Alzheimer Disease: Clément JP

Clément JP. · Pôle de psychiatrie du sujet âgé, centre hospitalier Esquirol, SHU, 15, rue du Dr-Marcland, 87025 Limoges cedex, France. · Morphologie. · Pubmed #18243028 No free full text.

Abstract: The Alzheimer's disease (AD) is multifactorial. How to explain this group of very heterogeneous factors? Many of them can be considered as biopsychosocial risk factors. In other words, the risk factors, in link with the physiological functioning and a physiopathology, are difficultly dissociable of contingencies of psychological and/or social nature. The vital lead could be the stress bound to these variables, be it biological or psychosocial. It remains to ask the question of the preventive efficiency of treatments to relieve the impact of the traumatizing events of life that entail a depressive state or a state of posttraumatic stress. The hippocamp has to be the object of a quite particular attention. AD is a disease of the adaptation. This integrative model combines three vulnerabilities: a genetic vulnerability which would be there to dictate the type of lesions, their localization and the age of occurence; a psychobiographic vulnerability corresponding to a personality with inadequate mechanisms of defence, precarious adaptability in front of the adversity, weak impact strength and biography built on events of life during childhood, then during the grown-up life of traumatic nature, with a psychosocial environment insufficiently auxiliary; a neuroendocrinologic vulnerability which would base on a deregulation of the corticotrope axis, acquired during its infantile maturation, hampered by too premature stress. It would lead to a bad biological adaptability in stress later, at the origin of the observable lesions in the insanities.

Charles E, Bouby-Serieys V, Thomas P, Clément JP. · Service Hospitalo-Universitaire de Psychiatrie Adulte (Professeur Clément), Centre Hospitalier Esquirol, 15, rue du docteur Marcland, 87025 Limoges cedex. · Encephale. · Pubmed #17099599 No free full text.

Abstract: Ageing is due to a progressive loss of the person's adaptation capability, whereas during this period environmental aggression increases. In the elderly, life events re-present a psychological traumatism that overwhelms the old person and related family, disrupting and fragilising homeostatic balance. A number of authors have suggested a possible link between life traumatisms and the dementia processes. The aim of this study is to reveal the presence of life traumatisms preceding the apparition of the dementia syndrome. Method. This is a retrospective and comparative work based on the PIXEL study on complaints and demands from the principle informal caregivers of Alzheimer patients. It includes 565 patients presenting the criterion of dementia as defined by the DSM IV, and questionnaires filled out by the principle caregivers. One item of the questionnaire referred to life events which could have played a part in the development of the disorder. In a second stage, the reported events were classified into 4 distinct categories: loss, repeated or prolonged stress, psychotraumatism and depression-inducing events. The statistics were produced using SAS and Stat 10 software. Student's test, ANOVA and chi2-test were used. RESULTS: 372 caregivers answered the first item (65%); 76 of them believed there was no event while 296 related the disorder to one or several life events (79% of responders, 52% of the sample). These results confirm Persson and Clement's study which evidenced a higher frequency of stressing life events for subjects afflicted with dementia as compared with older people without any psychic disorder. Reported events and their respective frequency: spouse death (15.39%), parents' death (15%), familial difficulty (10.08%), anaesthesia (8.49%), child's death (4.42%), somatic disturbance (4%), depression (3.89%), retirement (3.89%), financial problems (2.65%), loneliness (2.65%), removal (1.76%), fall (1%), alcohol (0.8%), traumatism (0.53%), spouse care (0.35%), leaving for home care, storm and caregiver change in life (0.17%). Regrouping the data: 82.71% of the answers can be connected to prolonged stress, 62.85% to real or symbolic loss, 39% to a psychotraumatic event and finally, most of these events can potentially induce depression. DISCUSSION: Some of the events refer to difficulties concerning people close to the subject (death of a close relation, hospitalisation of husband or wife) in a period when the loss of autonomy or handicap means greater dependence on surrounding people. General anaesthesia is mentioned by 48 caregivers. In fact, this usually implies surgery, the presence of organic pathology or the need for hospitalisation, which we know has a destabilizing effect in the elderly. It is therefore not surprising that 23 answers mentioned somatic disorders (4% of the sample). According to Leger, it's mostly a loss type event which is implied in the elderly. Such losses would induce a weakening of cognitive stimulation which could decompensate an infraclinical dementia or accelerate an emerging dementia process. Antecedents of depressive illness are considered as an element of risk for the development of Alzheimer's disease. Depression is spontaneously mentioned by 22 caregivers. We must add the many reported life events which are well known to induce depression in older people. Most of the events considered in this study are liable to provoke manic mood swings. Depression resulting from life events can be considered either as an affection occurring along with dementia or as the aggravating factor of an infraclinical process or, finally, as an additional factor of vulnerability. With older people, many events may constitute a trauma because of the proximity of death and because of their sudden onset (fall, hospitalisation, somatic illness). Several studies have pointed out that a particularly traumatic event could enhance the risk of dementia. Life events associated with chronic or repeated stress are characterized by their permanence or their repetition. According to a general psychosomatic biological pattern, psychic distress will engender a series of degradations or an acute or chronic response to an early trauma. According to this hypothesis, prolonged exposure to an excess of glucocorticosteroids at the time of a disadaptative stress would have deleterious effects on the hippocampus. Indeed, the hippocampus plays a part in a number of functions affected by dementia such as memory, learning process and emotional adjustment. This study takes into account stress factors ("stressors") but not factors influencing their impact on the subject such as an individual predisposition (genetic, psychopathologic, coping abilities) and social support. The force of the impact of these events on older people and what is really experienced by them remain unknown. This study strengthens a number of others evincing an unusual frequency of life events in dementia processes. According to an integrative pattern, repeated or prolonged stress could be a deciding factor in the degenerative process or a factor of decompensation with older people presenting a genetic, biological or psychological vulnerability to dementia. The impact of such life events would vary according to the subject's pre-morbid personality, coping abilities and the support he/she can rely on. CONCLUSION: Some life events may be involved in the dementia process as shown by the results of this study, but this relationship does not imply direct causality. It's difficult to appreciate whether these results are not a consequence of the greater attention paid to the patient after the appearance of the first symptoms, leading to a closer observation. Stress could trigger the degenerative process. This argues for the necessity of an early diagnosis taking into account a traumatic event of life either precocious or late.

