Cognitive profiles of patients with mild cognitive impairment or dementia in Alzheimer's or Parkinson's disease

Background

Alzheimer's disease (AD) and Parkinson's disease (PD) are associated with severe cognitive decline, but it is still unclear to what extent they become functionally more similar over time.

Methods

We compared amnestic mild cognitively impaired (aMCI; n = 29) patients to mild cognitively impaired (MCI) PD patients (n = 25), and patients with AD (n = 34) to patients with PD dementia (PDD; n = 15) with respect to cognitive functioning and mood.

Results

aMCI patients were impaired in episodic memory, while MCI PD patients showed deficits in visuoconstruction and attention. AD and PDD patients showed comparable deficits on tests for language, attention and visuoconstruction. However, unlike PDD patients but similar to aMCI patients, AD patients showed a characteristic memory impairment, especially commission errors on recognition tasks, whereas PDD patients scored higher on the depressive mood questionnaire.

Conclusions

In advanced stages of both diseases, the pattern of functional deficits associated with parietal and temporal lobe functions (attention, visuoconstruction and language) is similar. However, specific differences, already present in the early stage (recognition errors in AD, associated with mediobasal temporal lobe functioning, and depressed mood in PDD, associated with non-motor basal ganglia loops), are also observed in the late stage.

Prism Adaptation Improves Ego-Centered but Not Allocentric Neglect in Early Rehabilitation Patients

Background and Objective. Unilateral neglect due to parieto-temporo-frontal lesions has a negative impact on the success of rehabilitation, and prism adaptation (PA) enhances recovery from neglect. However, it is unclear if this effect holds also in severely impaired patients and/or in the postacute phase of rehabilitation. Moreover, it is not known whether PA affects all aspects of neglect recovery or ego-centered spatial orientation only. Methods. Sixteen patients in a postacute stage (on average 36 days after a large right cerebrovascular stroke) were entered into a series of single case design studies with 4 measurements: 2 before and 2 after 1 week of PA treatment. All patients had severe neglect (showing trunk, head, and eye deviation; canceling less than 20% of targets in a visual cancellation test). Lesions were transferred to a standard brain to analyze size and location. Results. Patients improved in cued body orientation and in the cancellation task, that is, in ego-centered neglect. However, none of the measures used to evaluate neglect of left side of objects irrespective of their position on the right or left side of the patient (allocentric neglect) showed an improvement. Treatment effects were not influenced by total lesion size, but lesions including the postcentral cortex were related to smaller recovery gains. Conclusion. PA is helpful in treating severely impaired patients in the postacute phase, but the effect is restricted to ego-centered neglect. Lesions in the postcentral cortex (middle occipito-temporal, middle temporal, and posterior parietal areas) seem to limit the effect of PA.

Impact of Collateral Circulation on Early Outcome and Risk of Hemorrhagic Complications after Systemic Thrombolysis

Background

In stroke patients, collateral flow can rapidly be assessed on computed tomography angiography (CTA).

Aims

In this study, the impact of baseline collaterals on early outcome and risk of symptomatic intracerebral hemorrhages after systemic thrombolysis in patients with proximal arterial occlusions within the anterior circulation were analyzed.

Methods

Collateralization scores were determined on the CT angiography source images (0 = absent; 1 ≤ 50%, 2 > 50% but <100%, and 3 = 100% collateral filling) of patients with distal intracranial carotid artery and/or M1 segment occlusions treated from 2008 to December 2011. A collateral score of 0 to 1 was designated as poor and 2 to 3 as good collateral vessel status. Outcome variables included in hospital mortality, favorable outcome at discharge (modified Rankin score ≤ 2), and rates of symptomatic intracerebral hemorrhage based on the European–Australasian Acute Stroke Study II definition.

Results

Among 246 subjects (mean age of 74 years; median National Institutes of Health Stroke Scale N at admission 14), 205 patients (83%) had good collaterals, whereas 41 patients (17%) had poor collaterals, respectively. Patients with poor collaterals had significantly higher rates of in-hospital mortality (41% vs. 12%, P < 0·001), of symptomatic intracerebral hemorrhage (15% vs. 4·9%, P < 0·05) and had significantly lower rates of favorable early clinical outcome (0% vs. 28%, P < 0·001) compared with those with good collaterals. The grade of collateralization was independently associated with in-hospital mortality ( P < 0·001), early clinical outcome ( P < 0·01), and rates of symptomatic intracerebral hemorrhage ( P < 0·01).

Conclusion

Patients with proximal arterial occlusions within the anterior circulation and poor baseline collaterals have a poor early functional outcome and high rates of symptomatic intracerebral hemorrhage after systemic thrombolysis. Since similar findings have also been reported after endovascular therapy, strategies to improve collateral blood flow should be assessed in this patient population.

