Respiratory function and cognitive profile in amyotrophic lateral sclerosis

Clinical usefulness of the Verbal Fluency Index (VFI) in amyotrophic lateral sclerosis

BACKGROUND

This study aimed at assessing the clinical utility of the Verbal Fluency Index (VFI) over a classical phonemic verbal fluency test in Italian-speaking amyotrophic lateral sclerosis (ALS) patients.

METHODS

N = 343 non-demented ALS patients and N = 226 healthy controls (HCs) were administered the Verbal fluency - S task from the Edinburgh Cognitive and Behavioural ALS Screen (ECAS). The associations between the number of words produced (NoW), the time to read words aloud (TRW) and the VFI (computed as [(60"-TRW)/NoW]) on one hand and both bulbar/respiratory scores from the ALS Functional Rating Scale - Revised (ALSFRS-R) and the ECAS-Executive on the other were tested. Italian norms for the NoW and the VFI were derived in HCs via the Equivalent Score method. Patients were classified based on their impaired/unimpaired performances on the NoW and the VFI (NoW-VFI-; NoW-VFI+; NoW + VFI-; NoW + VFI+), with these groups being compared on ECAS-Executive scores.

RESULTS

The VFI, but neither the NoW nor the TRW, were related to ALSFRS-Bulbar/-Respiratory scores; VFI and NoW measures, but not the TRW, were related to the ECAS-Executive (p < .001). The NoW slightly overestimated the number of executively impaired patients when compared to the VFI (31.1% vs. 26.8%, respectively). Patients with a defective VFI score - regardless of whether they presented or not with a below-cutoff NoW - reported worse ECAS-Executive scores than NoW + VFI + ones.

CONCLUSIONS

The present reports support the use of the Italian VFI as a mean to validly assess ALS patients' executive status by limiting the effect of motor disabilities that might undermine their speech rate.

Cognitive reserve as a modulator of cognitive decline and of behavioral symptoms in patients with amyotrophic lateral sclerosis

Introduction: Amyotrophic lateral sclerosis (ALS) has heterogeneous manifestations ranging from motor neuron degeneration to cognitive and behavioral impairment. This study aims to clarify the interactions between cognition and behavioral symptoms with relevant disease predictors and with cognitive reserve (CR), quantified through education, physical activity, and occupation proxies. Methods: A prospective sample of 162 ALS patients and 61 controls were evaluated with the Edinburgh Cognitive and Behavioral ALS Screen (ECAS) (dependent variable), a Cognitive Reserve Index questionnaire (CRIq) and demographic data (age and sex), and, for patients, clinical variables: disease duration, site of onset, the ALS Functional Rating Scale (ALSFRS), forced vital capacity (FVC), and gene mutation chromosome 9 open reading frame 72 (C9orf72) (independent variables). Multiple regression and mediation analyses were performed to predict cognitive and behavioral symptoms. Results: For the ALS group, the statistical model explained 38.8% of variance in ECAS total (p < 0.001), 59.4% of executive functions (p < 0.001), and 55% of behavioral symptoms (p < 0.001). For controls, it accounted for 52.8% of variance in ECAS total (p < 0.001). Interaction effects and mediation analysis showed CR is an ECAS total modulator, with a differential effect within groups (p < 0.001). Verbal fluency was the single best cognitive score to differentiate patients from controls (p = 0.004), and the gene mutation C9orf72 was found to be a behavioral symptom' predictor in patients (p = 0.009). Conclusion: This study supports the proposed concept that CR acts as a cognitive modulator in ALS patients and healthy individuals. Moreover, CR also modulates behavioral manifestations in ALS.

Mediation analysis of cognitive function in the relationship between pulmonary function and depression among middle-aged and older adults

AIM

This study aims to explore the association between declining lung function and depression in middle-aged and older adults, with a special focus on the mediating role of cognitive function.

METHODS

This study utilizes self-reported and physical examination data from 5345 individuals participating in the 2015 cycle of the China Health and Retirement Longitudinal Study (CHARLS) to explore the role of cognitive function changes in mediating the effects of diminished lung function on depression among middle-aged and older adults.

