The Luigi Sacco Hospital VAS-COG stroke care pathway: A five-year experience

Background

Psycho-cognitive consequences are a frequent cause of disability in stroke survivors but are often underdiagnosed also because of lack of services dedicated to these aspects. We started assessing systematically cognitive and behavioral functions in acute stroke patients and to follow them up. Here, we report a retrospective analysis of the organization of the Sacco VAS-COG stroke care pathway and the refinements implemented during 5 years of activity.

Methods

The protocol includes baseline collection of clinical history, general and neurologic examinations, functional, neuropsychological, and neuroimaging assessment. At follow-up, a diagnosis of cognitive decline was made based on best clinical judgment in the first period (January 2018 to May 2019, namely VAS-COG protocol 1.0) and then based on an extensive neuropsychological battery (May 2019 to January 2023, namely VASCOG protocol 2.0); psychiatric and behavioral disturbances are investigated through suitable scales.

Results

From January 2018 to December 2022, 834 patients (mean age 76±13.6 years; 46.6 % females) with acute cerebrovascular events were admitted to the stroke unit, mostly (80 %) for ischemic strokes. Pre-event cognitive impairment was not assessable in 78 patients (9.3 %) because no reliable informant was present and was reported in 327/756 (43 %) patients. During follow-up, post-stroke cognitive impairment was detected in 124/217 (57.1 %) patients in VAS-COG protocol 1.0 and in 137/201(68.2 %) patients in VAS-COG protocol 2.0, while 95/218 (43.2 %) patients were found to be depressed and patients presented on average 2.5 neuropsychiatric symptoms on Neuropsychiatric Inventory-questionnaire.

Conclusions

The VAS-COG stroke care pathway represents a model for patients and for their families.

Early predictors of dysphagia in ischemic stroke patients

INTRODUCTION

Post-stroke dysphagia affects outcome. In acute stroke patients, we aimed to evaluate clinical, cognitive, and neuroimaging features associated with dysphagia and develop a predictive score for dysphagia.

METHODS

Ischemic stroke patients underwent clinical, cognitive, and pre-morbid function evaluations. We retrospectively scored dysphagia on admission and discharge with the Functional Oral Intake Scale (FOIS).

RESULTS

We included 228 patients (mean age 75.8; 52% males). On admission, 126 (55%) were dysphagic (FOIS≤6). Age (OR 1.03, 95%CI 1.00-1.05), pre-event modified Rankin scale (mRS) (OR 1.41, 95%CI 1.09-1.84), National Institute of Health Stroke Scale (NIHSS) (OR 1.79, 95%CI 1.49-2.14), frontal operculum lesion (OR 8.53, 95% CI 3.82-19.06), and Oxfordshire total anterior circulation infarct (TACI) (OR 1.47, 95%CI 1.05-2.04) were independently associated with dysphagia at admission. Education (OR 0.91, 95%CI 0.85-0.98) had protective role. At discharge, 82 patients (36%) were dysphagic. Pre-event mRS (OR 1.28, 95%CI 1.04-1.56), admission NIHSS (OR 1.88, 95%CI 1.56-2.26), frontal operculum involvement (OR 15.53, 95%CI 7.44-32.43), and Oxfordshire classification TACI (OR 3.82, 95%CI 1.95-7.50) were independently associated with dysphagia at discharge. Education (OR 0.89, 95%CI 0.83-0.96) and thrombolysis (OR 0.77, 95%CI 0.23-0.95) had protective role. The 6-point "NOTTEM" (NIHSS, Opercular lesion, TACI, Thrombolysis, Education, MRS) score predicted dysphagia at discharge with good accuracy. Cognitive scores had no role in dysphagia risk.

CONCLUSIONS

We defined dysphagia predictors and developed a score to evaluate dysphagia risk during stroke unit stay. In this setting, cognitive impairment is not a predictor of dysphagia. Early dysphagia assessment may help planning future rehabilitative and nutrition strategies.

Case Identification and Characterization of Migrants with Dementia in the Lazio Region Using Health Administrative Data

BACKGROUND

A crucial step for planning effective public health policies for migrants with dementia is the collection of data on the local dimensions of the phenomenon and patients' characteristics.

OBJECTIVE

This study aimed to identify and characterize migrants with dementia in the Lazio region using health administrative databases.

METHODS

Residents with dementia aged 50 years or older, living in the Lazio region as of December 31, 2018, were identified using a validated algorithm based on hospital discharge(s), claims for antidementia drugs, and co-payment exemption for dementia. Migrants were defined as people born abroad and grouped in migrants from High Migratory Pressure Countries (HMPCs) and Highly Developed Countries (HDCs). Overall and age-specific prevalence rates were estimated in native- and foreign-born patients.

RESULTS

Dementia was ascertained in 38,460 residents. Among them, 37,280 (96.9%) were born in Italy, 337 (0.9%) were migrants from HDCs, and 843 (2.2%) from HMPCs. Dementia prevalence was higher among natives (1.15%, 95% CI 1.14-1.16) relative to migrants from HDCs (0.60%, 95% CI 0.54-0.67) and HMPCs (0.29%, 95% CI 0.27-0.31). The prevalence of comorbidities did not differ between groups. Migrants with dementia had a lower likelihood of receiving antidementia treatments compared with natives (51.6% in migrants from HDCs, 49.3% in migrants from HMPCs, and 53.5% among Italians).

