P118 THE ROLE OF PULMONARY ACT IN THE PATIENT WITH SARS–COV–2 INFECTION

Already from the first data in China it emerged that patients with cardiovascular comorbidities had an increased risk of contracting SARS–CoV–2 infection and a more unfavourable clinical course. From March to May 2020, 85 patients affected by COVID–19 were enrolled, hospitalized at the Hospital of Reggio Calabria. All patients underwent anamnesis, clinical evaluation, chest CT, ECG and measurement of markers of cardiovascular damage (Troponin I, CK–MB, LDH, D–dimer, BNP) and of inflammation (PCR, IL–6, and PCT). Thirty–one patients underwent echocardiography. In particular, we evaluated parietal dimensions and thicknesses, biventricular function and transvalvular tricuspid and pulmonary flows and correlated the data obtained with ECG, radiological, clinical, and biohumoral parameters. The aim of our study was to evaluate the prognostic impact of cardiovascular involvement in COVID– 19, investigating the effect of cardiovascular risk factors, levels of cardiovascular damage markers and newly emerging ECG and echocardiographic changes on a composite primary endpoint, consisting of the combination of death and the need for intensive care (ICU). The enrolled patients were divided into two subpopulations: those with better prognosis and those with poorer prognosis (ICU/exitus). We analysed the reciprocal correlation of each of the parameters and searched for the presence of echocardiographic signs of repercussion on the right sections of the pulmonary pathology. All markers of cardiovascular damage had significantly higher values in the most critically ill patients and similar behaviour had indices of inflammation. Patients with poorer prognosis had significantly lower lung AcT values, which correlated with higher D–dimer levels and more complicated hospital stays. There were no statistically significant differences between PAPs, right ventricular size, TAPSE and pulmonary trunk diameter in the two subpopulations. Larger right ventricular diameters were associated with more dilated lung trunks and higher IL–6 levels. The most interesting data of our study is the behaviour of pulmonary AcT: lower values of AcT were associated with higher levels of D–dimer, expression of a greater pulmonary microthrombotic burden, and a poorer prognosis, in the presence of PAPs normal. The dynamic analysis of this parameter, which is easy to calculate in the patient’s bed, can play a crucial role in the instrumental follow–up of patients hospitalized for SARS–CoV–2 infection.

P312 A CASE OF TAKOTSUBO CARDIOMYOPATHY IN SARS–COV–2 INFECTION

Cardiovascular complications are a frequent occurrence in Sars–CoV–2 infection. Takotsubo cardiomyopathy is a possible cause of transient ST segment elevation (1–3% of total cases) and is characterized by a reversible left ventricular dysfunction with coronary arteries free from critical stenosis. The predominant echocardiographic pattern is an akinesia of the mid–apical myocardial segments with preserved kinetics of the basal segments. The incidence of Takotsubo cardiomyopathy showed a marked increase during the COVID–19 pandemic. Three factors mainly contribute to the onset of cardiomyopathy in patients with COVID–19: cytokine storm, adrenergic hyperactivation and microvascular dysfunction. A 79–year–old woman was hospitalized in the Pneumology department of our hospital for bilateral interstitial pneumonia Sars–CoV–2 related. In remote medical history: in 2010 diagnosis of breast cancer with negative follow–up for disease recovery, arterial hypertension, hypercholesterolemia and syndrome of reduced mobility as a result of a previous ischemic stroke. Non–invasive mechanical ventilation with c–PAP was started and, for the detection of anterolateral electrocardiographic anomalies (diffuse symmetrical negative T waves) and an increase in myocardionecrosis markers, echocardiographic evaluation was performed, which revealed an akinesia of the mid–apical segments of the left ventricle with preserved kinetics of the basal segments and severely depressed global systolic function (ejection fraction: 30%). BNP (18.100 pg /mL), interleukin–6 (339 pg /mL) and CRP (136 mg /L) were elevated on blood chemistry tests. In the suspicion of Takotsubo cardiomyopathy (InterTAK Score: 67, probability: 79.8%), cardioprotective therapy with ACE inhibitor, beta–blocker, diuretics, low molecular weight heparin, double antiaggregation and statin was started, deferring coronary angiography to improved clinical conditions. In the following days, due to the respiratory and haemodynamic worsening, the patient was transferred to an intensive setting, where she was intubated and treated with levosimendan and noradrenaline. Serial echocardiograms showed a progressive improvement of the global systolic function (ejection fraction at the last checkup: 55%), with complete regression of the kinetic anomalies, confirming of the diagnostic hypothesis of stress cardiomyopathy. For a pulmonary mycotic superinfection, complicated by iatrogenic pneumothorax, in the following days the patient died.

4093Beyond global longitudinal strain: early impairment of apical function after antracyclines therapy

Purpose

To confirm GLS diagnostic sensitivity as parameter for the evaluation of LV systolic function in women with breast cancer who underwent chemotherapy including anthracyclines and to identify a pattern of decreased 2D speckle tracking regional longitudinal strain through the analysis of polar maps obtained with AFI technology.

