Do extrapyramidal features in Alzheimer patients treated with acetylcholinesterase inhibitors predict disease progression?

The objective of the study is to explore the longitudinal course of patients with Alzheimer's disease (AD) with and without extrapyramidal signs (EPS) taking donepezil. A cohort of 106 community-dwelling patients with probable AD receiving donepezil in Sydney, Australia (n = 52) and Manchester, UK (n = 54) was followed over 12 months. Cognition was measured by the Mini-Mental State Exam (MMSE) and the Alzheimer Disease Assessment Scale-Cognitive test (ADAS-Cog) and function by the Alzheimer Disease Cooperative Study-Activities of Daily Living Scale (ADCS-ADL). A further follow-up at five years was conducted to examine mortality and institutionalisation. At baseline, EPS were correlated with MMSE (r = -0.467, p < 0.01), ADAS-Cog (r = 0.485, p < 0.01) and ADCS-ADL (r = -0.526, p < 0.01) scores. Patients with EPS had lower MMSE (F = 9.95, df = 1, p = 0.002) and ADCS-ADL (F = 9.41, df = 1, p = 0.003) scores than patients without EPS. Over one year no time main effects or time x group interaction effects were observed for either dependent variable. At five years patients with EPS were found to have a hazard of institution or death 2.2 times higher than those without EPS (p = 0.018; 95% CI: 1.2, 4.4). There was a positive association between EPS and cognitive and functional impairment. However, EPS did not predict more rapid cognitive or functional decline of patients taking donepezil or response to donepezil. The presence of EPS was a risk factor both for institutionalisation and for death.

Behavioural and psychological symptoms of dementia associated with Parkinson's disease

Assessment of behavioural and psychological symptoms is important in brain disorders

Developing the consumer interface for the MyPyramid Food Guidance System

OBJECTIVE

To assess consumer response to potential graphics, slogans, and messages for the consumer interface of the MyPyramid Food Guidance System.

DESIGN

Qualitative research conducted in two phases, composed of focus groups and Web-TV testing.

SETTING

Professional market research facilities in Baltimore, MD, and Chicago, IL, and Web-TV.

PARTICIPANTS

Phase 1,77 adults in 10 groups; Phase 2,407 adults via Web-TV.

PHENOMENON OF INTEREST

Consumer response to potential graphic images, slogans, and messages for the Food Guidance System.

ANALYSIS

A content analysis was used to summarize comments from focus groups and Web-TV tests into meaningful themes. Frequencies were calculated for responses.

RESULTS

Respondents preferred the familiarity of the pyramid shape and found graphics and slogans that were personal, active, and positive to be appealing.

CONCLUSIONS AND IMPLICATIONS

The consumer interface for the MyPyramid Food Guidance System was shaped by consumer feedback that identified appealing and useful elements and avoided elements that were potentially confusing or less meaningful. Consumers preferred images and messages that were perceived as new, personal, and active, but they desired some continuity with the original Pyramid shape.

Outbreak of norovirus illness associated with a swimming pool

On 3 February 2004, the Vermont Department of Health received reports of acute gastroenteritis in persons who had recently visited a swimming facility. A retrospective cohort study was conducted among persons attending the facility between 30 January and 2 February. Fifty-three of 189 (28%) persons interviewed developed vomiting or diarrhoea within 72 h after visiting the facility. Five specimens tested positive for norovirus and three specimen sequences were identical. Entering the smaller of the two pools at the facility was significantly associated with illness (RR 5.67, 95% CI 1.5-22.0, P=0.012). The investigation identified several maintenance system failures: chlorine equipment failure, poorly trained operators, inadequate maintenance checks, failure to alert management, and insufficient record keeping. This study demonstrates the vulnerability of recreational water to norovirus contamination, even in the absence of any obvious vomiting or faecal accident. Our findings also suggest that norovirus is not as resistant to chlorine as previously reported in experimental studies. Appropriate regulations and enforcement, with adequate staff training, are necessary to ensure recreational water safety.

Genetic associations between cathepsin D exon 2 C-->T polymorphism and Alzheimer's disease, and pathological correlations with genotype