CONCLUSION

Routinely collected data in healthcare administrative databases can support the identification of migrants with dementia. Migrants exhibited a lower age-standardized prevalence of registered dementia and lower access to dedicated treatments than Italians. These findings are suggestive of underdiagnosis and undertreatment of dementia in migrants.

The clinical profile of cerebral small vessel disease: Toward an evidence-based identification of cognitive markers

There is no consensus on which test is more suited to outline the cognitive deficits of cerebral small vessel disease (cSVD) patients. We explored the ability of eight cognitive tests, selected in a previous systematic review as the most commonly used in this population, to differentiate among cSVD patients, controls, and other dementing conditions performing a meta-analysis of 86 studies. We found that cSVD patients performed worse than healthy controls in all tests while data on the comparison to neurodegenerative diseases were limited. We outlined a lack of data on these tests' accuracy on the diagnosis. Cognitive tests measuring processing speed were those mostly associated with neuroimaging cSVD markers. There is currently incomplete evidence that a single test could differentiate cSVD patients with cognitive decline from other dementing diseases. We make preliminary proposals on possible strategies to gain information about the clinical definition of cSVD that currently remains a neuroimaging-based one.

Clinical uses of Bupropion in patients with Parkinson's disease and comorbid depressive or neuropsychiatric symptoms: a scoping review

OBJECTIVE

Bupropion, an antidepressant inhibiting the reuptake of dopamine and noradrenaline, should be useful to treat depressive symptoms in patients with Parkinson's disease (PD). Limited and conflicting literature data questioned its effectiveness and safety in depressed PD patients and extended its use to other neuropsychiatric symptoms associated with this disorder.

DESIGN

The databases PubMed, Embase, Web of Sciences, Cochrane Library, and the grey literature were searched. Following a scoping review methodology, articles focusing on Bupropion uses in PD patients who manifested depressive or other neuropsychiatric alterations were reviewed.

RESULTS

Twenty-three articles were selected, including 7 original articles, 3 systematic reviews or meta-analyses, 11 case reports, 1 clinical guideline, and 1 expert opinion. Bupropion showed considerable effectiveness in reducing depressive symptoms, particularly in relation to apathy. Solitary findings showed a restorative effect on compulsive behaviour secondary to treatment with dopamine as well as on anxiety symptoms. The effect on motor symptoms remains controversial. The safety profile of this medication seems positive, but additional precautions should be used in subjects with psychotic symptoms.

CONCLUSION

The available literature lacks good evidence to support the use of Bupropion in PD patients presenting depressive symptoms. Further investigations are needed to extend and confirm reported findings and to produce accurate clinical guidelines.

Predictivity of the clock drawing test in the acute phase of cerebrovascular diseases on cognitive decline at a 6-month neuropsychological evaluation

INTRODUCTION

We showed that the Clock Drawing Test (CDT) performed during the acute phase of cerebrovascular diseases predicted worsening of cognitive function defined based on a clinical judgement at a 3-month follow-up. The aim of this study was to verify the predictivity of the CDT on the worsening of cognitive status assessed with an extensive neuropsychological evaluation 6 months after the acute event.

METHODS

Patients with a stroke or transient ischemic attack underwent a baseline clinical, neuroimaging, and neuropsychological assessment, including the CDT. Premorbid cognitive status was evaluated by means of the Clinical Dementia Rating scale. Between 6 and 7 months after the acute event, all patients underwent a neuropsychological evaluation that included tests for executive function, attention, language, memory, and visuospatial abilities.

RESULTS

Fifty patients (29 males; mean age 72.2 years) were enrolled: 28 (56%) had no premorbid cognitive impairment, 15 (30%) had premorbid mild cognitive impairment (MCI), and 4 (8%) had premorbid dementia; for 3 patients, evaluation of premorbid status was not available. At follow-up, 11 (22%) had no cognitive impairment, 28 (56%) were diagnosed with MCI, and 11 (22%) dementia. In patients who were non-demented before the event, on regression analysis, the score obtained at CDT was predictive of decline of cognitive status at the 6-month follow-up (OR 1.65; 95% CI 1.08-2.52).

DISCUSSION

Our study confirms that administering the CDT during the acute phase of cerebrovascular diseases is informative with regard to the worsening of cognitive function after 6 months.

A nationwide survey of Italian centers for cognitive disorders and dementia on the provision of care for international migrants

Background

More than 500,000 dementia cases can be estimated among migrants living in Europe. There is the need to collect “real world” data on the preparedness of healthcare services to support the inclusion of migrants in the public health response to dementia. The present study aimed (i) to estimate the number of migrants referred to Italian memory clinics (Centers for Cognitive Disorders and Dementia [CCDDs]) and (ii) to identify possible barriers and resources for the provision of diversity‐sensitive care.

Methods

A survey of all Italian CCDDs was conducted between December 2020 and April 2021. An online questionnaire was developed to obtain information on the number of migrants referred to Italian CCDDs in 2019, the challenges encountered in the diagnostic approach, and possible facilitators in the provision of care.

