Vascular higher-level gait disorders--a step in the right direction?

Effects of Motor Learning Interventions on Walking Performance and Physical Function in Older Adults With Cognitive Impairment and Dementia: A Systematic Review and Meta-Analysis

Older adults with cognitive impairment have deficits in executive systems that affect their gait automaticity. The aim of the meta-analysis and systematic review was to examine the effects of interventions focus on only motor learning principles on gait performance and physical functions (e.g., dynamic balance). After inspections of 879 articles, 11 relevant studies were selected for systematic review and meta-analysis. The PEDro scale and Modified Downs and Black checklist were used to assess the quality of studies, and a random-effect model was used at a 95% confidence interval for calculating pooled effect sizes. The results of this systematic review and meta-analysis showed that motor learning interventions increased gait speed, cadence, stride length, and reduced gait cognitive cost but did not affect gait variability and physical function. In conclusion, practitioners should pay attention more to the potential benefits of motor learning interventions in rehabilitating older adults with cognitive impairment.

A Safe Mobilisation Program to Improve Functional Mobility and Reduce Fall Risks in Cognitively Impaired Older Adults with Higher Level Gait Disorders: A Pilot Study

BACKGROUND

The association between gait and cognition, and their combined impact on postural stability may underlie the increased fall risk in older adults with dementia. However, there are few interventions to improve functional mobility and reduce fall risks in people with cognitive impairment.

OBJECTIVES

This study aims to investigate the feasibility and acceptability of a Safe Mobilisation Program for cognitively impaired older adults with higher level gait disorders. It also explores the potential effectiveness of the program on mobility and fall risks.

METHODS

Fifteen community-dwelling older adults participated in a 3-week pre-post intervention study. They were trained to take steady steps in transfers and mobilization using errorless learning and spaced retrieval teaching techniques.

RESULTS

The intervention program was feasible, all the participants completed the program and were able to mobilize safely. The program was acceptable and participants reported an increase in safety awareness, improvement in confidence while transferring and mobilising, and better quality of life. There was a trend of improvement in Falls Efficacy Scale-international (FES-I), 360° turn and Tinetti Performance Oriented Mobility Assessment (POMA), which may indicate improvement in balance and mobility.

CONCLUSION

The Safe Mobilisation Program was feasible and acceptable in older adults with cognitive impairment and gait disorders and warrants further evaluation.

Review of Gait, Cognition, and Fall Risks with Implications for Fall Prevention in Older Adults with Dementia

BACKGROUND

Older people with cognitive impairment are at increased risk of falls; however, fall prevention strategies have limited success in this population. The aim of this paper is to review the literature to inform a theoretical framework for fall prevention in older adults with dementia.

SUMMARY

A narrative review was conducted on fall risk factors in people with cognitive impairment, the relationship between cognition and gait, and their joint impact on the risk of falls. This was used to develop a theoretical framework for fall prevention for people with dementia. Executive function and motor function are closely related as they share neuroanatomy. This close relationship has been confirmed by observational studies including neuroimaging and intervention studies. Executive function is the cognitive domain most commonly associated with gait dysfunction. Attention, sensory integration, and motor planning are the sub-domains of executive function associated with risk of falls through gait dysfunction, whereas cognitive flexibility, judgement, and inhibitory control affect risk of falls through risk-taking behaviour. Key Messages: Gait, cognition, and falls are closely related. The comorbidity and interaction between gait abnormality and cognitive impairment may underpin the high prevalence of falls in older adults with dementia. Gait assessment and cognitive assessment, particularly executive function, should be integrated in fall risk screening. Assessment results should be interpreted and utilised using a multidisciplinary approach; specific strategies such as customised gait training and behavioural modulation should be considered as part of falls prevention for people with dementia.

Attitudes to outcomes measured in clinical trials of cardiovascular prevention

BACKGROUND

Selecting outcome measures in cardiovascular prevention trials should be informed by their importance to selected populations. Major vascular event outcomes are usually prioritized in these trials with considerably less attention paid to cognitive and functional outcomes.

AIM

To examine views on importance of outcome measures used in clinical trials.

DESIGN

Cross-sectional survey.

METHODS

Of 367 individuals approached, 280 (76%) participated: outpatients attending cardiovascular prevention clinics (n = 97), active retirement groups members (n = 75), medical students (n = 108). Participants were asked to rank, in order of importance, outcome measures, which may be included in cardiovascular prevention trials. Results were compared between two groups: <65s (n = 157) and ≥65s (n = 104).

