Les troubles du sommeil chez les patients atteints d’un trouble neurocognitif

IntroductionSleep disorders are prevalent in patients with a neurocognitive disorder, and diagnosis and treatment in these patients remain challenging in clinical practice.MethodsThis narrative review offers a systematic approach to diagnose and treat sleep disorders in neurocognitive disorders.ResultsAlzheimer's disease is often associated with circadian rhythm disorders, chronic insomnia, and sleep apnea-hypopnea syndrome. Alpha-synucleinopathies (e.g., Parkinson's disease and Lewy body dementia) are often associated with a rapid eye movement sleep behavior disorder, restless legs syndrome, chronic insomnia, and sleep apnea-hypopnea syndrome. A focused history allows to diagnose most sleep disorders. Clinicians should ensure to gather the following information in all patients with a neurocognitive disorder: (1) the presence of difficulties falling asleep or staying asleep, (2) the impact of sleep disturbances on daily functioning (fatigue, sleepiness and other daytime consequences), and (3) abnormal movements in sleep. Sleep diaries and questionnaires can assist clinicians in screening for specific sleep disorders. Polysomnography is recommended if a rapid eye movement sleep behavior disorder or a sleep apnea-hypopnea syndrome are suspected. Sleep complaints should prompt clinicians to ensure that comorbidities interfering with sleep are properly managed. The main treatment for moderate to severe obstructive sleep apnea-hypopnea syndrome remains continuous positive airway pressure, as its efficacy has been demonstrated in patients with neurocognitive disorders. Medications should also be reviewed, and time of administration should be optimized (diuretics and stimulating medications in the morning, sedating medications in the evening). Importantly, cholinesterase inhibitors (especially donepezil) may trigger insomnia. Switching to morning dosing or to an alternative drug may help. Cognitive-behavioral therapy for insomnia is indicated to treat chronic insomnia in neurocognitive disorders. False beliefs regarding sleep should be addressed with the patient and their caregiver. The sleep environment should be optimized (decrease light exposure at night, minimize noise, avoid taking vital signs, etc.). Sleep restriction can be considered as patients with a neurocognitive disorder often spend too much time in bed. The need for naps should be assessed case by case as naps may contribute to insomnia in some patients but allow others to complete their diurnal activities. Trazodone (50 mg) may also be used under certain circumstances in chronic insomnia. Recent evidence does not support a role for exogenous melatonin in patients with a neucognitive disorder and insomnia. Patients in long-term care facilities are often deprived of an adequate diurnal exposure to light. Increasing daytime exposure to light may improve sleep and mood. Patients with circadian rhythm disorders can also benefit from light therapy (morning bright light therapy in case of phase delay and evening bright light therapy in case of phase advance). Rapid eye movement sleep behavior disorder can lead to violent behaviors, and the sleeping environment should be secured (e.g., mattress on the floor, remove surrounding objects). Medication exacerbating this disorder should be stopped if possible. High dose melatonin (6 to 18 mg) or low dose clonazepam (0.125–0.25 mg) at bedtime may be used to reduce symptoms. Melatonin is preferred in first-line as it is generally well tolerated with few side effects. Patients with restless legs syndrome should be investigated for iron deficiency. Medication decreasing dopaminergic activity should be reduced or stopped if possible. Behavioral strategies such as exercise and leg massages may be beneficial. Low-dose dopamine agonists (such as pramipexole 0.125 mg two hours before bedtime) can be used to treat the condition, but a prolonged treatment may paradoxically worsen the symptoms. Alpha-2-delta calcium channel ligands can also be used while monitoring for the risk of falls.ConclusionMultiple and sustained nonpharmacological approaches are recommended for the treatment of sleep disturbances in patients with neurocognitive disorder. Pharmacological indications remain limited, and further randomized clinical trials integrating a multimodal approach are warranted to evaluate the treatment of sleep disorders in specific neurocognitive disorders.     