Results

Overall, 343 of the 570 contacted CCDDs completed the survey questionnaire (response rate: 60.2%). Nearly 4527 migrants were referred to these services in 2019. Migrants accounted for a median 1.1% (IQR: 0.9%–2.8%) of overall CCDD referrals. More than one‐third of respondents reported that the number of migrants referred to their facilities had increased in the last 5 years. The overall quality of the migrants' cognitive assessment was deemed to be very poor or insufficient in most cases. A minority of CCDDs had translated information material on dementia and reported the possibility to contact cultural mediators and interpreters.

Conclusions

A relevant number of migrants are being referred to Italian CCDDs that are still not adequately prepared to deliver diversity‐sensitive care and support.

The Clock Drawing Test as a predictor of cognitive decline in non-demented stroke patients

BACKGROUND

The early detection of patients at risk of post-stroke cognitive impairment (PSCI) may help planning subacute and long-term care. We aimed to determine the predictivity of two screening cognitive tests on the occurrence of mild cognitive impairment or dementia in acute stroke patients.

METHODS

A cognitive assessment within a few days of ischemic or hemorrhagic stroke was performed in patients consecutively admitted to a stroke unit over 14 months by means of the Clock Drawing Test (CDT) and the Montreal Cognitive Assessment-Basic (MoCA-B).

RESULTS

Out of 191 stroke survivors who were non-demented at baseline, 168 attended at least one follow-up visit. At follow-up (mean duration ± SD 12.8 ± 8.7 months), 28 (18.9%) incident cases of MCI and 27 (18%) cases of dementia were recorded. In comparison with patients who remained cognitively stable at follow-up, these patients were older, less educated, had more comorbidities, a higher score on the National Institutes of Health Stroke Scale (NIHSS) at admission, more severe cerebral atrophy, and lower MoCA-B and CDT scores at baseline. In multi-adjusted (for age, education, comorbidities score, NIHSS at admission and atrophy score) model, a pathological score on baseline CDT (< 6.55) was associated with a higher risk of PSCI at follow-up (HR 2.022; 95% CI 1.025-3.989, p < 0.05) with respect to non-pathological scores. A pathological baseline score on MoCA-B (< 24) did not predict increased risk of cognitive decline at follow-up nor increased predictivity of stand-alone CDT.

CONCLUSION

A bedside cognitive screening with the CDT helps identifying patients at higher risk of PSCI.

Translations and cultural adaptations of the Montreal Cognitive Assessment: a systematic and qualitative review

This study provides a systematic review of linguistically and culturally adapted versions of the original Montreal Cognitive Assessment (MoCA) full version. Adapted versions were identified through a systematic review in 3 databases and on the MoCA website. Overall, 86 culturally different versions of MoCA are available: 74 versions on the MoCA website (25 of them have a corresponding paper concerning the translation process found with the systematic review) and 12 additional versions identified only with the search in biomedical databases. Culturally different adapted versions of the MoCA were unevenly distributed across different geographic areas. The quality of the process of cultural adaptation of MoCA differs considerably among different available versions as well as the number of items adapted in the various language versions. The potential availability of many culturally adapted and translated versions of the MoCA increases the chance of offering a linguistically and culturally sensitive screening for cognitive impairment to diverse populations; further studies are needed to identify if MoCA can be considered a truly cross-cultural fair test.

Spinal direct current stimulation (tsDCS) in hereditary spastic paraplegias (HSP): A sham-controlled crossover study

Objective: Hereditary spastic paraplegia (HSP) represents a heterogeneous group of neurodegenerative diseases characterized by progressive spasticity and lower limb weakness. We assessed the effects of transcutaneous spinal direct current stimulation (tsDCS) in HSP.Design: A double-blind, randomized, crossover and sham-controlled study.Setting: Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan.Participants: eleven patients with HSP (six men, mean age ± SD: 37.3 ± 8.1 years), eight affected by spastin/SPG4,1 by atlastin1/SPG3a, 1 by paraplegin/SPG7 and 1 by ZFYVE26/SPG15.Interventions: tsDCS (anodal or sham, 2.0 mA, 20', five days) delivered over the thoracic spinal cord (T10-T12).Outcome measures: Motor-evoked potentials (MEPs), the H-reflex (Hr), F-waves, the Ashworth scale for clinical spasticity, the Five Minutes Walking test and the Spastic Paraplegia Rating Scale (SPRS) were assessed. Patients were evaluated before tsDCS (T₀), at the end of the stimulation (T₁), after one week (T₂), one month (T₃) and two months (T₄).Results: The score of the Ashworth scale improved in the anodal compared with sham group, up to two months following the end of stimulation (T₁, P = .0137; T₄, P = .0244), whereas the Five Minutes Walking test and SPRS did not differ between the two groups. Among neurophysiological measures, both anodal and sham tsDCS left Hr, F-waves and MEPs unchanged over time.Conclusions: Anodal tsDCS significantly decreases spasticity and might be a complementary strategy for the treatment of spasticity in HSP.