RESULTS

When asked what outcomes were most important to measure in cardiovascular prevention trials, respondents reported: death (31.6%) stroke (28.5%), dementia (26.9%), myocardial infarction (MI) (7.9%) and requiring nursing home (NH) care (5.1%). When asked the most relevant outcomes regarding successful ageing respondents reported; maintaining independence (32.4%), avoiding major illness (24.3%), good family life (23.6%), living as long as possible (15.8%), avoiding NH care (3.1%) and contributing to society (0.8%) as most important. When asked what outcome concerned them most about the future, respondents reported: dementia (32.6%), dependence (30.4%), death (12.8%), stroke (12.5%), cancer (6.2%) requiring NH care (4.8%) and MI (0.7%). Maintaining independence was considered most important in younger and older cohorts.

CONCLUSION

Cognitive and functional outcomes are important patient-relevant outcomes, sometimes more important than major vascular events. Incorporating these outcomes into trials may encourage patient participation and adherence to preventative regimens.

Geriatric syndromes--vascular disorders?

The term geriatric syndrome is used to characterize multifactorial clinical conditions among older people which are not subsumed readily into disease entities, but which nevertheless predispose older people to disability and death. Commonly included are frailty, dementia, delirium, incontinence, falls, and dizziness. Geriatric syndromes are common among older people: in a recent survey, 50% of those aged more than 65 had one or more of these conditions. Better methods for prevention and treatment are needed, but current strategies have lacked a coherent conceptual and diagnostic framework. Prevention and interventions need to be targeted at earlier ages, with geriatrics expertise needed in the definition and operationalization of these complex entities. In this review we consolidate evidence that vascular disorders, including vascular ageing and vascular diseases, are key etiological factors of geriatric syndromes. Identifying this vascular dimension would offer opportunities for more efficient preventive strategies and mandates earlier intervention, especially for women, among whom vascular disease is often expressed more insidiously than among men. This would entail a sensitization of the health care system to the systematic detection of the syndromes, which are currently underdiagnosed. Further disentangling of the mechanisms of vascular ageing may offer therapies for vascular diseases and geriatric syndromes alike.

High-level gait disorder: associations with specific white matter changes observed on advanced diffusion imaging

BACKGROUND AND PURPOSE

High-level gait disorder (HLGD) is a debilitating disorder causing mobility decline in the elderly. Although its clinical characteristics are well described, its anatomical and pathophysiological underpinnings are poorly understood. This study examined the anatomical distribution of white matter (WM) changes in patients with mild to moderate HLGD of the cautious/disequilibrium type, using advanced magnetic resonance imaging (MRI) methods.

METHODS

Thirteen patients with HLGD, 9 elderly and 13 middle-aged healthy controls were scanned using diffusion tensor imaging, Q-space imaging, and conventional MRI. The regions of significant differences between the HLGD group and the elderly control group were defined, and the mean fractional anisotropy and displacement values of these areas were extracted.

RESULTS

The HLGD patients had lower fractional anisotropy and higher displacement values in regions related to the motor system, including those along the corticospinal tract and the superior cerebellar peduncles, as well as in cognitive and affective-related areas, including the anterior limbs of the internal capsule and the genu of the corpus callosum.

CONCLUSIONS

The anatomical distribution associated with HLGD of the cautious/disequilibrium type involves WM pathways that convey motor-related, cognitive and affective-related functions. The underlying pathological process leading to these changes most probably includes demyelination.

Development of a universal psycho-educational intervention to prevent common postpartum mental disorders in primiparous women: a multiple method approach

BACKGROUND

Prevention of postnatal mental disorders in women is an important component of comprehensive health service delivery because of the substantial potential benefits for population health. However, diverse approaches to prevention of postnatal depression have had limited success, possibly because anxiety and adjustment disorders are also problematic, mental health problems are multifactorially determined, and because relationships amongst psychosocial risk factors are complex and difficult to modify. The aim of this paper is to describe the development of a novel psycho-educational intervention to prevent postnatal mental disorders in mothers of firstborn infants.

METHODS

Data from a variety of sources were synthesised: a literature review summarised epidemiological evidence about neglected modifiable risk factors; clinical research evidence identified successful psychosocial treatments for postnatal mental health problems; consultations with clinicians, health professionals, policy makers and consumers informed the proposed program and psychological and health promotion theories underpinned the proposed mechanisms of effect. The intervention was pilot-tested with small groups of mothers and fathers and their first newborn infants.

RESULTS

What Were We Thinking! is a psycho-educational intervention, designed for universal implementation, that addresses heightened learning needs of parents of first newborns. It re-conceptualises mental health problems in mothers of infants as reflecting unmet needs for adaptations in the intimate partner relationship after the birth of a baby, and skills to promote settled infant behaviour. It addresses these two risk factors in half-day seminars, facilitated by trained maternal and child health nurses using non-psychiatric language, in groups of up to five couples and their four-week old infants in primary care. It is designed to promote confidence and reduce mental disorders by providing skills in sustainable sleep and settling strategies, and the re-negotiation of the unpaid household workload in non-confrontational ways. Materials include a Facilitators' Handbook, creatively designed worksheets for use in seminars, and a book for couples to take home for reference. A website provides an alternative means of access to the intervention.

