PET in patients with clear-cut multiple chemical sensitivity (MCS)

Aim: Multiple chemical sensitivity (MCS) is a controversially discussed symptom complex. Patients afflicted by MCS react to very low and generally nontoxic concentrations of environmental chemicals. It has been suggested that MCS leads to neurotoxic damage or neuroimmunological alteration in the brain detectable by positron emission tomography (PET) and single photon emission computer tomography (SPECT). These methods are often applied to MCS patients for diagnosis, although they never proved appropriate. Method: We scanned 12 MCS patients with PET, hypothesizing that it would reveal abnormal findings. Results: Mild glucose hypometabolism was present in one patient. In comparison with normal controls, the patient group showed no significant functional brain changes. Conclusion: This first systematic PET study in MCS patients revealed no hint of neurotoxic or neuroimmuno-logical brain changes of functional significance.

Behavioral variant frontotemporal dementia: advanced disease stages and death. A step to palliative care

OBJECTIVE

The aim of the present study was to gain insight into the living and care situation in advanced behavioral variant frontotemporal dementia (bvFTD), to describe symptoms and findings in advanced bvFTD, and to evaluate somatic comorbidities and circumstances of death.

METHODS

Standardized interviews were conducted with family caregivers of 83 patients with bvFTD. Forty-four percent of the patients were already deceased at the time of the interview.

RESULTS

At the time of the interview or death, respectively, 47% of the patients lived in a nursing home. The median time between symptom onset and nursing home admission was 5.0 ± 5.5 years. In moderate and severe dementia stages almost all patients suffered from severe disabilities including impairment of language, gait, swallowing, and of the ability to care for themselves. Sixteen percent of the patients had got enteral tube feeding. Comorbid somatic diseases were diagnosed in 46% of the patients. Twenty-three percent of the deceased patients had been admitted into a hospital before death. Cardiovascular disease and respiratory disease, mostly pneumonia, were the most frequent causes of death.

CONCLUSIONS

Advanced bvFTD is characterized by severe cognitive impairment and physical disabilities. BvFTD leads to a premature death. Our findings stress the importance of strategies that maximize patient comfort in advanced disease stages and allow for a peaceful death. Copyright © 2016 John Wiley & Sons, Ltd.

[Connections between sleep and Alzheimer's disease : Insomnia, amnesia and amyloid]

Sleep plays an essential role in memory consolidation. Although sleep problems are common in Alzheimer's disease, they are not usually thought to be key features of the disease; however, new experimental research has shown that sleep disturbances not only occur before the onset of typical cognitive deficits but are also associated with the pathogenesis of Alzheimer's disease and may have a decisive influence on the symptoms and course. Thus, sleep disturbances may be potentially modifiable risk factors for Alzheimer's disease that deserve more attention in research, diagnostics and treatment.

A Support Group for Caregivers of Patients with Frontotemporal Dementia

Several recent articles have pointed out that caregivers of patients with frontotemporal dementia (FTD) need counselling and support. To date, however, no support groups have been provided other than those available to caregivers of patients with Alzheimer's disease (AD). At our outpatient unit for cognitive disorders we initiated a specific support group for caregivers of patients with FTD. This pilot project had four objectives: 1) to provide information, advice and support to caregivers, 2) to learn more about the specific problems and needs of family carers of patients with FTD and to explore the differences to caregiver burden in AD, 3) to encourage mutual support and development of coping strategies, 4) to evaluate the intervention using a questionnaire completed by the caregiver. Eight spouse caregivers of patients diagnosed with frontotemporal dementia (FTD) participated in special support groups. Seven weekly sessions of 90 minutes' duration were held. To evaluate the program participants were asked to complete a questionnaire about their satisfaction with the support group immediately after the final session. Six months after the intervention they received a questionnaire by mail gathering information on coping efficacy. It became obvious that many problems faced by caregivers of patients with FTD are different from those encountered in AD. During group meetings participants were encouraged to express their own needs and to deal with painful emotions, including aggression, anger, mourning and guilt. Caregivers felt relieved by sharing their problems with others. They were able to learn from each other and to share coping strategies. The group also helped to establish new social relations contacts and even friendships. The participants rated the program as useful and said that benefits were sustained even six months after termination. We conclude from these initial observations that caregiver support groups are a useful component in the management of patients with FTD. Such groups should be tailored to the specific problems and needs of these caregivers. To maintain benefits, self-help groups are recommended even in the absence of professional input.

Over-the-counter-drugs for the treatment of mood and anxiety disorders--the views of German pharmacists

INTRODUCTION

Depression, anxiety, agitation and sleep disorders are highly prevalent in the general population, but few persons receive psychiatric care.

METHODS

Our aim was to study the views of 690 German pharmacists on "over-the counter" (OTC) drugs for these indications.

