A population-based study of cognitive impairment in socially vulnerable adults in Argentina. The Matanza Riachuelo study preliminary results

Population aging has taken place intensively worldwide, even in developing countries. These countries have population groups with low resources and basic unmet needs that are frequently omitted from epidemiological studies.

OBJECTIVE

The purpose of this study was to determine the prevalence of cognitive impairment (CI) and dementia in an economic and socially vulnerable population from Argentina.

METHODS

A door-to-door observational population-based survey among adults over 60 years of cognitive impairment and dementia in the social vulnerable area of the Matanza Riachuelo Basin, in the suburban area of Buenos Aires, Argentina was conducted. Trained psychologists interviewed subjects and a proxy informant. A standardized protocol including a socio-demographic questionnaire, the Mini-Mental State Examination, the Geriatric Depression Scale and a functional inventory for IADL and ADL was administered. Diagnoses were divided into three general categories: normal cognitive function, cognitive impairment-no dementia (CIND) and dementia.

RESULTS AND CONCLUSIONS

A total of 2437 elderly persons were assessed, of which 73.6% fulfilled inclusion criteria. The prevalence of CI among those over 60 was 26.4% (18.1% CIND and 8.3% dementia) with higher prevalence of dementia in younger individuals than rates reported in developed counties, probably due to low control of vascular risk factors. This information can help inform health public decisions in the generation of programs and plans for the prevention, diagnosis and treatment of cognitive impairment in this type of socially vulnerable population.

[Theory of Mind in eating disorders: endophenotype of the disease?]

Considering the clinical and empirical evidence of socio-cognitive difficulties in patients with eating disorders, this paper aims to critically review the current state of research on theory of mind in anorexia and bulimia, to evaluate if there is any alteration of it in these pathologies and to determine whether there are indicators that can be considered endophenotype.

METHOD

We conducted a literature search of PubMed database, using keywords related to the topic. The papers were analyzed according to inclusion/ exclusion criteria.

RESULTS

We identified seven studies of patients with anorexia, one on bulimia and four on both pathologies. Most studies reported that patients with anorexia have alterations in the theory of mind. Studies on bulimia are scarce, and their results contradictory.

CONCLUSION

Research on theory of mind in eating disorders at initial level, being the most of works on anorexia. There are indicators of deficits for this pathology on ToM tasks, and they might be considered endophenotypes, although studies that evaluate unaffected first-degree relatives are still lacking.

Long Term Neuropsychological Follow-up in Patients With Herpes Simplex Encephalitis and Predominantly Left-sided Lesions

Five patients with predominantly dominant cerebral hemisphere lesions due to herpes simplex encephalitis are described. Verbal amnesia was the main deficit but amnesic aphasia sometimes associated with impairment of remote memory also occurred. Semantic and episodic memory deficits were also explored in one case and the role of the right cerebral hemisphere in facilitating recovery of learning is discussed.

MM1+2C sporadic Creutzfeldt-Jakob disease presenting as rapidly progressive nonfluent aphasia

We report a 77-year-old man, presenting with progressive aphasia as an initial symptom, who developed severe dementia over the course of 20 months. Frontal cortex PrPSc western blot was type 2 and codon 129 was MM; brain neuropathology showed cortical vacuoles with perivacuolar PrP immunostaining characteristic of MM2C. Cerebellum showed focal coarse, patchy staining in different sections of the molecular layer, diffuse fine punctuate and coarse PrP immunopositive deposits in the granule cell layer, and focal synaptic immunostaining in the molecular layer, suggestive of MM1+2C by histotyping. This clinical presentation has not yet been described in an MM1+2C subtype by histotyping.

