A comparison of neuropsychological tests for the assessment of chronic toxic encephalopathy

Cognition and mental wellbeing after electrical accidents: a survey and a clinical study among Swedish male electricians

PURPOSE

The purpose was to examine long-term consequences of exposure to electrical current passing through the body. We investigated (1) whether electricians after having experienced an electrical accident report more cognitive problems and lower mental wellbeing and (2) have objectively verifiable reduced cognitive function; and (3) which circumstances at the time of the accident affect long-term subjective cognitive function and mental wellbeing?

METHODS

A survey of male electricians who had experienced electrical accidents (n = 510) and a clinical study in a subsample (n = 23) who reported residual health problems was carried out. Both groups were examined regarding subjective cognitive function (Euroquest-9) and mental wellbeing (Symptom Checklist-90 subscales). The clinical study included neuropsychological tests of memory, attention, spatial function, and premorbid intellectual capacity. A matched control group was retrieved from reference data.

RESULTS

The survey participants reported more cognitive problems and lower mental wellbeing than referents. Of the examined circumstances, having experienced mortal fear at the time of the accident and health complaints, especially mental symptoms, for > 1 week after the accident were the most significant risk factors for later subjective cognitive problems and lower mental wellbeing. The only statistically significant difference in neuropsychological tests was better performance in part of the memory tests by the clinical study group compared to the control group.

CONCLUSIONS

The participants reported more cognitive problems and lower mental wellbeing than referents, but no long-term objective cognitive dysfunction was detected. Emotional response at the time of the accident and health complaints in the aftermath of the accident may constitute important indications for medical and psychological follow-ups.

Impaired brain metabolism and neurocognitive function in childhood leukemia survivors despite complete hormone supplementation in adulthood

Cranial radiotherapy is a known risk factor for neurocognitive impairment in survivors of childhood acute lymphoblastic leukemia (ALL). Understanding the nature of cognitive dysfunction during adulthood in ALL survivors is important as it has an impact on major life situations. Thirty-eight (21 women) ALL survivors were investigated 34 years after diagnosis. Median-age was 38 (27-46) years. All were treated with a CRT dose of 24Gy and 11 years (3-13) of complete hormone supplementation. Comparisons were made to 29 matched controls. Assessments of magnetic resonance spectroscopy (white and grey matter metabolic alterations), brain volume and neuropsychological tests were performed. ALL survivors demonstrate a generally lower performance in neuropsychological tests. ALL survivors scored lower than controls in vocabulary (p<0.001), memory (p<0.001), learning capacity (p<0.001), spatial ability (p<0.001), executive functions and attention (p<0.001) 34 years after ALL treatment. Compared to controls ALL survivors had reduced white matter (WM) (492 vs 536cm³, p<0.001) and grey matter (GM) volumes (525 vs 555cm³, p=0.001). ALL survivors had lower levels of WM N-acetyl aspartate/creatin (NAA/Cr) (1.48 vs 1.63, p=0.004), WM NAA+NAAG (N-acetylaspartylglutamate)/Cr (1.61 vs 1.85, p<0.001) and lower levels of GM NAA/Cr (1.18 vs 1.30, p=0.001) and GM NAA+NAAG/Cr (1.28 vs 1.34, p=0.01) compared to controls. ALL survivors had higher levels in WM MI (Myoinositol)/NAA (0.65 vs 0.56, p=0.01) concentrations compared to controls. There was a significantly negative correlation of years since ALL diagnosis to WM NAA+NAAG/Cr (r=-0.4, p=0.04) in ALL survivors. The present study shows impaired brain metabolism detected by MRS, reduced brain volumes and neurocognitive impairment in childhood ALL survivors treated with cranial radiotherapy and chemotherapy, despite complete hormone substitution. We also report an impairment of metabolites correlated to time since treatment and a progressive impairment in sustained attention, suggesting an accelerated aging in the irradiated brain. Following these survivors many decades, or throughout life, after treatment with cranial radiotherapy and chemotherapy is highly warranted for a broader understanding of long-term outcome in this patient group.

Neuropsychological sequelae of work-stress-related exhaustion

The aim was to assess long-term cognitive performance after substantial recovery from work-stress-related exhaustion, in relation to subjective cognitive complaints and return to active work. In total, 54 patients previously diagnosed with work-stress-related exhaustion participated in a neuropsychological examination ∼2 years after initial sick leave. Most participants were substantially recovered at follow-up, with only 13% still meeting the criteria for exhaustion disorder suggested by the Swedish National Board of Health and Welfare. When participants' scores on 14 neuropsychological tests were compared to a matched group of 50 controls, the former patient group showed lower performance mainly on attention tests of the reaction time type, but also slightly lower scores on visuo-spatial constructional ability. However, the former patient group performed better than controls on two memory tests and, in part, on a test of simultaneous capacity. Self-ratings of everyday cognitive problems remained significantly higher in the former patient group than among controls, but the extent of self-rated cognitive problems was generally unrelated to performance on the neuropsychological tests. No relationship between performance on these tests and the extent of work resumption was observed. In summary, persons with previous work-stress-related exhaustion showed persistent signs of a minor attention deficit, despite considerable general recovery and return to work.