La fatigue des patients atteints d’une maladie de Crohn en rémission : exploration du rôle du parcours médical et des facteurs psychologiques

ObjectivesFatigue is a common complaint in IBD disease. Medical factors (anemia, medicinal side effects, activity of the disease) partially explain IBD-related fatigue. Research has shown that fatigue is persistent even if the disease is in remission. Other factors need to be considered in order to understand this phenomenon. Fatigue could be considered as a consequence of disease history. But it also appears necessary to consider patients’ causal attribution of the disease, the perceived gravity of their trouble and the presence of psychological suffering.MethodsSeventy-seven patients with Crohn's Disease in remission were enrolled. They answered questionnaires assessing fatigue (MFI), depression (HADS), anxiety (HADS, STAI YA/B), perceived severity (CGI1), pain EVS and a causal attribution scale. Information about disease history was collected from the MICISTA database for the 10-year period preceding the assessments (the number and severity of clinical relapses, the number of hospitalizations due to a major degradation of the clinical condition, the number of intestinal surgeries, the severity of bowel resection evaluated by the Post Surgical Handicap Index, type of medical treatment taken at the time of evaluation). Patients were compared using the CGI1 median (ANOVA) and the General Fatigue median (t-test). Then MFI scores were analyzed with a multiple regression.ResultsThe results showed only one significant relation between perceived severity of the disease and pain. Dichotomization of patients according to the median level of general fatigue showed that patients were significantly more tired, more depressed, anxious, and in pain than less tired patients. They also had a more serious bowel resection and a significantly worse perception of the severity of their current troubles. The analysis of correlation showed that none of the medical disease-related history was linked in fatigue scores. In contrast, intensity of depression and anxiety-related variables (more particularly trait-anxiety) were the most involved in fatigue scores intensity. Only the perceived severity and the internal-external dimension of causal attributions respectively were linked to the severity of general fatigue and reduced activity.ConclusionThese results confirm that if fatigue is associated with medical factors including the period of clinical activity (as was demonstrated elsewhere), this medical reality would not play a role when the disease is in remission. The influence of anxiety and depression is consistent with that observed in other studies. Trait-anxiety would increase the vulnerability to the onset of fatigue. This could partially explain why some patients remain tired even in remission. Fatigue could be also understood as a manifestation of the work of the disease which can be conceived as the totality of psychic operations involved in the subject's relation to his illness. This psychic work is particularly difficult because it requires both development and a waiver of certain aspects of the self. This difficulty is reflected in the appearance of depression, but may also occur to a lesser extent by the complaint of being tired. In the context of chronic disease, it is then possible to hypothesize that fatigue could be a manifestation of the work of the disease in individuals already vulnerable because of an anxious dimension of personality. Understanding and management of fatigue in patients with Crohn's disease requires the transition to a more personal understanding of the meaning attributed to each patient's illness and fatigue. In any case, it seems essential to reconsider the weight of the patient's objective medical history in fatigue and the physicians’ attributions linking it to the disease.     

Diagnostic et prise en charge des troubles respiratoires d’un patient en situation de polyhandicap. Construction d’une échelle de choix

Patients with multiple disabilities have a respiratory morbidity, which must be detected and treated. But respiratory diseases are difficult to explore in these patients because of poor relation capacities. The initial management includes correct position, limiting inhalation risk and adverse effects of drugs. Clinical examination is the basis of the diagnostic process and guide the treatment. If we need to treat, complementary investigations (night oxygen saturation, capnography, polysomnography or polygraphy) are sometimes necessary to make right diagnosis and adapt management.     

La maladie du sommeil,fin d’une épidémie ?

Sleeping sickness or human African trypanosomiasis is a parasitic disease transmitted by tsetse flies and therefore confined to its habitat, the central part of the African continent. Two disease forms are linked to two different parasites: T. b. gambiense and T. b. rhodesiense. Actual epidemiological data and precise and dynamic mapping of foci are in favor of a real decrease of the disease. Not all areas are under control and resurgence can still not be avoided from the remote areas where the disease is endemic. However, recent advances in knowledge in parasite genetics are giving hope of control. In 2009, for the first time since 50 years, less than 10,000 cases were declared to the World Health Organization. Clinical trials allowed revising some clinical concepts and linking them with parasite genetics: both disease forms can show variations from asymptomatic, chronic to acute and are linked to genetic differences in the host or the parasite. Parasitological diagnosis may be facilitated by the introduction of individual rapid tests and PCR-based field tests. Knowledge in mechanisms of brain invasion and screenings of inflammatory molecules allow new marker combinations for staging but they do not avoid lumbar puncture. Therapeutic options remain limited but there is hope to develop a new drug orally available in a near future.     

