- 1 - Abstract Geriatric palliative care integrates two medical disciplines, namely geriatrics, focused on the diagnosis and treatment of diseases specific to the elderly, and palliative care, which is a comprehensive, active and qualified approach aimed at improving the quality of life of patients and their families in a situation where they suffer life-threatening illnesses. Palliative care is realized through multidisciplinary teams and a nutrition specialist is one of the most important specialization in the care of frail geriatric patients, even though its position in teams is still not firmly established. This work is dedicated to nutrition specialists, aims to introduce them into the issue of geriatric palliative care and to help them with a complex perception of the patients and the application of a palliative approach into nutritional care. It also deals in detail with anorexia and dysphagia, two of the frequent and major symptoms that we encounter in frail geriatric patients. The nutrition specialists can best try to solve these problems. The work should also help other professionals who are involved in providing palliative care, understanding the role of nutrition specialist and its effective use to improve the quality of patient's life. The empirical part describes a case report of almost one...

Thèse de doctorat : Médecine : Nancy 1 : 2000. / 2000NAN11315. Titre provenant de l'écran-titre.

Thesis deals with the issue of food intake disorders in secondary school. The theoretical part of the work is focused on defining the terms anorexia nervosa and bulimia nervosa. Starting with historical development of these diseases, through complexity of causes and consequences of the disease and description of an endangered group of patients, I got to the contemporary medical treatment used. The practical part of this work consists of the questionnaire survey of adolescent students. Based on the results of this survey I proposed a brief prevention program, targeting in particular parents and teachers, including practical advices how to support the prevention of food intake disorder diseases of adolescents.

Introduction: Recently published reviews and meta-analytic studies have shown increased interest in research of the ADHD and ED comorbidity. We conducted a case-control study (133 ED female patients/93 healthy control), screening for ED among ADHD patients (N=64) and a pilot study of a support group program for adults with ADHD and psychiatric comorbidities. Methods: Adult and childhood ADHD symptoms were assessed by self-report and other- report versions of a Barkley Adult ADHD questionnaire (BAARS-IV). Patients with ED and ADHD comorbidity underwent a structured interview (DIVA 2) and Integrated Visual and Auditory Performance Tests (IVA Plus) to confirm the ADHD diagnosis. Participants of the pilot program were assessed prior to and after the therapy by the Schwartz Outcome Scale (SOS) and Quality of life (SQUALA) questionnaires. Results: Using self-report questionnaire of current symptoms 61 (46 %) of ED patients were detected as likely having ADHD compared to 22 (24 %) from a healthy control group, 37 (28 % ) of ED patients were identified with the high probability of ADHD diagnose compared to 12 (13 %) from a healthy control group with significant differences. Screening for disordered eating behaviors indicated previously documented higher prevalence of overweight among men with ADHD...

SOCIAL INPACT OF THE MENTAL ANOREXIA AFFECTING CHILDREN´S PATIENTS ON HE FAMILY In choosing the subject of my degree work I was influenced fundamentally by my experience gained during the department of children´s psychiatry. At thes very interesting work I had opportunity to become acquainted not only with various psychiatric diagnoses but with plenty of human fates in particular. The girls with plenty of human fates in particular. The girls wth mental anorexia were frequent patients of this department. During their long-term and often repeated hospitalization I met both the patients and the whole families. That´s why I could follow the development of the children affected like this and the impact of this illness on the family as well. The mental anorexia is a very grave and lingering illness belonging to the group of disorders in food ingestion. The consequences of this illness for he health can be of an persistent character and it is not exceptional that this illness is even fatal. The therapy is spite of all therapeutical possibilities, the modern psychiatry has at disposal. Therefore, the families of the patients have not only to get over the fear for the life and health of their members, but they have also to overcome longlasting psychological stress connected with the care of the person affected like this. This care can influence the running of the family fundamentally. It often happens that the family has to reduce the professional activities with respect to the exacting care. This can result in aggravation of the economic situation of the family. A considerable lowering of the living standard and the following crisis can take place in families with low incomes. Permanent psychological stress, deterioration of the economic situation and fair for the child can influence also the relations between individual members of the family. It is no exception that this stress has an adverse effect on the marriage of the parents, and that expecially in the case that the marriage was a problematic one as early as before the child fell ill.

In my Master thesis I summarize up-to-date information on anorexia nervosa. In the theoratical part I introduce casuistics of young females suffering from anorexia nervosa. In the practical part I present the evaluation of research data dealing with particular risk factors that may lead to the development of anorexia nervosa in students of lower stage of grammar school.

This thesis deals with the issue of eating disorders of pupils attending upper primary schools of rural and urban type. The issue of eating disorders is very complex and public often fails to understand it. People do not see the fact that the food and its rejection can turn into a real habit. Eating disorders are not only observed in young women, but also increasingly in children and adolescents. Eating disorders involve serious psychosomatic disorders, significantly affecting the mental and physical status. Thus, they may very negatively affect personality development from childhood to adulthood. They are accompanied with many somatic problems and complications and they can have a very negative influence to the overall health status of an individual. Eating disorders cause long-term problems not only to patients themselves but also to their families, spouses and friends. It is very easy to fall ill with eating disorder, but is very hard to get better.

