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van’t Westeinde A, Padilla N, Fletcher-Sandersjöö S, Kämpe O, Bensing S, Lajic S. Increased Resting-State Functional Connectivity in Patients With Autoimmune Addison Disease. J Clin Endocrinol Metab 2024; 109:701-710. [PMID: 37820745 PMCID: PMC10876407 DOI: 10.1210/clinem/dgad592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 09/08/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023]
Abstract
CONTEXT Individuals with autoimmune Addison disease (AAD) take replacement medication for the lack of adrenal-derived glucocorticoid (GC) and mineralocorticoid hormones from diagnosis. The brain is highly sensitive to these hormones, but the consequence of having AAD for brain health has not been widely addressed. OBJECTIVE The present study compared resting-state functional connectivity (rs-fc) of the brain between individuals with AAD and healthy controls. METHODS Fifty-seven patients with AAD (33 female) and 69 healthy controls (39 female), aged 19 to 43 years were scanned with 3-T magnetic resonance imaging (MRI). RESULTS Independent component and subsequent dual regression analyses revealed that individuals with AAD had stronger rs-fc compared to controls in 3 networks: the bilateral orbitofrontal cortex (OFC), the left medial visual and left posterior default mode network. A higher GC replacement dose was associated with stronger rs-fc in a small part of the left OFC in patients. We did not find any clear associations between rs-fc and executive functions or mental fatigue. CONCLUSION Our results suggest that having AAD affects the baseline functional organization of the brain and that current treatment strategies of AAD may be one risk factor.
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Affiliation(s)
- Annelies van’t Westeinde
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Nelly Padilla
- Department of Women's and Children's Health, Karolinska Institutet, Unit for Neonatology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Sara Fletcher-Sandersjöö
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Olle Kämpe
- Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Sweden and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
- Department of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Pediatric Endocrinology Unit, Sahlgrenska University Hospital, SE-416 50 Gothenburg, Sweden
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Russell G, Kalafatakis K, Durant C, Marchant N, Thakrar J, Thirard R, King J, Bowles J, Upton T, Thai NJ, Brooks JCW, Wilson A, Phillips K, Ferguson S, Grabski M, Rogers CA, Lampros T, Wilson S, Harmer C, Munafo M, Lightman SL. Ultradian hydrocortisone replacement alters neuronal processing, emotional ambiguity, affect and fatigue in adrenal insufficiency: The PULSES trial. J Intern Med 2024; 295:51-67. [PMID: 37857352 PMCID: PMC10952319 DOI: 10.1111/joim.13721] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Primary adrenal insufficiency (PAI) mortality and morbidity remain unacceptably high, possibly arising as glucocorticoid replacement does not replicate natural physiology. A pulsatile subcutaneous pump can closely replicate cortisol's circadian and ultradian rhythm. OBJECTIVES To assess the effect of pump therapy on quality of life, mood, functional neuroimaging, behavioural/cognitive responses, sleep and metabolism. METHODS A 6-week randomised, crossover, double-blinded and placebo-controlled feasibility study of usual dose hydrocortisone in PAI administered as either pulsed subcutaneous or standard care in Bristol, United Kingdom (ISRCTN67193733). Participants were stratified by adrenal insufficiency type. All participants who received study drugs are included in the analysis. The primary outcome, the facial expression recognition task (FERT), occurred at week 6. RESULTS Between December 2014 and 2017, 22 participants were recruited - 20 completed both arms, and 21 were analysed. The pump was well-tolerated. No change was seen in the FERT primary outcome; however, there were subjective improvements in fatigue and mood. Additionally, functional magnetic resonance imaging revealed differential neural processing to emotional cues and visual stimulation. Region of interest analysis identified the left amygdala and insula, key glucocorticoid-sensitive regions involved in emotional ambiguity. FERT post hoc analysis confirmed this response. There were four serious adverse events (AE): three intercurrent illnesses requiring hospitalisation (1/3, 33.3% pump) and a planned procedure (1/1, 100% pump). There was a small number of expected AEs: infusion site bruising/itching (3/5, 60% pump), intercurrent illness requiring extra (3/7, 42% pump) and no extra (4/6, 66% pump) steroid. CONCLUSIONS These findings support the administration of hormone therapy that mimics physiology.
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Affiliation(s)
- Georgina Russell
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
- North Bristol NHS TrustBristolUK
| | - Konstantinos Kalafatakis
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- Department of Informatics and Telecommunications, Human‐Computer Interaction LaboratoryUniversity of IoanninaArtaGreece
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
- Faculty of Medicine and Dentistry (Malta Campus)Queen Mary University of LondonVictoriaMalta
| | - Claire Durant
- Department of Brain SciencesFaculty of MedicineImperial College LondonLondonUK
| | - Nicola Marchant
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Jamini Thakrar
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
| | - Russell Thirard
- Bristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Jade King
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
- North Bristol NHS TrustBristolUK
| | - Jane Bowles
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Thomas Upton
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
| | - Ngoc Jade Thai
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
- Neurosciences and Mental HealthLiverpool Health PartnersLiverpoolUK
| | | | - Aileen Wilson
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
| | - Kirsty Phillips
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Stuart Ferguson
- School of MedicineUniversity of TasmaniaHobartTasmaniaAustralia
| | | | - Chris A. Rogers
- Bristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Theodoros Lampros
- Department of Informatics and Telecommunications, Human‐Computer Interaction LaboratoryUniversity of IoanninaArtaGreece
| | - Sue Wilson
- Department of Brain SciencesFaculty of MedicineImperial College LondonLondonUK
| | - Catherine Harmer
- Department of PsychiatryOxford University and Oxford Health NHS Foundation TrustOxfordUK
| | - Marcus Munafo
- MRC Integrative Epidemiology UnitSchool of Psychological ScienceUniversity of BristolBristolUK
| | - Stafford L. Lightman
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
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3
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Ramos-Leví AM, Cañada E, Matias-Guiu JA. Cognitive dysfunction in patients with primary adrenal insufficiency: A systematic review. APPLIED NEUROPSYCHOLOGY. ADULT 2023; 30:802-813. [PMID: 35767730 DOI: 10.1080/23279095.2022.2090256] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Addison's disease (AD) entails a chronic insufficient production of gluco- and mineralocorticoids. Fatigue and decreased quality of life are frequently reported symptoms, but little is known about its effects on cognition. This study aims to explore the existence of cognitive impairment in patients with AD and the influence of treatment regimens. We conducted a systematic review. Inclusion criteria were met by 10 articles, most of them ranked as intermediate quality. Three studies analyzed the relationship between AD and cognitive impairment; one explored the effect of delaying treatment showing no effect on cognitive performance, and another one studied the effect of fludrocortisone treatment. Episodic memory was the most frequent cognitive domain impaired across studies, in comparison to healthy controls. Two papers investigated the relationship between impaired sleep quality and poor cognitive performance. Two studies related cognitive impairments with hypocortisolism-derived brain neuroglycopenia. Two studies investigated the effect of DHEA substitution. In conclusion, patients exhibit a moderately reduced performance in verbal learning. The pathophysiology of this impairment is likely multifactorial. Future studies should include larger sample sizes, the use of comprehensive and multi-domain neuropsychological and behavioral protocols, and neuroimaging.
