Risk factors for reduced survival after traumatic brain injury: a 30-year follow-up study

PRIMARY OBJECTIVE

To evaluate risk factors for reduced survival in subjects with traumatic brain injury (TBI).

PARTICIPANTS AND METHODS

A retrospective follow-up of three decades included 192 subjects with TBI. Cognitive testing was carried out on average 2 years after the injury (at mean age of 39.0 years), during the years 1966-1972. Cox's regression and logistic regression analyses were used and the survival of the subjects was compared with the general population using the standardized mortality ratio (SMR).

RESULTS

Reduced survival was significantly associated with age at injury (p < 0.001) and vocational outcome (p = 0.003). Vocational outcome in turn was associated with age (p = 0.010), TBI severity (p < 0.001), cognitive impairment (p = 0.010), later TBIs (p = 0.007) and alcohol abuse (p = 0.015). Mortality in the younger patient group (age at death <40 years) was higher than in the general population (SMR 4.50, 95% CI = 2.02-10.01).

CONCLUSIONS

A reduced working ability, influenced by age-, injury- and lifestyle-related factors, is associated with long-term survival after TBI. The mortality among younger patients is high, a finding which should be considered when planning the care after TBI.

Estrogen + progestin therapy and cognition: a randomized placebo-controlled double-blind study

AIMS

The use of hormone therapy (HT) is a relevant and topical issue in the treatment of menopausal symptoms in women. Information regarding the effects of combination treatment with estrogen and progesterone as well as treatment timing on cognitive function is lacking and was evaluated in healthy pre- and postmenopausal women.

METHODS

Sixteen premenopausal (45-51 years) and 16 postmenopausal (58-70 years) women were randomly assigned to receive either estrogen + progestin therapy (HT) or placebo (PL) for six months. The study was double-blind. Cognitive performance was measured at baseline and follow up with tests of verbal and visuomotor functions, verbal and visual memory, and attention.

RESULTS

In premenopausal women, cognitive attention, when compared to baseline, improved with HT but declined slightly with PL in the two-choice reaction time task (P = 0.049), while PL was associated with better performance in tests of shared attention (P = 0.024) and auditory attention (P < 0.05). In postmenopausal women, HT was associated with improved performance in verbal episodic memory (P = 0.024) and a minor decline in auditory attention (P = 0.025).

CONCLUSIONS

HT, with estradiol valerate and norethisterone, in healthy women showed only minor effects on attention around the menopausal transition and on memory in postmenopause.

Attention and depressive symptoms in chronic phase after traumatic brain injury

OBJECTIVE

To study whether attention deficits differ between TBI (traumatic brain injury) patients with and without depressive symptoms.

METHOD

The study group (n = 61, mean age = 59 years) consisted of symptomatic TBI patients injured on average 30 years earlier. They were studied with a broad range of attention tasks including computerized methods. The patients were divided into those with depressive symptoms (n = 32) and those without (n = 29), according to the short form of the Beck depression scale with a cut-off score of 5. In addition, a diagnosis of major depression was applied according to the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) (n = 6). The groups with depression or depressive symptoms were compared with the non-depressed TBI patients and with an age- and education-matched healthy control group (n = 31).

RESULTS

Cognitive methods that require flexibility (Trail making B, Card sorting, Word fluency) and working memory (Subtraction test) were sensitive to discriminate TBI patients without depressive symptoms from the control subjects (p < 0.001). Only a few methods were able to discriminate the TBI patients with depressive symptoms from those without (p < 0.001 for Simple reaction time, p < 0.003 for Vigilance test). The depressed TBI patients (assessed by SCAN) did not differ from the non-depressed TBI patients in attention functions.

CONCLUSIONS

The results suggest that problems in complex attention processing are more specific to TBI, while slowness in simple psychomotor speed and impaired sustained attention may be mostly related to depressive symptoms in patients with chronic TBI sequelae.

Cognitive functions in relation to MRI findings 30 years after traumatic brain injury

OBJECTIVE

The aim of the study was to relate cognitive effects of a remote traumatic brain injury (TBI) to MRI findings and severity of injury.

METHOD

Sixty-one patients were assessed on average 30 years after a TBI of variable severity. A comprehensive cognitive test battery was used to evaluate memory, executive functions and cognitive overall impairment. Multiple regression analyses were used to examine the relationships between cognitive variables and MRI volumetric findings (the volumes of the hippocampus and the lateral ventricles) and local contusions on MRI. Also, the effect of injury severity on cognitive outcome was evaluated.

RESULTS

Reductions in hippocampal volumes and lateral ventricular enlargement were significantly associated with impaired memory functions, memory complaints and executive functions. Of the MRI parameters used, the best predictor for cognitive outcome was the volume of the lateral ventricle. There was only a modest relationship between severity of injury and cognitive performance.

CONCLUSIONS

The results show that long-term memory impairments after TBI are associated with MRI volumetric measures. This suggests that the degree of diffuse injury leading to atrophic changes is prognostically more important than the initial severity of TBI.

Does hormone therapy affect attention and memory in sleep-deprived women?

OBJECTIVES

To evaluate whether hormone therapy (HT) modifies cognitive performance during sleep deprivation in postmenopausal women. Comparison was made with a group of young women.

METHODS

Participants included 26 postmenopausal women (age 58-72 years, 16 HT users, 10 non-users), 11 young women (age 20-26 years). They spent four consecutive nights in the sleep laboratory. Cognitive tests of attention, working memory, and verbal episodic memory were carried out after the baseline night, 25-h sleep deprivation, and recovery night.

RESULTS

Sleep deprivation impaired performance in all groups. It was manifested either as delayed practice effect or deteriorated performance (p < 0.05). In simple reaction time and 10-choice reaction time, non-users and young maintained their performance, whereas HT users suffered a minor impairment (p < 0.01). In other measurements, there was no interaction of group and condition. In 10-choice reaction time and vigilance, postmenopausal women made fewer errors and omissions than the young (p < 0.05). For most tasks, all groups showed improvement after one recovery night.