RESULTS

Multivariate linear regression analysis revealed a positive correlation between pulmonary and cognitive functions (β = 0.003, 95% CI: 0.002∼0.003, P < 0.01) and a negative correlation between cognitive function and depression (β = -0.279, 95% CI: -0.330-0.228, P < 0.01). Cognitive function plays a mediating role in linking pulmonary function with depression, exhibiting a mediation effect of -0.0007 and a total effect of -0.0046, wherein the mediation effect contributes to 15.22% of the total effect. For females, the mediating effect of cognitive function was stronger (β = -0.0013, 95% CI: -0.0018∼-0.0008, P < 0.01) than it was for males (β = -0.0006, 95% CI: -0.0009∼-0.0003, P < 0.01).

CONCLUSIONS

The study underscores the importance of monitoring lung and cognitive functions as interconnected factors contributing to the mental health of middle-aged and older adults. It suggests that interventions aimed at improving pulmonary health and cognitive function may help mitigate depressive symptoms among middle-aged and older adults. Further research is warranted to validate these findings across diverse cultural and demographic settings. Geriatr Gerontol Int 2024; 24: 1210-1217.

Relationship between anthropometric indicators and cognitive function in older women

The authors aimed to explore the association between anthropometric indicators and cognitive function and determine which aspects of anthropometric indicators are most closely related to cognitive function. A sum of 3269 older women were included in this study. Body mass index (BMI), waist circumference, hip circumference, calf circumference, and waist-to-hip ratio were obtained to reflect anthropometric indicators. Cognitive function was assessed using Mini-Mental State Examination (MMSE). Researchers revealed statistically significant differences in total MMSE scores among the low, medium, and high groups of BMI, waist circumference, hip circumference, and calf circumference. Researchers also observed that calf circumference, hip circumference, and waist circumference are significantly associated with the total MMSE score. Our findings highlighted that older women with greater BMI, waist circumference, hip circumference, and calf circumference have a better level of cognitive function. Calf circumference is the most closely anthropometric indicator related to cognitive function in Chinese older women.

Association of Tai Chi and Square Dance with Cognitive Function in Chinese Older Adults

OBJECTIVE

This study explores the association of Tai Chi and square dance with cognitive function and compares the effects of the two fitness programs on cognitive function in Chinese older adults.

METHODS

A total of 1732 older people (aged 60 years and over) met the inclusion criteria from the 2018 Chinese Longitudinal Healthy Longevity Survey. Based on the frequency of participating in Tai Chi and square dance, older adults were divided into three groups: a Tai Chi group (n = 234), a square dance group (n = 345), and a control group (n = 1153). Cognitive function was measured using a modified Mini-Mental State Examination (MMSE). Participation in Tai Chi or square dance was investigated by asking the subjects to report how often they participated in the fitness programs.

RESULTS

Older adults in both the Tai Chi group and the square dance group had higher scores in all MMSE items, including orientation, registration, attention and calculation, recall, and language, compared to those in the control group. But there were no significant differences in any MMSE items between the Tai Chi group and the square dance group. Multiple regression analysis showed that participating in Tai Chi or square dance, age, educational level, and sex can predict cognitive function in older people.

CONCLUSION

Our findings suggest that participating in Tai Chi and square dance are associated with better cognitive function, and Tai Chi and square dance have similar effects on cognitive function in the Chinese older population.

Chronic respiratory failure negatively affects speech function in patients with bulbar and spinal onset amyotrophic lateral sclerosis: retrospective data from a tertiary referral center

Background: Although dysarthria and respiratory failure are widely described in literature as part of the natural history of Amyotrophic lateral sclerosis (ALS), the specific interaction between them has been little explored.Aim: To investigate the relationship between chronic respiratory failure and the speech of ALS patients.Materials and methods: In this cross-sectional retrospective study we reviewed the medical records of all patients diagnosed with ALS that were accompanied by a tertiary referral center. In order to determine the presence and degree of speech impairment, the Amyotrophic Lateral Sclerosis Functional Rating Scale-revised (ALSFRS-R) speech sub-scale was used. Respiratory function was assessed through spirometry and through venous blood gasometry obtained from a morning peripheral venous sample. To determine whether differences among groups classified by speech function were significant, maximum and mean spirometry values of participants were compared using multivariate analysis of variance (MANOVA) with Tukey's post hoc test.Results: Seventy-five cases were selected, of which 73.3% presented speech impairment and 70.7% respiratory impairment. Respiratory and speech functions were moderately correlated (seated FVC r = 0.64; supine FVC r = 0.60; seated FEV1 r = 0.59 and supine FEV1 r = 0.54, p < .001). Multivariable logistic regression revealed that the following variables were significantly associated with the presence of speech impairment after adjusting for other risk factors: seated FVC (odds ratio [OR] = 0.862) and seated FEV1 (OR = 1.106). The final model was 81.1% predictive of speech impairment. The presence of daytime hypercapnia was not correlated to increasing speech impairment.Conclusion: The restrictive pattern developed by ALS patients negatively influences speech function. Speech is a complex and multifactorial process, and lung volume presents a pivotal role in its function. Thus, we were able to find that lung volumes presented a significant correlation to speech function, especially in those with bulbar onset and respiratory impairment. Neurobiological and physiological aspects of this relationship should be explored in further studies with the ALS population.