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Affiliation(s)
- Ana M Ramos-Leví
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Universidad Autónoma, Madrid, Spain
| | - Emma Cañada
- Department of Endocrinology, Hospital Universitario La Princesa, Instituto de Investigación Princesa, Universidad Autónoma, Madrid, Spain
| | - Jordi A Matias-Guiu
- Department of Neurology, Hospital Clínico San Carlos, Instituto de Investigación San Carlos, IdISSC, Universidad Complutense, Madrid, Spain
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De Alcubierre D, Ferrari D, Mauro G, Isidori AM, Tomlinson JW, Pofi R. Glucocorticoids and cognitive function: a walkthrough in endogenous and exogenous alterations. J Endocrinol Invest 2023; 46:1961-1982. [PMID: 37058223 PMCID: PMC10514174 DOI: 10.1007/s40618-023-02091-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/05/2023] [Indexed: 04/15/2023]
Abstract
PURPOSE The hypothalamic-pituitary-adrenal (HPA) axis exerts many actions on the central nervous system (CNS) aside from stress regulation. Glucocorticoids (GCs) play an important role in affecting several cognitive functions through the effects on both glucocorticoid (GR) and mineralocorticoid receptors (MR). In this review, we aim to unravel the spectrum of cognitive dysfunction secondary to derangement of circulating levels of endogenous and exogenous glucocorticoids. METHODS All relevant human prospective and retrospective studies published up to 2022 in PubMed reporting information on HPA disorders, GCs, and cognition were included. RESULTS Cognitive impairment is commonly found in GC-related disorders. The main brain areas affected are the hippocampus and pre-frontal cortex, with memory being the most affected domain. Disease duration, circadian rhythm disruption, circulating GCs levels, and unbalanced MR/GR activation are all risk factors for cognitive decline in these patients, albeit with conflicting data among different conditions. Lack of normalization of cognitive dysfunction after treatment is potentially attributable to GC-dependent structural brain alterations, which can persist even after long-term remission. CONCLUSION The recognition of cognitive deficits in patients with GC-related disorders is challenging, often delayed, or mistaken. Prompt recognition and treatment of underlying disease may be important to avoid a long-lasting impact on GC-sensitive areas of the brain. However, the resolution of hormonal imbalance is not always followed by complete recovery, suggesting irreversible adverse effects on the CNS, for which there are no specific treatments. Further studies are needed to find the mechanisms involved, which may eventually be targeted for treatment strategies.
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Affiliation(s)
- D De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D Ferrari
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - G Mauro
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - J W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - R Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK.
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5
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Harbeck B, Kropp P, Kreitschmann-Andermahr I. Glucocorticoid replacement therapy for primary and secondary adrenal insufficiency and their impact on cognition. Front Endocrinol (Lausanne) 2023; 14:1153595. [PMID: 37008924 PMCID: PMC10064134 DOI: 10.3389/fendo.2023.1153595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/07/2023] [Indexed: 03/19/2023] Open
Abstract
Patients with adrenal insufficiency (AI) are treated with conventional or modified-release glucocorticoid (GC) replacement therapy (GRT). Although current GRT regimens aim to mimic the physiological circadian pattern of cortisol secretion, temporary phases of hypo- and hypercortisolism are common. There is good evidence that prolonged phases of hypo- or hypercortisolism are associated with impaired cognitive functioning. However, little is known about cognitive functioning in patients with AI regarding the effects of dosage and duration of glucocorticoid replacement therapy. There is also little data available comparing the effects of GC therapy on patients with primary and secondary forms of AI as well as with respect to different formulas. This Mini-Review gives an overview of the current studies on GRT for primary and secondary AI and their impact on cognition. Strengths and weaknesses of the studies and their Implications for clinical daily routine are discussed with a special emphasis on practical considerations for the treating endocrinologist.
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Affiliation(s)
- Birgit Harbeck
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Medizinisches Versorgungszentrum (MVZ) Amedes Experts, Endocrinology, Hamburg, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University of Rostock, Rostock, Germany
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6
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Pierpont EI, Isaia AR, McCoy E, Brown SJ, Gupta AO, Eisengart JB. Neurocognitive and mental health impact of adrenoleukodystrophy across the lifespan: Insights for the era of newborn screening. J Inherit Metab Dis 2023; 46:174-193. [PMID: 36527290 PMCID: PMC10030096 DOI: 10.1002/jimd.12581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/09/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
X-linked adrenoleukodystrophy (ALD) is a rare inherited neurological disorder that poses considerable challenges for clinical management throughout the lifespan. Although males are generally more severely affected than females, the time course and presentation of clinical symptoms are otherwise difficult to predict. Opportunities to improve outcomes for individuals with ALD are rapidly expanding due to the introduction of newborn screening programs for this condition and an evolving treatment landscape. The aim of this comprehensive review is to synthesize current knowledge regarding the neurocognitive and mental health effects of ALD. This review provides investigators and clinicians with context to improve case conceptualization, inform prognostic counseling, and optimize neuropsychological and mental health care for patients and their families. Results highlight key predictive factors and brain-behavior relationships associated with the diverse manifestations of ALD. The review also discusses considerations for endpoints within clinical trials and identifies gaps to address in future research.