Money for value: the Kinzigtal-way to measure the produced value and health gain in a local area

‘Triple Aim’ is the buzzword for the initiatives of the Obama-administration in the US and is referring to a famous article of Don Berwick et al. in 2008 in health affairs asking for better health, better health care, and lower per capita costs. A similar venture started already in 2006 in Germany. One of the most challenging ventures towards reorienting health care in the direction of outcome-orientation is the measurement of the produced value and health gain in a local area. In this keynote the financial architecture and the specific way to measure the produced value and health gain in the integrated care pilot ‘Gesundes Kinzigtal’ will be described—as well some of the operating details and the results within.

Located in Southwest Germany, Gesundes Kinzigtal is the only population-based integrated care approaches in Germany, organising care across all health service sectors and indications, that is thoroughly scientifcally evaluated on its medical outcomes in regard to normal care. The system serving nearly half of the population of the region is run by a regional health management company in cooperation with the physicians’ network in the region, a German health care management company with a background in medical sociology and health economics and with two statutory health insurers.

Having started in 2006 the more effective trans-sector organisation of the local health care system and increased investments in well-designed preventive and health promotion programmes have led to a reduction in morbidity and mortality, and in particular to reduced overall costs for the insurees of these sickness funds. The results for one of the insurers show a substantial morbidity adjusted efficiency gain already for the years 2007–2010, rising to more than 16% of total costs (included are pharmaceutical, hospital, nursing, emergency as well as physiotherapist and sick leave costs).

More Information can be found on www.optimedis.de and www.gesundes-kinzigtal.de and on the evaluation (in German and English) www.ekiv.org.

Working on eye-level: The Kinzigtal-way to produce value and health gain—some insights into the cooperation of health, nursing and social services

Located in Southwest Germany, Gesundes Kinzigtal develops a fully integrated health care over all sectors of care for the population of the region on a shared gain contract with two statutory health insurers which cover nearly half of the population. It is run by a regional health management company in cooperation with a physicians’ network and a health sciences based health care management company.

Having started in 2006 the more effective trans-sector organisation of the local health care system and increased investments in well-designed preventive and health promotion programmes have led to a reduction in morbidity and mortality. The results for one of the insurers show a substantial morbidity adjusted efficiency gain already for the years 2007–2010, rising to more than 16% of total costs. The workshop will share insights into some of the interventions, which were most effective, and discusses the challenges which had to be overcome. A key-word seems to be to produce an “eye-level paradigm of management” between doctors and patients as well as betweeen all the health professions and between management and providers. More information can be found on www.optimedis.de and www.gesundes-kinzigtal.de and on the evaluation (in German and English) www.ekiv.org

Self-reported sleep problems, but not fatigue, lead to decline in sustained attention in MS patients

OBJECTIVE

According to the compensation theory, fatigue in MS results from efforts to compensate for a reduction in capacity due to demyelination or neurodegeneration. Recently, it has been argued that fatigue may result from poor sleep. Both explanations predict a worsening of fatigue and a cognitive decline during sustained attention tasks (higher fatigability).

METHOD

We compared MS patients with and without self-reported cognitive fatigue, in three sessions with a two-back working memory task, registering hits and response latencies as well as changes in fatigue. In the two breaks between the sessions, either a video instruction to relax or a stimulating video was presented. Subsequently, patients were divided into those with and those without self-reported sleep problems and the analyses were repeated.

RESULTS

Patients with fatigue performed worse than healthy controls, irrespective of task duration and type of video during the break. The task-related increase of fatigue also did not differ between the groups and no differential effect of the videos was observed in the MS patients with fatigue. In contrast, patients with sleep problems did show a performance decline as predicted by the compensation theory.

CONCLUSION

MS patients with fatigue were impaired in working memory, but did not show greater fatigability, whereas MS participants with self-reported sleep problems showed fatigability, which could be improved with a restorative rest period. Our data therefore do not support the compensation theory of fatigue, and we argue that sleep problems and fatigue in MS patients differ with respect to their functional consequences.

A randomized controlled trial comparing 2 interventions for visual field loss with standard occupational therapy during inpatient stroke rehabilitation

BACKGROUND AND PURPOSE

Compensatory and restorative treatments have been developed to improve visual field defects after stroke. However, no controlled trials have compared these interventions with standard occupational therapy (OT).

METHODS

A total of 45 stroke participants with visual field defect admitted for inpatient rehabilitation were randomized to restorative computerized training (RT) using computer-based stimulation of border areas of their visual field defects or to a computer-based compensatory therapy (CT) teaching a visual search strategy. OT, in which different compensation strategies were used to train for activities of daily living, served as standard treatment for the active control group. Each treatment group received 15 single sessions of 30 minutes distributed over 3 weeks. The primary outcome measures were visual field expansion for RT, visual search performance for CT, and reading performance for both treatments. Visual conjunction search, alertness, and the Barthel Index were secondary outcomes.