A follow-up of cognitive performance and diurnal salivary cortisol changes in former burnout patients

The purpose of this study was to determine whether recovery from burnout is associated with improved cognitive functioning, and whether such improvement is associated with changes in hypothalamic-pituitary-adrenal axis activity and return to work. Forty-five former burnout patients were followed up after 1.5 years with a neuropsychological examination, diurnal salivary cortisol measurements, dexamethasone suppression test (DST), and self-ratings of cognitive problems. At follow-up, improved cognitive performance was observed on several tests of short-term memory and attention. Self-rated cognitive problems decreased considerably, but this decrease was unrelated to the improvement on neuropsychological tests. Diurnal salivary cortisol concentrations at awakening, 30 min after awakening, and in the evening, did not change from baseline to follow-up, nor did the cortisol awakening response. However, slightly, but significantly, stronger suppression of cortisol in response to the DST was observed at follow-up. Improvements in subjective or objective cognitive functioning and changes in diurnal cortisol concentration were unrelated to the extent of work resumption. However, a decreased DST response at follow-up was partially related to improved cognitive performance and work resumption. The clinical implications are that burnout seems to be associated with slight and significantly reversible cognitive impairment, and that self-rated cognitive change during recovery poorly reflects objective cognitive change.

Chronic solvent-induced encephalopathy: European consensus of neuropsychological characteristics, assessment, and guidelines for diagnostics

INTRODUCTION

The presence of neuropsychological impairment is a hallmark of chronic solvent-induced encephalopathy (CSE), and using clinical neuropsychological procedures to generate a valid assessment of the condition is crucial for its diagnosis. The goals of this consensus document are to provide updated knowledge of the neuropsychological characteristics of CSE and to provide internationally acceptable guidelines for using neuropsychological assessments in the process of diagnosing patients who are suspected of having CSE.

MATERIALS AND METHODS

A European working group that was composed of experts in the field of the clinical diagnosis of CSE met at several round-table meetings and prepared this report. The first section of the consensus paper addresses a review of the relevant literature that was published between 1985 and March 2012. The second section addresses recommendations for the clinical neuropsychological assessment of patients who are suspected of having CSE.

RESULTS

The literature review indicates that the most common neuropsychological impairments in CSE patients are within the domains of attention, particularly the speed of information processing, memory, and motor performance. It appears that the influence of CSE on memory processes mainly involves immediate recall and generally involves verbal, visual and visuospatial material. In the second section, six recommendations are presented regarding important functional domains for the neuropsychological diagnostic process of CSE that relate to the evaluation of neuropsychological impairment, the assessment and evaluation of symptoms, differential diagnostic considerations, the reliability and validity of neuropsychological test results, and the retesting of patients.

DISCUSSION AND CONCLUSIONS

These recommendations will contribute to the improvement of the process for accurately diagnosing CSE, better counselling for CSE patients, the comparability of epidemiological data between countries, and finally, by raising awareness, these recommendations will contribute to combating the adverse health effects of occupational exposure to solvents.

Cognitive performance in patients with burnout, in relation to diurnal salivary cortisol

This study investigated cognitive performance in patients with burnout, in relation to the flexibility of the hypothalamic-pituitary-adrenal (HPA) axis. Clinical cases with work stress-induced burnout (n = 65), and demographically matched, healthy reference subjects (n = 65), were given six neuropsychological tests and a self-rating scale for cognitive problems. Diurnal salivary cortisol was measured among burnout cases and an external reference group (n = 174), including a dexamethasone suppression test (DST) among burnout cases. Compared with referents, the burnout group under-performed in a cognitive speed test (Wechsler Adult Intelligence Scale-Revised (WAIS-R) Digit Symbol), but not in any other test of sustained attention, episodic memory, or vocabulary. Burnout cases had considerably more subjective cognitive problems, but ratings were unrelated to test performance. Compared with referents, burnout cases had similar morning salivary cortisol levels and similar awakening response, but lower evening cortisol. Among burnout cases, lower diurnal cortisol variability was related to slower performance in several tests. The DST response showed no consistent relationship with any cognitive parameter. Hence, despite considerable subjective cognitive problems, the burnout group showed only a partial, mild deviation in cognitive performance. A flatter diurnal cortisol profile was related to lower cognitive processing speed, but diurnal cortisol pattern and DST response were normal, suggesting a maintained HPA axis flexibility.