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Affiliation(s)
| | - Ashley R. Isaia
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Erin McCoy
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Sarah J. Brown
- Health Sciences Library, University of Minnesota, Minneapolis, Minnesota
| | - Ashish O. Gupta
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Julie B. Eisengart
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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7
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Van't Westeinde A, Padilla N, Siqueiros Sanchez M, Fletcher-Sandersjöö S, Kämpe O, Bensing S, Lajic S. Brain structure in autoimmune Addison's disease. Cereb Cortex 2022; 33:4915-4926. [PMID: 36227196 PMCID: PMC10110435 DOI: 10.1093/cercor/bhac389] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/12/2022] Open
Abstract
Long-term disturbances in cortisol levels might affect brain structure in individuals with autoimmune Addison's disease (AAD). This study investigated gray and white matter brain structure in a cohort of young adults with AAD. T1- and diffusion-weighted images were acquired for 52 individuals with AAD and 70 healthy controls, aged 19-43 years, using magnetic resonance imaging. Groups were compared on cortical thickness, surface area, cortical gray matter volume, subcortical volume (FreeSurfer), and white matter microstructure (FSL tract-based spatial statistics). Individuals with AAD had 4.3% smaller total brain volume. Correcting for head size, we did not find any regional structural differences, apart from reduced volume of the right superior parietal cortex in males with AAD. Within the patient group, a higher glucocorticoid (GC) replacement dose was associated with smaller total brain volume and smaller volume of the left lingual gyrus, left rostral anterior cingulate cortex, and right supramarginal gyrus. With the exception of smaller total brain volume and potential sensitivity of the parietal cortex to GC disturbances in men, brain structure seems relatively unaffected in young adults with AAD. However, the association between GC replacement dose and reduced brain volume may be reason for concern and requires follow-up study.
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Affiliation(s)
- Annelies Van't Westeinde
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Karolinskavagen 37A, SE-171 76 Stockholm, Sweden
| | - Nelly Padilla
- Unit for Neonatology, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Karolinskavagen 37A, SE-171 76 Stockholm, Sweden
| | - Monica Siqueiros Sanchez
- Brain Imaging, Development and Genetics (BRIDGE) Lab, Division of Interdisciplinary Brain Sciences, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5101, United States
| | - Sara Fletcher-Sandersjöö
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Olle Kämpe
- Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.,Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Svetlana Lajic
- Pediatric Endocrinology Unit, Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Karolinskavagen 37A, SE-171 76 Stockholm, Sweden
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8
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Van't Westeinde A, Ström S, Hirvikoski T, Dahlqvist P, Wahlberg J, Gezelius A, Kämpe O, Bensing S, Lajic S. Young adult Swedish patients with autoimmune Addison's disease report difficulties with executive functions in daily life despite overall good cognitive performance. Psychoneuroendocrinology 2022; 140:105714. [PMID: 35290880 DOI: 10.1016/j.psyneuen.2022.105714] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES Sub-optimal replacement of glucocorticoids (GC) in autoimmune Addison's disease (AAD) may affect cognitive functioning. The present study therefore sought to investigate cognitive performance and self-reported problems with executive functions in a cohort of young adult patients with AAD. DESIGN AND METHODS 67 patients with AAD (39 females), mean age 32 yrs. (range 19-41), and 80 control participants (43 females), mean age 29 yrs. (range 19-43), completed neuropsychological tests estimating verbal and non-verbal intellectual ability, learning, memory and executive functioning, in addition to self-report scales assessing problems with executive functions, fatigue and symptoms of anxiety and depression. RESULTS Patients performed within the average range on all cognitive tests compared to population norms. However, female AAD patients reported more problems than controls with both hot (emotion regulation) and cold (cognitive regulation) executive functions in daily life. Moreover, experienced problems with executive functions in both male and female patients were associated with increased mental fatigue and lower GC replacement doses. CONCLUSIONS Despite average performance in neuropsychological tests by both sexes, young adult female patients with AAD experience problems with executive functions in daily life. Coping with mental fatigue and optimization of pharmacotherapy may be important factors to be addressed in order to provide timely support for patients. Future research is needed to further determine other risk factors for experiencing executive function impairments in AAD.
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Affiliation(s)
- Annelies Van't Westeinde
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Sara Ström
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Tatja Hirvikoski
- Department of Women's and Children's Health, Pediatric Neuropsychiatry Unit, Center for Neurodevelopmental Disorders at Karolinska Institutet (KIND), Karolinska Institutet, SE-17177 Stockholm Sweden; Unit for Habilitation & Health, Stockholm County Council, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, SE-901 87 Umeå, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology and Department of Medical and Health Sciences, Linköpings University, SE-581 83 Linköping, Sweden; Department of Internal Medicine, School of Health and Medical Sciences, Örebro University, SE-702 81 Örebro, Sweden
| | - Anton Gezelius
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Olle Kämpe
- Department of Medicine (Solna), Center for Molecular Medicine, Karolinska Institutet, Sweden
| | - Sophie Bensing
- Department of Molecular Medicine and Surgery, Karolinska Institutet and Department of Endocrinology, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Svetlana Lajic
- Department of Women's and Children's Health, Karolinska Institutet, Pediatric Endocrinology Unit, Karolinska University Hospital, SE-171 76 Stockholm, Sweden.
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Blacha AK, Kropp P, Rahvar AH, Flitsch J, van de Loo I, Harbeck B. Poor quality of life and sleep in patients with adrenal insufficiency-another cause of increased mortality? Ir J Med Sci 2021; 191:1653-1658. [PMID: 34389925 PMCID: PMC9308573 DOI: 10.1007/s11845-021-02731-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 07/28/2021] [Indexed: 11/26/2022]
Abstract
Background Patients with adrenal insufficiency (AI) are treated with glucocorticoid replacement therapy (GRT). Although current glucocorticoid regimens aim to mimic the physiological circadian rhythm of cortisol secretion, temporary phases of hypo- and hypercortisolism are common undesired effects which lead to a variety of consequences like increased cardiovascular risk and premature mortality. Additionally, poor quality of life (QoL) and impaired sleep have been reported. However, little is known about these topics regarding the effects of daily dosage, duration of therapy, and patients with different forms of AI (primary, PAI, and secondary, SAI). Methods In this study, 40 adults with AI substituted with hydrocortisone (HC) and 20 matched healthy controls completed questionnaires evaluating depressive symptoms, subjective health status, quality of sleep and daytime sleepiness. Furthermore, demographic data, dosage of HC, duration of therapy and co-medication were evaluated. Patients were compared in different groups. Results Patients assessed general health significantly worse than controls; likewise, daytime sleepiness was reported significantly more often. Depressive symptoms differed significantly in the two groups but did not reach clinically relevant scores. There was no difference between patients with PAI and SAI. High dosage of hydrocortisone had negative impact on mental health but not on sleep quality or daytime sleepiness. Conclusions The present data highlight that poor QoL and impaired sleep are still severe and underrated issues in current GRT and might be additional factors for premature mortality in patients with AI. Some AI patients reach normal or near-normal self-assessed QoL and sleep, even despite unphysiological replacement.