Thomas P, Lalloué F, Preux PM, Hazif-Thomas C, Pariel S, Inscale R, Belmin J, Clément JP. · University Department of Psychogeriatrics & Memory Clinic CH Limoges, France. · Int J Geriatr Psychiatry. · Pubmed #16323256 No free full text.

Abstract: BACKGROUND: Alzheimer's disease and related syndromes have heavy social and human consequences for the patient and his family. Beyond the neuropsychiatric effects of specific therapies for dementia, one of today's challenges is the quality of life for both patients and their informal caregivers. OBJECTIVES: This survey tends to determine parameters influencing caregivers' quality of life, and its possible link with patients' quality of life. METHODS: A scale measuring caregivers' quality of life, developed from data from previous PIXEL studies was used. It is a questionnaire composed of 20 items. The scale was related to the socio-demographic data of both patients and their main caregivers, to the ADRQL scale (Alzheimer Disease Related Quality Life) of Rabins for the QoL of dementia patients, to the patients medical and therapeutic data, specially a neuropsychological inventory: Folstein's cognition test, Cornell's depression scale, the fast battery of frontal assessment, Katz's dependence index, Cummings' neuropsychiatric inventory for behavioral and psychological symptoms of dementia and to a physician evaluation of caregiver's depression. RESULTS: One hundred patients diagnosed with dementia who live at home with their principal caregivers were recruited for this survey. Patients were 80.2 +/- 6.8 years old and caregivers were 65.7 +/- 12.8 years old. The caregivers' quality of life was correlated to the quality of life of the patients they cared for, the importance of behavioral disorders, and the duration of dementia evolution. Women caregivers had a worse quality of life and were more depressive than men. DISCUSSION: Caregivers' and patients' quality of life are related and both share a community of distress.

Thomas P, Hazif-Thomas C, Delagnes V, Bonduelle P, Clément JP. · Centre Mémoire de ressources et de recherche du Limousin, Pôle universitaire de psychiatrie du sujet âgé, Centre hospitalier Esquirol, Limoges. · Psychol Neuropsychiatr Vieil. · Pubmed #16126473 No free full text.

Abstract: Caregivers of demented outpatients can have a weak health, are often old and alone, and the burden of care can generate precariousness. OBJECTIVES: This survey tends to determine the parameters influencing the caregiver's Quality of Life (QoL) and precariousness, and to measure their consequences. METHODS: A scale measuring caregivers' QoL and a scale measuring precariousness, developed from data of previous PIXEL studies were used. Each scale is a 20-item questionnaire. The results were related to the socio-demographic data of both patients and their principal caregivers, and to the patients' medical and therapeutic data. RESULTS: 1.410 patients diagnosed with dementia who lived at home with their principal caregivers were included in this survey. The caregivers' QoL was correlated to the carers' precariousness. Females caregivers had poorer QoL and more precariousness than men. Caregivers' QoL and precariousness were favourably influenced by specific dementia treatment. Frail caregivers had a poor QoL and an important precariousness. They were often sick and had to deal with nutritional difficulties with the demented patient. They were less satisfied with their care ability and their relationships with their patients. DISCUSSION: Caregivers' QoL and precariousness are related and both express their distress. The specific treatment of dementia is beneficial for both of them. Presumably, this benefit would be increased by supportive care of carer and patient.