Dados sociodemográficos e condições de trabalho de pintores expostos a solventes em uma universidade pública da cidade do Rio de Janeiro

O artigo apresenta os dados sociodemográficos e as condições de trabalho de pintores de uma universidade pública da cidade do Rio de Janeiro expostos a solventes. O desenho de pesquisa utilizado foi estudo transversal. Foram avaliados 55 pintores, sendo os dados sociodemográficos e da história ocupacional coletados através do Bloco de Entrevista de Saúde do Trabalhador. A faixa etária mais freqüente foi de 41-50 anos de idade (38,18%) e a maioria dos pintores trabalhava na universidade há mais de 10 anos (70,91%). Quanto às condições de trabalho, 58,2% dos pintores informaram que nunca usavam equipamento de proteção individual; 52,73% desconheciam a existência da Comissão Interna de Prevenção de Acidentes de Trabalho; 92,73% realizavam algum tipo de movimento repetitivo; 60% deles possuíam outra fonte de renda (sendo a maioria como pintor autônomo) e 87,3% consideravam bom o relacionamento no trabalho. Vinte e cinco (45,45%) já exerciam atividade como pintores antes de trabalharem na universidade. O inventário do local de trabalho revelou que o ambiente e as condições de trabalho eram inadequados.

Adult survivors of childhood acute lymphoblastic leukaemia with GH deficiency have normal self-rated quality of life but impaired neuropsychological performance 20 years after cranial irradiation

OBJECTIVE

Cranial radiotherapy (CRT) was, until recently, important for achieving long-term survival in acute lymphoblastic leukaemia (ALL). Because survival rates have improved markedly, the long-term complications, such as GH deficiency (GHD) and neuropsychological impairment, have become increasingly important.

DESIGN AND PATIENTS

The level of self-reported quality of life and neuropsychological functioning was investigated in 44 adults (21 women) with a median age of 25 years who had been treated for childhood onset (CO) ALL with CRT (median 24 Gy). Comparison was made with matched population controls. A subset of patients with GHD was evaluated for neuropsychological functioning after 1 year of GH treatment.

RESULTS

Compared to controls, the patients had significantly lower performance in neuropsychological tests. Early age at treatment had a significant negative impact on neuropsychological performance in adulthood. No relationship was found between dose of CRT, time since treatment of ALL or gender and neuropsychological performance. Compared to controls, the patients did not show a poor quality of life or a lowered availability of social interactions or social networks; however, significantly more patients were living alone or with their parents. After GH testing, the patients were all considered GH deficient or insufficient, but no relationship was observed between stimulated peak GH secretion and neuropsychological performance. Treatment with GH for 1 year in a subgroup of the patients did not improve their neuropsychological performance.

CONCLUSIONS

This study showed that adults treated with CRT for CO ALL had GHD and significantly impaired neuropsychological performance, although self-reported quality of life was not affected. The effect of GH treatment in this patient group has to be further elucidated.

Solvent-related chronic toxic encephalopathy as a target in the worker's mental health research

The article is aimed at discussing the theoretical grounds which support the diagnosis of solvent-related chronic encephalopathy in the field of the worker's mental health, having it as a target in this area. The psychiatric, neurological and labor health postulates which contribute to the multidisciplinary description of such diagnostic category are presented.

EUROQUEST--a questionnaire for solvent related symptoms: factor structure, item analysis and predictive validity

The study evaluates the factor structure and predictive validity of the symptom questionnaire EUROQUEST (EQ) that had been developed with the goal of simplifying the evaluation of health effects associated with long-term solvent exposure. The EQ was added to the normal evaluation procedures for 118 male patients with suspected solvent-induced toxic encephalopathy (TE) referred to seven Swedish clinics of occupational medicine during an 18-month period. EQ was also completed by 239 males from a random sample of 400 Swedish males aged 25-64 years selected from the general population and a sample of 559 occupationally active male spray painters aged 25-64 years. Factor and item analyses of EQ responses were performed. Ordinary least square regression analysis was used to evaluate sensitivity and correlation to evaluate the specificity of EQ and the separate components. Questions concerning memory and concentration symptoms alone showed better sensitivity than the other five EQ dimensions singly or combined for the entire EQ and for a subset of questions approximating Q16, a widely used organic solvent symptom screening questionnaire. However, the diagnosis of TE required information in addition to exposure and responses to EQ and Q16-like questions. The results indicate that the subset of EQ questions concerning memory and concentration might replace the more cumbersome EQ and less sensitive Q16 in screening for TE, although none of the screening instruments alone replaces current clinical diagnostic procedures.