Mild Cognitive Impairment in the Migrant Population Living in Europe: An Epidemiological Estimation of the Phenomenon

Background:

The construct of mild cognitive impairment (MCI) is triggering growing clinical and research interest. The detection of MCI may be affected by diverse ethno-cultural determinants possibly influencing the personal and social perception of the individual cognitive functioning as well as the reliability of objective cognitive assessment. These challenges may acquire special relevance in subjects with a migration background and composing ethnic minority groups.

Objective:

The present study is aimed at providing an estimate of the number of MCI cases occurring in the migrant population living in the extended European Union (EU) in 2018.

Methods:

The number of MCI cases in older migrants living in Europe and in each of the 32 considered countries was estimated by multiplying the number of migrants, provided by Eurostat, with the age-specific prevalence rates, derived by the harmonized data produced by the COSMIC collaboration and based on different operational definitions of MCI.

Results:

Nearly 686,000 cases of MCI were estimated in the extended EU by applying age-specific prevalence rates based on the International Working Group criteria. Higher figures were obtained when the Clinical Dementia Rating- and the Mini Mental State Examination-based criteria were applied. The proportion of MCI cases in migrant subjects ranged from 1.1% (Romania) to 54.1% (Liechtenstein) (median: 8.4%; IQR: 4.7%–14.2%).

Conclusions:

MCI represents and will increasingly constitute a relevant issue in the migrant population living in Europe. The present data reinforce the need of developing approaches and models of care that may be diversity-sensitive and inclusive for a culturally variegated population.

Neuropsychological screening in the acute phase of cerebrovascular diseases

INTRODUCTION

Cognitive impairment is a common and disabling consequence of stroke. Its prevalence, the best way to screen for it in the acute setting, and its relation with premorbid status have not been thoroughly clarified.

MATERIALS AND METHODS

Ischemic and hemorrhagic stroke patients admitted to our stroke unit underwent a baseline assessment that included a clinical and neuroimaging assessment, two cognitive tests (clock-drawing test, CDT; Montreal Cognitive Assessment-Basic, MoCA-B) and measures of premorbid function (including the Clinical Dementia Rating Scale). A follow-up examination was repeated 3-4 months after the acute event.

RESULTS

Two hundred and twenty-three patients (52.5% women, mean age ± SD 75.8 years ± 12.3) were evaluated. Prestroke cognitive impairment was present in 91 patients (40.8%). At follow-up, the prevalence of cognitive impairment was 49%, while its incidence among patients who did not have any prestroke cognitive impairment was 38.8%. Of the originally admitted 223 patients (71 were lost to follow-up), only 60 (26.9%) were still cognitively intact at follow-up. On regression analysis, age and baseline CDT were associated with worsening of cognitive status at follow-up. In patients without cognitive impairment at baseline, a cutoff of 23 for MoCA-B and of 8.7 for CDT scores predicted the diagnosis of post-stroke cognitive impairment with sufficient accuracy.

DISCUSSION AND CONCLUSION

Prestroke and post-stroke cognitive impairment affect a large proportion of patients with stroke. Our findings suggest that a neuropsychological screening during the acute phase might be predictive of the development of post-stroke cognitive impairment.

The emerging issue of cognitive disorders and dementia among migrants

Background

Due to population aging, people with a migration background are (and will be) increasingly exposed to the burden of chronic, age-related diseases. Specifically, the occurrence of dementia and cognitive disorders in this population of individuals can assume special clinical and public health relevance. The ImmiDem project (GR-2016-02364975) is aimed at characterizing the emerging phenomenon of cognitive disorders in migrants in Italy.

Methods

The number of dementia and mild cognitive impairment (MCI) cases among migrants living in the extended European Union was calculated by applying the age- and gender-specific prevalence rates of these conditions to the population data of international migrants provided by Eurostat. A pilot survey was addressed to a representative sample of Italian centers for cognitive disorders and dementia (CCDDs) with the aim of collecting information on the number of migrants attending these services, the adopted diagnostic, and the possible barriers and resources in the provision of care.

Results

Nearly 700,000 cases of dementia and 680,000 cases of MCI can be estimated in the migrant population living in Europe in 2018. Nevertheless, the number of migrants referred to the surveyed CCDDs was very low and was considered as stable over the last 5 years. Most of CCDDs reported the possibility of contacting cultural mediators and/or interpreters, while only a few reported the availability and regular use of translated and/or cross-cultural cognitive assessment tools.

Conclusions

The data produced by the ImmiDem project allow a preliminary characterization of the emerging phenomenon of cognitive disturbances in the migrant population. The survey will be extended to all Italian dementia services (CDCD, day centers, residential structures). Activities aimed at identifying and promoting dedicated care pathways or good practices will also be conducted.

Key messages

The clinical and epidemiological characterization of cognitive disorders occurring in migrants represent an emerging public health matter for Western countries. The onset of dementia in migrants can result in important clinical-diagnostic and healthcare complexities.

Cognitive disorders in migrants: retrospective analysis in a Center for Cognitive Disorders and Dementia in Milan

BACKGROUND

The number of migrants with dementia in Italy might increase considerably over the coming years due to the increasing flow of immigration and the aging of the population.