Genetic variations represent major risk factors for Alzheimer's disease (AD). While familial early onset AD is associated with mutations in the amyloid precursor protein and presenilin genes, only the e4 allele of the apolipoprotein E (APOE) gene has so far been established as a genetic risk factor for late onset familial and sporadic AD. It has been suggested that the C-->T (224Ala-->Val) transition within exon 2 of the cathepsin D gene (CTSD) might represent a risk factor for late onset AD. The objective of this study was to investigate whether possession of the CTSD exon 2 T allele increases the risk of developing AD, and to determine whether this modulates the amyloid pathology of the disease in conjunction with, or independent of, the APOE e4 allele. Blood samples were obtained from 412 patients with possible or probable AD and brain tissues from a further 148 patients with AD confirmed by postmortem examination. CTSD and APOE genotyping were performed by PCR on DNA extracted from blood, or from frontal cortex or cerebellum in the postmortem cases. Pathological measures of amyloid beta protein (Abeta), as plaque Abeta40 and Abeta42(3) load and degree of cerebral amyloid angiopathy were made by image analysis or semiquantitative rating, respectively. CTSD genotype frequencies in AD were not significantly different from those in control subjects, nor did these differ between cases of early or late onset AD or between younger and older controls. There was no gene interaction between the CTSD T and APOE e4 alleles. The amount of plaque Abeta40 was greater in patients carrying the CTSD T allele than in non-carriers, and in patients bearing APOE e4 allele compared with non-carriers. Possession of both these alleles acted synergistically to increase levels of plaque Abeta40, especially in those individuals who were homozygous for the APOE e4 allele. Possession of the CTSD T allele had no effect on plaque Abeta42(3) load or degree of CAA. Possession of the CTSD T allele does not increase the risk of developing AD per se, but has a modulating effect on the pathogenesis of the disorder by increasing, in concert with the APOE e4 allele, the amount of Abeta deposited as senile plaques in the brain in the form of Abeta40.

Abstracts from the Society for Acute Medicine: Spring meeting

We have successfully been running with a Consultant presence in day-time (0900-1700) in the admissions area for a number of years. The recent NCEPOD report - an Acute Problem, criticised the lack of Consultant input into care of patients being transferred to Critical care areas out of hours. The DoH Hospital at Night project has suggested extending the normal working day into the twilight shift.

Relationship of deep white matter hyperintensities and cerebral blood flow in severe carotid artery stenosis

Leukoaraiosis (LA) has been associated with abnormalities of both large and small blood vessels. This study attempts to clarify the pathogenesis of LA by testing the hypothesis that increased frequency of LA with occlusive extra-cranial arterial disease results directly from global reduction in cerebral blood flow (CBF). Thirty-five normal subjects and 55 patients with carotid stenosis (>70%) were studied using MR. CBF was measured using phase contrast MR angiography and LA was scored using previously validated scoring system. Patients were divided into those with evidence of previous infarction on MRI and those without. LA was more severe in patients than in normal subjects (P<0.01) and correlated with age in normal subjects but not in patients. CBF in patients with (809+/-214 ml/min) and without infarction (mean 792+/-181 ml/min) was significantly lower than in normal subjects (mean 1073+/-194 ml/min). There was no correlation between the severity of LA and measured CBF in any group. The severity of LA is greater in patients with severe carotid stenosis but is not correlated to reductions in CBF. This suggests that microvascular abnormality is the dominant pathogenetic factor in LA even in the presence of severe stenotic/occlusive large vessel disease.

Survival of microvascular free flaps in head and neck surgery after early interruption of the vascular pedicle

Six to nineteen days after insertion of free flaps in oral defects three patients had secondary haemorrhages that necessitated the abolition of venous drainage in two cases and venous and arterial connections in the third. The flaps survived.

Older people with chronic schizophrenia

Older people with chronic schizophrenia are a numerically small but important group with complex clinical and service needs. Along with a reduction in positive schizophrenic symptoms with increasing age, a majority suffer from negative symptoms, cognitive deficits, depression, side effects due to long-term use of antipsychotics and co-morbid medical problems. They may have social disabilities making them vulnerable to poverty, isolation and poor quality of life. Evidence suggests that judicious use of antipsychotics combined with psychotherapy and psychosocial interventions are effective. There are shortcomings in the standard of both hospital and community care, and the cost implications of providing adequate services are high.

A G/C element mediates repression of the SM22alpha promoter within phenotypically modulated smooth muscle cells in experimental atherosclerosis