CONCLUSIONS

HT had a minor adverse effect on cognitive performance during sleep deprivation. Attention and memory deteriorated similarly in postmenopausal and young women, despite the lower initial performance level of postmenopausal women. One night of sleep ensured recovery in most tasks.

Neurological symptoms and natural course of xeroderma pigmentosum

We have prospectively followed 16 Finnish xeroderma pigmentosum (XP) patients for up to 23 years. Seven patients were assigned by complementation analysis to the group XP-A, two patients to the XP-C group and one patient to the XP-G group. Six of the seven XP-A patients had the identical mutation (Arg228Ter) and the seventh patient had a different mutation (G283A). Further patients were assigned to complementation groups on the basis of their consanguinity to an XP patient with a known complementation group. The first sign of the disease in all the cases was severe sunburn with minimal sun exposure in early infancy. However, at the time the diagnosis was made in only two cases. The XP-A patients developed neurological and cognitive dysfunction in childhood. The neurological disease advanced in an orderly fashion through its successive stages, finally affecting the whole nervous system and leading to death before the age of 40 years. Dermatological and ocular damage of the XP-A patients tended to be limited. The two XP-C patients were neurologically and cognitively intact despite mild brain atrophy as seen by neuroimaging. The XP-G patients had sensorineural hearing loss, laryngeal dystonia and peripheral neuropathy. The XP-C patients had severe skin and ocular malignancies that first presented at pre-school age. They also showed immunosuppression in cell-mediated immunity. Neurological disease appears to be associated with the complementation group and the failure of fibroblasts to recover RNA synthesis following UV irradiation, but not necessarily to the severity of the dermatological symptoms, the hypersensitivity of fibroblasts to UVB killing or the susceptibility of keratinocytes to UVB-induced apoptosis.

Distress among Prostate Cancer Patients and Spouses is Associated with Hormone Treatment and Participation in Decision-Making

Background

The aim of this study was to chart cancer experience and distress shared between prostate cancer (PC) patients and their spouses, focusing on effects of hormone treatment and treatment decision-making.

Patients and methods

This observational prospective study involved 203 PC patients and 194 spouses surveyed within 5 years from being diagnosed with PC. Fifty percent of the patients had received hormone treatment.

Results

Younger (<65 years) patients and spouses were significantly more distressed than the older. Patients receiving hormone treatment tended to be more distressed than those not treated (sum of scores, 5.6 vs 4.3, p = 0.017), and the same trend was seen in their spouses (p = 0.08). The spouse experienced difficulties in concentration and decision-making (Chi-squared test, p = 0.012) and somatic symptoms (p = 0.049) more often if the patient suffered the same problems. Use of alcohol/drugs was significantly more common among younger (<65 years) spouses (27.8% vs 7.2%, p < 0.001) and in those with higher level of education (26.1% vs 12.2%, p = 0.015).

Conclusions

Significant associations were observed in distress variables between prostate cancer patients and spouses, especially among younger patients and when hormone treatment was used. Distress among patients was associated with participation in treatment-decision making, and among spouses with age and educational level.

Outcome of Traumatic Brain Injury after Three Decades— Relationship to ApoE Genotype

Significant traumatic brain injury (TBI) is nearly always associated with cognitive deficits, but in a highly variable manner. Apolipoprotein E (ApoE) plays a pivotal role in CNS response to injury. To examine the association of ApoE genotype with long-term outcome in TBI patients, we determined the ApoE genotype from 61 TBI patients who had been injured over three decades earlier. All patients had been studied neuropsychologically after their injuries. The long-term outcome was evaluated with repeated neuropsychological testing and by applying various measures of everyday functioning and quality of life. After three decades, TBI patients with the ApoE epsilon4 allele showed significantly poorer general cognitive level than those without this allele. This decline was wholly accounted for by a subgroup of these patients who had developed incident or clinical dementia, while the majority of the ApoE epsilon4 positive patients showed no decline at all. The other outcome measures describing vocational, physical, or subjective symptom outcome did not show significant relationships to the ApoE genotype. A portion of the TBI patients with the ApoE epsilon4 allele seem to be at risk of long-term cognitive decline.

Hippocampal volume, brain atrophy, and APOE genotype after traumatic brain injury

OBJECTIVE

To examine the association between hippocampal volumes, general brain atrophy, and apolipoprotein E (APOE) polymorphism in patients with a remote traumatic brain injury (TBI).

METHODS

MRI-based volumetric analyses of the hippocampus and lateral ventricles were performed in 58 patients with TBI of varying severity on average 31.3 years after the trauma. The APOE genotype was determined using standard methods and correlated with the MRI volumetric measurements.

RESULTS

Hippocampal or lateral ventricle volumes did not differ significantly in those patients with the APOE-epsilon4 allele (APOE4) vs those without this allele.

CONCLUSIONS

The APOE-epsilon4 allele was not associated with the development of hippocampal or ventricular atrophy after traumatic brain injury. If the APOE-epsilon4 allele is associated with an unfavorable outcome after traumatic brain injury as proposed, this association may involve mechanisms other than those responsible for the development of brain atrophy.

Estrogen therapy and cognition: a 6-year single-blind follow-up study in postmenopausal women

The authors evaluated the effect of long-term hormone therapy (HT) on cognition in 60 postmenopausal women (aged 53 to 72 years) in a single-blind, 6-year follow-up study. The subjects were divided into three groups: non-HT users, continuous HT users, and irregular HT users. Measures of verbal and visuomotor skills, verbal and visual memory, and attention were used. All women had well-maintained cognitive performance. Long-term HT did not affect cognition, either for better or for worse.