AIMS

We retrospectively registered rate and characteristics of demented migrant outpatients referred to one hospital in Milan from 2001 to 2017.

METHODS

Information about country of origin of migrants attending general neurology and memory clinics was obtained from their Italian tax code. Socio-demographic, cultural, and clinical characteristics were derived from their medical records.

RESULTS

Migrants with cognitive decline represented a minimal fraction (3.1%) of demented outpatients, but a grow rate of 400% was registered within the period of observation. A linguistic barrier resulted as the main obstacle for the application of available diagnostic tools for dementia.

DISCUSSION/CONCLUSION

Given the above-reported data, the implementation of strategies (such as transcultural diagnostic instruments) and policies dedicated to this growing health problem appears a priority for our health systems.

Dementia among migrants and ethnic minorities in Italy: rationale and study protocol of the ImmiDem project

INTRODUCTION

Due to the ongoing demographic and epidemiological transitions, estimating the phenomenon of dementia in migrants and minority groups, exploring its characteristics and challenges and implementing dedicated healthcare policies, constitute emerging and urgent matters for Western countries. In the present paper we describe the rationale and design of the 'Dementia in immigrants and ethnic minorities living in Italy: clinical-epidemiological aspects and public health perspectives" (ImmiDem) project.

METHODS AND ANALYSIS

Three main aims will be pursued by the ImmiDem project. First, a survey of all Italian dementia services will be conducted with dedicated questionnaires in order to estimate and describe the proportion and characteristics of migrants seeking help for cognitive disturbances. The different clinical approaches for diagnosing dementia and the challenges encountered in the assessment of cognitive functioning and in the provision of care in these groups of individuals will also be investigated. Second, record linkage procedures of data routinely collected in regional Health Information Systems will be conducted in order to identify and monitor migrant individuals with dementia living in the Lazio region. Third, tailored national and local care-coordination pathways and/or good practices dedicated to migrants affected by dementia and cognitive disorders will be identified and promoted.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Italian National Institute of Health (protocol 10749; 5 April 2018). The project was launched in November 2018 and will end in November 2021. The findings of the project will be disseminated through scientific peer-reviewed journals as well as to the public via the Dementia Observatory website (https://demenze.iss.it).

Non-invasive Cerebellar Stimulation in Cerebellar Disorders

BACKGROUND & OBJECTIVE

Non-invasive brain stimulation (NIBS) might be a valuable therapeutic approach for neurological diseases by modifying the cortical activity in the human brain and promoting neural plasticity. Currently, researchers are exploring the use of NIBS on the cerebellum to promote functional neural changes in cerebellar disorders. In the presence of cerebellar dysfunction, several movement disorders, such as kinetic tremor, ataxia of gait, limb dysmetria and oculomotor deficits, become progressively more disabling in daily life, and no pharmacological treatments currently exist.

CONCLUSION

In the present mini-review, we report the main evidence concerning the use of NIBS in three specific cerebellar dysfunctions, cerebellar ataxias (CA), essential tremor (ET) and ataxic cerebral palsy, in which abnormalities of neuroplasticity and cortical excitability can be important pathophysiological factors.

Estimating dementia cases amongst migrants living in Europe

BACKGROUND AND PURPOSE

The phenomenon of dementia amongst migrants and ethnic minorities represents an emerging concern for European healthcare systems, posing additional challenges in terms of clinical approach, access to care and resource utilization. The aim of the present study was to estimate the cases of dementia amongst immigrant older subjects living in Europe and in each European country.

METHODS

The estimated cases of dementia amongst older (i.e. 65+) migrants living in the European Union (EU-28) and European Free Trade Association member states were calculated by multiplying the number of migrants (obtained through the data provided by Eurostat) with the age- and sex-specific prevalence rates (derived by a recent meta-analysis).

RESULTS

Overall, 6 507 360 older migrants lived in Europe in 2017. In addition, 1 204 671 migrants were registered in Germany in 2010. Nearly 475 000 dementia cases (329 028 women, 147 410 men) were estimated in this population by applying age- and sex-specific prevalence rates. When considering each European country, the number of estimated cases ranged from 108 (Iceland) to 119 161 (France). In parallel, the proportion of dementia cases occurring in migrants ranged from 0.9% (Czech Republic) to 51.2% (Liechtenstein).

CONCLUSIONS

The issue of dementia in migrants and ethnic minorities is emerging but already relevant for European healthcare systems. The magnitude of this phenomenon and its complexities reinforce the need for coordinated initiatives both at a national and continental level. These epidemiological data should ideally be integrated with those coming from 'real world' services in order to better calibrate these actions.

Exploring cocoa properties: is theobromine a cognitive modulator?

Nutritional qualities of cocoa have been acknowledged by several authors; a particular focus has been placed on its high content of flavanols, known for their excellent antioxidant properties and subsequent protective effect on cardio- and cerebrovascular systems as well as for neuromodulatory and neuroprotective actions. Other active components of cocoa are methylxanthines (caffeine and theobromine). Whereas the effects of caffeine are extensively researched, the same is not the case for theobromine; this review summarizes evidence on the effect of theobromine on cognitive functions. Considering animal studies, it can be asserted that acute exposition to theobromine has a reduced and delayed nootropic effect with respect to caffeine, whereas both animal and human studies suggested a potential neuroprotective action of long-term assumption of theobromine through a reduction of Aβ amyloid pathology, which is commonly observed in Alzheimer's disease patients' brains. Hence, the conceivable action of theobromine alone and associated with caffeine or other cocoa constituents on cognitive modulation is yet underexplored and future studies are needed to shed light on this promising molecule.