A hallmark of smooth muscle cell (SMC) phenotypic switching in atherosclerotic lesions is suppression of SMC differentiation marker gene expression. Yet little is known regarding the molecular mechanisms that control this process. Here we show that transcription of the SMC differentiation marker gene SM22alpha is reduced in atherosclerotic lesions and identify a cis regulatory element in the SM22alpha promoter required for this process. Transgenic mice carrying the SM22alpha promoter-beta-galactosidase (beta-gal) reporter transgene were crossed to apolipoprotein E (ApoE)-/- mice. Cells of the fibrous cap, intima, and underlying media showed complete loss of beta-gal activity in advanced atherosclerotic lesions. Of major significance, mutation of a G/C-rich cis element in the SM22alpha promoter prevented the decrease in SM22alpha promoter-beta-gal reporter transgene expression, including in cells that compose the fibrous cap of the lesion and in medial cells in proximity to the lesion. To begin to assess mechanisms whereby the G/C repressor element mediates suppression of SM22alpha in atherosclerosis, we tested the hypothesis that effects may be mediated by platelet-derived growth factor (PDGF)-BB-induced increases in the G/C binding transcription factor Sp1. Consistent with this hypothesis, results of studies in cultured SMCs showed that: (1) PDGF-BB increased expression of Sp1; (2) PDGF-BB and Sp1 profoundly suppressed SM22alpha promoter activity as well as smooth muscle myosin heavy chain promoter activity through mechanisms that were at least partially dependent on the G/C cis element; and (3) a short interfering RNA to Sp1 increased basal expression and attenuated PDGF-BB induced suppression of SM22alpha. Together, these results support a model whereby a G/C repressor element within the SM22alpha promoter mediates transcriptional repression of this gene within phenotypically modulated SMCs in experimental atherosclerosis and provide indirect evidence implicating PDGF-BB and Sp1 as possible mediators of these effects.

The use of assessment scales in Old Age Psychiatry Services in England and Northern Ireland

Implementation of the Single Assessment Process in the UK is designed to ensure that more standardized assessment procedures are in place across all areas and agencies, that practice improves and older people's needs are comprehensively assessed. This study provides a unique picture of the range and prevalence of standardized scales used within Old Age Psychiatry Services in England and Northern Ireland, reported by 73% of old age psychiatrists. Most services (64%) used three or more standardized assessment scales (range 1-12). Sixty-two separate instruments were identified. The six most used measures were the Mini Mental State Examination (95%), the Geriatric Depression Scale (52%) and the Clock Drawing (50%), the Clifton Assessment Procedures for the elderly (26%), the Barthel Index (18%) and the Health of the Nation Outcome Scales (HoNOS) 65 + (18%). A number of factors were associated with greater use of certain standardized assessment scales. Shared documentation, along with other indicators of integration between health and social care were associated with greater use of standardized scales. The provision of a memory clinic was associated with greater use of neuropsychiatric scales and lower levels of use of cognitive scales. These results provide key material for shaping the provision of psychiatric services for older people

Efficacy of rivastigmine in subjects with moderately severe Alzheimer's disease

BACKGROUND

Cholinesterase (ChE) inhibitors are primarily used in the treatment of mild to moderate Alzheimer's disease (AD), but may also be effective in more severe disease.

OBJECTIVE

To evaluate the dual ChE inhibitor, rivastigmine, in more severe dementia.

METHODS

We retrospectively analysed pooled data from three randomised, placebo-controlled, double-blind, 6-month trials, involving 2126 AD subjects. Subjects were selected according to baseline Mini-Mental State Examination (MMSE) score to identify subjects with more severe cognitive impairment (10-12 MMSE points). One-hundred-and-seventeen subjects were included who had been treated with rivastigmine 6-12 mg/day or placebo. The AD Assessment Scale-Cognitive Subscale (ADAS-Cog), the MMSE, a six-item subscore of the Progressive Deterioration Scale (PDS) and the BEHAVE-AD assessed efficacy. Tolerability was assessed by recording adverse events (AEs) and the relative risk (RR) of discontinuation.

RESULTS

This group of subjects responded well to rivastigmine. After 6 months, the mean ADAS-Cog score declined by 6.3 points in the placebo group and increased by 0.2 points in the rivastigmine group (observed cases; p<0.001). Clinical benefits were also observed with the MMSE, the six-item PDS score and items of the BEHAVE-AD. Rivastigmine showed the same pattern of AEs as in other studies, but the RR of dropping out due to AEs was lower than in subjects with milder AD.

CONCLUSION

Current treatment guidelines do not recommend treating individuals with severe AD with ChE inhibitors. However, this retrospective analysis suggests that rivastigmine 6-12 mg/day may benefit subjects with more severe disease, as well as subjects with mild to moderate impairment.

Delirium

Delirium is a common cause of mortality and morbidity in older people in hospital, and indicates severe illness in younger patients. Identification of risk factors, education of professional carers, and a systematic approach to management can improve the outcome of the syndrome. Physicians should be aware that delirium sufferers often have an awareness of their experience, which may be belied by their varying grasp of reality.

Orientation of histopathology specimens

We present a simple way of orientating large specimens being sent to the laboratory for histopathological examination by supplementing the pinning of the specimen on a cork board with Polaroid photographs of the specimen and numbered tags.

Treatment response in late-onset depression: relationship to neuropsychological, neuroradiological and vascular risk factors

BACKGROUND

Late-onset depressive disorder is associated with white matter lesions and neuropsychological deficits that in some studies are linked to a poorer outcome for depression. Some white matter lesions may be vascular in origin. This study investigated the relationship between response or non-response to antidepressant monotherapy and neuropsychological function, structural brain measures and vascular factors.