RESULTS

Compared with OT, CT resulted in a better visual search performance, and RT did not result in a larger expansion of the visual field. Intragroup pre-post comparisons demonstrated that CT improved all defined outcome parameters and RT several, whereas OT only improved one.

CONCLUSIONS

CT improved functional deficits after visual field loss compared with standard OT and may be the intervention of choice during inpatient rehabilitation. A larger trial that includes lesion location in the analysis is recommended.

Virtual study tour to integrated care in Germany

In Germany health policy-makers of all parties believe in competition as an incentive for creating innovation and to keep costs down. Sickness funds cover about 90% of the population=regulated market/10% are covered by health insurance plans=private market. The sickness funds in the regulated market have the same premium (this goes to a national agency and is distributed to the funds after a risk adjusted scheme that uses morbidity trees to develop a fair payment to the funds) but vary whether they have to ask for a separately paid surplus premium.

Sickness funds compete about surplus premiums, services and offers to the patients and about selection (healthy vs. sick). They have to ask:

What are the strongest interventions in increasing health status and keeping costs down?

Who is offering a comprehensive and sustainable solution serving my population?

With what kind of reimbursement scheme do I attract the right spirit … not too much interventions, but not too few as well …. tackling the right people … using the newest technology, but with as few costs as possible?

For more information on integrated care in Germany, please follow the link to the power point presentation below.

„Starkes Herz“/Strong heart: integrated health care for patients with history of heart failure in the Kinzigtal region, a rural area in South of Germany

Introduction

Cardiovascular diseases are the most cost intensive health conditions in German health care. Heart failure in combination with old age is the most frequent reason for in-patient clinical admission [1].

The demographic development—in combination with the decline of patient’s access to medical care in rural areas—increases overall health care expenses. Therefore, innovative concepts are needed in order to maintain sufficient medical care.

The ‘Gesundes Kinzigtal GmbH’ is a health management organisation for integrated health care that delivers a systematic support program for its members. The goal is an enhancement of participants’ quality of life, a reduction of clinical admission and a reduction in overall health care cost.

Theoretical background

International studies prove that hospitalisation of patients with heart failure can be successfully avoided when utilizing disease management programs. Continuous observation of patients’ relevant medical parameters identifies cases with urgent need for therapy. Literature describes two promising approaches of observation:

Telemonitoring [2] and

A structured case-management by the staff of the medical surgery.

In the Kinzigtal region both approaches are subject to an analysis in order to determine benefit-costs-relation. We expect a decrease in rate of mortality as well as rate of morbidity. Furthermore, a positive effect on the patient’s self-management concerning the maintenance of their health condition can be anticipated.

Description of care

The participants of the telemonitoring group are observed by a telemetric scale and by regular blood pressure measurement. A contact person provides continuous observation (via phone). Training material and feedback reports are also provided. In critical situations a visit at the doctor’s surgery is recommended.

The participants of the surgery-programme are regularly contacted by a case-manager. Health insurance companies collect patients’ relevant personal data such as hospitalization rate, medical prescriptions and mortality which are analysed by a service provider (OptimedisAG).

Results and conclusion

Since 2007, 68 patients participated in the program. First analyses show a decrease of total costs, in particular lower morbidity costs and a positive profit contribution (as of 28th March 2011).

Better health, improved care and lower health care costs—the international strive for integration. Should not we be confident enough to go into risk? Integrated Care = higher quality but less costs to the sickness funds/health insurances. Results of the German and Swiss experiences of the last years

Shared savings contracts between physician networks/health maintenance organisations and insurances or sickness funds in Germany and Switzerland showed quite impressive results of between 5 and 15% savings, similar to those being demonstrated in the US during the 1990s in the beginning of managed care last century. While managed care in the US got into a lot of ethical questions the European examples are on the rise and a new international debate on integrated care is emerging.

The ‘triple aim’ as Donald M. Berwick emphasized in his famous Health Affairs article in 2008 called for better health, improved care and lower health care costs and the Obama administration took this notion into its new accountable care organisation approach. The author suggests that it is time to develop comprehensive integration policies for whole regional populations. He can tear on at least five years of experiences in Germany (GesundesKinzigtal) as well as on several years of experiences of other networks in Switzerland and other parts of Germany.

These experiences are indicating that effective trans-sector organisation of health care and increased investments in well-designed preventive programmes will lead to a reduction in morbidity, and in particular to a reduced incidence and prevalence of chronic diseases and offer substantial efficiency gains for sickness funds and health insurances.