Nubukpo P, Le Bruchec M, Clément JP. · Service hospitalo-universitaire de psychiatrie, Centre Hospitalier Esquirol, Limoges. · Presse Med. · Pubmed #15988336 No free full text.

Abstract: OBJECTIVE: Assess and describe the organization, operation, and aims of Alzheimer health networks in France. METHODS: Questionnaire sent by post or handed to physicians in France identified as involved in management of Alzheimer patients by Novartis Pharma sales representatives. RESULTS: 166 networks managing Alzheimer's disease (2/3 primarily gerontological and 1/3 specializing specifically in Alzheimer's). In 61.9% of the cases, the physician supervising the network was a hospital staff physician, often a geriatrician (48%). The other member physicians were essentially general practitioners. Several paramedics and social workers also participated. Most networks were organized as not-for-profit organizations. Financial support most often came from the relevant ministries and the health insurance funds. The number of active cases handled by the networks could not be globally assessed. The operating tools for the networks included membership charters, management guidelines and protocols, and shared medical files, but fewer than 30% of the networks used any one of these. The networks had as their primary objectives training and information, patient follow-up and gerontological coordination. These aims were consistent with the goals they felt that had come closest to attaining, i.e., improving the quality and organization of care, sharing information with and training other health professionals, and providing information to the public. Barely one third of the networks had developed an assessment procedure. Among the obstacles to network operations were the participants' lack of availability, the absence of collaboration between professionals, and financial problems. CONCLUSION: Despite the disparity in the quality and exhaustiveness of the data collected, our survey confirmed the diversity and dynamism, but also the lack of formal structure and the difficulties confronted by the Alzheimer networks in France.

Clément JP. · Pôle universitaire de psychiatrie du sujet âgé, Centre Hospitalier Esquirol, Limoges, France. · Psychol Neuropsychiatr Vieil. · Pubmed #15899647 No free full text.

Abstract: Extensive research has been achieved on the old age depression during the last decades. Specific clinical features and management have been reported. Indirect clinical and behavioural indicators, and even biological ones should be considered for the detection of depression. Cognitive assessment must be promoted in standard practice to differentiate depression from incipient dementia, but also in depression occurring in long stay care, vascular depression and in the depression-executive dysfunction syndrome. Distinction between recurrent depressive episode and late-onset depression has to be clarified. Therapeutic strategies have to be reconsidered in duration, according to the trend toward chronicity of late life depression. They remain based on the use of pluri-aminergic antidepressants. Depressive disorder in the elderly is associated with hippocampus dysfunction, but other biological variables should be taken into account according to a dynamic stress-vulnerability model.

Thomas P, Clément JP, Hazif-Thomas C, Léger JM. · Louis Pasteur Geriatric Daycare Hospital, F-86036 Poitiers, France. · Int J Geriatr Psychiatry. · Pubmed #11241725 No free full text.

Abstract: BACKGROUND: The aim of this study is to look at the correlation between the presence of apathy measured by Marin's scale and family complaints related to withdrawal and the loss of motivation, or depression. The multicentre study was performed on 58 non-demented elderly people, 132 outpatients with Alzheimer's-type dementia, as well as their main caregiver. METHODS: After agreement of the patients and the family, the patients were assessed using different scales: Cornell's for depression, Marin's for apathy, MMS for cognitive disorders, and IRG for dependence. At the same time, two self-administered questionnaires were given to the patients' families: one concerning a list of complaints scored from 1 to 4 relating to various disorders and the other addressing the boundary ambiguities translated from Boss' questionnaire. The 58 non-demented people were 81.20 years old+/-13.75. One hundred and thirty-two demented patients were included: 39 men and 93 women. The mean age was 79.47 years+/-9.03. RESULTS: The first family complaint relates to the loss of motivation (65%). Apathy and depression occur more frequently in dementia, in particular when the MMS is degraded. Depression and apathy attracted a high complaint score. In our study the score of boundary ambiguity is higher among patients with a weak cognitive status. A high level of ambiguity is accompanied by a high score of family complaints. When the family complaint concerning the loss of motivation is present, apathy is significantly more common. Family complaints about withdrawal and loss of motivation are frequently present, and are congruent with the actual presence of apathy in the patient. It bears witness to the distress felt by families faced with the loss of ability noted in the demented person. The family's difficulties are increased by the patient's depression.