METHOD

This was a case control study. Fifty patients with late-onset major depressive disorder (29 who were responders to antidepressant monotherapy and 21 who were not) were compared with 35 non-depressed control subjects. Measures included assessment of vascular risk factors, neuropsychological testing and a magnetic resonance imaging (MRI) scan.

RESULTS

After adjustment for depressed mood and medication at evaluation, both patient groups had significantly more impairment compared to control subjects on verbal learning tasks involving immediate or delayed recall. Patients who did not respond to antidepressant monotherapy had significantly poorer performance than controls on tests involving visuospatial ability, language, word recognition and tests of executive function, whereas there were no differences between control subjects and responders. On two tests of executive function (verbal fluency and the Stroop test) non-responders scored significantly worse than responders. There were no significant group differences on MRI measures of atrophy or of white matter lesions apart from a higher periventricular hyperintensity score in non-responders compared to controls. There were no group differences on measures of vascular disease.

CONCLUSION

The results lend support to the emerging evidence that resistance to treatment in late-onset depression may be associated with impaired executive function. Subtle cerebrovascular mechanisms may be involved.

Does integration really make a difference? A comparison of old age psychiatry services in England and Northern Ireland

OBJECTIVE

This paper seeks to address whether integrated structures are associated with more integrated forms of service. Northern Ireland has one of the most structurally integrated and comprehensive models of health and personal social services in Europe. Social and health services are jointly administered and this arrangement should, in theory, promote collaborative working and interdisciplinary arrangements.

DESIGN

The study employed a cross-sectional survey of consultants in old age psychiatry in England and Northern Ireland. Potential respondents were sourced from the UK Royal College of Psychiatrists membership list and locally collected information.

MEASURES

A self-administered postal questionnaire. Along with general service arrangements, the domains measured reflect core policy issues for older people's services. Under particular scrutiny in this study were the degree of integration of health and social service provision, as well as inter-professional team working.

RESULTS

The integrated health and social care services in Northern Ireland do appear to provide more integrated patterns of working, primarily in managerial arrangements and in the location of staff. There was no evidence of the impact of integration on practice in areas such as: assessment, referral and medical screening. The factors found to be associated with greater integration of health and social care in the prediction model fell into three categories: provision of specialist services; provision of outreach activities; and shared policies by which the whole team worked.

CONCLUSIONS

Health and personal social services in Northern Ireland have a distinct advantage over their counterparts in comparable areas of England. The results indicate that integrated structures in old age psychiatry services are associated more with integrated management systems and less with integrated practice-related activities. Further research is required on the effectiveness and cost effectiveness of integrating services in general. It is important that future intervention studies systematically measure the component parts, nature and extent of integration and their individual and joint contribution to the effectiveness and efficacy of services.

Right-hemisphere encephalopathy in elderly subjects with schizophrenia: evidence from neuropsychological and brain imaging studies

RATIONALE

Cognitive impairment is a recognised feature of schizophrenia. Elderly patients with early-acquired schizophrenia are seriously affected, with a proportion of them showing clinically significant dementia, not accounted for by any recognized degenerative processes common in this age group, such as Alzheimer's disease. Progression of cognitive deficits is described in elderly institutionalised patients, but disputed amongst community dwelling subjects. The pattern of cognitive deficits in this age group is not yet clearly defined, although there is some evidence that it differs from that in Alzheimer's disease. There is little evidence of any underlying specific brain abnormality.

OBJECTIVES

To characterize the neuropsychological deficits in elderly schizophrenia patients and distinguish them from those in Alzheimer's disease. To establish the presence of underlying structural brain abnormality using MRI.

METHODS

Twenty-eight elderly schizophrenia patients with onset before the age of 45 years carried out neuropsychology tests. Twelve scored in the dementia range and were compared with 16 equally impaired patients with early Alzheimer's disease. Thirteen of the schizophrenia patients consented to brain MRI. The imaging data were analysed using a newly developed automated method of measuring CSF volume distributions and compared with data from 30 age-matched normal controls.

RESULTS

The schizophrenia group was more impaired on visuo-spatial tasks than the Alzheimer's group but less impaired on corresponding verbal tasks, despite similar overall cognitive impairment. The MR scans revealed right-sided enlargement of ventral CSF spaces in the schizophrenia patients especially in the posterior third, and this correlated with their impaired performance on visuo-spatial tasks.

CONCLUSIONS

The results suggest that right hemisphere impairment underlies the specific profile of cognitive impairment in elderly patients with schizophrenia.