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Affiliation(s)
- Antje K Blacha
- I. Department of Medicine, University of Luebeck, Luebeck, Germany
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University of Rostock, Rostock, Germany
| | - Amir H Rahvar
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Flitsch
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Birgit Harbeck
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Amedes Experts, Hamburg, Germany.
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10
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Krekeler C, Kropp P, Blacha AK, Rahvar AH, Harbeck B. Dual-release hydrocortisone and its benefits on cognitive function and quality of sleep. Endocrine 2021; 72:223-233. [PMID: 33625720 DOI: 10.1007/s12020-020-02552-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 11/11/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE Patients with adrenal insufficiency are usually treated with conventional hydrocortisone replacement therapy which fails to mimic the circadian rhythm of cortisol secretion. Dual-release hydrocortisone (DR-HC) resembles the daily normal cortisol profile improving metabolic parameters and quality of life. However, currently little is known about its impact on cognitive function. Aim of this study was to evaluate cognitive function and well-being in DR-HC treated patients compared to healthy controls and conventional HC treatment. METHODS Twenty adults with adrenal insufficiency treated with DR-HC (Plenadren®) underwent 10 neuropsychological tests, evaluating cognitive functions. Furthermore, demographic data, quality of life, symptoms of depression, and quality of sleep were evaluated by well-established questionnaires. Patients were compared by diagnosis (PAI/SAI) and dose (≥20 mg). In addition, eighteen DR-HC treated adults were compared to eighteen matched conventionally treated adults. RESULTS With respect to diagnosis patients with PAI performed significantly better on intellectual abilities (p = 0.038) and on executive functioning (p = 0.026) and reported a significant longer time to fall asleep (p = 0.026). Regarding DR-HC dosage, there were no significant differences in cognitive functions. Patients on high dose reported a better subjective quality of sleep (p = 0.028) than patients on low dose. In comparison to conventional HC treatment, patients with DR-HC tended to show better results in executive functioning (p = 0.099). CONCLUSION Patients with PAI reached better results in several cognitive functions and had a worse quality of sleep than patients with SAI. Our data suggest a positive impact of DR-HC on quality of sleep. DR-HC may be better for executive functioning.
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Affiliation(s)
| | - Peter Kropp
- Institute of Medical Psychology and Medical Sociology, University of Rostock, Rostock, Germany
| | | | - Amir-Hossein Rahvar
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Birgit Harbeck
- Department of Medicine I, University of Luebeck, Luebeck, Germany.
- MVZ Amedes Experts, Endocrinology, Hamburg, Germany.
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Blacha AK, Rahvar AH, Flitsch J, van de Loo I, Kropp P, Harbeck B. Impaired attention in patients with adrenal insufficiency - Impact of unphysiological therapy. Steroids 2021; 167:108788. [PMID: 33412217 DOI: 10.1016/j.steroids.2020.108788] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 12/14/2020] [Accepted: 12/28/2020] [Indexed: 12/26/2022]
Abstract
Patients with adrenal insufficiency (AI) are treated with glucocorticoid (GC) replacement therapy. Although current GC regimens aim to mimic the physiological circadian rhythm of cortisol secretion, temporary phases of hypo- and hypercortisolism are common undesired effects. Both conditions may lead to impairment in cognitive functioning. At present, little is known about cognitive functioning in patients with AI, especially regarding the effects of dosage and duration of glucocorticoid replacement therapy. There is also little data available comparing the effects of GC therapy on patients with primary (PAI) and secondary (SAI) forms of AI. In this study 40 adults with AI (21 PAI, 19 SAI) substituted with hydrocortisone (HC) and 20 matched healthy controls underwent 10 different neuropsychological tests evaluating memory, executive functioning, attention, psychomotricity and general intellectual ability. Furthermore demographic data, dosage of HC, duration of therapy and co-medication were evaluated. Patients were compared in groups with regard to diagnosis, dosage and duration of therapy. Patients showed worse performance than controls in attention, though patients with PAI and SAI seemed to be equally impaired. There were no limitations in intellectual abilities or memory function. High dosage of HC was found to impair attention, visual-motoric skills and executive functioning while the duration of therapy showed no significant impact on cognitive functions. In conclusion, our study showed that AI patients on HC replacement therapy reveal significant cognitive deficits concerning attention. There was no difference between patients with PAI and SAI. Furthermore, high dosage seems to have a negative impact especially on executive functioning.
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Affiliation(s)
| | - Amir H Rahvar
- University Medical Center Hamburg-Eppendorf, Germany
| | - Jörg Flitsch
- University Medical Center Hamburg-Eppendorf, Germany
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12
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Henry M, Thomas KGF, Ross IL. Sleep, Cognition and Cortisol in Addison's Disease: A Mechanistic Relationship. Front Endocrinol (Lausanne) 2021; 12:694046. [PMID: 34512546 PMCID: PMC8429905 DOI: 10.3389/fendo.2021.694046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/02/2021] [Indexed: 11/19/2022] Open
Abstract
Sleep is a critical biological process, essential for cognitive well-being. Neuroscientific literature suggests there are mechanistic relations between sleep disruption and memory deficits, and that varying concentrations of cortisol may play an important role in mediating those relations. Patients with Addison's disease (AD) experience consistent and predictable periods of sub- and supra-physiological cortisol concentrations due to lifelong glucocorticoid replacement therapy, and they frequently report disrupted sleep and impaired memory. These disruptions and impairments may be related to the failure of replacement regimens to restore a normal circadian rhythm of cortisol secretion. Available data provides support for existing theoretical frameworks which postulate that in AD and other neuroendocrine, neurological, or psychiatric disorders, disrupted sleep is an important biological mechanism that underlies, at least partially, the memory impairments that patients frequently report experiencing. Given the literature linking sleep disruption and cognitive impairment in AD, future initiatives should aim to improve patients' cognitive performance (and, indeed, their overall quality of life) by prioritizing and optimizing sleep. This review summarizes the literature on sleep and cognition in AD, and the role that cortisol concentrations play in the relationship between the two.