Hormone treatment gives no benefit against cognitive changes caused by acute sleep deprivation in postmenopausal women

The objective was to evaluate whether hormone therapy (HT) gives any benefit against the possible impairment of cognitive performance when challenged by acute sleep deprivation. Twenty postmenopausal women volunteered (age range 59-72 years, mean=64.4 years, SD=4.4): 10 HT users and 10 nonusers. Eleven young women served as a control group for the cognitive age effect (age range 20-26 years, mean age 23.1 years, SD=1.6). The subjects spent four consecutive nights at the sleep laboratory and were exposed to acute sleep deprivation of 40 h. Measures of attention (reaction speed and vigilance), alertness, and mood were administered every 2 h during the daytime and every hour during the sleep deprivation night. Postmenopausal women performed slower than young controls, whereas young controls made more errors. In HT users, the recovery night did not fully restore the performance in the simple and two-choice reaction time tasks, but in nonusers it did so. Sleep deprivation had a detrimental, yet reversible effect on vigilance in all groups. In all groups, sleepiness started to increase after 15 h of sleep deprivation and remained elevated in the morning after the recovery night. Prolonged wakefulness or HT had no effect on mood. In conclusion, sleep deprivation impaired cognitive performance in postmenopausal as well as young women. Postmenopausal women kept up their performance at the expense of reaction speed and young women at the expense of accuracy. One night was not enough for HT users to recover from sleep deprivation. Thus, HT gave no benefit in maintaining the attention and alertness during sleep deprivation.

MRI findings and Axis I and II psychiatric disorders after traumatic brain injury: a 30-year retrospective follow-up study

We studied the association between psychiatric disorders and the presence and location of traumatic lesions on magnetic resonance imaging (MRI) in 58 patients, on average, 30 years after traumatic brain injury. Axis I psychiatric disorders that had begun after the injury were assessed with the Schedules for Clinical Assessment in Neuropsychiatry (version 2.1), and Axis II disorders with the Structured Clinical Interview for DSM-III-R Personality Disorders. A 1.5-Tesla MRI scanner was used. One-third of the subjects had traumatic lesions visible on MRI. Only three psychiatric disorders, that is, delusional disorder, dementia, and the disinhibited type of organic personality syndrome, were significantly more common in subjects with contusions. Concerning the location of contusions, organic personality syndrome and its disinhibited subtype were associated with frontal lesions, and major depression was, surprisingly, inversely associated with temporal lesions. These results, which should be interpreted with caution due to the limited size of the study group, suggest that the majority of psychiatric disorders after traumatic brain injury are not closely related to the specific location or even the presence of contusions detectable with post-acute MRI.

Longitudinal cognitive changes in traumatic brain injury: a 30-year follow-up study

OBJECTIVE

To evaluate longitudinal cognitive changes in patients over three decades following traumatic brain injury (TBI).

METHOD

Two hundred ten patients with substantial TBI of variable severity were initially assessed between 1966 and 1972 at Turku University Hospital (Finland). Of these, 61 patients could be studied using the same assessments in the follow-up examination, on average 30 years after the TBI. The results of the follow-up assessment were also compared with an age- and education-matched control group. During each examination, patients were assessed with five subtests of the Wechsler Adult Intelligence Scale, three tests for episodic memory, and the general cognitive decline was determined.

RESULTS

The general pattern of slight cognitive decline during a 30-year follow-up contrasted with improvement in semantic memory. Women maintained their cognitive level, but men showed a decline during the follow-up, especially in visuospatial ability and visual memory. Younger patients were likely to maintain or even improve their cognitive functioning.

CONCLUSIONS

Most of the patients had mild cognitive decline during the follow-up, but this decline was influenced by gender and age at injury. Unlike the long-term course in the other domains of cognition, semantic memory showed good recovery potential after traumatic brain injury (TBI). The profile of long-term cognitive decline after TBI seems to be qualitatively different from the early signs of dementia of the Alzheimer type.

Alexithymia after traumatic brain injury: its relation to magnetic resonance imaging findings and psychiatric disorders

OBJECTIVE

People with traumatic brain injury (TBI) were studied to assess the prevalence of alexithymia and its relationship to magnetic resonance imaging (MRI) findings and psychiatric disorders.

METHODS

Fifty-four participants, 67% men, were evaluated after a median of 30 years since TBI. A control group was matched for age, gender, and severity of depression. Alexithymia was measured with the 20-item Toronto Alexithymia Scale (TAS-20). In patients with TBI, axis I psychiatric disorders were assessed with the Schedules for Clinical Assessment in Neuropsychiatry (SCAN, version 2.1), and axis II disorders with the Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). MRI examinations were carried out with a 1.5 T MRI scanner.

RESULTS

Alexithymia was significantly more common in patients with TBI than in controls (31.5% versus 14.8%; odds ratio 2.64, 95% confidence interval 1.03-6.80). None of the variables representing TBI, ie, severity of TBI or the presence, laterality, or location of contusions on MRI, was associated with the TAS-20 total scores. Several current axis I and II psychiatric disorders, particularly organic personality syndrome, were connected to higher TAS-20 scores.

CONCLUSION

Alexithymia is common, along with psychiatric disorders, in patients with TBI. Both of them may reflect dysfunction of the injured brain. In clinical practice, alexithymic features should be taken into consideration in psychosocial rehabilitation after TBI.

Sleep deprivation, cognitive performance, and hormone therapy in postmenopausal women

OBJECTIVE

To study the effects of sleep deprivation on cognitive performance in postmenopausal women and to evaluate whether hormone therapy (HT) has a modifying effect on coping.

DESIGN

Twenty-six postmenopausal women, aged 58 to 72 years (mean 64 years), volunteered for the study (HT users, n = 16; nonusers, n = 10). They spent four consecutive nights in the sleep laboratory. The cognitive tests were performed three times: after the baseline night, after one night of sleep deprivation, and after the rebound night. The cognitive measures included visual episodic memory, visuomotor performance, verbal attention, and shared attention.

RESULTS

The practice effect typically occurring in cognitive tests was blunted during sleep deprivation, which indicated deterioration of performance. At rebound, performance improved in visual episodic memory (immediate recall P < 0.01; delayed recall P < 0.05), visuomotor performance (P < 0.001), verbal attention (P < 0.0001), and shared attention (P < 0.05). HT users performed better than nonusers in the visual episodic memory test (P < 0.05) and in one of three subtests of shared attention (cancellation P = 0.040). Otherwise hormone therapy did not influence the results.

CONCLUSIONS

In postmenopausal women, sleep deprivation impaired visual functions and attention. However, this effect was not prolonged because after one rebound night the performance was improved, compared with baseline. Hormone therapy did not modify the cognitive performance during sleep deprivation.