Bulbar involvement and cognitive features in amyotrophic lateral sclerosis: a retrospective study on 347 patients

Background

This study aimed at clarifying the role of bulbar involvement (BI) as a risk factor for cognitive impairment (CI) in non-demented amyotrophic lateral sclerosis (ALS) patients.

Methods

Data on N = 347 patients were retrospectively collected. Cognition was assessed via the Edinburgh Cognitive and Behavioral ALS Screen (ECAS). On the basis of clinical records and ALS Functional Rating Scale-Revised (ALSFRS-R) scores, BI was characterized as follows: (1) BI at onset-from medical history; (2) BI at testing (an ALSFRS-R-Bulbar score ≤11); (3) dysarthria (a score ≤3 on item 1 of the ALSFRS-R); (4) severity of BI (the total score on the ALSFRS-R-Bulbar); and (5) progression rate of BI (computed as 12-ALSFRS-R-Bulbar/disease duration in months). Logistic regressions were run to predict a below- vs. above-cutoff performance on each ECAS measure based on BI-related features while accounting for sex, disease duration, severity and progression rate of respiratory and spinal involvement and ECAS response modality.

Results

No predictors yielded significance either on the ECAS-Total and -ALS-non-specific or on ECAS-Language/-Fluency or -Visuospatial subscales. BI at testing predicted a higher probability of an abnormal performance on the ECAS-ALS-specific (p = 0.035) and ECAS-Executive Functioning (p = 0.018). Lower ALSFRS-R-Bulbar scores were associated with a defective performance on the ECAS-Memory (p = 0.025). No other BI-related features affected other ECAS performances.

Discussion

In ALS, the occurrence of BI itself, while neither its specific features nor its presence at onset, might selectively represent a risk factor for executive impairment, whilst its severity might be associated with memory deficits.

Iranian clinical practice guideline for amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegeneration involving motor neurons. The 3-5 years that patients have to live is marked by day-to-day loss of motor and sometimes cognitive abilities. Enormous amounts of healthcare services and resources are necessary to support patients and their caregivers during this relatively short but burdensome journey. Organization and management of these resources need to best meet patients' expectations and health system efficiency mandates. This can only occur in the setting of multidisciplinary ALS clinics which are known as the gold standard of ALS care worldwide. To introduce this standard to the care of Iranian ALS patients, which is an inevitable quality milestone, a national ALS clinical practice guideline is the necessary first step. The National ALS guideline will serve as the knowledge base for the development of local clinical pathways to guide patient journeys in multidisciplinary ALS clinics. To this end, we gathered a team of national neuromuscular experts as well as experts in related specialties necessary for delivering multidisciplinary care to ALS patients to develop the Iranian ALS clinical practice guideline. Clinical questions were prepared in the Patient, Intervention, Comparison, and Outcome (PICO) format to serve as a guide for the literature search. Considering the lack of adequate national/local studies at this time, a consensus-based approach was taken to evaluate the quality of the retrieved evidence and summarize recommendations.