Methods

We enrolled 60 female patients (age with 56.5±12 years) with breast cancer before the beginning of chemotherapy. The study protocol included clinical examination, ECG with QTc calculation, lab test (BNP and troponin I) and echocardiography with TDI and speckle tracking analysis (STI), that were performed before the beginning of the chemotherapy (basal) and after 3, 6 and 12 months. Echocardiography evaluation included the following parameters: LV end-diastolic and end-systolic volumes, LV ejection fraction (EF), average TDI S' at the mitral annulus, Global Longitudinal Strain (GLS), regional longitudinal strain, E/A ratio, E/E' ratio and sPAP. For each patient we analyzed the bull's eye maps before the beginning of the therapy (basal value) and when GLS showed the lowest values during the FU (FU value), to identify the pattern of regional longitudinal strain alterations. We compared basal and FU strain values for each of the 17 LV segments and the difference between them (delta) was calculated according to the formula [(FU LS –basal LS, (%)].

Results

During the FU, systolic blood pressure, systolic pulse pressure and BNP values increased from the basal assessment to the 3 and 6 months FU. Similarly, a progressive worsening of GLS values has been observed (basal −20.4±2.6%, 3 months FU −18.2±2.5%, 6 months FU −17.7±2.9, 12 months FU −17.6±3, p value <0.001). Through the analysis of polar maps, we observed that regional strain values worsened significantly in all the LV segments but the most evident impairment was reported in the apical cap (−22.8±3.9 vs −17.1±3.8; p<0.001, Δ=−5,78%) and in the apical segment of the anterior interventricular septum (−23.4±4.5 vs −17±6.3; p<0.001, Δ=−6,2%), as reported in Figure.

Conclusion

GLS is able to identify LV systolic dysfunction that EF is not able to detect. However, since that it describes the global function of LV, GLS could result as normal (18–20%) when strain impairment of some LV segments is counterbalanced by the compensatory strain increase of other segments, determining an misdiagnosis of myocardial damage. Regional strain and particularly the Δ-strain, seem to suggest that anthracyclines induce a damage more evident in the apical cap and in the apical segment of the interventricular septum and this pattern could be typical in these patients. Thus, polar maps analysis could be provide additional information about cardiac damage in this population.

Effects of Speaking Speed on Cerebral Lateralization of Speech Assessed by a Dual-Task Interference Paradigm

Cerebral asymmetry for speech was assessed by means of a verbal-manual interference paradigm in a sample of 16 right-handed men at two different speaking rates. Normal speech rate disrupted the right hand significantly more than the left, whereas increased speech rate showed no differences between right and left hands during verbal-manual interference tasks. This result suggests a role of speaking speed in modifying cerebral motor functions related to speech production.

Use of the Ten-Point Clock Test to Compare Executive Functioning across 24 Months in Patients with Subcortical Vascular Dementia

The Ten-point Clock Test can be used to identify early forms of Alzheimer's disease because it is reliable, well accepted, and easily administered at the bedside. Nevertheless, its clinical role in the detection of early dementia and its correlations with other cognitive processes is still under investigation. Vascular dementia is an uncertain nosological entity, in which unevenly distributed patterns of cognitive deficits comprising slowing of cognitive processing and impairment of executive function occur. The present study assessed how the Clock Test scores correlated with a number of other neuropsychological and functional tests in a sample of 144 patients with vascular dementia, who were followed for a period of 24 mo. At baseline, at 12 mo. and at 24 mo. subjects were administered a battery of tests, including the Mini-Mental State Examination, word fluency, visuospatial skills, an evaluation of hetero- and autotopognosia (knowledge of self), the Proverbs Test, and the Ten-point Clock Test. For these patients scores on the Clock Test correlated significantly with semantic abilities, with abstract reasoning capacities, visuospatial perception, and with right and left recognition.

Frontal Lobe Dementia and Subcortical Vascular Dementia: A Neuropsychological Comparison

We compared the performance of 40 patients with frontal lobe dementia to that of 40 patients with subcortical vascular dementia (80 patients including, 46 men and 34 women) in a set of tasks assessing attentional, executive, and behavioural tasks. The frontal lobe dementia represents an important cause for degenerative disruption and is increasingly recognised as an important form (up to 25%) of degenerative dementia among individuals of late-middle-age. The main involvement is the frontal-subcortical pathway, which is the final target of impairment even in subcortical vascular dementia. A wider involvement of the cortical (decisional) layers in frontal dementia, in contrast with the prominent and widespread involvement of the subcortical pathways (refinement and corrections programs) creates the different profiles of the two groups. Frontal patients have more difficulties in abstract reasoning, focusing attention, and implementing strategies to solve problems. They exhibit more profound behavioural alterations in personality and social conduct and show only moderate depression, and a total lack of insight concerning their clinical condition. In contrast, the patients with subcortical vascular dementia have poor general cognitive functions, high insight, and important depression and apathy as the principal and most salient characteristic of their behavioral conduct.

Writing Errors by Normal Subjects

Writing is a complex process requiring visual memory, attention, phonological and semantic operations, and motor performance. For that reason, it can easily be disturbed by interfering with attention, memory, by interfering subvocalization, and so on. With 16 female third-year students (23.4 ± 0.8 yr.) from the University of Trieste, we investigated the production of errors in three experimental conditions (control, articulatory suppression, and tapping). In the articulatory suppression condition, the participants produced significantly more linguistic impairments (such as agrammatism, unrelated substitutions, sentence omissions, and semantically deviant sentences), which are similar to linguistic impairments found in aphasia. On the tapping condition there were more perseverations, deletions, and substitutions of both letters and words. These data suggest that writing is not an automatic skill. Only after many years of experience and practice of processing information (through cortical to subcortical channels) can writing be considered an automatic skill. Limited experimental conditions can disrupt the writing system of normal subjects, probably interfering with the cortical to subcortical loops, and link normality to pathology.