George‐Hyslop P, Schultz M, Sevlever G, Allegri RF. Familial dementia with frontotemporal features associated with M146V presenilin-1 mutation

Most of the mutations in the presenilin-1 gene (PS-1) are associated with familial Alzheimer's disease (AD). However, certain examples can be associated with frontotemporal dementia (FTD). We performed a clinical evaluation of individuals belonging to a family with the FTD phenotype, and additional molecular studies and neuropathological assessment of the proband. The PS-1 M146V mutation was found in the 50-year-old subject (the proband) with family history of early-onset FTD. Neuropathological examination showed abundant amyloid plaques, widespread neurofibrillary pathology, Pick bodies in the hippocampus and cortex, cortical globose tangles and ubiquitin-positive nuclear inclusions in white matter oligodendrocytes. We report a kindred with clinical features of FTD, whose proband bore the PS-1 M146V mutation and showed diffuse Alzheimer's type pathology and Pick bodies on post-mortem neuropathological examination. As with other mutations within the same codon, this substitution may predispose to both diseases by affecting APP and/or tau processing.

The safety, tolerability, and efficacy of once-daily memantine (28 mg): a multinational, randomized, double-blind, placebo-controlled trial in patients with moderate-to-severe Alzheimer's disease taking cholinesterase inhibitors

INTRODUCTION

Immediate-release memantine (10 mg, twice daily) is approved in the USA for moderate-to-severe Alzheimer's disease (AD). This study evaluated the efficacy, safety, and tolerability of a higher-dose, once-daily, extended-release formulation in patients with moderate-to-severe AD concurrently taking cholinesterase inhibitors.

METHODS

In this 24-week, double-blind, multinational study (NCT00322153), outpatients with AD (Mini-Mental State Examination scores of 3-14) were randomized to receive once-daily, 28-mg, extended-release memantine or placebo. Co-primary efficacy parameters were the baseline-to-endpoint score change on the Severe Impairment Battery (SIB) and the endpoint score on the Clinician's Interview-Based Impression of Change Plus Caregiver Input (CIBIC-Plus). The secondary efficacy parameter was the baseline-to-endpoint score change on the 19-item Alzheimer's Disease Cooperative Study-Activities of Daily Living (ADCS-ADL19); additional parameters included the baseline-to-endpoint score changes on the Neuropsychiatric Inventory (NPI) and verbal fluency test. Data were analyzed using a two-way analysis of covariance model, except for CIBIC-Plus (Cochran-Mantel-Haenszel test). Safety and tolerability were assessed through adverse events and physical and laboratory examinations.

RESULTS

A total of 677 patients were randomized to receive extended-release memantine (n = 342) or placebo (n = 335); completion rates were 79.8 and 81.2 %, respectively. At endpoint (week 24, last observation carried forward), memantine-treated patients significantly outperformed placebo-treated patients on the SIB (least squares mean difference [95 % CI] 2.6 [1.0, 4.2]; p = 0.001), CIBIC-Plus (p = 0.008), NPI (p = 0.005), and verbal fluency test (p = 0.004); the effect did not achieve significance on ADCS-ADL19 (p = 0.177). Adverse events with a frequency of ≥5.0 % that were more prevalent in the memantine group were headache (5.6 vs. 5.1 %) and diarrhea (5.0 vs. 3.9 %).

CONCLUSION

Extended-release memantine was efficacious, safe, and well tolerated in this population.

News in aging and dementia at the 13th Pan American Congress of Neurology

The Pan American Congress of Neurology was organized by the Bolivian Society of Neurology on behalf of the World Federation of Neurology in La Paz, Bolivia. Aging and dementia was one of the main congress tracks that has been highlighted in recent Latin American research in the field, focusing specifically on epidemiological studies, the economic cost of dementia and new Alzheimer's disease (AD) biomarkers. A 4-year follow-up study of AD biomarkers was discussed and a survey was conducted in Argentina on the opinion of the general population in relation to the clinical use of these biomarkers, and early diagnosis criteria of AD were presented. In parallel, a newly developed Neurology International Conference for Primary Care was run that was designed for the education of more than 350 general practitioners from all the regions of Bolivia.