The meta-contrast technique: relationships with personality traits and cognitive abilities in a healthy male study sample

The relationship between defensive strategies as measured by the Meta-Contrast Technique (MCT) and self-reported trait anxiety, trait aggression and defensiveness, as measured by the Karolinska Scales of Personality (KSP), was investigated in 83 healthy men. Further aims of the study were to describe and document how a healthy and demographically well defined group of subjects responded to the MCT, and to investigate whether age, personality traits and cognitive abilities influenced the reports of picture recognition thresholds in the MCT. The results indicated no agreement between the conceptualization of anxiety as measured by the MCT and anxiety as measured by the KSP inventory. Nor was there any agreement between defensive strategies in the MCT and trait defensiveness as defined with the KSP. However, age, personality traits, and cognitive abilities all contributed to explain the variations in the threshold values of recognition of stimuli pictures, all of which are of central importance in the scoring of MCT protocols.

Personality, mental distress, and risk perception in subjects with multiple chemical sensitivity and toxic encephalopathy

Personality, mental distress, and risk perception were assessed in (a) cases of multiple chemical sensitivity (MCS; n = 17), (b) chemically intolerant toxic encephalopathy cases (TE), type 2A (n = 31) and 2B (n = 26), and (c) healthy referents (n = 200). MCS cases showed elevated mental distress scores on the Depression, Interpersonal Sensitivity, Global Severity Index, and Somatization scales in the Symptom Checklist 90 (SCL-90). In the Karolinska Scales of Personality (KSP) the MCS group showed an elevation only on the Psychasthenia scale. Both TE groups showed elevations across the KSP anxiety scales Muscular Tension, Psychasthenia, and Somatic Anxiety. TE type 2B subjects also showed elevations on the Irritability and Indirect Aggression scales. However, neither MCS nor TE groups showed deviating personality characteristics in the Meta Contrast Technique test. Similarly, none of the groups deviated from referents in a risk perception inventory.

High incidence of mental disorders, reduced mental well-being and cognitive function in hypopituitary women with GH deficiency treated for pituitary disease

OBJECTIVE

Previous studies have shown possible neuroendocrine effects of GH. In the present study we investigated the incidence of mental disorders and the prevalence of mental distress and cognitive dysfunction in hypopituitary women with untreated GH deficiency compared to population-based controls.

DESIGN AND PATIENTS

Thirty-three hypopituitary women with a median age of 64 years (range 39--77 years) were investigated cross-sectionally, without any change in hormone substitutions. Twenty-nine of the patients had been operated for a pituitary tumour, 25 had received radiotherapy and 15 had visual dysfunction. The patients were with a very high probability GH deficient, as 29 had subnormal IGF-I levels and the other four were GH deficient as assessed by an insulin tolerance test. The patients were compared with 33 controls matched for sex, age, smoking habits, educational level and residence.

MEASUREMENTS

The incidence of mental disorders was calculated from the date of diagnosed hypopituitarism to the time of the present investigation. Mental well-being was assessed by three self-rating questionnaires: the Symptom Checklist-90 (SCL-90), the Interview Schedule for Social Interaction (ISSI) and the social network concept. The subjects were examined with neuropsychological tests of vocabulary (SRB:1 vocabulary test), perceptual speed (WAIS-R Digit Symbol), spatial ability (WAIS-R Block Design), verbal memory (Cronholm--Molander verbal memory test), spatial learning (Austin Maze Test) and reaction time (APT Two-way Reaction Time and APT Inhibition).

RESULTS

The hypopituitary women had a higher incidence of mental disorders than the controls; Incidence Rate Ratio 4.5 (95% CI 1.0--21). The Global Severity Index, i.e. the average score of all 90 questions of the SCL-90, was higher in patients (P = 0.001), and the patients had significantly more symptoms of somatization, anxiety, depression, obsession--compulsion, hostility--irritability, phobic and psychotic symptoms (all P less-than-or-equal 0.04). Moreover, 14 patients compared to four controls were classified as possible cases of mental distress according to the SCL-90 (P = 0.006). The patients experienced lower availability of both social attachment (P = 0.02) and integration (P = 0.001), but there were no group differences in the adequacy of these dimensions or in emotional support. The patients had lower scores in four of seven neuropsychological tests (all P less-than-or-equal 0.04).

CONCLUSIONS

The hypopituitary women had a higher incidence of mental disorders, more symptoms of mental distress and increased prevalence of cognitive dysfunction. The impaired results in the patients could possibly be explained by several factors, such as transfrontal surgery, radiotherapy, visual dysfunction and unphysiological hormone substitution. Moreover, it is probable that GH deficiency contributed, but placebo-controlled double-blind studies are warranted to investigate whether the psychological dysfunction is reversible on GH substitution.