Italian Right Hemisphere Language Battery: the normative study

Clinical neurolinguistics still lacks consolidated and standardised tools for the assessment of impairments of pragmatics of verbal communication. In the present paper we present norms of the Italian version of the Right Hemisphere Language Battery (Batteria del Linguaggio dell'Emisfero Destro, BaLED) originally devised by Bryan. The normative study has been conducted with the recruitment of 440 healthy subjects. The battery of tests was not intended to be cognitively oriented, by providing evidence of the cognitive impairments underpinning verbal pragmatic deficits; on the contrary, it permits the detection of the presence/absence of impairments in processing the main pragmatic features of verbal communication traditionally associated with right hemisphere lesions. Thus, apart from being a clinical tool for diagnosing pragmatic impairments of verbal communication, the BaLED represents a useful initial battery of tests for clinical assessment and for selecting specific populations of neurological patients suitable for investigation in further experimental studies.

Rivastigmine in frontotemporal dementia: an open-label study

OBJECTIVE

This preliminary open-label study aims to investigate the effects of rivastigmine, an inhibitor of acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE), in 20 patients diagnosed with frontotemporal dementia (FTD).

PATIENTS AND METHODS

Study subjects were men and women 60-75 years of age diagnosed with probable FTD. The rivastigmine group received doses of 3-9 mg/day. The control group included matched patients receiving antipsychotics, benzodiazepines and selegiline (deprenyl). All patients completed a 12-month follow-up period.

RESULTS

Rivastigmine treatment was well tolerated. At 12 months, there was a general amelioration of behavioural changes as demonstrated by reductions in Neuropsychiatric Inventory (p<0.001 vs baseline and control), Behavioral Pathology in Alzheimer's Disease Rating Scale (p<0.001 vs baseline and control) and Cornell Scale for Depression in Dementia scores (p<0.05 vs baseline, p<0.001 vs control) in the rivastigmine group. Caregiver burden was reduced, as shown by reduced Relative Stress Scale scores (p<0.001 vs baseline and control). Mean scores on outcome measures evaluating executive function stabilised in the rivastigmine group (p<0.05 vs controls). Rivastigmine did not prevent the disease-related deterioration of cognition as assessed using the Mini-Mental State Examination.

CONCLUSION

In this open-label study, rivastigmine-treated patients were less behaviourally impaired, and caregiver burden was reduced, at 12 months, compared with baseline. The use of cholinesterase inhibitors in FTD warrants further research.

Neuropsychological evaluation of late-onset post-radiotherapy encephalopathy: a comparison with vascular dementia

It is known that radiotherapy (RT) may cause cerebral injury. The most frequent neurotoxic effect of RT at any age is diffuse cerebral injury. Brain injury by therapeutic irradiation has traditionally been classified according to its time of onset into acute, early delayed, and late forms. The latter is not reversible. The neurocognitive sequelae of cranial irradiation can be mediated through vascular injury. Because the pathologic changes are most profound in the white matter, we compared a group of patients treated by RT (n=34) with a group of patients affected by subcortical vascular dementia (sVaD, n=34). Patients with a total radiation does <35 cGy did not show any sign of cognitive impairment. All the patients with a total irradiation dose >45 cGy did show profound cognitive and behavioural alteration. The patients who received a total dose of brain radiation comprised between 35 and 45 cGy did show slowness of executive function, and profound alterations of frontal functions, such as attention focusing, mentation control, analogical judgement and insight. The patients who suffered from the consequences of RT had slowness of executive functions, and profound alterations of frontal functions, such as attention focusing, mentation control, analogical judgement and insight, similar to those obtained by the patients suffering from subcortical vascular dementia. High dose RT might result in a severely demented, bedridden patient, who "has been cured" from his primary disease, the brain tumour. This constellation demands serious consideration before RT is given.

Rivastigmine in vascular dementia

Patients with vascular dementia (VaD) show cholinergic deficits that may result in characteristic clinical syndromes for different subtypes of the condition. Subcortical VaD is characterised by executive dysfunction and behavioural problems, reflecting deterioration of the frontal lobe. Based on limited open-labelled controlled studies of rivastigmine in VaD, this article aims to determine whether rivastigmine, a dual inhibitor of acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE), has any effects on the typical symptoms of subcortical VaD. Long-term rivastigmine treatment is safe and effective. Improvements in domains that characterise subcortical VaD were observed, indicating that rivastigmine may have provided targeted treatment in areas of the brain that are particularly affected in this patient population. A large, double-blind study of rivastigmine in patients with VaD is clearly warranted.