APOE- 4 predicts dementia but not other psychiatric disorders after traumatic brain injury

The authors studied the association between APOE-epsilon4 genotype and axis I and II psychiatric disorders an average of 30 years after traumatic brain injury. Sixty patients were dichotomized into subjects with and without APOE-epsilon4 allele. Dementia and subclinical dementia were significantly more common with the presence of APOE-epsilon4. The occurrence of other psychiatric disorders did not differ between patients with and without APOE-epsilon4 allele.

Visual object recognition deficits in early Parkinson's disease

The nature of the visual perception deficits in Parkinson's disease (PD) has remained unclear. The present study explored whether there emerge deficits in the different stages of visual object recognition in early PD. Twenty-eight patients and 14 healthy controls were studied. A set of reaction time tasks were applied to measure the different stages of object recognition. The results indicate some selective problems in both basic perceptual and semantic visual processing at an early stage of cognitive deterioration in PD.

Androgen deprivation and cognition in prostate cancer

Androgen deprivation (AD) is commonly used in neoadjuvant and adjuvant setting with prostate cancer (PC) radiotherapy. This prospective study assessed whether cognitive functioning is impaired during 12 months of AD therapy. Longitudinal testing of 25 patients treated with AD and curative radiotherapy was undertaken at baseline, and at 6 and 12 months. CogniSpeed software was used for measuring attentional performances. Other cognitive performances were evaluated using verbal, visuomotor and memory tests. The Beck depression inventory was employed to evaluate depressive mood and EORTC QLQ-C30 for quality of life (QoL). During longitudinal testing of the AD group, no impairment in cognitive performances was found. Instead, improvement was observed in object recall (immediate, P=0.035; delayed, P<0.001), and in semantic memory (P=0.037). In QoL, impairment in physical function was observed. Androgen deprivation of 12 months appears to be associated with preserved cognitive functioning, although physical impairment occurs. These results have implications for counseling and psychosocial support of patients in the context of treatment options in PC.

Visual object recognition in early Alzheimer's disease: deficits in semantic processing

OBJECTIVES

The purpose of the present study was to divide visual object recognition into different stages and to reveal which of these stages are impaired in early Alzheimer's disease (AD).

METHODS

Performance in object detection, familiarity detection, semantic name and word categorization, and identification with naming were studied by using two-choice reaction-time tasks. Ten patients with newly diagnosed AD and 14 healthy subjects were studied.

RESULTS

Patients with early AD had impairments in several stages of the object recognition process. After controlling for the basic visuomotor slowness, they were as fast and as accurate as the controls in object detection, but had difficulties in all stages that required semantic processing.

CONCLUSIONS

Semantic memory impairments contribute to the deficits in visual object recognition in early AD. Thus, the semantic memory deficit may be manifested in several ways in the difficulties that AD patients experience in everyday life.

Cognitive functioning in severe somatization--a pilot study

OBJECTIVE

Somatizing patients often report cognitive complaints but neuropsychological research on somatization is scarce. We investigated somatizing patients for functioning in different cognitive domains.

METHOD

Ten female patients with somatization disorder or undifferentiated somatoform disorder and 10 non-somatizing controls participated in neuropsychological examinations.

RESULTS

The patients performed at a lower level than the controls in tests involving semantic memory, verbal episodic memory and visuo-spatial tasks, and were slower in attentional tasks.

CONCLUSION

Somatization patients may suffer from substantial problems in cognitive performance.

Axis I and II psychiatric disorders after traumatic brain injury: a 30-year follow-up study

OBJECTIVE

Patients who had suffered traumatic brain injury were evaluated to determine the occurrence of psychiatric disorders during a 30-year follow-up.

METHOD

Sixty patients were assessed on average 30 years after traumatic brain injury. DSM-IV axis I disorders were diagnosed on a clinical basis with the aid of the Schedules for Clinical Assessment in Neuropsychiatry (version 2.1), and axis II disorders were diagnosed with the Structured Clinical Interview for DSM-III-R Personality Disorders. Cognitive impairment was measured with a neuropsychological test battery and the Mini-Mental State Examination.

RESULTS

Of the 60 patients, 29 (48.3%) had had an axis I disorder that began after traumatic brain injury, and 37 (61.7%) had had an axis I disorder during their lifetimes. The most common novel disorders after traumatic brain injury were major depression (26.7%), alcohol abuse or dependence (11.7%), panic disorder (8.3%), specific phobia (8.3%), and psychotic disorders (6.7%). Fourteen patients (23.3%) had at least one personality disorder. The most prevalent individual disorders were avoidant (15.0%), paranoid (8.3%), and schizoid (6.7%) personality disorders. Nine patients (15.0%) had DSM-III-R organic personality syndrome.

CONCLUSIONS

The results suggest that traumatic brain injury may cause decades-lasting vulnerability to psychiatric illness in some individuals. Traumatic brain injury seems to make patients particularly susceptible to depressive episodes, delusional disorder, and personality disturbances. The high rate of psychiatric disorders found in this study emphasizes the importance of psychiatric follow-up after traumatic brain injury.

Positron emission tomography shows that impaired frontal lobe functioning in Parkinson's disease is related to dopaminergic hypofunction in the caudate nucleus

We examined the relation between the dopaminergic function and the cognitive performance of patients with Parkinson's disease (PD). The subject sample consisted of ten patients in the early course of PD and with no previous antiparkinsonian medication. The dopaminergic function of the caudate nucleus and the putamen was studied with [(18)F]fluorodopa positron emission tomography, and the cognitive performance with a comprehensive battery of neuropsychological tests including tests sensitive to frontal lobe function. The decreased [(18)F]fluorodopa uptake in the right caudate nucleus was found to be related to slow processing time, measured as the difference between the incongruent and the congruent subtests of the Stroop Test (r=-0.85, P=0.002), a similar trend was seen in the left caudate (r=-0.60, P=0.07). Similar correlation was not detected in the putamen. The present findings provide evidence that the decreased dopaminergic function in the right caudate nucleus is related to the impaired performance in tests sensitive to frontal lobe function in patients at an early stage of PD and with no antiparkinsonian medication.