Diagnostic biomarkers for Parkinson's disease at a glance: where are we?

Parkinson's disease (PD) is a neurodegenerative disorder whose aetiology remains unclear: degeneration involves several neurotransmission systems, resulting in a heterogeneous disease characterized by motor and non-motor symptoms. PD causes progressive disability that responds only to symptomatic therapies. Future advances include neuroprotective strategies for use in at-risk populations before the clinical onset of disease, hence the continuing need to identify reliable biomarkers that can facilitate the clinical diagnosis of PD. In this evaluative review, we summarize information on potential diagnostic biomarkers for use in the clinical and preclinical stages of PD.

Resolution of unilateral upper limb action tremor after surgical treatment of a contralateral frontoparietal arachnoid cyst

PURPOSE

Arachnoid cysts (ACs) are cerebrospinal fluid-filled sacs. Although ACs are a frequent finding on neuroimaging, most remain asymptomatic during lifetime.

CASE REPORT

We report a very rare case of a 62-year-old female patient presenting with a tremor due to a giant arachnoid cyst, which completely resolved after cyst-peritoneal shunting.

Living Alone and Dementia Incidence: A Clinical-Based Study in People With Mild Cognitive Impairment

INTRODUCTION

Social isolation and living alone have been associated with negative outcomes, especially in the older population. We aim to investigate the effect of living alone on the development of dementia in people with mild cognitive impairment (MCI).

MATERIALS AND METHODS

In this longitudinal study, we enrolled 345 outpatients with MCI evaluated at baseline through a clinical and neuropsychological protocol. Data on living situation (living alone vs. living with someone) were also collected. The development of dementia at follow-up was the outcome of the study. Hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated using Cox regression analyses. Laplace regression was used to model the time-to-dementia diagnosis as a function of living situation.

RESULTS

During the follow-up time (mean [SD]: 2.8 [2.2] years), 172 (50%) participants developed dementia. After controlling for age, sex, years of education, MCI subtype, presence of comorbidities, and antidepressant therapy, people with MCI living alone were more likely to develop dementia (HR: 1.5; 95% CI: 1.1-2.1), when compared to those living with someone. In addition, participants with MCI living alone were diagnosed with dementia 1 year earlier than those living with someone ( P = .012).

CONCLUSION

Living alone increases by 50% the risk of developing dementia and anticipates by 1 year the diagnosis in people with MCI. These results, in line with findings of previous population-based studies, emphasize the pivotal role of the living situation in identifying a frailer share of the population at higher risk of dementia to which devote ad hoc assessment and care.

Intercepting Parkinson disease non-motor subtypes: A proof-of-principle study in a clinical setting

The construct of non-motor symptoms (NMS) subtyping in Parkinson Disease (PD) is emerging as a line of research in the light of its potential role in etiopathological interpretation of PD heterogeneity. Different approaches of NMS subtyping have been proposed: an anatomical model suggests that NMS aggregate according to the underpinning pathology; other researchers find aggregation of NMS according to the motor phenotype; the contribution of genetic background to NMS has also been assessed, primarily focusing on cognitive impairment. We have analyzed NMS burden assessed through an extensive clinical and neuropsychological battery in 137 consecutive non-demented PD patients genotyped for MAPT haplotypes (H1/H1 vs H2 carriers) in order to explore the applicability of the "anatomo-clinical", "motor" or "genetic" models for subtyping PD in a clinical setting; a subsequent independent analysis was conducted to verify a possible cluster distribution of NMS. No clear-cut NMS profiles according to the previously described models emerged: in our population, the autonomic dysfunctions and depressive symptoms represent the leading determinant of NMS clusters, which seems to better fit with the hypothesis of a "neurotransmitter-based" model. Selective preferential neurotransmitter network dysfunctions may account for heterogeneity of PD and could address translational research.

Self-Awareness for Memory Impairment in Amnestic Mild Cognitive Impairment: A Longitudinal Study

AIM

To assess memory impairment insight as a predictor of dementia and Alzheimer's disease (AD) in amnestic mild cognitive impairment (MCI).

METHODS

To verify whether the awareness of memory impairment assessed by Geriatric Depression Scale (GDS) was associated with the risk of progression to dementia and AD in a cohort of MCI, we used a Cox regression model adjusted for age, sex, education, subtypes of amnestic MCI, Mini-Mental State Examination, Cumulative Illness Rating Scale severity index, and apolipoprotein E genotype.

RESULTS

During a follow-up of 27.7 (20.8) months, 205 (63.3%) of 324 patients with amnestic MCI progressed to dementia, including 141 to AD. No association was found in the unadjusted, partially adjusted (for sociodemographic variables), and fully adjusted multivariate Cox analysis between the awareness of memory impairment and the progression to dementia and AD.

