 202 and 175 +/- 85 ng/mL, respectively, after multiple dosing. Minimum plasma concentrations of tianeptine were about half those of its MC5 metabolite (68 +/- 41 and 121 +/- 64 ng/mL-1 on day 5), and for each compound, they were not statistically different from day 5 to day 18 of the chronic administration. This finding is compatible with the terminal half-lives that were observed after the single dose that was 2.8 +/- .9 hr for tianeptine and 12.3 +/- 7 hr for the MC5 metabolite. For both compounds, the area-under-the-plasma levels time curve at steady state was as predicted from the initial single dose that showed no deviation from linearity with time. The kinetics of tianeptine in elderly patients were similar to those reported for young adults. However, MC5 metabolite plasma levels were higher in elderly patients than in younger patients.(ABSTRACT TRUNCATED AT 250 WORDS)

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Anticoagulants constitute the rational treatment of thromboembolic accidents occurring in elderly people, but they are often not prescribed because of the risk of haemorrhage. The chronological age by itself is not a contra-indication, the limitations being the diseases associated with ageing. Anticoagulants may be used as curative treatment in atrial fibrillation with dilated left atrium (greater than 45 mm at echocardiography), in myocardial infarction, embolic strokes and complicated arteritis. They may also be used as preventive and curative treatment in phlebitis and pulmonary embolism. The complications of anticoagulant therapy will be better prevented by using the international normalized ratio and by prescribing doses that are adequate for each indication.

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Several studies have demonstrated that the corticotropin-releasing factor test (CRF) is useful for the aetiological diagnosis of Cushing's syndrome: in Cushing's disease, as opposed to ectopic ACTH secretion syndrome, the hypothalamus-pituitary-adrenal (HPA) axis can still be stimulated by CRF. In the present study, we compared the CRF test with the reinforced dexamethasone suppression test in 18 patients: 11 with Cushing's disease, 6 with ectopic ACTH secretion and 1 with adrenal gland adenoma. We obtained 2 false-negative results with the CRF test and 1 false-positive result with the dexamethasone suppression test. Our study, together with published data, suggests that the CRF test is useful in the exploration of Cushing's syndromes of uncertain origin. However, the results obtained with this test must be compared with those of other methods used to explore the HPA axis and which are still necessary.

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Two cases of polyneuropathy in patients with hypothyroidism are reported. In both cases, the polyneuropathy involved the lower limbs and was predominantly distal. It was sensorimotor in the first patient and purely sensory in the second one. Electrophysiological findings were consistent with an axonopathy. Symptoms and electrophysiological parameters improved with thyroid therapy. Neuropathy in such cases is probably related to the duration of hypothyroidism.

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We evaluated the reliability of very low serum thyroglobulin (Tg) levels (less than 3 ng/ml) obtained after withdrawal of thyroid suppression therapy in 224 patients without anti-Tg antibodies, who had undergone total thyroidectomy (125 patients) or thyroidectomy followed by 1 or more courses of 131I therapy (99 patients), by performing whole body scans after a therapeutic course of 131I given at the same time of Tg measurement. In 79 patients (35%) a positive scan, associated with a very low level of Tg, was noted. The 131I uptake was limited to the thyroid bed in 60 patients, but metastases were demonstrated in 19 patients (8.5%). These results are mainly explained by the much improved performance of scintigraphy after administration of therapeutic doses of 131I. In the majority of patients, especially those whose 131I uptake was limited to the thyroid bed, further scans were negative. Therefore, in these cases, negative Tg values can generally be considered an early indication of satisfactory evolution. However, in 8.5% of all cases, very low Tg levels were associated with metastases. Thus the follow up of thyroid cancer should not rely only upon Tg determination, even after suppression therapy withdrawal.

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We studied the electrophysiological properties of individually characterized TSH-secreting cells cultured from pituitary fragments surgically removed from three patients, two who had primary TSH-secreting adenomas and one who had chronic TSH hypersecretion (hyperplasia) secondary to primary hypothyroidism. The TSH-secreting cells were excitable and had calcium-dependent action potentials. More than 80% of the cells cultured from the two patients with TSH-secreting adenomas were spontaneously active, whereas fewer cells (20%) cultured from the hypothyroid patient were spontaneously active. TRH (50 nmol/L) induced a complex pattern of electrical changes. The initial response was transient hyperpolarization (activation of potassium conductance), followed by increased low amplitude voltage fluctuations occasionally leading to action potentials. These TRH-induced electrophysiological changes were similar to those reported in rat and human PRL-secreting adenoma cells. These results suggest that TRH may have an identical mode of action in tumoral PRL and TSH cells. In the cells from the hypothyroid patient, the initial response to TRH cells was similar, but the second phase response was greater. The findings that the cells cultured from these patients behaved differently with regard to their electrophysiological characteristics (action potentials) and responses to TRH may reflect the different clinical conditions from which they were derived.

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Since thallium-201 imaging has been reported as a potential means of follow-up of patients with differentiated thyroid carcinoma (DTC) during ongoing thyroid suppression therapy, the authors evaluated the diagnostic sensitivity of this procedure in 31 patients known to have metastases or local recurrence. Among 51 tumor sites 201TI imaging had a detection rate of 45% whereas 84% was noted for imaging with 131I administered in therapeutic doses. Thus, even though the effectiveness of the two radionuclides is not strictly comparable due to the difference in the administered doses, Thallium imaging cannot be recommended as the only modality for the follow-up of patients with DTC. Six of the eight tumor sites negative with 131I were positive with 201TI (especially metastatic cervico-mediastinal lymph nodes). So 201TI imaging may particularly be helpful in localizing metastases or recurrences in patients with a negative 131I scan and abnormal levels of serum thyroglobulin.

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