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Affiliation(s)
- Michelle Henry
- Centre for Higher Education Development, University of Cape Town, Cape Town, South Africa
- *Correspondence: Michelle Henry,
| | | | - Ian Louis Ross
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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13
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Wingenfeld K, Otte C. Mineralocorticoid receptor function and cognition in health and disease. Psychoneuroendocrinology 2019; 105:25-35. [PMID: 30243757 DOI: 10.1016/j.psyneuen.2018.09.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 09/06/2018] [Accepted: 09/10/2018] [Indexed: 02/04/2023]
Abstract
The steroid hormone cortisol is released in response to stress and exerts its effects in the brain via two different receptors: the mineralocorticoid receptor (MR) and the glucocorticoid receptor (GR). This review - dedicated to Dirk Hellhammer - focusses on the role of MR on cognitive and emotional function in healthy individuals and in stress-associated disorders such as major depressive disorder (MDD) or borderline personality disorder (BPD). Animal data and studies from healthy individuals converge such that MR play an important role in the appraisal of new situations and the following response selection. Decision-making and empathy are important determinants of this response selection and both are affected by MR function. Furthermore, MR are crucially involved in visuospatial navigation and memory in young and elderly healthy individuals whereas the exact physiological role of MR in verbal learning and verbal memory needs to be further characterized. In contrast to studies in healthy participants, age played a moderating role on the effects of MR stimulation on cognition in depressed patients. In young depressed patients, MR stimulation exerted beneficial effects on verbal memory and executive function, whereas in elderly depressed patients MR stimulation led to impaired verbal learning and visuospatial memory. Similar to healthy controls, BPD patients showed enhanced emotional empathy but not cognitive empathy after MR stimulation. Accordingly, this make MR an interesting target for potential pharmacological augmentation of psychotherapy in BPD. Given the important role MR play in cognitive and emotional function in health and disease, further studies should examine whether MR modulation can alleviate cognitive and emotional problems in patients with stress-associated disorders.
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Affiliation(s)
- Katja Wingenfeld
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Psychiatrie und Psychotherapie, Campus Benjamin Franklin, Berlin, Germany.
| | - Christian Otte
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Klinik für Psychiatrie und Psychotherapie, Campus Benjamin Franklin, Berlin, Germany
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14
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Cheung YT, Brinkman TM, Li C, Mzayek Y, Srivastava D, Ness KK, Patel SK, Howell RM, Oeffinger KC, Robison LL, Armstrong GT, Krull KR. Chronic Health Conditions and Neurocognitive Function in Aging Survivors of Childhood Cancer: A Report from the Childhood Cancer Survivor Study. J Natl Cancer Inst 2019; 110:411-419. [PMID: 29088360 DOI: 10.1093/jnci/djx224] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/20/2017] [Indexed: 11/12/2022] Open
Abstract
Background Neurocognitive impairment in survivors of childhood cancer may be associated with direct neurotoxicity, as well as indirect effects of systemic health complications. We evaluated associations among treatment exposures, chronic health conditions, and neurocognitive outcomes in adult survivors of childhood cancer. Methods Participants included 5507 adult survivors of childhood cancer (47.1% male; mean [SD] age = 31.8 [7.6] years at evaluation; 23.1 [4.5] years postdiagnosis) in the Childhood Cancer Survivor Study who completed a self-report measure of neurocognitive function. Cardiac, pulmonary, and endocrine chronic health conditions were graded using the National Cancer Institute Common Terminology Criteria for Adverse Events (version 4.03). Structural equation modeling was used to examine a priori hypothesized causal pathways among cancer treatment, subsequent chronic health conditions, and neurocognitive outcomes. Multivariable models were used to estimate relative risk for associations of treatments and chronic conditions on neurocognitive function. All statistical tests were two-sided. Results One-third of survivors with a grade 2 or higher chronic condition reported impairments in task efficiency and memory. In addition to direct effects of cranial radiation, path analyses and multivariable models demonstrated direct effects of cardiopulmonary (β = 0.10, P = .002; relative risk [RR] = 1.27, 95% confidence interval [CI] = 1.12 to 1.44) and endocrine (β = 0.07, P = .04; RR = 1.14, 95% CI = 1.02 to 1.28) conditions on impaired task efficiency. We identified similar effects of cardiopulmonary condition on memory (P = .01) and emotional regulation (P = .01). Thoracic radiation was associated with impaired task efficiency (P = .01) and emotional regulation (P = .01) through endocrine morbidity. Conclusions Non-neurotoxic exposures, such as thoracic radiation, can adversely impact survivors' neurocognitive function through chronic conditions. Management of chronic diseases may mitigate neurocognitive outcomes among aging survivors of childhood cancer.
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Affiliation(s)
- Yin Ting Cheung
- Departments of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
| | - Tara M Brinkman
- Departments of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN.,Psychology and Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Chenghong Li
- Psychology and Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Yasmin Mzayek
- Departments of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
| | - Deokumar Srivastava
- Psychology and Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Kirsten K Ness
- Departments of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
| | - Sunita K Patel
- Departments of Population Sciences and Supportive Care Medicine, City of Hope National Medical Center, Duarte, CA
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Leslie L Robison
- Departments of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
| | - Gregory T Armstrong
- Departments of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN
| | - Kevin R Krull
- Departments of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN.,Psychology and Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
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15
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Oprea A, Bonnet NCG, Pollé O, Lysy PA. Novel insights into glucocorticoid replacement therapy for pediatric and adult adrenal insufficiency. Ther Adv Endocrinol Metab 2019; 10:2042018818821294. [PMID: 30746120 PMCID: PMC6360643 DOI: 10.1177/2042018818821294] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 12/04/2018] [Indexed: 02/04/2023] Open
Abstract
Adrenal insufficiency is defined as impaired adrenocortical hormone synthesis. According to its source, the deficit is classified as primary (adrenal steroidogenesis impairment), secondary (pituitary adrenocorticotropic hormone deficit) or tertiary (hypothalamic corticotropin-releasing hormone deficit). The management of adrenal insufficiency resides primarily in physiological replacement of glucocorticoid secretion. Standard glucocorticoid therapy is shrouded in several controversies. Along the difficulties arising from the inability to accurately replicate the pulsatile circadian cortisol rhythm, come the uncertainties of dose adjustment and treatment monitoring (absence of reliable biomarkers). Furthermore, side effects of inadequate replacement significantly hinder the quality of life of patients. Therefore, transition to circadian hydrocortisone therapy gains prominence. Recent therapeutic advancements consist of oral hydrocortisone modified-release compounds (immediate, delayed and sustained absorption formulations) or continuous subcutaneous hydrocortisone infusion. In addition to illustrating the current knowledge on conventional glucocorticoid regimens, this review outlines the latest research outcomes. We also describe the management of pediatric patients and suggest a novel strategy for glucocorticoid replacement therapy in adults.
