Evidence of dysexecutive syndrome in patients with acromegaly

Acromegalic Rat Model Presented Cognitive Impairments and Tau Hyperphosphorylation in the Hippocampus

INTRODUCTION

Acromegaly patients, in addition to the most prominent physical and endocrine changes, also exhibit a higher risk of cognitive dysfunction. However, the reasons and mechanisms underlying cognitive impairments in acromegaly patients remain unknown.

METHODS

Acromegalic rats were induced by subcutaneous injection of tumor cells, with continuous monitoring of the body weight and hormones to confirm the occurrence of acromegaly. Behavioral assessments, including open field test, novel object recognition test, and Barnes maze test, were conducted to evaluate the animals' cognitive function. Western blotting, immunohistochemistry, and immunofluorescence techniques were employed to examine changes in the hippocampal tau protein, Aβ, and associated signaling pathways.

RESULTS

The tumor cells secreting growth hormone increased the secretion of growth hormone, resulting in changes in body size and endocrine functions, thus causing acromegaly. The acromegaly model showed deficiencies in working memory and spatial memory. Hyperphosphorylation of tau protein was observed in the hippocampus of the acromegaly model, but no Aβ deposition was observed. The acromegaly model exhibits hippocampal growth hormone (GH) resistance, decreased expression of GH receptors, and subsequently reduced expression activity of the PI3K-Akt-GSK3β signaling pathway, which is responsible for the hyperphosphorylation of tau protein.

CONCLUSION

The prolonged elevation of GH and insulin-like growth factor 1 caused by acromegaly may lead to abnormalities in the SD rat's PI3K-Akt-GSK3β signaling pathway, subsequently resulting in hyperphosphorylation of the hippocampal tau protein and cognitive impairment.

Cognitive Dysfunction, an Increasingly Valued Long-Term Impairment in Acromegaly

Acromegaly is a chronic disease caused by the overproduction of growth hormone (GH) and accompanying insulin-like growth factor-1 (IGF-1), which is often caused by GH-secreting pituitary adenomas. In addition to its somatic burden, a growing number of studies have found that patients suffering from acromegaly exhibit psychosocial and personality changes. Over the past 70 years, there has been increasing interest in the cognitive impairment and neuropsychological issues of patients with acromegaly, and a variety of neuropsychological and neurophysiological tests have been used to measure cognitive changes in patients. The impact of disease progression status, treatment modalities, and various comorbidities on cognitive function and the mechanisms of cognitive impairment in patients with acromegaly are therefore outlined in this review. Multidisciplinary assessment has important implications for the management of acromegaly, particularly in relation to cognitive function. Here, we summarize the relevant literature concerning cognitive-behavioral research on acromegaly to demonstrate the impact of long-term impairment caused by GH and IGF-1 on the cognitive behavior of patients.

Cognitive behavioral therapy adapted for patients with acromegaly

In acromegaly, excess secretion of growth hormone and insulin-like growth factor 1 may result in coarse features and enlargement of the extremities. Its negative repercussion on self-esteem can impair quality of life. Ten patients with acromegaly participated in this study. The treatment covered nine weekly group sessions. Unhealthy behaviors, thoughts, and emotions were identified, and healthy behaviors and thoughts were constructed, along with positive reflections on their associated emotions. In Session 7, the “Think healthy and feel the difference” technique was adapted to help patients better deal with their physical appearance and improve their quality of life. Qualitative data was obtained from an analysis of the content of a collaborative exercise developed in Session 7. Factors, especially thoughts, emotions, and advantages and disadvantages associated with both healthy and unhealthy behaviors, were identified. The technique improved quality of life for patients with acromegaly in relation to their acceptance of their physical appearance. UTN U 1111–1220-9846 (September 24th, 2018).

Growth hormone (GH) and synaptogenesis

Growth hormone (GH) is known to exert several roles during development and function of the nervous system. Initially, GH was exclusively considered a pituitary hormone that regulates body growth and metabolism, but now its alternative extrapituitary production and pleiotropic functions are widely accepted. Through excess and deficit models, the critical role of GH in nervous system development and adult brain function has been extensively demonstrated. Moreover, neurotrophic actions of GH in neural tissues include pro-survival effects, neuroprotection, axonal growth, synaptogenesis, neurogenesis and neuroregeneration. The positive effects of GH upon memory, behavior, mood, sensorimotor function and quality of life, clearly implicate a beneficial action in synaptic physiology. Experimental and clinical evidence about GH actions in synaptic function modulation, protection and restoration are revised in this chapter.