Vitamin B12 and folate depletion in cognition: a review

In cross-sectional studies, low levels of folate and B12 have been shown to be associated with cognitive decline and dementia Evidence for the putative role of folate, vitamin B12 in neurocognitive and other neurological functions comes from reported cases of severe vitamin deficiencies, particularly pernicious anemia, and homozygous defects in genes that encode for enzymes of one-carbon metabolism. The neurological alterations seen in these cases allow for a biological role of vitamins in neurophysiology. Results are quite controversial and there is an open debate in literature, considering that the potential and differential role of folate and B12 vitamin in memory acquisition and cognitive development is not completely understood or accepted. What is not clear is the fact that vitamin B12 and folate deficiency deteriorate a pre-existing not overt pathological situation or can be dangerous even in normal subjects. Even more intriguing is the interaction between B12 and folate, and their role in developing hyperhomocysteinemia. The approach to the rehabilitation of the deficiency with adequate vitamin supplementation is very confusing. Some authors suggest it, even in chronic situations, others deny any possible role. Starting from these quite confusing perspectives, the aim of this review is to report and categorize the data obtained from the literature. Despite the plausible biochemical mechanism, further studies, based on clinical, neuropsychological, laboratory and (lastly) pathological features will be necessary to better understand this fascinating biochemical riddle.

Rivastigmine superior to aspirin plus nimodipine in subcortical vascular dementia: an open, 16-month, comparative study

Recent data indicate that patients with vascular dementia (VaD) show a cholinergic deficit. Having obtained good results in a previous study comparing rivastigmine, an inhibitor of acetylcholinesterase (AChE) and butyrylcholine-sterase (BuChE), vs. aspirin, we aimed to compare the efficacy and tolerability of rivastigmine vs. aspirin plus nimodipine. Patients with a diagnosis of dementia and probable VaD received rivastigmine 3-6 mg/day (n = 32) or aspirin plus nimodipine (n = 32) in an open study for 16 months. Patients treated with rivastigmine showed superior benefits, compared with those receiving aspirin plus nimodipine, in attention, executive function, instrumental activities of daily living, and behavioural and psychotic disturbances. Side-effects in both groups were tolerable and there were no study withdrawals. The benefits observed with rivastigmine may reflect its inhibitory effects on AChE and BuChE, and the drug's affinity for frontal brain areas.

Olanzapine as a possible treatment for anxiety due to vascular dementia: an open study

Disabilities caused by behavioral problems can be potentially devastating in cognitively impaired patients. These behavioral symptoms can be a major cause of stress, anxiety, and concern for caregivers. While psychotropic drugs are frequently used to control these symptoms, they can be accompanied by significant side effects, which include sedation, disinhibition, depression, falls, incontinence, parkinsonism, and akathisias. Agitation is a major problem in older patients with dementia. Agitation and aggression have always been difficult behaviors to manage, and when it is severe, agitation can be a behavioral emergency that requires urgent and immediate intervention. This six-month study included a group of 94 outpatients (48 men and 46 women) who had a diagnosis of subcortical vascular dementia (VaD). To be eligible for the study, patients needed a score of at least 3 for agitation/aggression on the Neuropsychiatric Inventory (NPI), suggesting at least moderate frequency and/or severity, and 0 for delusions and hallucinations. Patients were divided into two homogenous groups. Group A received olanzapine (2.5-5 mg/day) and Group B received bromazepam (0.25 percent, 15 drops, three times per day). Patients in both groups were allowed to continue any previous therapy. Patients receiving olanzapine at an average dose of 3.21 +/- 1.02 mg/day showed statistically significant improvement on the anxiety rating compared with those receiving bromazepam. Our patients had a host of medical conditions and received numerous concomitant medications. Given the potential complications associated with these therapeutic agents, these patients tolerated olanzapine quite well. It appeared that adverse events, particularly somnolence, postural instability, and postural hypotension, were mild and transient. Moreover, no anticholinerigic effect was registered. These findings suggest that olanzapine could be a safe and effective treatment for anxiety in cognitively impaired patients.

Gabapentin As A Drug Therapy of Intractable Hiccup Because of Vascular Lesion: A Three-Year Follow Up

BACKGROUND

Persistent and intractable hiccups indicate multiple neurologic and extraneurologic disorders. Chronic hiccup is not so rare in patients suffering from stroke: its impact on quality of life and on rehabilitation management is substantial, and it may be closely related to aspiration pneumonia, respiratory arrest and nutritional depletion.

REVIEW SUMMARY

Intractable hiccups can be associated with potentially fatal consequences and safe management may require inpatient rehabilitation. It has been suggested that hiccups could be a form of myoclonus, caused by repeated and abnormal activity of the solitary inspiratory nucleus. Because of this cause we decided to treat intractable hiccups in patients with ischemic lesions of the medulla with a short course of gabapentin.

CONCLUSIONS

The results were promising, with the immediate disappearance of the hiccups, and the complete absence of side effects. The 36-months follow up was favorable to all the patients, who, after 6 days of treatment remain asymptomatic.

Neuropsychological changes after subthalamic nucleus stimulation: a 12 month follow-up in nine patients with Parkinson's disease

Deep brain stimulation of the subthalamic nucleus has been recognized as one of the most promising techniques to decrease 'off' motor symptoms and motor fluctuations, allowing a reduction of drug therapy and limiting side effects of drug therapy. However, there is still open debate on the possible consequences of chronic subthalamic stimulation on general cognitive performance. A general amelioration of cognitive performance, in particular of executive functions has been reported but results are not homogeneous. We studied nine patients with Parkinson's Disease for 12 months following surgery for deep stimulation, studying their cognitive performances, paying particular attention to linguistic tests and selective alternating words production. Our results may be consistent with a slowing of cognitive activity, with a reduction of quantitative production, but with an increase in control of linguistic production, which is more precise and definite. We discuss the possible significance of these results, fully aware that only nine patients were involved, and that the potential for generalization is seriously limited, with a particular overview on the frontal-subthalamic pathway, which in our opinion is responsible for the results we observed.