Prise en charge du risque suicidaire : les centres d’accueil et de crise comme dispositif de soins

ObjectivesThe suicidal crisis is a public health problem (about 10,000 suicides a year in France). Our objective is to assess the relevance of care facilities for adult suicidal patients, particularly French crisis centers (CAC in French).Materials and methodsWe have identified the health care providers and the mechanisms at work in the suicidal crisis and the associated levels of effectiveness in the world. A full census of the french crisis centers was carried out as well as a quantitative analysis of caregivers (members of the association of French psychiatric residents, AFFEP and the members of an association of suicide prevention study in France, GEPS) on their perception of the suicidal crisis and the organization of care.ResultsOpening up call lines, maintaining contact with patients after a suicide attempt and training general practitioners are effective. The crisis centers census is incomplete because of lack of consensus on their definition. 761 members of the AFFEP and 24 of the GEPS replied to our qualitative analysis: 42% of the first and 50% of the second have difficulties in the care of suicidal patients for reasons of access to care. The care facilities put forward by the members of the AFFEP are the possibility to reconnect with a unit open 24/24 (62%), family interviews (61%) and the systematic implementation of follow-up (56%).ConclusionThis work makes it possible to sketch the modes of care of suicidal patients in France. The interest of crisis centers is to accommodate any urgent demand and to allow a work of reflection, understanding and treatment of the crisis. They use devices that have proved their effectiveness (maintaining contact through post-crisis consultations, a 24-hour call-center, setting up a follow-up in the continuity of the French psychiatric public departments). Crisis centers are an innovative health care system that is insufficiently supported by sectors and public authorities in France.     

Reconnaissance émotionnelle chez les enfants de 3 ans en fonction du sommeil et du risque de dépression

Introduction

The emotional process is characterized by a negative bias in depression, thus it was legitimate to establish if they same is true in very young at-risk children. Furthermore, sleep, also proposed as a marker of the depression risk, is closely linked in adults and adolescents with emotions. That is why we wanted first to better describe the characteristics of emotional recognition by 3-year-olds and their links with sleep. Secondly we observed, if found at this young age, an emotional recognition pattern indicating a vulnerability to depression.

Suivi qualitatif de l’évolution de 120 enfants porteurs de troubles du spectre autistique pris en charge par la méthode des 3i

AimThe 3i intervention is a developmental play-therapy method that considers that children with Autism Spectrum disorders (ASD) present an altered developmental process. It aims to help the child progress along a natural developmental path. Each developmental deficit is dealt with successively, with full attention to the specific sensory characteristics of each child. The method is based on Intensive Individual Interaction (the 3Is) of the child with adults. The 3i intervention is managed by the parents and selected care-givers, 5 to 6 hours per day, 7 days per week, to favor constant stimulation of the child. A key characteristic of the 3i method is the intervention of numerous selected care-givers, each contributing their preferred way of playing with the child and their enthusiasm. These selected care-givers are mostly non-professionals in the field of ASD. They undergo preliminary screening and receive initial training before interacting with the child in the playroom. They subsequently participate each month in a group session with the other participants, together with the parents, under the supervision of a trained psychologist.GoalThe main objective of this retrospective study was to assess the development of communication and social skills among children diagnosed with autism spectrum disorders (ASD), treated with the 3i method for 2 years.Methods120 subjects who pursued the 3i method for 24 months were included in this study, on the basis of their individual files kept by the psychologist, who conducted the monthly meeting with professionals during the implementation of the 3i method. The psychologist rated six indicators (Imitation, Gaze Quality, Social and Emotional Regulation, Verbal Expression, Non-Verbal Expression and Verbal Comprehension) from 1 to 3 (1: not acquired; 2: partially acquired and 3: competence acquired). Thus a developmental acquisition stage or score was allocated to each patient at the beginning of 3i Method and 24 months later.ResultsFor each indicator, the statistical analysis showed that the group of patients significantly increased their skills over the 24 months of the 3i method. On average, the patients reached a higher level of skills in four of the six skill areas. There was a relatively greater increase in the skills relating to imitation and non-verbal communication.DiscussionBeyond the limitations arising from the retrospective nature of the study, which used a non-standardized assessment scale, these results are consistent with a previous prospective study on 20 subjects using international standardized instruments. These results suggest that disabilities related to autism spectrum disorders decrease as a result of a 3i intervention, enabling better daily-life interaction with parents and as a second step better integration in school with peers.ConclusionThis method could reduce the intensity of the autistic syndrome and improve the ability of ASD children to interact with their environment.     