Cognitive impairment and the 10-year survival probability of a normal 62-year-old population

The predictive value of cognitive impairment together with demographic and health factors on long-term survival was evaluated. The population sample comprised 389 subjects, all 62 years old. Cognitive performances were measured using verbal, visuomotor and memory tests. Cognitive impairment was determined by comparing performances with norms derived from healthy controls. Ten years after testing, the probability of survival was 89% for the cognitively preserved subjects, 80% for those with mild impairment, and 71% for those with moderate impairment (p = 0.009). Relative risk (RR) for shortened survival was 1.7 (95% CI 0.9-3.2) for the mildly, and 2.6 (95% CI 1.4-4.8) for the moderately impaired. Perceived health problems were, as expected, related to reduced survival (p < 0.001, RR 3.6, 95% CI 2.1-6.0), and there was an association between cognitive impairment and impaired perceived health (p = 0.040). Multivariate analyses with Cox's regression models showed that cognitive impairment, in particular, impaired episodic memory had an association with survival, in addition to the expected effects. Thus, memory impairment may reflect very early signs of underlying disease, and so the findings provide predictive validity for the cognitive methods used.

Impairment of semantic knowledge in Parkinson disease

BACKGROUND

Parkinson disease (PD) is commonly characterized by cognitive deterioration, but it is still unclear whether PD is associated with semantic impairments.

OBJECTIVE

To evaluate semantic knowledge of concepts in patients with idiopathic PD, addressing concrete and abstract concepts, conceptual attributes, and conceptual relations.

METHODS

Twelve patients with preserved cognitive status, 12 patients with mildly deteriorated cognitive status, and 12 control subjects were studied. The cognitive status of patients and controls was determined using detailed cognitive testing. Patients were participants in a university-based movement disorder program, and their PD diagnoses were clinically confirmed during long-term follow-up. The 2 patient groups were similar in age, level of education, disease duration, and parkinsonian disability. Patients were required to produce verbal descriptions of concrete and abstract concepts, to give ratings of the importance of concept attributes, and to assess and construct conceptual hierarchies. The description tasks included guiding questions, which were used if the spontaneous productions of the patients lacked any essentials expected in the answers.

RESULTS

Patients with mild cognitive deterioration performed less well than the other groups in defining concrete and abstract concepts (P<.001 for both). External guidance did not help them markedly improve their performance. They also had difficulties in tasks calling for knowledge of the importance of given attributes to the concepts and in tasks demanding evaluation of hierarchical semantic relations between concepts (P<.001 for both).

CONCLUSION

Semantic disruption is implied in idiopathic PD in association with incipient cognitive impairment.

Cognitive impairment and the brain dopaminergic system in Parkinson disease: [18F]fluorodopa positron emission tomographic study

OBJECTIVE

To investigate the role of the brain dopaminergic system in cognitive impairment in patients with Parkinson disease (PD).

DESIGN

We studied 28 patients with PD and 16 age-matched healthy control subjects using [18F] fluorodopa (fluorodopa F 18) positron emission tomography. Patients with PD showed a variable degree of cognitive impairment, which was assessed using the Mini-Mental State Examination and detailed neuropsychologic assessment, including tests sensitive for frontal lobe function.

RESULTS

[18F] Fluorodopa uptake was reduced in the putamen (to 36% of the control mean; P<.001), the caudate nucleus (to 61% of the control mean; P<.001), and the frontal cortex (to 45% of the control mean; P<.001) in patients with PD compared with controls. There was no significant association between the degree of overall cognitive impairment of patients and [18F] fluorodopa uptake values. The influx constant (Ki(occ)) in the caudate nucleus had a negative association with performance in the attention-demanding Stroop interference task, especially with the interference time. The Ki(occ) in the frontal cortex had a positive correlation with performance in the digit span (backwards), verbal fluency, and verbal immediate recall tests. Thus, the better the patient performed in tasks demanding immediate and working memory and executive strategies, the better the [18F] fluorodopa uptake in the frontal cortex. In the putamen, no significant correlation was seen between the Ki(occ) value and any of the cognitive tests. The severity of the motor symptoms of PD and [18F]fluorodopa uptake showed a negative correlation in the putamen (r = -0.38; P = .04), and in the caudate nucleus a similar trend was seen (r = -0.36; P = .06).

CONCLUSIONS

Reduced [18F]fluorodopa uptake in PD in the caudate nucleus (and frontal cortex) is related to impairment in neuropsychologic tests measuring verbal fluency, working memory, and attentional functioning reflecting frontal lobe function. This indicates that dysfunction of the dopamine system has an impact on the cognitive impairment of patients with PD. However, our results do not exclude the possibility of more generalized cognitive impairment in PD, the pathophysiology of which is probably different and more generalized.

Does P3 reflect attentional or memory performances, or cognition more generally?

The study evaluated the off-line relationship of attention, memory and other cognitive performances with the auditory event-related potentials P3 (P300) and N2. The sample comprised 200 middle-aged construction workers. Verbal, visuomotor and memory tests were administered. Attentional domains were examined using CogniSpeed software. Slowed reaction times in the test of sustained attention (vigilance) were associated with delayed P3 latency (p < 0.001) and decreased P3 amplitude (p = 0.005), as well as with delayed N2 latency (p < 0.001). Visuomotor slowing in Digit Symbol was also related to delayed P3 latency (p = 0.030) and decreased P3 amplitude (p = 0.014). In contrast, mild cognitive impairment, short- and long-term memory, and concentrating or sharing attention with high working memory demands were not related to P3. The results suggest that P3 is linked to attentional performance with low working memory demands rather than to effortful working memory updating, retrieval from memory stores, or mild cognitive impairment.

Serum estrogen level, attention, memory and other cognitive functions in middle-aged women

OBJECTIVE

To evaluate the relationship between serum estradiol level and cognitive processing efficiency and memory.