Corticobasal degeneration: structural and functional MRI and single-photon emission computed tomography

We studied seven patients with corticobasal degeneration (CBD) from a clinical and imaging perspective. We describe the main morphological features of CBD and, using functional MRI, try to define the possible role of the parietal lobe in simple and complex learned motor sequences. We showed decreased activation of the parietal lobe contralateral to the more affected arm, when movements, simple or complex, are performed with that hand. Moreover we found that functional imaging can demonstrate parietal and motor cortex dysfunction before structural, and even single-photon emission computed tomography changes become evident.

Rivastigmine in subcortical vascular dementia: a randomized, controlled, open 12-month study in 208 patients

Subcortical vascular dementia (VaD) is characterized by executive dysfunction and behavioral problems, reflecting deterioration of the frontal lobe. This study aimed to determine whether rivastigmine, a dual inhibitor of acetylcholinesterase (AChE) and butyryl-cholinesterase (BuChE), has any effects on the typical symptoms of subcortical VaD. Patients receiving rivastigmine showed a slight improvement in executive functions and in behavior. Side effects in both groups were tolerable and there were no study withdrawals. Moreover, there are no drug interactions with other therapies previously and concomitantly assumed. Improvements in domains that characterize subcortical VaD were observed, indicating that rivastigmine may have provided targeted treatment in areas of the brain that are particularly affected in this patient population.

Olanzapine as a treatment of neuropsychiatric disorders of Alzheimer's disease and other dementias: a 24-month follow-up of 68 patients

Although the core feature of all types of dementia is progressive cognitive disruption, most demented patients also express noncognitive behavioral problems. These noncognitive problems lead to potentially devastating disabilities, and are often a major cause of stress, anxiety and concern for caregivers. Psychotropic drugs are frequently used to control these symptoms, but they have the potential for significant side effects, such as sedation, disinhibition, depression, falls, incontinence, parkinsonisms and akathisias. For 24 months, we monitored 68 outpatients suffering from Alzheimer's disease, vascular dementia, frontal lobe dementia, Parkinson dementia complex, and Lewy body disease. Our purpose was to identify the role and efficacy of olanzapine and the side effects which emerged during the treatment of behavioral alteration resulting from five etiological causes. This paper will discuss the results of this study, and will provide an overview of the existing literature.

Frontotemporal dementia: paroxetine as a possible treatment of behavior symptoms. A randomized, controlled, open 14-month study

Frontotemporal dementia (FTD) represents an important cause for degenerative disruption and is increasingly recognized as an important cause (up to 25%) of degenerative dementia among late-middle-age individuals. The serotoninergic system is tightly bound to frontal circuits, whose degeneration subserves FTD. Patients aged 64-68 years, with a diagnosis of FTD, were randomized to receive paroxetine up to 20 mg/day (n = 8) or piracetam up to 1,200 mg/day (n = 8). At 14 months, the patients treated with paroxetine showed significant improvements in behavioral symptoms, reflected by a reduction of caregiver stress. Side effects were easily tolerable, and there was no dropout. The results are presented with an overview of the literature on the topic.

Language recovery following subthalamic nucleus stimulation in Parkinson's disease

Neuropsychological consequences of stimulation of the subthalamic nucleus for treatment of drug-resistant Parkinson's disease (PD) have been studied previously. However, no detailed investigations of linguistic function modifications have been carried out. We studied four consecutive patients with PD who underwent chronic bilateral stimulation of the subthalamic nuclei. Neuropsychological and linguistic evaluations were performed before and 2 weeks after surgery. Linguistic abilities were studied also 1 year after surgery with stimulators both off and on. Intraphrasal hesitation pauses, phonemic paraphasias and morpho-syntactic errors were significantly reduced and lexical retrieval improved with stimulation of the subthalamic nuclei. Implicit linguistic phenomena, mainly occurring within basal ganglia circuitry, benefited by recovery of functional equilibrium within basal nuclei and between overall basal ganglia circuitry and cerebral cortex.

Gabapentin for the Treatment of Behavioural Alterations in Dementia

BACKGROUND

Although the core feature of dementia is progressive cognitive disruption, non-cognitive behavioural problems are expressed in most patients with dementia during the course of their illness. While psychotropic drugs are frequently used to control behavioural symptoms, comorbidities, which are very common in the geriatric population, could often limit their use. Gabapentin may be a potential treatment in such situations.

METHODS

In this open, baseline comparison study 20 patients with probable Alzheimer's disease with behavioural alterations and serious comorbidities (paralytic ileus, open-angle glaucoma, ischaemic cardiopathy, hepatic failure or severe prostatic hyperplasia) received gabapentin for 15 months. Patients were allowed to continue any previous therapy for concurrent diseases. However, concomitant antipsychotic or benzodiazepine intake was not permitted.