CONCLUSIONS

What Were We Thinking! is a postnatal mental health intervention which has the potential to contribute to psychologically-informed routine primary postnatal health care and prevent common mental disorders in women.

Probable trimethoprim/sulfamethoxazole-induced higher-level gait disorder and nocturnal delirium in an elderly man

OBJECTIVE

To report a case of probable trimethoprim/sulfamethoxazole (TMP/SMX)-induced higher-level gait disorder (HLGD) and nocturnal delirium in an elderly patient on high-dose oral therapy.

CASE SUMMARY

An 82-year-old man with a recent history of depression became comatose following an overdose of escitalopram and oxazepam. He was admitted, ventilated for 7 days in the intensive care unit, and treated with piperacillin/tazobactam and cefepime for aspiration pneumonia. Following discharge to a medical ward, respiratory symptoms persisted and imaging confirmed pulmonary abscesses. Stenotrophomonas maltophilia was isolated from sputum and, on day 15, TMP/SMX 800 mg/160 mg 1 tablet every 12 hours was initiated. On day 35, the dose was increased to 800 mg/160 mg 2 tablets every 12 hours. By day 37, the patient was unsteady when attempting to stand. From day 40, he was noted to have features of HLGD with gait ignition failure, poor balance, and frequent falls. His other medications at this time were thiamine 100 mg daily, multivitamin 1 tablet daily, omeprazole 20 mg every 12 hours, and modified-release venlafaxine 150 mg daily. Investigation did not reveal any cause for his acute gait disturbance. TMP/SMX was stopped on day 48 and, by day 51, the patient's gait had returned to normal.

DISCUSSION

Neuropsychiatric adverse reactions with TMP/SMX have been infrequently reported. The Naranjo probability scale indicated that TMP/SMX was the probable cause of HLGD in this patient.

CONCLUSIONS

At time of writing, this was the first reported case of HLGD associated with TMP/SMX. Clinicians should consider this adverse reaction as a potential cause of HLGD, especially in the elderly and those with malnutrition and hepatic or renal dysfunction.

Gait and dementia: moving beyond the notion of gait apraxia

Highest level gait disorders are produced by pathology in one or more structures in the cortical-basal ganglia-thalamocortical loop, which plays an important role in producing movements and postural synergies that meet personal desires and environmental constraints. Virtually all patients with dementia have pathology in one or more components of this loop, so highest level gait disorders are common in patients with dementia. The terminology surrounding these gait disorders is unnecessarily complex and too heavily influenced by the controversial concept of gait apraxia. Straightforward descriptive diagnostic criteria are needed. To this end, four core clinical features of highest level gait disorders are proposed: 1) inappropriate (counterproductive) or bizarre limb movement, postural synergies, and interaction with the environment, 2) qualitatively variable performance, influenced greatly by the environment and emotion, 3) hesitation and freezing, and 4) absent or inappropriate (counterproductive) rescue reactions. These core features follow logically from the physiology of the cortical-basal ganglia-thalamocortical loop and should be regarded as signs of pathology in this loop. A clinical rating scale based on these features should be developed to facilitate clinical diagnosis and clinicopathological correlation, while avoiding the ambiguities and controversies of gait apraxia.

Higher risk of hyperglycemia in HIV-infected patients treated with didanosine plus tenofovir

The combination of didanosine (ddI) and tenofovir (TDF) has potential advantages, but because of several pitfalls (unexpected decreases in CD4+ T cells, increased risk of pancreatitis) its use has been questioned. Since anecdotal cases of transient insulin-dependent diabetes mellitus were seen in our clinic in patients on ddI + TDF-containing regimens, we explored the rate of this complication in more detail. Retrospective analysis of plasma glucose levels in patients who completed 12 months of treatment with three different triple antiretroviral regimens including ddI + TDF, TDF, or ddI was done. Patients taking antidiabetic drugs and/or those with baseline glucose levels >125 mg/dl were excluded. Weight, age, concomitant antiretrovirals, and ddI dose were assessed. At 12 months without treatment changes, fasting glucose levels were compared to baseline. A multivariate analysis was performed to evaluate which variables were associated with glucose elevations. A total of 177 HIV-infected patients were assessed (78 on ddI + TDF, 42 on TDF, and 57 on ddI). Mean baseline features were well balanced between groups for age (mean, 39 years), gender (78% male), CD4+ count (mean, 507 cells/mm3), weight (mean, 67 kg), and glucose level (mean, 95 mg/dl). There were only significant differences between groups for baseline viral load and protease inhibitor (PI) use (13% in the ddI + TDF arm vs. 7% and 9% in the TDF and ddI arms, respectively). At 12 months, 60% of the patients in the ddI + TDF arm were taking ddI 250 mg/day and the rest were on ddI 400 mg/day. At 12 months, hyperglycemia was significantly more frequent in the ddI + TDF arm (33%) when compared to patients on TDF or ddI separately (5% and 10%, respectively). In the multiple linear regression analysis, a lower weight (beta -0.35; 95% CI -0.67 to -0.03; p = 0.033) and use of ddI + TDF (beta: 13.05; 95% CI: 0.2 to 26; p = 0.047) were independently associated with a higher risk of developing hyperglycemia. The risk of hyperglycemia is increased in patients treated with ddI + TDF, particularly in those with lower weight. As high ddI exposure has been associated with endocrine pancreatic dysfunction and diabetes, ddI "overdosing" as result of concomitant TDF use and low weight might explain our findings. These results add a further note of caution to the use of TDF and ddI in combination.