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Affiliation(s)
- Alina Oprea
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Nicolas C. G. Bonnet
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Olivier Pollé
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Philippe A. Lysy
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Pôle PEDI, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Av. Hippocrate 10, B-1200 Brussels, Belgium
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16
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Ohara N, Hirokawa M, Kobayashi M, Ikeda Y, Yoneoka Y, Seki Y, Akiyama K, Tani T, Terajima K, Ozawa T. Reversible Non-parkinsonian Bradykinesia with Impaired Frontal Lobe Function as the Predominant Manifestation of Adrenal Insufficiency. Intern Med 2018; 57:3399-3406. [PMID: 30101905 PMCID: PMC6306535 DOI: 10.2169/internalmedicine.1101-18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A 69-year-old Japanese man with a history of suprasellar surgery and irradiation developed bradykinesia and mild fatigue without muscle weakness, myalgia, pyramidal or extrapyramidal signs, parkinsonian symptoms, or ataxia. An endocrinological work-up revealed anterior hypopituitarism associated with secondary adrenal insufficiency. Higher brain function tests indicated an impaired frontal lobe function. The patient's bradykinesia, fatigue, and frontal lobe dysfunction improved within 2 weeks after the initiation of corticosteroid replacement therapy. To our knowledge, this is the first reported case of adrenal insufficiency manifesting as non-parkinsonian bradykinesia. Physicians should consider reversible non-parkinsonian bradykinesia associated with frontal lobe dysfunction as an unusual manifestation of adrenal insufficiency.
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Affiliation(s)
- Nobumasa Ohara
- Department of Endocrinology and Metabolism, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Mayuko Hirokawa
- Department of Endocrinology and Metabolism, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Michi Kobayashi
- Department of Endocrinology and Metabolism, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Yohei Ikeda
- Department of Radiology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Yuichiro Yoneoka
- Department of Neurosurgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Yasuhiro Seki
- Department of Neurosurgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Katsuhiko Akiyama
- Department of Neurosurgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Takashi Tani
- Department of Neurology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Kenshi Terajima
- Department of Neurology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
| | - Tetsutaro Ozawa
- Department of Neurology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Japan
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17
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Human R, Henry M, Jacobs WJ, Thomas KGF. Elevated Cortisol Leaves Working Memory Unaffected in Both Men and Women. Front Hum Neurosci 2018; 12:299. [PMID: 30087603 PMCID: PMC6066520 DOI: 10.3389/fnhum.2018.00299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 07/10/2018] [Indexed: 01/10/2023] Open
Abstract
Activation of the hypothalamic-pituitary-adrenal (HPA) axis (as might occur, for example, when the organism encounters a threat to allostatic balance) leads to the release of cortisol into the bloodstream and, ultimately, to altered neural functioning in particular brain regions (e.g., the prefrontal cortex (PFC)). Although previous studies suggest that exposure to acute psychosocial stress (and hence, presumably, elevation of circulating cortisol levels) enhances male performance on PFC-based working memory (WM) tasks, few studies have adequately investigated female performance on WM tasks under conditions of elevated cortisol. Hence, we compared associations between elevated (relative to baseline) levels of circulating cortisol and n-back performance in a South African sample (38 women in the late luteal phase of their menstrual cycle, 38 men). On Day 1, participants completed practice n-back tasks. On Day 2, some completed the Trier Social Stress Test (TSST), whereas others experienced a relaxation period, before completing 1-back and 3-back tasks. We measured self-reported anxiety and salivary cortisol at baseline, post-manipulation and end of session. We reconstituted group assignment so that all women with elevated cortisol were in one group (EC-Women; n = 17), all men with elevated cortisol were in another (EC-Men; n = 19), all women without elevated cortisol were in a third (NoEC-Women; n = 21), and all men without elevated cortisol were in a fourth (NoEC-Men; n = 19) group. Analyses suggested this reconstitution was effective: in EC, but not NoEC, groups cortisol levels rose significantly from baseline to post-manipulation. Analyses of n-back data detected significant relations to task load (i.e., better performance on 1-back than on 3-back tasks), but no significant relations to sex, performance accuracy/speed, or cortisol variation. The data patterns are inconsistent with reports describing sex differences in effects of stress on WM performance. We speculate that cross-study methodological differences account for these inconsistencies, and, particularly, that between-study variation in the magnitude of baseline cortisol levels might affect outcomes. For instance, diurnal cortisol rhythms of South African samples might have flatter curves, and lower baseline values, than predominantly Caucasian samples from the United States and western Europe due to greater prenatal and lifetime stress, more socioeconomic disadvantage and faster ancestral life history (LH) strategies. We describe ways to disconfirm this hypothesis, and urge further cross-national research exploring these possibilities.
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Affiliation(s)
- Robyn Human
- ACSENT Laboratory, Department of Psychology, University of Cape Town, Rondebosch, South Africa
| | - Michelle Henry
- ACSENT Laboratory, Department of Psychology, University of Cape Town, Rondebosch, South Africa.,Academic Development Programme, Centre for Higher Education Development, University of Cape Town, Rondebosch, South Africa
| | - W Jake Jacobs
- Anxiety Research Group, Department of Psychology, University of Arizona, Tucson, AZ, United States
| | - Kevin G F Thomas
- ACSENT Laboratory, Department of Psychology, University of Cape Town, Rondebosch, South Africa
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18
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Santos A, Resmini E, Pascual JC, Crespo I, Webb SM. Psychiatric Symptoms in Patients with Cushing's Syndrome: Prevalence, Diagnosis and Management. Drugs 2017; 77:829-842. [PMID: 28393326 DOI: 10.1007/s40265-017-0735-z] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cushing's syndrome (CS) results from chronic exposure to cortisol excess, produced by the adrenal cortex. Hypercortisolism predisposes to psychiatric and neurocognitive disorders, mainly to depression and anxiety disorders. Screening tools to identify psychiatric symptoms are available for clinicians in their daily practice, although a specific diagnosis should be performed by specialists. Even if psychiatric symptoms improve after remission of hypercortisolism, complete recovery may not be achieved. Given the burden of these symptoms, psychiatric or psychological monitoring and treatment should be offered through all phases of CS, with a multidisciplinary approach. The aim of this article is to review data on the prevalence, diagnosis and management of psychiatric symptoms seen in patients with CS and to propose therapeutic approaches that may be followed in clinical practice. The prevalence of different psychiatric disorders has been described in both the active phase and after CS remission. Patients may not talk spontaneously about psychiatric symptoms they present, thus clinicians should ask directly about them. We recommend the use of screening tools in clinical practice to detect and treat these symptoms promptly. Even if reference endocrinologists cannot perform a definite psychiatric diagnosis, it will be important to ask patients directly about the presence of symptoms and refer if necessary to a psychiatrist. Additionally, patient information and educational programmes could be useful to manage psychiatric symptoms and to improve quality of life in patients with CS.