Correlation between cognitive impairment and CSF biomarkers in amnesic MCI, non-amnesic MCI, and Alzheimer's disease

Decreased delayed recall, decreased amyloid-β peptides (Aβ1-42), and increased tau protein concentration in cerebrospinal fluid (CSF) are generally regarded to be valid neuropsychological and biological markers for Alzheimer's disease (AD). Previous studies failed to demonstrate clear-cut correlations between neuropsychological impairment and CSF markers. In this study we test recent models of disease progression, that propose that changes in CSF biomarkers already reach a plateau in a preclinical phase, before cognitive decline begins, that is, even before MCI can be diagnosed. We recruited 73 patients with probable AD (n=36) and mild cognitive impairment (MCI) (amnesic MCI=25; non-amnesic MCI=12). We used the CERAD-NP, a widely used neuropsychological battery with norms for different age and education groups, and additional neuropsychological tests for assessing the cognitive profile of these patient groups. We found a significant correlation between Aβ1-42 in the CSF and memory performance for amnesic MCI patients, but not for non-amnesic MCI and AD patients. All other correlations between cognitive tasks and Aβ1-42 were not significant. Tau protein concentration in the CSF was not correlated with any neuropsychological marker in any of the patients groups. We conclude that the decrease of Aβ1-42 in the CSF mirrors disease progression during the early stages up into AD and therefore is not restricted to the preclinical phase. The decrease of Aβ1-42 reaches a plateau only in the full blown demented syndrome and further functional disease progression is then related to neurodegeneration without further reduction of Aβ1-42 in the CSF.

Decreased hippocampal volume, indirectly measured, is associated with depressive symptoms and consolidation deficits in multiple sclerosis

BACKGROUND

The human hippocampus plays a role in episodic memory and depression. Recently, it has been shown, using manual tracings, that the hippocampus is smaller in volume in MS patients compared with healthy controls, and that, at least for depression, hippocampal atrophy correlates with symptom severity.

METHODS

Because manual tracing of the hippocampus is time consuming, we used a semi-automatic procedure for temporal horn volumetry in 72 multiple sclerosis (MS) patients and 16 control subjects as an indirect measure of hippocampal volume. We analysed memory performance with the California Verbal Learning Test (using separate indices for encoding, consolidation and retrieval) and depressive mood with the Beck's Depression Inventory (distinguishing between psychic and somatic aspects).

RESULTS

MS patients had significantly larger temporal horn volumes and volume correlated with psychic symptoms of depressive mood. Temporal horn volume was also associated with consolidation, in particular in the most impaired group.

CONCLUSIONS

Temporal horn volume can be measured relatively easily and appears to correlate with two major clinical problems in MS patients: memory performance and depressive mood. The link between temporal horn volume, consolidation and depression may be hippocampal atrophy, as suggested by their adjacent neuroanatomical localization, and by the similarity in functional loss following impairment of these two structures.

Comparison of diffusion tensor-based tractography and quantified brain atrophy for analyzing demyelination and axonal loss in MS

We combined diffusion tensor imaging (DTI) measures of the corpus callosum (CC) and the superior longitudinal fascicle (SLF) with calculation of brain atrophy in 53 patients with relapsing-remitting multiple sclerosis (MS) and 15 healthy controls, to analyze their interrelation and their correlation with disease duration and clinical impairment. The lateral ventricle volume in MS patients was increased; the fractional anisotropy in the CC was decreased as was the fiber volume. Perpendicular (in the literature also referred to as radial) diffusivity (ped), which reflects the diffusion perpendicular to the long axis of the axons within the fiber bundle, was increased in the SLF and the posterior CC, but contrary to our predictions, parallel (also called axial) diffusivity (pad) that refers to the amount of diffusion in the direction of the axon was increased, too. Brain atrophy and DTI-derived parameters were highly intercorrelated and both correlated with disease duration. Discriminant analysis showed that DTI-derived atrophy measures are superior to brain atrophy measures in classifying patients and controls. In light of our results, animal studies focusing on demyelination and axonal loss are reinterpreted.

Working memory in schizophrenia: a systematic study of specific modalities and processes

Although many researchers agree that working memory (WM) impairments are a core symptom of schizophrenia, it remains unclear how the disturbances on specific WM components relate to one another. In this study, we presented a Delayed-Matching-To-Sample task to 24 schizophrenia patients and 24 healthy controls, matched on demographical variables. Verbal and visuospatial WM performance was investigated with pseudowords and Chinese characters as stimuli, respectively. Processing demands (maintenance and manipulation, measured with delay and mental rotation) were low or high. Reaction time and accuracy were recorded. All experimental factors had significant effects. In general, patients were slower and less accurate than controls. Patients were especially slower on verbal tasks but they were not less accurate. Accuracy differences did not increase when either maintenance or manipulation demands increased alone but they did when both maintenance and manipulation demands increased simultaneously. These findings indicate that performance impairment in patients was non-specific and that no specific deficit of any WM component was observed.