Sleep disorders and cognitive dysfunction in acromegaly

PURPOSE

In the general population, sleep disorders are associated with an increased risk of cognitive impairment. The prevalence of sleep disorders, such as sleep apnea, in acromegalic patients is higher than in the general population, and they may have additional risk of cognitive impairment due to acromegaly treatment and comorbidities. We aim to study the relationship between sleep disturbances and cognitive dysfunction in a group of acromegalic patients.

METHODS

We studied 67 consecutive acromegalic patients. We performed a neurocognitive assessment and patients completed the Acromegaly Quality of Life Questionnaire (AcroQoL), Epworth Sleepiness Scale, and Pittsburgh Sleep Quality Index.

RESULTS

Of the 67 acromegaly patients in the study, 38.8% were male and median age at the neurological examination was 56 (IQR 48, 65). Approximately 6-10% of patients had impaired cognitive assessment, depending on the test. In linear regression models adjusted for age, sex, BMI, disease duration, and disease activity, poorer sleep quality was associated with lower global cognitive z-score (B = -0.03, 95% CI -0.06, -0.002). Daytime somnolence was associated with poorer physical AcroQoL sub-score (B = -0.04, 95% CI -0.08, -0.002). Sleep quality was associated with poorer overall AcroQoL (B = -0.03, 95% CI -0.05, -0.006), physical AcroQoL (B = -0.04, 95% CI -0.07, -0.005), psychological AcroQoL (B = -0.02, 95% CI -0.04, -0.001), and social AcroQoL (B = -0.02, 95% CI -0.04, -0.0009).

CONCLUSIONS

In acromegaly patients, we found robust evidence that poor sleep quality is associated with poorer quality of life, and some evidence that it is associated with poorer cognitive function.

The Effect of Cognitive-Behavioral Therapy on Acromegalics After a 9-Month Follow-Up

Introduction: The quality of life of acromegalics is compromised. Treatment with the "Think healthy and feel the difference" technique has been described as effective in the improvement of the quality of life of these patients in the short term. However, its effectiveness in the long term needs to be evaluated. Objective: The purpose of this study was to evaluate whether the good results obtained from the "Think healthy and feel the difference" technique in the short term persists in the long term, after the end of the treatment. Method: This is a non-randomized longitudinal study with 23 acromegalic divided into two groups: an intervention group with 10 patients and a control group with 13 patients. The intervention itself covered nine group sessions, organized weekly, using a technique called "Think healthy and feel the difference." The control group did not receive the aforementioned treatment. The Short Form 36 Question Health Survey (SF-36) and the Beck Depression Inventory were administered before the sessions began, at the end of the nine therapy sessions and at the 9-month follow-up. Results: At the end of the treatment, the results of the SF-36 showed improvement in the mental health of the intervention group compared to the control group. The effects of therapy were maintained at the 9 month follow-up. Conclusion: Cognitive-behavioral therapy, applied in a group format, can improve the quality of life of acromegalic patients in the short- and long-term.

Cognitive-behavioral therapy improves the quality of life of patients with acromegaly

BACKGROUND

The delayed diagnosis, altered body image, and clinical complications associated with acromegaly impair quality of life.

PURPOSE

To assess the efficacy of the cognitive-behavioral therapy (CBT) technique "Think Healthy" to increase the quality of life of patients with acromegaly.

METHODS

This non-randomized clinical trial examined ten patients with acromegaly (nine women and one man; mean age, 55.5 ± 8.4 years) from a convenience sample who received CBT. The intervention included nine weekly group therapy sessions. The quality of life questionnaire the 36-Item Short Form Survey (SF-36) and the Beck Depression Inventory (BDI) were administered during the pre- and post-intervention phases. The Wilcoxon signed-rank test was performed to assess the occurrence of significant differences.

RESULTS

According to the SF-36, the general health domain significantly improved (d'  = - 0.264; p = 0.031). The mental health domain improved considerably (d'  = - 1.123; p = 0.012). Physical functioning showed a non-significant trend toward improvement (d'  = - 0.802; p = 0.078), although four of the five patients who showed floor effects improved and remained at this level. Regarding emotional well-being, five patients showed floor effects and four improved, and the condition did not change among any of the four patients who showed ceiling effects. No significant changes were found with regard to the other domains. No significant differences in the BDI were found before or after the intervention.

CONCLUSION

The technique presented herein effectively improved the quality of life of patients with acromegaly with different levels of disease activity, type, and treatment time.