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Affiliation(s)
- Alicia Santos
- Department of Endocrinology/Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER 747), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eugenia Resmini
- Department of Endocrinology/Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER 747), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain. .,Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Juan Carlos Pascual
- Department of Psychiatry, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Iris Crespo
- Department of Endocrinology/Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER 747), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Susan M Webb
- Department of Endocrinology/Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER 747), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
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19
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Henry M, Ross IL, Wolf PSA, Thomas KGF. Impaired quality and efficiency of sleep impairs cognitive functioning in Addison's disease. Psychoneuroendocrinology 2017; 78:237-245. [PMID: 28235729 DOI: 10.1016/j.psyneuen.2017.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 02/06/2017] [Accepted: 02/07/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Standard replacement therapy for Addison's disease (AD) does not restore a normal circadian rhythm. Periods of sub- and supra- physiological cortisol levels experienced by patients with AD likely induce disrupted sleep. Given that healthy sleep plays an important role in memory consolidation, the novelty of the current study was to characterise, using objective measures, the relationship between sleep and memory in patients with AD, and to examine the hypothesis that poor sleep is a biological mechanism underlying memory impairment in those patients. METHODS We used a within-subjects design. Ten patients with AD and 10 matched healthy controls completed standardised neuropsychological tests assessing declarative memory (Rey Auditory Verbal Learning Test) and procedural memory (Finger Tapping Task) before and after a period of actigraphy-measured sleep, and before and after a period of waking. RESULTS Relative to healthy controls, patients with AD experienced disrupted sleep characterised by poorer sleep efficiency and more time spent awake. Patients also showed impaired verbal learning and memory relative to healthy controls (p=0.007). Furthermore, whereas healthy controls' declarative memory performance benefited from a period of sleep compared to waking (p=0.032), patients with AD derived no such benefit from sleep (p=0.448). Regarding the procedural memory task, analyses detected no significant between-group differences (all p's<0.065), and neither group showed significant sleep-enhanced performance. CONCLUSIONS We demonstrated, using actigraphy and standardized measures of memory performance, an association between sleep disturbances and cognitive deficits in patients with AD. These results suggest that, in patients with AD, the source of memory deficits is, at least to some extent, disrupted sleep patterns that interfere with optimal consolidation of previously-learned declarative information. Hence, treating the sleep disturbances that are frequently experienced by patients with AD may improve their cognitive functioning.
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Affiliation(s)
- Michelle Henry
- ACSENT Laboratory, Department of Psychology, University of Cape Town, South Africa; Centre for Higher Education Development, University of Cape Town, South Africa.
| | - Ian Louis Ross
- Division of Endocrinology, Department of Medicine, University of Cape Town, South Africa
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20
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Cheung YT, Chemaitilly W, Mulrooney DA, Brinkman TM, Liu W, Banerjee P, Srivastava D, Pui CH, Robison LL, Hudson MM, Krull KR. Association between dehydroepiandrosterone-sulfate and attention in long-term survivors of childhood acute lymphoblastic leukemia treated with only chemotherapy. Psychoneuroendocrinology 2017; 76:114-118. [PMID: 27907849 PMCID: PMC5272831 DOI: 10.1016/j.psyneuen.2016.11.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/09/2016] [Indexed: 12/24/2022]
Abstract
Long-term survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for neurocognitive impairment, as well as compromised hypothalamic-pituitary-adrenal (HPA) function. Dehydroepiandrosterone-sulfate (DHEAS) is an adrenal androgen commonly used as a marker of HPA function. In the general population, a low level of DHEAS has been associated with poorer cognition. At ≥2years post-treatment, we examined the association of DHEAS with attention outcomes in 35 male and 34 female long-term survivors of childhood ALL (mean[standard deviation] age at evaluation 14.5[4.7] years; 7.5[1.9] years post-diagnosis) who were treated with only chemotherapy and without prophylactic cranial irradiation. Male survivors with low-normal levels of DHEAS had worse performance than male survivors with high levels of DHEAS on multiple measures of attention (all P's<0.05). However, association between DHEAS and attention measures were not found in female survivors. Our results suggest that survivors of ALL who suffer from partial but persistent adrenal insufficiency may be at risk for neurocognitive deficits. This finding should be validated in a larger prospective study, with attention to sex differences in the potential impact of adrenal insufficiency on neurocognitive outcomes.
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Affiliation(s)
- Yin Ting Cheung
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, USA
| | - Wassim Chemaitilly
- Department of Endocrinology, St Jude Children's Research Hospital, Memphis, USA
| | - Daniel A Mulrooney
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, USA; Department of Oncology, St Jude Children's Research Hospital, Memphis, USA
| | - Tara M Brinkman
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, USA; Department of Psychology, St Jude Children's Research Hospital, Memphis, USA
| | - Wei Liu
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, USA
| | - Pia Banerjee
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, USA
| | - Deokumar Srivastava
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, USA
| | - Ching-Hon Pui
- Department of Oncology, St Jude Children's Research Hospital, Memphis, USA
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, USA
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, USA; Department of Oncology, St Jude Children's Research Hospital, Memphis, USA
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, USA; Department of Psychology, St Jude Children's Research Hospital, Memphis, USA.
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21
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Bensing S, Hulting AL, Husebye ES, Kämpe O, Løvås K. MANAGEMENT OF ENDOCRINE DISEASE: Epidemiology, quality of life and complications of primary adrenal insufficiency: a review. Eur J Endocrinol 2016; 175:R107-16. [PMID: 27068688 DOI: 10.1530/eje-15-1242] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/06/2016] [Indexed: 12/13/2022]
Abstract
In this article, we review published studies covering epidemiology, natural course and mortality in primary adrenal insufficiency (PAI) or Addison's disease. Autoimmune PAI is a rare disease with a prevalence of 100-220 per million inhabitants. It occurs as part of an autoimmune polyendocrine syndrome in more than half of the cases. The patients experience impaired quality of life, reduced parity and increased risk of preterm delivery. Following a conventional glucocorticoid replacement regimen leads to a reduction in bone mineral density and an increase in the prevalence of fractures. Registry studies indicate increased mortality, especially evident in patients diagnosed with PAI at a young age and in patients with the rare disease autoimmune polyendocrine syndrome type-1. Most notably, unnecessary deaths still occur because of adrenal crises. All these data imply the need to improve the therapy and care of patients with PAI.