Cerebrolysin improves symptoms and delays progression in patients with Alzheimer's disease and vascular dementia

Dementia is the result of various cerebral disorders, leading to an acquired loss of memory and impaired cognitive ability. The most common forms are Alzheimer's disease (AD) and vascular dementia (VaD). Neurotrophic factors are essential for the survival and differentiation of developing neurons and protecting them against damage under pathologic conditions. Cerebrolysin is a peptide preparation that mimics the pleiotropic effects of neurotrophic factors. Several clinical trials investigating the therapeutic efficacy of Cerebrolysin in AD and VaD have confirmed the proof of concept. The results of these trials have shown statistically significant and clinically relevant treatment effects of Cerebrolysin on cognitive, global and functional domains in mild to moderately severe stages of dementia. Doses of 10 and 30 mL were the most effective, but higher doses of up to 60 mL turned out to be most effective in improving neuropsychiatric symptoms, which become relevant at later stages of the disease. Combining treatment with cholinesterase inhibitors and Cerebrolysin indicated long-term synergistic treatment effects in mild to moderate AD. The efficacy of Cerebrolysin persisted for up to several months after treatment suggesting Cerebrolysin has not merely symptomatic benefits, but a disease-delaying potential. This paper reviews the clinical efficacy of Cerebrolysin in the treatment of dementia. Data were obtained from international, multicenter, randomized clinical trials performed in compliance with Good Clinical Practice and the principles of the Declaration of Helsinki (1964) and subsequent revisions.

Relevance of the serial position effect in the differential diagnosis of mild cognitive impairment, Alzheimer-type dementia, and normal ageing

Serial position effects are observed when a person memorises a series of words exceeding his or her attention span. Cognitively normal individuals recall words at the beginning and end of the list more frequently than those in the middle, which reflects the way that short- and long-term episodic memory works.

OBJECTIVE

To study the serial position effect in patients with mild cognitive impairment (MCI) compared to subjects with Alzheimer-type dementia (AD) or normal ageing (NA).

METHODS

30 AD, 25 MCI and 20 NA subjects underwent neurological and neuropsychological assessment. The Rey Auditory Verbal Learning Test (RAVLT) was used to study primacy, middle, and recency effects and delayed recall for each group.

RESULTS

The general memory pattern of MCI subjects was very similar to that of AD subjects, and was characterised by reduced learning capacity, rapid forgetfulness and clear recency effect in learning. With regard to delayed recall, however, there were differences in performance; MCI subjects' ability to recall words at the beginning and middle of the list was similar to that of normal subjects, while their memory of words at the end of the list was poor, as in AD subjects.

CONCLUSIONS

RAVLT is a tool permitting us to distinguish between MCI and NA subjects. The recency index for the delayed recall task is a valid indicator for distinguishing between MCI patients and patients with normal ageing.

[Review of recommendations and new diagnosis criteria for mild cognitive impairment due to Alzheimer's disease]

The symptomatic predementia phase of Alzheimer's disease (AD), known as mild cognitive impairment (MCI) is a clinical and neuropsychological condition which defines the transitional state between normal aging and dementia, and is used as a clinical description of people at risk of developing AD. A review of the diagnostic criteria of MCI due to Alzheimer's disease was recently published by the Alzheimer's Association and the National Institute on Aging of the U.S. in order to ensure early diagnosis of the disease, useful for both clinical practice and clinical trials. The objectives of this paper are to review and analyze the revised diagnostic criteria for MCI due to Alzheimer's disease recently proposed, to compare with criteria for MCI available and to establish current strengths and limitations of the new proposal in clinical practice. The new diagnostic criteria for MCI due to AD have a radical importance since they are potentially applicable in the clinical or research protocols and in all clinical settings where such markers are available. They provide a useful, consistent and valuable tool to homogenize the subgroup of patients with MCI who already has AD in a predementia phase with inexorable progression to dementia by AD over the years.

Insurance status and demographic and clinical factors associated with pharmacologic treatment of depression: associations in a cohort in Buenos Aires

OBJECTIVE

There is a paucity of evidence about insurance status and the likelihood of receiving medical services in Latin America. The objective of this analysis was to examine the association between insurance status and pharmacologic treatment for depression.