RESULTS

Gabapentin appeared to be efficacious and well tolerated in this patient population, and did not appear to interact with other drugs. General benefit is reflected by a reduction of caregiver stress. No patients withdrew before the end of the study and no serious adverse events were reported.

CONCLUSION

The results of this study in patients with probable Alzheimer's disease with behavioural alterations and serious comorbidities indicate that gabapentin provides significant and sustained efficacy in terms of behaviour, with associated reductions in caregiver burden. The results of an ongoing larger, randomised, double-blind study of gabapentin are keenly awaited and may help to provide a safer and more efficacious treatment option for this group of patients.

Complex cognitive disruption in motor neuron disease

We describe 14 patients having been diagnosed as suffering from motor neuron disease (MND). These patients underwent a detailed and sequential neuropsychological evaluation, with particular care of neurolinguistic assessment. Their results have been compared to those obtained by a group of healthy volunteers. The most obvious disclosure was the finding of 4 cases of frontal dementia in the MND group. Apart from that, we demonstrated subtle though evident frontal disruption signs, evidenced by an alteration in language planning, language comprehension, morphosyntactic operations, planning, attention deficit, and abstract reasoning disturbances which got worse during the 15 months of follow-up in all the other subjects. We suggest that a specific and sensitive neurolinguistic and neuropsychological test battery could detect signs of disruption of cognition present even in the sporadic form of MND. We discuss the results with a review of the literature.

Crying of a newborn child: alarm signal or protocommunication?

The purpose of the study was to explore whether the new-born cry is a simple alarm signal or differentiated cries with different meanings. 12 digital audio taped recordings of 6 full-term healthy babies were analysed. Cries of 6 newborns in this preliminary study were recorded in a pain condition after a prick for the hematic check-up the third day after delivery and then while crying spontaneously in the cradle. The sounds were sampled at 44100 Hz with a 16-bit resolution and converted to the .wav format. All the analyses were performed with a software written in the MAT-LAB environment. The most important result was that these new-born children modulated the supralaryngeal tract considerably more in cries following the painful stimulus than in "spontaneous" ones, as would be expected by the hypothesis of crying as "protolanguage."

Gabapentin treatment of glossopharyngeal neuralgia: a follow-up of four years of a single case

Glossopharyngeal neuralgia causes intermittent, lancinanting pain, involving the posterior tongue and pharynx, with radiation to deep ear structures. There are different pharmacological therapies which are tried to treat the neuralgia: carbamazepin, phenytoin, diazepam, amytriptyline, phenobarbital, ketamine, and baclofen; there are also surgical treatment proposed in order to cure the neuralgia such as vascular decompression or electrical stimulation of the motor cortex controlateral to the pain area. We report a single case of a patient with glossopharyngeal neuralgia treated with Gabapentin, the first described, who was followed up for four years, who respond completely to the therapy and did not complain from side effects, reducing even the reminiscence of pain during the second cluster of crisis.

Rivastigmine in subcortical vascular dementia: an open 22-month study

Further to recent data indicating that patients with vascular dementia (VaD) show a cholinergic deficit, we aimed to determine whether rivastigmine, a dual inhibitor of acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE), has any effects on the symptoms of VaD. Patients aged 65-80, with a diagnosis of dementia and probable VaD, received rivastigmine 3-6 mg/day (n=8) or cardioaspirin (n=8) in an open study for 22 months. At 22 months, patients treated with rivastigmine showed significant improvements in executive function and behavioural symptoms (both p<0.05 vs. both baseline and control group), which were reflected in reduced caregiver stress (p<0.05 vs. baseline and controls). Baseline scores of global response, cognition, word fluency and activities of daily living were maintained in patients receiving rivastigmine, and there was no increase in benzodiazepine or neuroleptic intake. In contrast, the control group showed no improvements in any domain, and significant deterioration in global response and executive function (both p<0.05 vs. baseline and rivastigmine group). Side effects in both groups were tolerable and there were no study withdrawals. Long-term rivastigmine treatment appeared to be safe and effective in this patient population. In particular, improvements in domains particularly relevant to this condition were observed. These benefits may reflect the drug's dual inhibitory effects on the cholinergic system, and its particular activity in frontal areas of the brain. A large, double-blind study of rivastigmine in patients with VaD would be worthwhile.

Depression and Alzheimer's disease: symptom or comorbidity?

Alzheimer's disease is the most frequent form of dementia, where behavioral and cognitive disruption symptoms coexist. Depression, apathy, anxiety, and other conduct disorders are the complaints most often reported by caregivers. Fifty subjects were referred to our Institute with a diagnosis of probable Alzheimer's disease. Cognitive impairment was equally distributed among the subjects. Patients, aged 68 to 76 years old, were randomized to receive inhibitors of cholinesterase (Donepezil, 5 mg/day) alone, or inhibitors of cholinesterase plus selective serotonin reuptake inhibitors (SSRIs) (citalopram HBr, 20 mg/day). We followed up all the patients for one year, with particular concern for neuropsychological aspects associated with eventual behavioral changes. Results indicate that SSRI intake seems to be effective for depression, decreasing it and improving quality of life for both patients and caregivers. Side effects in both groups were few, and there were no study withdrawals. This paper discusses the relationship between dementia and depression, and presents our finding that depressive symptoms, if specifically treated, tend to reduce caregiver stress and improve well-being in patients with Alzheimer's disease.