Quercetin activates the Sestrin2/AMPK/SIRT1 axis to improve amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is a chronic neurodegenerative disease with poor prognosis. The intricacies surrounding its pathophysiology could partly account for the lack of effective treatment for ALS. Sestrin2 has been reported to improve metabolic, cardiovascular and neurodegenerative diseases, and is involved in the direct and indirect activation of the adenosine 5'-monophosphate (AMP)-activated protein kinase (AMPK)/silent information regulator 1 (SIRT1) axis. Quercetin, as a phytochemical, has considerable biological activities, such as anti-oxidation, anti-inflammation, anti-tumorigenicity, and neuroprotection. Interestingly, quercetin can activate the AMPK/SIRT1 signaling pathway to reduce endoplasmic reticulum stress, and alleviate apoptosis and inflammation. This report examines the molecular relationship between Sestrin2 and AMPK/SIRT1 axis, as well as the main biological functions and research progress of quercetin, together with the correlation between quercetin and Sestrin2/AMPK/SIRT1 axis in neurodegenerative diseases.

Care burden and related factors among informal caregivers of patients with amyotrophic lateral sclerosis

Objective: Amyotrophic lateral sclerosis (ALS) affects the life of the family caregiver as well as the patient. This study aimed to determine the care burden and related factors among family caregivers of Turkish ALS patients. Methods: This descriptive study was conducted with 108 ALS patients and their informal caregivers through face-to-face interviews at home. The data were collected using the ALS Functional Rating Scale, Zarit Burden Interview, European Quality of Life-Five Dimensions Questionnaire, Multidimensional Scale of Perceived Social Support, and the Hospital Anxiety and Depression Scale. Results: The mean age of the caregivers was 48.1 ± 13.4 years; the vast majority were female, and they were either spouses or children of the patients. While 49.1% reported moderate or severe burden, the quality of life was moderate (mean 70.4 ± 22.8). The caregiver burden was related to sex and the functional state of the patient, as well as caregiver factors such as the relation to the patient, sex, health status, time spent for care, and living in the same house with a limited environment. Walking ability, percutaneous endoscopic gastrostomy, tracheostomy, and communication problems were not associated with the burden. Furthermore, burden was associated with the caregiver's quality of life, social support, anxiety, and depression. Conclusions: The present study draws attention to the fact that the care burden in family caregivers of ALS patients is high and their quality of life is impaired. Our findings reveal that not only ALS patients but also caregivers need to be supported with an organized and planned system.

Non-invasive ventilation support for people with amyotrophic lateral sclerosis: multidisciplinary team management

PURPOSE OF REVIEW

To summarise recent developments in the use of noninvasive ventilation (NIV) for people with amyotrophic lateral sclerosis (pwALS), with a specific focus on how multidisciplinary teams (MDT) can support best practice.

RECENT FINDINGS

We included 13 papers, 12 with observational designs and one qualitative interview design. The review is structured using four content domains: prognosis, the effectiveness of NIV, NIV tolerance, and MDT structure and delivery. Findings suggest a modest survival benefit of NIV for pwALS. Further evidence is needed to consider the appropriate time of initiation in the context of respiratory status and the influence of NIV on cognitive function over the course of the disease. A key emerging determinant of tolerability of NIV is secretion load. Palliative care professionals within the MDT can play a key role in supporting pwALS to consider the potential benefits of NIV in the context of their preferences, prognosis, symptom burden, and ALS variant.

SUMMARY

ALS MDTs allow timely information sharing about NIV between experts that is likely to improve outcomes. MDT practice must continually adapt to reflect pwALS's preferences for care and ensure those caring for them at home have access to support using digital innovations.

The relationship between ventilatory function and cognitive and behavioral impairment in ALS

Objective: To study the association between ventilatory function and cognitive and behavioral impairment in ALS patients accounting for the effects of pertinent covariates. Methods: Four hundred and eighty-one patients were identified from the Mayo Clinic Florida ALS registry who had concurrent forced vital capacity (FVC) and cognitive and behavioral testing using the ALS Cognitive Behavioral Screen (ALS-CBS). Multiple linear regression analysis was used to study the effects of FVC and relevant covariates on the ALS-CBS cognition score, subscores, and caregiver behavioral inventory. Results: FVC was positively correlated to the cognitive and behavioral subscores on the ALS-CBS (p < 0.001), and the correlation was independent of the effects of site of ALS onset, age, and years of education. Conclusion: Cognitive and behavioral function may be adversely affected by ventilatory impairment in ALS. The presence of cognitive and behavioral impairment warrants a detailed assessment of ventilatory function.