Étayer les relations parents–enfants en groupe de jeux quand l’enfant souffre d’autisme ou de troubles envahissants du développement

The process of one's body mental integration depends notably on the quality of the first cares given to him/her in the beginning of his/her life in a reciprocal game of solicitations in his/her mothering surrounding. However, in autism and pervasive development disorders, the solicitations coming from the child are difficult to translate by parents. Then the sufferance of some parents settles in, from the fact that their child is different. This complicates the process of attachment, this threatens the homeostasis of the family system and then can threaten the required alliance with the family and the homeostasis of the therapeutic system. To prevent this we are looking to establish a partnership with these parents. Peter Pan is a playgroup bringing together children suffering of autism or pervasive development disorders with their parents. It is a part of the Mulhouse Psychotherapeutic Center for Children and Teenagers Daily Hospital, within the child–youthful psychiatrist sector 68I02 incorporated with the Rouffach Hospital (France). The project is a special adaptation to our public of the Calimusette and Pirouli^® Concept (parents–young children activities, around corporal and sensorial games). Peter Pan group's goal is to consolidate the relationship between child and parent notably by restoring a shared pleasure and the self-esteem in this bruised child–parent relationship. The designation “Peter Pan” refers to the child imaginary world and to the creativity potential that can immerged from interactions, where children and parents can learn together. The systemic inspired Structured Observation Model of the Children and Parents Interactions (MOSIPE^® in French) is one of our intervention resources. It's made of eight items: The existence of shared pleasure during the interactions, the possibility to benefit self-esteem from the interaction, child health, parent and child needs, how the interactions take place, the capacity to adapt when change occurs, which type of attachment, parents reactions from our restitution. We insist on the mimicry functions: To observe subtle signs, to get resonance with other with the goal to understand what he/her feels, to take contact with he/her and maintain it, to widen views, by introducing unobtrusively new element into the mimicry behavior, to develop subjectivity, to develop capacities to act. The meetings with our daily hospital colleagues are precious to maintain the homeostasis of the therapeutic system when developing its creativity and relevance. At Peter Pan playgroup, the bodily approach gives opportunities to get onto the relationship between a parent and his/her child in the most archaic dimension with their tonic, emotion, and affective components. All this work of observation, reading/decoding the psychomotor symptom, listening the sufferance of the parents, has enabled the parent to acquire what is required to decode, express ones needs and understanding to enable a better adjustment between each other. Supported in this way, parent recovers his/her parental function thanks the possibility to live shared pleasure and the self esteem in the interactions that restores their feeling of self efficacy and establishes identification ties with his/her child. He/her is recognized as an expert. This project is an answer to parents request to meet other parents that share common points: Having a disabled child who attends the daily hospital. Children come to the hospital with taxi, so parents do not have occasions to meet together, when other parents normally meet others waiting their children at the door of school. During the sessions we observed parents sharing advices to cope with problems, exchanging activities ideas, encouraging into ordeal. After some sessions parents have exchanged their addresses. In other words Peter Pan's Group has also functioned as a mutual aid group.