DISCUSSION

Awareness or anosognosia of memory deficits, identified by GDS, is not useful to predict progression to dementia of patients with amnestic MCI.

Body Mass Index Predicts Progression of Mild Cognitive Impairment to Dementia

AIMS

To examine the relationship between body mass index (BMI) and progression to dementia and Alzheimer's disease (AD) in mild cognitive impairment (MCI).

MATERIALS AND METHODS

Two hundred and twenty-eight MCI subjects (mean age 74.04 ± 6.94 years; 57% female) from a memory clinic were followed for 2.40 ± 1.58 years. Baseline height and weight were used to calculate the BMI. The main outcome was progression to dementia (DSM-IV criteria) and AD (NINCDS-ADRDA criteria). Cox proportional hazard models were used to assess the longitudinal association of BMI with dementia and AD, adjusting for a comprehensive set of covariates, including vascular risk factors/diseases and neuroimaging profiles.

RESULTS

Out of 228 subjects with MCI, 117 (51.3%) progressed to dementia. Eighty-nine (76%) of the incident dementia cases had AD. In both unadjusted and multi-adjusted models, a higher BMI was associated with a reduced risk of dementia (multi-adjusted HR 0.9; 95% CI 0.8-0.9) and AD (multi-adjusted HR 0.9; 95% CI 0.8-0.9). Being underweight increased the risk of all types of dementia (multi-adjusted HR 2.5; 95% CI 1.2-5.1) but was not specifically associated with AD (multi-adjusted HR 2.2; 95% CI 0.9-5.3).

CONCLUSIONS

BMI predicted progression of MCI to dementia and AD. In particular, a higher BMI was associated with a lower risk of dementia and AD, and underweight was associated with a higher risk of dementia. BMI assessment may improve the prognostic accuracy of MCI in clinical practice.

Mild brain injury and anticoagulants: Less is enough

BACKGROUND

Despite the higher theoretical risk of traumatic intracranial hemorrhage (ICH) in anticoagulated patients with mild head injury, the value of sequential head CT scans to identify bleeding remains controversial. This study evaluated the utility of 2 sequential CT scans at a 48-hour interval (CT1 and CT2) in patients with mild head trauma (Glasgow Coma Scale 13-15) taking oral anticoagulants.

METHODS

We retrospectively evaluated the clinical records of all patients on chronic anticoagulation treatment admitted to the emergency department for mild head injury.

RESULTS

A total of 344 patients were included, and 337 (97.9%) had a negative CT1. CT2 was performed on 284 of the 337 patients with a negative CT1 and was positive in 4 patients (1.4%), but none of the patients developed concomitant neurologic worsening or required neurosurgery.

CONCLUSIONS

Systematic routine use of a second CT scan in mild head trauma in patients taking anticoagulants is expensive and clinically unnecessary.

Treatment of Nonmotor Symptoms in Parkinson's Disease

Nonmotor symptoms (NMS) are integral to Parkinson's disease (PD) and the management can often be challenging. In spite of the growing evidence that NMS have a key impact on the quality of life of patients and caregivers, most clinical trials still focus on motor symptoms as primary outcomes. As a consequence strong evidence-based treatment recommendations for NMS occurring in PD are spare. In this chapter, the current data addressing the treatment of major NMS such as sleep, cognitive and autonomic dysfunction, and depression and anxiety are described.

Nutritional status and body composition by bioelectrical impedance vector analysis: A cross sectional study in mild cognitive impairment and Alzheimer's disease

AIMS

Analysis of nutritional status and body composition in Alzheimer's disease (AD) and Mild Cognitive Impairment (MCI).

METHODS

A cross-sectional study was performed in a University-Hospital setting, recruiting 59 patients with AD, 34 subjects with MCI and 58 elderly healthy controls (HC). Nutritional status was assessed by anthropometric parameters (body mass index; calf, upper arm and waist circumferences), Mini Nutritional Assessment (MNA) and body composition by bioelectrical impedance vector analysis (BIVA). Variables were analyzed by analysis of variance and subjects were grouped by cognitive status and gender.

RESULTS

Sociodemographic variables did not differ among the three groups (AD, MCI and HC), except for females' age, which was therefore used as covariate in a general linear multivariate model. MNA score was significantly lower in AD patients than in HC; MCI subjects achieved intermediate scores. AD patients (both sexes) had significantly (p<0.05) higher height-normalized impedance values and lower phase angles (body cell mass) compared with HC; a higher ratio of impedance to height was found in men with MCI with respect to HC. With BIVA method, MCI subjects showed a significant displacement on the RXc graph on the right side indicating lower soft tissues (Hotelling's T2 test: men = 10.6; women = 7.9;p < 0,05) just like AD patients (Hotelling's T2 test: men = 18.2; women = 16.9; p<0,001).

CONCLUSION

Bioelectrical parameters significantly differ from MCI and AD to HC; MCI showed an intermediate pattern between AD and HC. Longitudinal studies are required to investigate if BIVA could reflect early AD-changes in body composition in subjects with MCI.