Cognitive and behavioural impairment in amyotrophic lateral sclerosis: A landmark of the disease? A mini review of longitudinal studies

Amyotrophic lateral sclerosis (ALS) is a heterogeneous neurodegenerative disease marked by progressive loss of motor abilities. Approximately half of patents with ALS experience cognitive (ALSci) or behavioural impairment (ALSbi) during the course of the disease, with a small percentage developing overt frontotemporal dementia (FTD). ALSci and/or ALSbi can occur simultaneously with motor neuron degeneration or develop in advanced stages of the disease, but it can even precede motor involvement in some cases, namely in ALS patients meeting criteria for FTD. Despite clear evidence that cognitive/behavioural impairment may appear early in the course of ALS, no prominent deterioration seems to occur with disease progression. Longitudinal studies have failed to reach conclusive results on the progression of cognitive and behavioural involvement in ALS. This may be due to some structural limitations of the studies, such as attrition rate, practice effect, short-time interval between neuropsychological assessments, but it can also be due to the heterogeneity of ALS phenotypes. The objective of this review is to provide a comprehensive and critical analysis of results of longitudinal studies highlighting cognitive and behavioural domains mainly affected by neurodegeneration pointing out the determinants that might be associate with the development and worsening of frontotemporal symptoms in ALS. At this regard, older age, rapidly progressing ALS, bulbar-onset, advanced disease stages are among factors mainly associated with cognitive and behavioural involvement. Moreover, the progression of cognitive and behavioural deficits seems to be not directly related to the slope of motor disability, thus suggesting the independence of neuropsychological and motor functional decline in ALS. Cognitive and motor involvement may indeed present with distinct trajectories suggesting a differential vulnerability of motor and non-motor cortical networks. In this scenario, determining the progression of extra-motor involvement in ALS may help refine understanding of the clinical implications of cognitive and behavioural abnormalities, and provide clues to the aetiology of the disease.

Brain Stimulation as a Therapeutic Tool in Amyotrophic Lateral Sclerosis: Current Status and Interaction With Mechanisms of Altered Cortical Excitability

In the last 20 years, several modalities of neuromodulation, mainly based on non-invasive brain stimulation (NIBS) techniques, have been tested as a non-pharmacological therapeutic approach to slow disease progression in amyotrophic lateral sclerosis (ALS). In both sporadic and familial ALS cases, neurophysiological studies point to motor cortical hyperexcitability as a possible priming factor in neurodegeneration, likely related to dysfunction of both excitatory and inhibitory mechanisms. A trans-synaptic anterograde mechanism of excitotoxicity is thus postulated, causing upper and lower motor neuron degeneration. Specifically, motor neuron hyperexcitability and hyperactivity are attributed to intrinsic cell abnormalities related to altered ion homeostasis and to impaired glutamate and gamma aminobutyric acid gamma-aminobutyric acid (GABA) signaling. Several neuropathological mechanisms support excitatory and synaptic dysfunction in ALS; additionally, hyperexcitability seems to drive DNA-binding protein 43-kDA (TDP-43) pathology, through the upregulation of unusual isoforms directly contributing to ASL pathophysiology. Corticospinal excitability can be suppressed or enhanced using NIBS techniques, namely, repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), as well as invasive brain and spinal stimulation. Experimental evidence supports the hypothesis that the after-effects of NIBS are mediated by long-term potentiation (LTP)-/long-term depression (LTD)-like mechanisms of modulation of synaptic activity, with different biological and physiological mechanisms underlying the effects of tDCS and rTMS and, possibly, of different rTMS protocols. This potential has led to several small trials testing different stimulation interventions to antagonize excitotoxicity in ALS. Overall, these studies suggest a possible efficacy of neuromodulation in determining a slight reduction of disease progression, related to the type, duration, and frequency of treatment, but current evidence remains preliminary. Main limitations are the small number and heterogeneity of recruited patients, the limited "dosage" of brain stimulation that can be delivered in the hospital setting, the lack of a sufficient knowledge on the excitatory and inhibitory mechanisms targeted by specific stimulation interventions, and the persistent uncertainty on the key pathophysiological processes leading to motor neuron loss. The present review article provides an update on the state of the art of neuromodulation in ALS and a critical appraisal of the rationale for the application/optimization of brain stimulation interventions, in the light of their interaction with ALS pathophysiological mechanisms.