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Affiliation(s)
- Sophie Bensing
- Department of Molecular Medicine and SurgeryKarolinska Institutet, and Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Anna-Lena Hulting
- Department of Molecular Medicine and SurgeryKarolinska Institutet, Stockholm, Sweden
| | - Eystein S Husebye
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway Department of MedicineHaukeland University Hospital, Bergen, Norway
| | - Olle Kämpe
- Department of Medicine (Solna)Centre for Molecular Medicine, Karolinska Institutet, and Department of Endocrinology, Diabetes and Metabolism, Karolinska University Hospital, Stockholm, Sweden
| | - Kristian Løvås
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway Department of MedicineHaukeland University Hospital, Bergen, Norway
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Early-Life Adversity Interacts with FKBP5 Genotypes: Altered Working Memory and Cardiac Stress Reactivity in the Oklahoma Family Health Patterns Project. Neuropsychopharmacology 2016; 41:1724-32. [PMID: 26632991 PMCID: PMC4869048 DOI: 10.1038/npp.2015.347] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 10/23/2015] [Accepted: 11/16/2015] [Indexed: 12/30/2022]
Abstract
Exposure to stress during critical periods of development can have adverse effects on adult health behaviors, and genetic vulnerabilities may enhance these stress effects. We carried out an exploratory examination of psychological, physiological, and behavioral characteristics of 252 healthy young adults for the impact of early-life adversity (ELA) in relation to the G-to-A single nucleotide polymorphism (SNP), rs9296158, of the FKBP5 gene. FKBP5 is a molecular cochaperone that contributes to the functional status of the glucocorticoid receptor (GR) and to the quality of corticosteroid signaling. FKBP5 expression is upregulated by cortisol exposure during stressful episodes, with greater upregulation seen in A-allele carriers. As such, FKBP5 expression and GR function may be environmentally sensitive in A-allele carriers and therefore suitable for the study of gene-by-environment (G × E) interactions. Compared with FKBP5, GG homozygotes (N=118), A-allele carriers (N = 132) without psychiatric morbidity had progressively worse performance on the Stroop color-word task with increasing levels of ELA exposure (Genotype × ELA, F=5.14, P=0.007), indicating a G × E interaction on working memory in early adulthood. In addition, heart rate response to mental stress was diminished overall in AA/AG-allele carriers (F=5.15, P=0.024). Diminished working memory and attenuated autonomic responses to stress are both associated with risk for alcoholism and other substance use disorders. The present data suggest that FKBP5 in the GR pathway may be a point of vulnerability to ELA, as seen in this group of non-traumatized young adults. FKBP5 is accordingly a potential target for more extensive studies of the impact of ELA on health and health behaviors in adulthood.
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Schultebraucks K, Wingenfeld K, Otte C, Quinkler M. The Role of Fludrocortisone in Cognition and Mood in Patients with Primary Adrenal Insufficiency (Addison's Disease). Neuroendocrinology 2016; 103:315-20. [PMID: 26227663 DOI: 10.1159/000438791] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 07/15/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Primary adrenal insufficiency (AI) requires hormone replacement therapy with fludrocortisone and hydrocortisone stimulating glucocorticoid (GR) and mineralocorticoid receptors (MR). Evidence from animal and human studies shows that MR function is crucial for cognitive function and mood. Regarding patients with AI, very little is known about the role of MR in cognitive function and mood. METHODS A repeated-measures within-subject design was used to determine whether cognitive function and mood are related to MR occupation in patients with AI. Intraindividually, patients were examined twice, with 1 week between testing days: once with fludrocortisone (high MR occupation) and once without fludrocortisone (low MR occupation). All patients kept their stable regimen of hydrocortisone. The assessment of cognitive function included executive function, attention, and verbal, visuospatial and working memory. Additionally, mood and blood pressure were measured. RESULTS Verbal memory improved significantly during high MR occupation (after fludrocortisone intake) compared to low MR occupation [without fludrocortisone, t(29) = -2.1, p = 0.046]. There were trend level differences in the Number-Combination test [t(29) = -1.9, p = 0.074] and in the Stroop interference task [t(29) = -1.9, p = 0.068]. No significant differences in visuospatial and working memory were found. Furthermore, the current mood state was better during high MR occupation compared to low MR occupation [t(29) = -2.4, p = 0.023] as was diastolic blood pressure [F(2, 29) = 3.6, p = 0.07]. CONCLUSIONS Cognitive function and mood in patients with AI depend in part on MR occupation. Because the medium effect size indicates a potential clinical significance, further studies should systematically examine which dosages of fludrocortisone are associated with optimal cognitive function and mood in AI patients.
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Affiliation(s)
- Katharina Schultebraucks
- Department of Psychiatry and Psychotherapy, Charitx00E9; University Medical Center, Campus Benjamin Franklin, Berlin, Germany
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Tiemensma J, Andela CD, Biermasz NR, Romijn JA, Pereira AM. Mild cognitive deficits in patients with primary adrenal insufficiency. Psychoneuroendocrinology 2016; 63:170-7. [PMID: 26454105 DOI: 10.1016/j.psyneuen.2015.09.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND The brain is a major target organ for cortisol considering its high density of glucocorticoid receptors. Several states of hypothalamus-pituitary-adrenal dysregulation point towards impairments in cognitive functioning. However, there is a very limited body of research on the effects of hypocortisolism on cognitive functioning. AIM To evaluate cognitive functioning in patients with hypocortisolism (i.e., primary adrenal insufficiency (PAI)) and to examine the possible effect of postponing early-morning hydrocortisone intake on cognitive functioning. METHODS Thirty-one patients with PAI on regular morning hydrocortisone intake and 31 healthy matched controls underwent nine neuropsychological tests, evaluating memory and executive functioning. In addition, the effect of normal timing and postponement of morning hydrocortisone intake on neuropsychological tests were assessed in an additional 29 patients with PAI. RESULTS Compared to controls, patients with PAI performed worse on auditory and visual memory tasks (all P ≤ 0.024) and executive functioning tasks (all P ≤ 0.012). In contrast, patients performed better on a concentration and an attention task (both P<0.05). Postponement of hydrocortisone intake in the morning did not affect the outcomes of neuropsychological tests. CONCLUSION Patients on long-term hydrocortisone replacement for PAI show mild cognitive deficits compared to controls. There was no effect of postponement of regular hydrocortisone intake on cognition.
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Affiliation(s)
- Jitske Tiemensma
- Psychological Science, University of California, Merced, CA, USA.
| | - Cornelie D Andela
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke R Biermasz
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Johannes A Romijn
- Department of Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Alberto M Pereira
- Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
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