L'anorexie mentale (AM) est un trouble du comportement alimentaire qui se caractérise par une recherche obsessionnelle de minceur, une forte réduction de la prise alimentaire et une distorsion de l'image de soi. Elle est associée à de multiples perturbations endocriniennes et métaboliques, et à une altération de la masse et de la microarchitecture osseuses. Les facteurs et les mécanismes qui interviennent dans cette maladie sont très mal connus ce qui limite les options thérapeutiques. Il est donc nécessaire de développer un modèle animal qui reproduise les perturbations physiologiques observées en AM et permette d'étudier les facteurs associés à l'altération osseuse. Dans ce but nous avons développé un modèle murin avec une restriction du temps d'accès à l'alimentation associée à un stress induit par la séparation (separation-based anorexia, SBA). Cette phase SBA de 10 semaines est suivie d'une phase de récupération en conditions standard (REC) de 10 semaines. Chez les souris femelles C57B1/6 en fin de croissance rapide, la phase SBA induit une perte rapide et importante du poids corporel. L'analyse de la composition corporelle par DEXA révèle une diminution rapide de près de 40% de la masse grasse ainsi qu'une baisse progressive de la masse maigre et un arrêt de l'acquisition de la masse osseuse. Au niveau des tibias, la densité minérale cortical et la microarchitecture trabéculaire sont altérées. L'observation des frottis vaginaux et la mesure des ovaires révèlent une perturbation importante des fonctions reproductrices. Les tests de tolérance au glucose ont montré que les souris SBA ont une capacité très élevée à corriger la glycémie. Ces animaux sont fortement hypoleptinémiques, et l'axe GH-IGF-1 est très perturbé. L'étude de l'expression génique de différents tissus adipeux a montré une augmentation du niveau des marqueurs de lipogénèse et de lipolyse, ainsi qu'une forte induction du phénotype "adipocyte brun" dans le tissu adipeux sous-cutané. Après deux semaines de REC, les souris SBA retrouvent très rapidement leur poids corporel, leurs masses maigre et grasse. La masse minérale toujours basse à ce stade est corrigée après 10 semaines de REC, ainsi que la microarchitecture osseuse (étude préliminaire). Tous les autres paramètres étudiés sont normalisés, sauf l'hypoleptinémie qui étonnamment persiste même après 10 semaines de protocol REC et malgré la normalisation de la masse adipeuse. D'après ces résultats, on peut conclure que le modèle SBA reproduit de nombreuses perturbations physiologiques observées en AM. La phase de REC révèle que ces souris ont une importante capacité de récupération. L'hypoleptinémie persistante pourrait favoriser la récupération. L'identification des mécanismes impliqués pourrait fournir des pistes thérapeutiques afin de favoriser la reconstitution du capital osseux des patientes anorexiques. / Anorexia nervosa (AN) is an eating disorder mainly developed in adolescent girls and young women. It is characterized by an obsessive search for thinness, a profound undernutrition and a distorted self-image.It is associated with multiple endocrine and metabolic disturbances, decreased bone mass and microarchitectural alteration. Some of the developed adaptations are supposed to be involved in the blockade of the pathologic state. Unfortunately, these adaptations are poorly known and most of them cannot be studied on patients. So it is necessary to develop an animal model which mimics the main consequences observed in human pathology and allows studying the recovery process. For this purpose we adapted a murine model of time restricted feeding associated with chronic stress induced by separation-based anorexia (SBA). C57B1/6 female mice are submitted to a long term SBA protocol (10 weeks) and then a long term phase of recovery (10 weeks). At the beginning of the protocol mice are 8 weeks old, so their fast growth is finishing. SBA protocol induced a rapid and significant loss of body weight. Body composition analysis by DEXA showed a 40% decrease of the fat mass, a progressive loss of lean mass and a blockade of bone mass acquisition. Mice deveoped a high glucose tolerance. The observation of vaginal smears revealed a disruption of the estrous cycle and ovarian histology showed an atrophy of the ovaries. These two alterations suggest a major alteration of reproductive functions. These animals showed a very low leptinemia, and the GH/IGF-1 axis was disrupted. The study of bone alteration by microtomography indicated an alteration of bone microarchitecture and of cortical bone mass, mimicking osteoporosis often described in AN patients. Body weight, lean and fat masses were normalized quickly during the REC protocol. Bone mineral content still low after 2 weeks of REC protocol was fully corrected after 10 weeks. The estrous cycle ovarian size and the GH/IGF-I were normalized. Surprisingly, hypoleptinemia persisted even after 10 weeks of REC and despite the normalization of the fat mass. This result has been confirmed by the low level of leptin gene expression in various adipose tissues. Finally, the SBA protocol is valuable model of AN because numerous physiological alterations described in AN are mimicked in this model. The recovery phase revealed the high capacity of mice to normalize the long term alterations. Persitent hypoleptinemia could contribute to the normalization of body composition. However, the balance between central and peripheral effects of the uncorrected hypoleptinemia remains to be determined. This persisting hypoleptinemia could be used for the revision of the therapeutic strategies aiming to correct AN-induced osteoporosis.