METHODS

Sixty-three healthy women aged 45-65 years were recruited through a newspaper announcement. The subjects were divided into two subgroups (low-estrogen group, n = 37 and high-estrogen group, n = 26) according to their serum follicle stimulating hormone (FSH) and estradiol levels. In the high-estrogen group, estrogen was either endogenous or supplied by estrogen replacement therapy. Automatic and controlled cognitive processing and attentional resources were measured using CogniSpeed software, together with conventional tests of cognitive performance: similarities, digit span, digit symbol, block design, object naming and recall, paired word associates (PWA) recall, Benton visual retention and paced auditory serial addition test (PASAT). The Beck depression inventory was also assessed.

RESULTS

Cognitive reaction speeds were similar in both groups. Women with low estrogen levels made more errors in the vigilance test (sustained attention, p = 0.040). There were no differences in short-term or long-term memory, or verbal, visual or working memory between the study groups. Older women were slower in the ten-choice reaction time (10-CRT) test (r = 0.25, p = 0.047) and made more errors in the test of suppressing attention (Stroop incongruence test; r = 0.34, p = 0.007) and in the sustaining attention test (vigilance test; r = 0.47, p < 0.001). Depression scores did not correlate with cognitive variables.

CONCLUSIONS

Cognitive performance was well preserved in healthy middle-aged women. Cognitive speed, accuracy, attentional resources and memory did not show impairment with decline of serum estrogen level in this age group.

Sematic memory deficit in multiple sclerosis; impaired understanding of conceptual meanings

The aim of the present study was to determine whether a cognitive decline, related to multiple sclerosis (MS), also involves deficits in semantic memory. Semantic memory function was evaluated by studying the conscious understanding of conceptual meanings. A group of MS patients with cognitive decline was presented with four tasks concerning concepts, their attributes and relationships to other concepts. The tasks were designed to measure spontaneous, cued and recognition performance separately. The patients had difficulties in understanding conceptual meanings. Easing the retrieval demands of the tasks did not help them to improve their performance which was poorer than the control group's on every task used. The results indicate a retrieval deficit combined with an underlying storage deficit in the semantic memory of MS patients with cognitive decline.

Semantic processing of spoken words in Alzheimer's disease: an electrophysiological study

Patients suffering from Alzheimer's disease (AD) have severe difficulties in tasks requiring the use of semantic knowledge. The semantic deficits associated with AD have been extensively studied by using behavioral methods. Many of these studies indicate that AD patients have a general deficit in voluntary access to semantic representations but that the structure of the representations themselves might be preserved. However, several studies also provide evidence that to some extent semantic representations in AD may in fact be degraded. Recently, a few studies have utilized event-related brain potentials (ERPs) that are sensitive to semantic factors in order to investigate the electrophysiological correlates of the semantic impairment in AD. Interest has focused on the N400 component, which is known to reflect the on-line semantic processing of linguistic and pictorial stimuli. The results from studies of N400 changes in AD remain somewhat controversial: Some studies report normal or enlarged N400 components in AD, whereas others report diminished ones. One issue not reported in previous studies is whether word-elicited ERPs other than N400 remain normal in AD. In the present study our aim was to find out whether the ERP waveforms N1, P2, N400, and Late Positive Component (LPC) to semantically congruous and incongruous spoken words are abnormal in AD and whether such abnormalities specifically reflect deficiencies in semantic activation in AD. Auditory ERPs from 20 scalp sites to semantically congruous and incongruous final words in spoken sentences were recorded from 17 healthy elderly adults and 9 AD patients. The early ERP waveforms N1 and P2 were relatively normal for the AD patients, but the N400 and LPC effects (amplitude difference between congruous and incongruous conditions) were significantly reduced. We interpret the present results as showing that semantic-conceptual activation and other high-level integration processes are defective in AD. However, a word congruity effect earlier than N400 (phonological mismatch negativity), reflecting lexical selection processes, is at least to some extent preserved in AD.

Automatic influences of memory in Alzheimer's disease

Automatic and controlled influences of memory were examined in 12 patients with early Alzheimer's disease (AD) and 12 control subjects. The subjects studied a list of words and then received three-letter word stems in three different retrieval tasks. In an indirect memory task (word-stem completion priming), they were asked to produce the first word that came to mind in response to each stem. In an inclusion task, they were required to produce a studied word in response to each stem, and in an exclusion task they were asked to produce a new, unstudied word for each stem. The performance of the subjects with AD was equal in the inclusion and exclusion conditions, showing no evidence of controlled recollection for the studied words, while their automatic memory as well as priming were preserved. The results provide neuropsychological support for the distinction between controlled and automatic memory processes.

The effect of short-term estrogen replacement therapy on cognition: a randomized, double-blind, cross-over trial in postmenopausal women

OBJECTIVE

To evaluate the effect of estrogen replacement therapy on cognitive functioning.

METHODS

The study consisted of two 3-month treatment periods, one with estrogen and one with the placebo, in random order, separated by a 1-month wash-out period. The study group comprised 70 healthy postmenopausal women, aged 47-65 years, with previous hysterectomy. Sixty-two women completed the study. Cognitive speed and accuracy, attention, and memory were evaluated. Serum estradiol (E2) and FSH levels were controlled at the end of the estrogen, placebo, and wash-out periods.

RESULTS

Most of the cognitive tests correlated with age: older women were slower and made more errors than younger women. Estrogen replacement therapy was not superior to the placebo in any test of cognitive performance. In two out of ten visual detection tasks, recognition thresholds were longer with estrogen than with the placebo (P < .001 and P = .004). On the most demanding test of working memory, the reaction times (P = .045) and error rates (P = .043) differed between treatments, yet this finding proved to be an effect of learning rather than treatment. There was no correlation between cognitive performance and serum E2 levels.

CONCLUSION

Cognitive performance decreased with age. Short-term estrogen replacement therapy did not provide any advantage over the placebo in terms of improving the performance.

Climacteric symptoms do not impair cognitive performances in postmenopause

OBJECTIVE

To investigate whether information processing and attention performances are affected by climacteric vasomotor symptoms.

METHODS

The study group comprised 66 healthy hysterectomized postmenopausal women. The subjects were divided into two subgroups (high symptomatic and low symptomatic) according to the quantity of climacteric vasomotor symptoms. Information processing was examined using CogniSpeed, a reaction time software that separates, for example, pure controlled processing and working memory from perceptual and motor components. Attention was examined by using visual and auditory tasks. The role of climacteric depression as a determinant of cognitive performance was evaluated by the Beck Depression Inventory and dividing subjects according to self-reported climacteric mood symptoms. The effects of serum oestrogen level and ageing on cognitive performances were also studied.