METHODS

Patients referred to a memory clinic of a public hospital in Buenos Aires, Argentina, and identified with any of four types of depression (subsyndromal, dysthymia, major, and due to dementia) were included. Age, years of education, insurance status, Beck Depression Inventory score, and number of comorbidities were considered. Associations between these factors and not receiving pharmacologic treatment for depression were examined with logistic regression. Use of prescription neuroleptics, hypnotics, and anticholinesterase inhibitors was also explored.

RESULTS

Out of 100 patients, 92 with insurance status data were used. Sixty-one patients (66%) had formal insurance and 31 patients (34%) lacked insurance. Twenty-seven (44%) insured patients and 23 (74%) uninsured patients did not receive antidepressants (P = 0.001). Controlling for other factors, uninsured patients had 7.12 higher odds of not receiving treatment compared to insured patients (95% confidence interval 1.88-28.86). Older patients and those with more comorbidities had higher odds of not receiving treatment. More educated patients, those with higher Beck Depression Inventory score, and those without subsyndromal depression had lower odds of not receiving treatment. None of those associations were statistically significant.

CONCLUSIONS

These results suggest a potential negative effect of the lack of formal insurance regarding pharmacologic treatment for depression. These findings should be confirmed with larger samples, and for other diseases.

The economic cost of Alzheimer's disease: Family or public health burden?

Alzheimer’s disease (AD) patients suffer progressive cognitive, behavioral and functional impairment which result in a heavy burden to patients, families, and the public-health system. AD entails both direct and indirect costs. Indirect costs (such as loss or reduction of income by the patient or family members) are the most important costs in early and community-dwelling AD patients. Direct costs (such as medical treatment or social services) increase when the disorder progresses, and the patient is institutionalized or a formal caregiver is required. Drug therapies represent an increase in direct cost but can reduce some other direct or indirect costs involved. Several studies have projected overall savings to society when using drug therapies and all relevant cost are considered, where results depend on specific patient and care setting characteristics. Dementia should be the focus of analysis when public health policies are being devised. South American countries should strengthen their policy and planning capabilities by gathering more local evidence about the burden of AD and how it can be shaped by treatment options.

[Cognitive intervention in mild cognitive impairment. A review]

Cognitive intervention involves training, stimulation and rehabilitation of higher brain functions, and stands as a non pharmacological treatment option for patients with cognitive symptoms and dementia. Mild Cognitive Impairment is a syndrome that appears to capture a group of individuals in a transitional state between normal aging and dementia. Patients with Mild Cognitive Impairment have a higher risk of progression to dementia. There are different subtypes of Mild Cognitive Impairment taking in consideration the cognitive domains that are affected, being the amnestic subtype the most common. This review examines the publications that explored the utility and efficacy of cognitive intervention in patients with Mild Cognitive Impairment. Although there is great variability in the studies design, in the type of intervention, in the treatment length and in the outcome measures selected, the majority of the papers reviewed reported a beneficial effect of the intervention, and none of them found an unfavorable result. Further adequately designed studies of cognitive treatment interventions in the different Mild Cognitive Impairment subtypes are needed to evaluate their potential benefits in ameliorating the patients' symptoms and in reducing the rate of progression to dementia.

[Disinhibition in psychogeriatry: differential diagnosis with frontotemporal dementia]

Disinhibition is the loss of psychological and physiological inhibition that leads to cognitive and motor impulsivity. The notion of impulsiveness is often linked to the function of the prefrontal cortex, and is usually understood as a lack of response inhibition. In other words, the subject is unable to suppress or withhold a previously rewarding response and the behavior appears impulsive. This has a social impact as disinhibition often affects the human social behavior. The "human social behavior" is how a person behaves properly with other people in a social environment. Frontotemporal Dementia produces changes in patients' behavior that frequently, manifest as disinhibition. Patients' social cognition is impaired and this is one of the key points for early diagnosis. All of these concepts will be review for a better understanding of Frontotemporal Dementia, and therefore, being able to differentiate it from other psychogeriatric disorders.

Role of cognitive reserve in progression from mild cognitive impairment to dementia

Cognitive reserve is the ability to optimize performance through differential recruitment of brain networks, which may reflect the use of alternative cognitive strategies.