La capacité de juger ses propres actions se trouve être perturbée dans l'anorexie mentale (AM). Les patientes souffrant d’anorexie mentale surestime notamment le seuil de passabilité d’une ouverture (par rapport à un groupe témoin) lors d’une simulation ou d’un franchissement d’ouverture réelle. Ces données sont en accord avec les plaintes des patientes qui se sentent plus grosses qu’elles ne le sont en réalité. Le jugement des patientes est perturbé lorsqu’elles adoptent une perspective en première personne (j’effectue l’action), mais reste préservé lorsque la perspective est en troisième personne (je regarde un sujet effectuer l’action). Ces résultats suggèrent une atteinte spécifique du schéma corporel et non d’une perturbation globale des jugements perceptifs.Cette surestimation du schéma corporel dans l'AM pourrait être liée à l'existence d'un trouble de l'intégration multisensorielle, l’élaboration d’un schéma corporel harmonieux résultant de l'intégration des afférences visuelles, tactiles, proprioceptives et vestibulaires. Une corrélation existe entre la baisse des performances comportementales et l’intensité des troubles de l'alimentation, qu’il s’agisse de la recherche de minceur, des préoccupations corporelles et de l’insatisfaction générée. Les perturbations corporelles ainsi que les répercussions comportementales engendrées pourraient induire un renforcement des comportements alimentaires restrictifs.Les performances des patientes sont liées à la fois à leur perte de poids au cours des mois précédents et à leur poids avant la décompensation. Ce résultat pourrait appuyer l’hypothèse d’un défaut d’actualisation du schéma corporel, les modifications morphologiques engendrées par une perte de poids rapide et massive n’étant pas prises en compte par le système nerveux central. L'AM touche essentiellement les jeunes femmes entre 15 et 19 ans. De véritables bouleversements physiologiques et psychologiques se produisent lors de la puberté, ayant un impact sur le schéma corporel. Les variations de poids induites par les troubles du comportement alimentaire pourraient venir renforcer ces perturbations. L'étude des phénomènes neurologiques, tel que le syndrome du membre fantôme, pourraient faire la lumière sur ce point. En effet, de nombreuses personnes amputées continuent à ressentir la présence d'un membre fantôme après amputation. Beaucoup de modèles explicatifs ont émergé ces dernières années. L'un d'eux postule une certaine inadéquation entre la rétroaction sensorielle du fantôme et les régions corticales représentant le membre. Dans l’AM, un conflit similaire pourrait se produire entre un schéma corporel antérieur n’ayant pas pris en compte les variations pondérales et la rétroaction sensori-motrice. Ainsi, les patientes se trouveraient enfermés dans un corps plus gros. / The everyday human ability to make judgments about one’s own and other people’s body-scaled actions is disrupted in anorexia nervosa (AN). AN patients significantly overestimated their own passability (relative to a control group) in a simulated body-scaled action. These data were concordant with the patients' clinical complaints that they feel larger than they really are. Judgments in AN patients were significantly affected in the first-person-perspective condition (1PP) but not in the third-person-perspective condition (3PP; see Figure). These overall results suggest that the overestimation of the passability ratios in AN are likely to be caused by an overestimation of their own body schema. They are not symptomatic of a general impairment in perceptual judgments.This overestimation of the body schema in AN can be related to the existence of disturbance in multisensory integration in AN, since the body schema is the product of multisensory integration of visual, tactile, proprioceptive and vestibular inputs. A significant relationship exist between the behavioural performances and the severity of eating disorders by revealing a significant, positive correlation between the patient’s own body action on one hand and body concern, body dissatisfaction and drive for thinness on the other. This disruption causes restrictive eating behaviours to persist.The patients\\\\\\\' performances were related to their body weight loss over the previous months and to their pre-AN body weight. This finding provides a possible explanation for the disruption of body-scaled actions in anorexic people: the body schema modified by the rapid weight loss may not have been updated by the central nervous system. Anorexia nervosa mainly affects young women in the 15-19 age group. However, many of the neurological, morphological and psychological changes occur during puberty and they will have an impact on the body schema. Weight changes induced by eating disorders could reinforce these disturbances. The knowledge gained by studying neurological phenomena such as phantom limbs might shed light on this topic. In fact, many amputees continue to feel the presence of a phantom limb after amputation. Many explanatory models of phantom limb syndrome have emerged in recent years. One of these postulates a degree of mismatch between the sensory feedback from the phantom and the cortical regions representing the limb. In anorexic patients, there could be a conflict between the previous body schema (i.e. before the weight change) and the current sensorimotor feedback. Thus, patients would find themselves locked into a larger body.

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