Adaptation and psychometric properties of the Italian version of the Non-Motor Symptoms Questionnaire for Parkinson's disease

Although non-motor symptoms (NMS) of Parkinson's disease (PD) are very common also in early stages of the disease, they are still under-recognized. Screening tools for non-motor symptoms, such as non-motor symptoms questionnaire (NMSQuest), help clinicians to recognize NMS and to evaluate if patients could require further assessment or specific treatments. To validate an adapted Italian version of NMSQuest and study its psychometric properties, Italian PD patients self-completed Italian NMSQuest, and then underwent a standard clinical evaluation including motor assessment (by Hoehn and Yahr staging, unified Parkinson's disease rating scale part III) and non-motor assessment (by Montreal cognitive assessment, Beck depression inventory, neuropsychiatric inventory, Epworth sleepiness scale, scale for outcomes in Parkinson's disease-Autonomic and movement disorder society-sponsored revision of the unified Parkinson's disease rating scale part I). Somatic comorbidities were quantified using the modified cumulative illness rating scale (CIRS). Seventy-one subjects were assessed (mean age years 69.8 ± 9.6 SD; 31% women; mean duration of disease 6.3 ± 4.6 years; H&Y median 2). Italian NMSQuest showed adequate satisfactory clinimetrics in terms of data quality, precision, acceptability, internal consistency and reliability. A significant correlation was found between NMSQuest and most of non-motor assessment scales, while no significant correlation appeared with motor severity as well as with age of patients, disease duration, levodopa equivalent daily dose, L-DOPA/dopamine agonists assumption and CIRS total score. The Italian version of the NMSQuest resulted as a reliable instrument for screening NMS in Italian PD patients.

Weight Loss Predicts Progression of Mild Cognitive Impairment to Alzheimer's Disease

Background

Weight loss is common in people with Alzheimer’s disease (AD) and it could be a marker of impending AD in Mild Cognitive Impairment (MCI) and improve prognostic accuracy, if accelerated progression to AD would be shown.

Aims

To assess weight loss as a predictor of dementia and AD in MCI.

Methods

One hundred twenty-five subjects with MCI (age 73.8 ± 7.1 years) were followed for an average of 4 years. Two weight measurements were carried out at a minimum time interval of one year. Dementia was defined according to DSM-IV criteria and AD according to NINCDS-ADRDA criteria. Weight loss was defined as a ≥4% decrease in baseline weight.

Results

Fifty-three (42.4%) MCI progressed to dementia, which was of the AD-type in half of the cases. Weight loss was associated with a 3.4-fold increased risk of dementia (95% CI = 1.5–6.9) and a 3.2-fold increased risk of AD (95% CI = 1.4–8.3). In terms of years lived without disease, weight loss was associated to a 2.3 and 2.5 years earlier onset of dementia and AD.

Conclusions

Accelerated progression towards dementia and AD is expected when weight loss is observed in MCI patients. Weight should be closely monitored in elderly with mild cognitive impairment.

A review of current treatment strategies for restless legs syndrome (Willis-Ekbom disease)

Restless legs syndrome (RLS), recently renamed Willis-Ekbom disease (WED), is a common movement disorder. It is characterised by the need to move mainly the legs due to uncomfortable, sometimes painful sensations in the legs, which have a diurnal variation and a release with movement. Management is complex. First, centres should establish the severity of RLS using a simple 10-item RLS severity rating scale (IRLS). They should also exclude secondary causes, in particular ensuring normal iron levels. Mild cases can be managed by lifestyle changes, but patients with a IRLS score above 15 usually require pharmacological treatment. Dopaminergic therapies remain the mainstay of medical therapies, with recent evidence suggesting opioids may be particularly effective. This article focuses on the different treatment strategies in RLS, their associated complications and ways to manage them.

Does vascular burden contribute to the progression of mild cognitive impairment to dementia?

AIMS

To investigate the contribution of vascular risk factors (VRFs), vascular diseases (VDs) and white matter lesions (WMLs) to the progression of mild cognitive impairment (MCI) to dementia and Alzheimer's disease (AD).

METHODS

Two hundred forty-five consecutive subjects with MCI (age 74.09 ± 6.92 years) were followed for an average of 2.4 years. The Hachinski Ischemic Score and the Framingham Stroke Risk Profile were used to summarize VRFs and VDs. WMLs were graded using the Age-Related White Matter Changes Scale.

RESULTS

One hundred twenty-nine (52.6%) out of 245 subjects at risk converted to dementia, including 87 cases of AD. When hypertension occurred in MCI with deep WMLs, a 1.8-fold increased risk of dementia was observed (95% CI = 1.0-3.4). When deep WMLs occurred in MCI with high scores (≥4) on the Hachinski scale, a 3.5-fold (95% CI = 1.6-7.4) and 3.8-fold (95% CI = 1.2-11.5) risk of progression to dementia and AD was observed, respectively. Analogously, the joint effect of WMLs and high scores (≥14) on the Framingham scale nearly doubled the risk of dementia (hazard ratio = 1.9, 95% CI = 1.1-3.3).

CONCLUSIONS

Accelerated progression of MCI to dementia and AD is to be expected when VRFs and VDs occur together with WMLs.