Learned movements in a left-handed pianist: an f-MRI evaluation

The spatial arrangement of neuronal sources for digit movement is non somatotopic, and is structured as extensively arranged through different regional cortex. We have functionally examined the cerebro-cortical activation during simple and complex motor sequences, before and after learning sessions, in healthy volunteers, both considering left- and right-dominant hand use, and left non dominant hand use, skillfulness and educational level. We discuss the results with a review on the topic.

Cognitive changes following subthalamic nucleus stimulation in two patients with Parkinson disease

The limits of a drug therapy in severe forms of Parkinson disease have led to refining neurosurgery on the basal ganglia. Deep brain stimulation of the subthalamic nucleus has been recognized as one of the most promising techniques to decrease "off" motor symptoms and motor fluctuations, allowing a reduction of drug therapy and limiting side effects of the drugs. There is still open debate on the possible consequences of chronic subthalamic stimulation in other ways, apart from motor symptoms, of general cognitive performance. We examined and followed two patients with Parkinson disease for 9 mo. after surgery for deep stimulation, studying their cognitive performances. There is a general amelioration of cognitive performances, in particular as far as linguistic capabilities is concerned. We discuss the possible significance of these results, reminding strenuously that only two patients were involved, so the potential for generalization is seriously limited.

Reading errors in patients with cerebellar vermis lesions

Dyslexia, both developmental and acquired, has been considered the result of cerebrocortical dysfunction, affecting the temporo-parieto-occipital brain regions. However, dyslexia may involve abnormalities of the magnocellular component of the visual system, leading to binocular instability or alterations of accommodation. To test the hypothesis of cerebellar involvement in the reading process -- justified by its emergent role in language and cognition -- we studied 10 patients with cerebellar vermis/paravermis lesions using reading tests and we compared the results with those produced by 10 normal volunteers. The data obtained demonstrate an increased number of reading mistakes in the patient group, resulting from a possible alteration of the diffuse connection system from the cerebellum to different cerebrocortical and subcortical structures. Acquired dyslexia due to cerebellar impairment may be due to oculomotor alteration or, more subtly, to the intimate cerebellar-encephalic projections, connecting the cerebellum to the attentive and alerting processes and to the language system. We discuss the data with an overview of literature.

Complex distal movement in cortical-basal ganglionic degeneration. A functional evaluation

We evaluated cortical activation during simple and complex learned movements in five patients diagnosed with cortical-basal ganglionic degeneration. Since the parietal area is one of the areas most involved in this degenerative pathology, we focused on the possible role of the parietal lobe, in learning and executing simple and complex motor sequences. We also attempted to describe the role of the parietal area in spatial and visual control, which is necessary to define and optimise movement execution in daily living. We discuss the results of our evaluation, and give an overview of the literature on the topic.

Ten-Point Clock Test: a correlation analysis with other neuropsychological tests in dementia

BACKGROUND

Neuropsychology can be useful for differentiating patients with fronto-temporal dementia (FTD) from those with Alzheimer disease (AD) and those with Vascular Dementia (VaD).

OBJECTIVES

The purpose of this study was twofold: to explore possible employment of the Ten-Point Clock Test in early identification of different types of cognitive distribution and to relate to its execution to other specific impairment, bound to the selected pathology.

METHOD

We compared 30 patients with FLD, to a group of 30 probable-AD patients accordingly to the NINCDS-ADRDA criteria, and to a group of 30 probable VaD patients, according to the NINDS-AIREN criteria.

RESULTS

AD group showed the worst results in Clock Drawing Test. On the contrary, FLD group did produce the worst performances in Proverb Interpretation Tasks. VaD worst performance was that of phonological fluency. Our data seem to demonstrate that in mild dementia, stated by the MMSE score (around 22) and confirmed by the data derived from the other neuropsychological evaluation, the Clock Drawing Test is quite sensitive to detect cognitive impairment, even if of different origins.

CONCLUSIONS

Ten-Point Clock Test is a strong tool, in order to identify early forms of Alzheimer, and to help differential diagnosis when frontal or vascular dementia have been taken into account. More data will be necessary to give to this speculative interpretation, a neuroimaging and neuroanatomical support. However, this report may encourage the wider use of this parametric test, easily applicable and well accepted by the population in order to implement data concerning cognitive disruption.

Peculiar aspects of reading and writing performances in patients with olivopontocerebellar atrophy

Olivopontocerebellar atrophy (OPCA) is a still debated condition, of which motor disruption is the most common feature. A high incidence of associated mood disorders may exist, but there are few studies on concomitant cognitive impairment. Our aim was to assess whether there is reading and writing disruption in olivopontocerebellar atrophy (OPCA). 6 patients were administered different reading and writing tasks. Scores were then compared to those obtained by healthy volunteers. There was an evident impairment in reading and writing execution in our patients compared to those of the control group. On the contrary, no difference could be found in abstraction, problem-solving, and memory tasks. We discuss the results, debating the role of the cerebellum in the conscious process of cognition or in ocular movement control (necessary for reading and writing fluidity and effective execution) and in the dynamic activation of all the cerebral cortex mediated by the diffuse projection to the reticular system.