RESULTS

Cognitive performances were similar in high symptomatic and low symptomatic women. On the Verification test younger women had shorter reaction times (P = 0.002) and on the Subtraction test they had fewer errors (P = 0.015) than older women. These tests required working memory and decision making. Accuracy in the tests of sustained and auditory attention worsened slightly with age. Cognitive performances neither correlated with scores on the Beck Depression scale nor with serum oestrogen level. Climacteric mood symptoms did not impair cognitive performance.

CONCLUSIONS

Despite subjective complaints of memory impairment in association with climacteric vasomotor symptoms, our results did not support a direct cause-and-effect relationship. Thus, the minor deficits found in cognitive processing efficiency seem to be related rather to age than climacteric symptoms.

Tone duration discrimination in Parkinson's disease

Patients with Parkinson's disease (PD) and healthy controls took a computerized test of tone duration discrimination (TDD) using pairs of tones of 0.4-1.6 sec duration, presented at intervals of 0.5-4 sec. In PD patients as well as controls, TDD was impaired by even slight degrees of cognitive deterioration. PD yielded impaired TDD in females, but not in males. This suggests that the dopamine-powered biological clock, which is vulnerable to PD, is more important for the processing of durations in the 1-sec range in women than in men.

Knowledge of concept meanings in Alzheimer's disease

The present study focuses on semantic deficits in Alzheimer's disease (AD). We distinguish three different levels of semantic knowledge: (1) lexical, (2) semantic-conceptual, (3) conscious understanding. We devised methods that tap levels (2) and (3). Our aim was to determine how much guidance AD patients need to consciously access a given semantic-conceptual field and how well they can understand the meanings of concepts and semantic relations. Four different tasks were used to tap different kinds of concepts, the relationships between concepts and their attributes, and the hierarchical structure among different concepts. The retrieval demands of the tasks were eased by presenting guiding questions. The results revealed that AD patients have deficient voluntary access to semantic-conceptual representations. The deficits persist even in passive recognition and forced-choice tasks. We conclude that AD patients have a generalized access deficit, although some aspects of the results are suggestive of storage deficit.

The progress of cognitive decline in multiple sclerosis. A controlled 3-year follow-up

The purpose of this study was to illustrate how cognitive functioning evolves over time in patients with multiple sclerosis. We followed the evolution of cognitive performances in two clinically and demographically similar multiple sclerosis groups, the 'cognitively preserved' (n = 20) and the 'cognitively mildly deteriorated' (n = 22), and in healthy controls (n = 34). We conducted the follow-up examination using the Mild Deterioration Battery, the Mini-Mental State Examination, and a set of additional neuropsychological measures after an interval of 3 years. The drop-out rate in our study was only 5%. The 'cognitively preserved' multiple sclerosis group showed substantial neuropsychological stability by performing as well as the controls both at baseline and at follow-up. By contrast, the initially 'cognitively mildly deteriorated' group demonstrated progressive cognitive decline on many neuropsychological tests. The intermediate-length screening battery, the Mild Deterioration Battery, was sensitive to this decline, whereas the briefer Mini-Mental State Examination was not. The progressive cognitive decline could not be predicted from other disease variables. The study demonstrated that intact cognitive functioning in multiple sclerosis may remain stable, whereas incipient cognitive decline seems to be widespread and progressive in nature. Thus, progressive cognitive deterioration should be considered as one of the characteristics of multiple sclerosis.

Language functions in incipient cognitive decline in multiple sclerosis

Although the mechanisms of cognitive impairment in multiple sclerosis (MS) have been extensively studied, evaluation of language functions has been given little attention. In the present study, we evaluated whether impairment of language functions is associated with cognitive decline in MS. We studied naming, reading, and writing performance of two carefully matched patient groups differing only with respect to cognitive status. In language tasks, the patients with incipient cognitive decline not only demonstrated performance slowness but also made more errors than the patients with preserved cognitive capacity and the healthy controls. The comprehensive naming error analysis revealed that the cognitively deteriorated patients produced error types not present in the other two study groups. Contrary to previous suggestions, the present study indicates that impaired language performances in MS are attributable to mild cognitive deterioration rather than to sensory or motor factors. Thus, assessment of language functions should be included in neuropsychological evaluations of MS patients.

Perceptual priming in Alzheimer's and Parkinson's diseases

The present study focused on perceptual identification priming (implicit memory) in early stages of dementia by studying demographically and cognitively matched patients with Alzheimer's disease (AD) and Parkinson's disease (PD). The AD and PD groups performed normally on perceptual identification priming, whereas their explicit recognition memory was equally impaired compared to normal controls. These results imply that priming in perceptual identification relies on the perceptual memory system which can resist not only impairments of explicit memory but also widespread cognitive deterioration induced by the neurodegenerative processes in AD or PD.

Memory deficits and early cognitive deterioration in MS

INTRODUCTION

In the present study, the pattern of memory and learning deficits in two cognitively different, but clinically and demographically similar, multiple sclerosis (MS) groups was compared.

MATERIAL & METHODS

23 patients represented the cognitively preserved MS group and 22 patients the MS group with early cognitive decline. A control group of 35 healthy controls was also included. The cognitive status of the subjects was defined using the Mild Deterioration Battery (MDB). Furthermore, all subjects were given a set of memory and learning tests and were instructed to evaluate the frequency of their memory and learning difficulties. The Mini-Mental State Examination (MMSE) was also administered to all subjects.

RESULTS

The cognitively deteriorated patients, even those with normal MMSE performance, showed widespread memory and learning deficits, but adequate self-evaluation of their everyday memory and learning difficulties. The preserved group, in turn, performed similarly to the controls.

CONCLUSION

Widespread memory and learning deficits are associated with relatively mild cognitive decline in MS. These deficits were observable in the intermediate-length screening battery, the MDB, but not in the MMSE. The present study suggests that the accuracy of patients' own evaluations of their memory and other cognitive problems is superior to the results of very brief screening batteries, like the MMSE. Therefore, brief screening in neuropsychological assessment of MS patients is not recommendable.