Common Carotid Artery Intima-Media Thickness, Carotid Plaques, and Walking Speed

Background and Purpose— Gait dysfunction is an important cause of disability among the elderly and may be, in part, of vascular origin. We studied the association between carotid ultrasound parameters and measures of gait and balance in subjects 65 to 85 years of age who participated in the baseline phase of the Three-City Study in the Dijon center.

Methods— The study population comprised 2572 noninstitutionalized individuals. Carotid plaques and common carotid artery intima-media thickness (CCA-IMT) were measured using ultrasonography. Gait and balance measures included walking speed and a modified version of the Tinetti scale.

Results— Mean maximum walking speed (MWS) decreased with increasing CCA-IMT and number of plaques ( P <10 −4 ). Compared with subjects in the lowest CCA-IMT quintile, the odds ratio (95% CI) for being in the lowest MWS quartile was 1.1 (0.8 to 1.6) in the second, 1.3 (0.9 to 1.8) in the third, 1.7 (1.2 to 2.4) in the fourth, and 2.2 (1.6 to 3.1) in the higher CCA-IMT quintile ( P <10 −4 ). Mean (SD) CCA-IMT was 0.716 (0.118) mm in subjects with a modified Tinetti score <16 (25th percentile) and 0.685 (0.109) mm in subjects with a score of ≥16 ( P =0.006). The proportion of subjects in the lowest MWS quartile ( P =0.006) or with a modified Tinetti score <16 ( P =0.05) increased with the number of plaques. These relations were attenuated after adjustment for vascular risk factors.

Conclusions— Carotid plaques and higher CCA-IMT values are associated with worse performances on gait and balance tests. Our results suggest that vascular factors may play an important and under-recognized role in motor function.

Oskar Kokoschka and Auguste Forel

In the spring of 1910, Oskar Kokoschka painted a portrait of the eminent Swiss psychiatrist, neuroanatomist, temperance champion, and myrmecologist Auguste Forel. The painting is a remarkable psychological portrait but also appears to predict the strokes and right hemiparesis that affected Forel more than a year later. Although it is possible that Kokoschka shared a gift of psychic prediction with his mother and grandmother, a more likely explanation can be ascribed to a combination of the artist’s acute perception and the presence of subclinical signs of stroke disease.

Early virological failure in treatment-naive HIV-infected adults receiving didanosine and tenofovir plus efavirenz or nevirapine

A 50% rate of early virological failure associated with the selection of resistance mutations was seen in a group of 14 antiretroviral-naive adults who initiated highly active antiretroviral therapy with tenofovir and didanosine plus efavirenz or nevirapine. At month 6, the mutations detected were K65R, L74V, L100I, K103N/R/T, Y181C and G190E/Q/S. These results argue against the use of tenofovir plus didanosine in HIV-infected antiretroviral-naive adults even when the third drug is a non-nucleoside reverse transcriptase inhibitor.

From trepidant abasia to motor network failure--gait disorders as a consequence of subcortical vascular encephalopathy (SVE): review of historical and contemporary concepts

Gait disorders in progressive subcortical vascular encephalopathy (SVE) and their impact on the burden of disability in the growing elderly population are underrepresented in medical scientific literature. The absence of a clear framework for the diagnosis and classification for gait disorders on the basis of SVE has multiple reasons: (1) neither movement disorder specialists nor stroke specialists are truly familiar with this topic and feel responsible for its treatment, (2) the existing terminology lacks a clear concept and a consistent classification, and (3) only in recent years have large prospective trials started to address the natural course of SVE. This article reviews the classical descriptions of gait disturbances with preferential view to our present concept of SVE, and comments on historical and current nosology of gait disorders aiming to propose for a new classification.