Bilingual aphasia and subcortical-cortical lesions

The use of the mother tongue relies on implicit memory procedures that are mainly controlled by subcortical structures. A second language depends on the integrity of the explicit memory system, largely subserved by cortical areas. Therefore, bilinguals can be considered as neurolinguistic models which contribute to the understanding of how the cortical and subcortical language systems communicate while maintaining independent functions. We describe a patient who developed an impairment of the mother tongue after an infarct of the caudate. During follow-up, a dramatic improvement of the mother tongue accompanied by worsening of the second language became evident after the extension of the ischemic lesion to the cortex.

Speaking speed effects on delayed auditory feedback disruption of speech fluency

24 Italian medical students performed a task of verbal fluency. 12 students (the control group) receiving Normal Auditory Feedback and 12 students receiving Delayed Auditory Feedback (delay of 200 msec.) performed six trials in six different experimental settings: normal or increased speaking rate, and, for each condition, once with bilateral input of the auditory feedback, once to the right ear, and once to the left ear. At the normal speaking rate, the disruptive effect of delayed feedback was confirmed. As the speaking rate increased, the total number of errors increased within the control group but decreased within the group given delayed feedback, although the total number of errors was always greater for the latter. In addition, speech was more disrupted when the auditory input was returned to the right ear (left hemisphere) for all the different conditions: Normal and Delayed Auditory Feedback, normal and increased speaking rate. In particular, the left hemisphere was less resistant to the disruptive effect of the delayed feedback than the right hemisphere. From these results, we suggest that, when speaking more quickly, one uses more central mechanisms of movement programming (cortical-cerebellum-thalamus-cortical, cortical-corpus striatum-thalamus-cortical, and cortical-thalamus-cortical circuits), or attentional control (cortico-reticular-cortical circuits) than peripheral mechanisms (tactile, proprioceptive, and acoustic circuits). This may explain the decreased disruptive influence of delayed auditory feedback on speed, fluency, and quality at increased speaking rates. Hemispheric specialization processes, however, may explain the more pronounced susceptibility of the left hemisphere or the less pronounced susceptibility of the right hemisphere during the delayed feedback condition. In fact, the former processes phonemic, grammatical, and lexical features of words whilst the latter is competent in using metaphors and prosody in controlling the emotional aspects of language. Moreover, the right hemisphere is more active on attentional tasks.

Effects of praying and a working memory task in participants trained in meditation and controls on the occurrence of spontaneous thoughts

So-called "intrusive thoughts" appear independently from external stimuli and are the cause of severe disturbances in depressed patients. Following Baddeley's 1986 discoveries regarding "articulatory suppression," we investigated the influence of praying and of a working memory task on the number of spontaneous thoughts reported by 20 subjects compared to the control (quiet) state. Two groups of subjects were tested: those trained in meditation and controls. Significant reduction in simultaneous thought arousal was obtained during both the working memory task and the recitation of prayer. In all three experimental conditions, meditation practitioners reported significantly fewer spontaneous thoughts.

Encoding and recall of parsed stories in hypnosis

To define the relationship between aspects of memory concerning encoding and recall of short texts and hypnosis, standardized stories were narrated to 12 subjects, both during ordinary state of consciousness and after hypnotic induction by means of the Stanford Hypnotic Susceptibility Scale (Form C). The narrative material used as a stimulus was based on several stories taken from popular oral tradition, previously analyzed according to the classic criteria proposed by Rumelhart in 1975 and Mandler and Johnson in 1977. The subjects' memory performance during both experimental conditions was tape-recorded and compared with the analysis of the original stories (Terminal Nodes) as well as with the higher linguistic structures of the scheme (Basic Nodes), according to Rumelhart's typology. During hypnosis, the subjects recalled significantly fewer narrative elements at both levels of analysis (Terminal Nodes and Basic Nodes). We conclude that hypnosis does not enhance recent memory.

Asymmetries of facial motility during the dissimulation of emotion

The asymmetrics of facial expression were estimated in a sample of 14 experimental subjects with the Facial Action Coding System during voluntary control of facial mimicry while viewing videotapes. The subjects were instructed to express facially the emotion experienced or to dissimulate their true emotion with a facial expression opposite (incongruous) to what they actually felt. Only during dissimulation did facial mimicry show an asymmetric distribution toward the lower left side of the face.

Effects of left basal ganglia lesions on language production

Three patients with lesions mainly confined to the left basal ganglia were studied with a series of neuropsychological and neurolinguistic tests. Two patients were nonfluent, whereas one presented with fluent spontaneous speech. All of them produced agrammatic sentences and lexical and semantic mistakes. Perserverations and echolalias were two further characteristic disorders of their speech production. The linguistic symptoms observed in these three patients suggest that the left basal ganglia play an important role (a) in regulating arousal and speech initiation, (b) in monitoring the semantic and lexical aspects of language, and (c) in switching from one linguistic element to the following during language production.

Effects of hypnosis on the fundamental frequency of voice in different emotional imitations

The modifications of human vocal fundamental frequency (fa) were studied in six emotional imitations of a sequence during normal and hypnotic conditions. In hypnosis the fundamental frequency was significantly lower than in the normal condition; in particular, in this altered state of consciousness two emotional imitations (angry and crying conditions) were significantly different with respect to the normal condition.