Education, gender and cognitive performance in a 62-year-old normal population: results from the Turva Project

Four WAIS (Wechsler Adult Intelligence Scale) subtests, and tasks of memory and cognitive control were administered to a population sample of 143 men and 179 women. Subjects with a minor advantage in years of education out-performed those with only primary schooling. Gender-related effects were also remarkable. Whereas the general abilities were equal in the genders, women out-performed men on recall of word pairs and objects, on verbal cognitive control and on Digit Symbol. In contrast, men excelled on Trail Making A, and on Block Design. The findings emphasize the need for age norms by gender and education for cognitive tests.

Attention related performance in two cognitively different subgroups of patients with multiple sclerosis

To evaluate the underlying mechanisms of cognitive decline in multiple sclerosis, two clinically and demographically matched multiple sclerosis groups differing in cognitive status were assessed with attention related tasks. In addition to the attention tests recommended by the Cognitive Function Study Group of the American National Multiple Sclerosis Society, a test of sustained attention was used to evaluate the role of possible fatigue on cognitive performance. The cognitively mildly deteriorated group was slower than the cognitively preserved group and the controls on all tests of attention. The mildly deteriorated group did not, however, consistently differ from the other groups in the error scores of the attention tests. The preserved group exhibited slowness at the end of the visual vigilance test, but no deficits were found on the other attention related tests in this group. It is suggested that dissociable kinds of processing slowness are the origin of the deficits found on the attention tests in the two multiple sclerosis groups. Our preserved group exhibited signs of motor and fatigue related slowness, whereas the mildly deteriorated group also had extensive cognitive slowness. As sensitive indicators of cognitive slowness, attentional tests should be included in evaluation of the cognitive status of patients with multiple sclerosis.

Automatic and controlled information processing in multiple sclerosis

The purpose of this study was to evaluate the kind of slowing of information processing associated with multiple sclerosis and how this possible slowness is related to cognitive deterioration. We selected 45 patients with definitive multiple sclerosis diagnosis and 35 control subjects. Twenty-two patients had mild cognitive deterioration and 23 patients had preserved cognitive capacities, otherwise the groups were matched. Using computerized tests, we investigated three separate stages of information processing: automatic and controlled processing, and motor programming. The results indicate that patients with mild cognitive deterioration are slower than patients with preserved capacities or controls in every stage of processing measured in this study. Additionally, the preserved patients showed signs of mild slowing in automatic visual processing. These results show that, in multiple sclerosis patients, widespread information processing slowness is associated with multiple sclerosis-related cognitive deterioration. This study emphasizes the importance of studying subgroups rather than cognitively heterogeneous patient samples and, furthermore, the need to divide information processing into different stages is indicated.

Slowing of information processing in Parkinson's disease

In this study, we criticize the notion of bradyphrenia and argue that "slowness of thought" in Parkinson's disease (PD) must be analyzed as slowness of different information-processing stages and that unselected patients should not be used in experimental studies. We selected 32 patients with a long history of PD and 50 control subjects. Sixteen patients had mild cognitive deterioration (not dementia) and 16 patients had preserved cognitive capacities; otherwise the groups were matched. By using computerized tests, we investigated three separate stages: automatic and controlled processing and motor programming. The results indicate that patients with mild cognitive deterioration are slower than patients with preserved cognitive capacities or controls in automatic visual and in controlled processing but not in motor programming. We conclude that the slowing of controlled processing reflects the disruption of central neural networks, that a long history of PD does not necessitate cognitive slowing, and that PD is not a neuropsychologically serviceable category.

Quality of life and cognitive performance after carotid endarterectomy during long-term follow-up

The quality of life and the cognitive performance of patients with extracranial carotid stenosis were investigated 8-11 years after treatment in 18 non-operatively treated patients and 44 patients treated with carotid endarterectomy. The cognitive performance was compared with data on a normal control group. Cognitive performance was assessed with neuropsychological tests and the quality of life by personal interview based on a questionnaire. Most of the carotid stenosis patients recovered well both subjectively and cognitively regardless of the type of treatment. Only the subgroup operated twice was subjectively worse compared to the other groups. Even 10 years later the cognitive performance of carotid stenosis patients was remarkably close to normal.

Senile dementia of the Alzheimer type treated with aniracetam: a new nootropic agent

Forty-four patients with senile dementia of the Alzheimer type were randomly allocated into double-blind treatment with either aniracetam (RO 13-5057) 1 g or placebo daily for 3 months. Neurological examinations were made before and after treatment and psychometric tests were performed before and after 1 month's and after 3 month's treatment. Treatment was interrupted due to occurrence of confusion in four cases in the aniracetam group and in one case in the placebo group. During treatment, an improvement was seen in several cognitive tests, especially those associated with memory, but this improvement occurred in the placebo as well as in the aniracetam-treated group. In clinical evaluation no difference was seen in efficacy between the two treatment groups.

The effect of deprenyl (selegiline) on cognition and emotion in parkinsonian patients undergoing long-term levodopa treatment

The effects of deprenyl on memory, other cognitive functions, vigilance and emotional processes were investigated in seven parkinsonian patients undergoing long-term levodopa treatment. The patients were selected on the basis of their cognitive impairment, observed during a follow-up study of 8-10 years. Four of the patients had progressive dementia and three did not. After deprenyl treatment lasting 4 weeks, there were two patterns of responses. Patients with slow progressive dementia failed to respond to treatment, whereas patients without progressive impairment tended to show improvement in memory and motor speed; the former group also showed more emotional changes than the latter. Typical responses in all patients treated with deprenyl were: increased arousal, paradoxical spells of tiredness, deterioration in vigilance and in set shifting, but improvement of parkinsonian disability. These preliminary findings indicate that there is a dissociation between pure motor responses and cognitive as well as other behavioural responses to deprenyl. It is probable that although enhanced availability of dopamine by MAO-B inhibition partly explains the present neuropsychological findings, also other brain mechanisms are involved.