RESULTS

They reported dispensing OTC medication to an average of 12 customers per day, and this corresponded to almost one quarter of the medications provided for these indications. Herbal drugs and complex homeopathic formulations were used most frequently. Patients preferring OTC substances were described as being younger, with shorter durations of illness and less severe symptoms, and more skeptical regarding psychopharmacology. While genuine pharmacological effects were considered as most relevant, pharmacists were highly aware of placebo and interpersonal factors. Symptoms, comorbidity and advice on drug intake were prominent topics during pharmacy consultations.

CONCLUSION

German pharmacists report dispensing large amounts of OTC drugs for anxiety, agitation, sleep disturbances or depression. It is unclear whether this constitutes a rational and cost effective method to deal with mild courses of high prevalence diseases or must be seen critically.

Alzheimer's Disease: Differences of Transdermal versus Oral Treatment on Caregiving Time

Background

Data on indirect effects of dementia treatment on caregiver burden obtained from naturalistic studies are still lacking. We explored differences between patients with oral and transdermal application of acetylcholine esterase inhibitors regarding caregiver's time burden and psychopathology.

Methods

A cross-sectional naturalistic cohort study of 403 patients in outpatient care with three treatment groups (none, oral, and transdermal) was conducted. Assessments included a standardized clinical burden questionnaire and a standardized caregiver interview.

Results

Any treatment was associated with lower burden in most measures. Transdermal treatment was superior regarding (1) administration time (p < 0.001); (2) rates of administration problems (p = 0.031); (3) burden in activities of daily living (p = 0.008), and (4) caregiver anxiety (OR 0.25; 95% CI 0.05–0.99). Caregivers did not report better quality of life regarding mental/physical health. Physicians’ and caregivers’ ratings of patients’ improvements were not associated (κ = 0.01–0.06).

Conclusions

Benefits associated with transdermal treatment do not translate into a better ‘generic quality of life’ of the caregiver. The substantially different perceptions of patients’ improvements need to be considered in future studies.

Memantine in everyday clinical practice: a comparison of studies in Germany and Greece

BACKGROUND/AIMS

Results from German and Greek non-interventional studies were compared to investigate possible differences concerning efficacy, tolerability and compliance between both countries.

METHODS

In two open-label, multicentre, non-interventional studies, 4,305 patients with mild to severe Alzheimer's disease (AD) were treated with daily doses of 20 mg memantine for 6 months. Efficacy was assessed using the Mini-Mental State Examination (MMSE) and instrumental activities of daily living (IADL) scales. Safety and tolerability were recorded.

RESULTS

After 6 months, the patients showed an improvement of their cognitive performance by 2 MMSE points compared to baseline (p < 0.001). MMSE values were improved in 67.4% of the patients, while 15.1% remained stable, and MMSE deteriorated in 17.5% only. The ability to perform IADL increased, as is indicated by lower values (baseline: 70.5; after 6 months: 66.6 points). Improvement of cognition and IADL was nearly identical in both countries. Treatment discontinuation was significantly more frequent in the Greek population, mainly due to non-adherence (9.4% of the safety population). 345 adverse events were recorded in 245 patients (6.3%), and they were significantly associated with country and age.

CONCLUSION

The results correspond to those of clinical trials and support the efficacy and good tolerability of memantine in a realistic setting. Differences between the countries were observed regarding the baseline characteristics of patients (more female, older and more severe patients in Germany as well as less pretreatment with cholinesterase inhibitors) and regarding premature discontinuation and reported adverse drug reactions, which were both higher in Greece.

Agomelatine improves sleep in a patient with fatal familial insomnia

A young patient with FFI was started on agomelatine 25 mg to medicate nocturnal insomnia. Under this treatment sleep efficiency was improved, slow wave sleep was high and awakenings during sleep period time were far less than before. Clinically the patient was less restless during nighttime.

The Deceleration Capacity - a New Measure of Heart Rate Variability Evaluated in Patients With Schizophrenia and Antipsychotic Treatment

Background

Schizophrenia is associated with increased cardiac mortality. A disturbed autonomic modulation of heart rate (HR) has been described in patients with schizophrenia in whom antipsychotic medication may represent an additional cardiac risk. The novel measure deceleration capacity (DC) of heart rate predicts cardiac mortality in patients with cardiovascular illnesses. The aim of the present paper was to calculate DC in patients with schizophrenia and to compare this measure with established parameters of heart rate variability (HRV).

Methods

HRV and DC were calculated in 24-hour electrocardiogram (ECG) recordings of 20 unmedicated, 40 medicated patients with schizophrenia and 40 controls. As activity has a major influence on HRV, 4-hour periods of “sleep-” and “wake-” ECG were evaluated as additional parameters. Actigraphy was used to ensure comparable levels of activity in patients and controls.

Results

The DC as well as the other established HRV measures were not significantly different comparing unmedicated patients with schizophrenia to healthy controls. However, medicated patients showed a significant reduction of DC calculated from ECG recordings during 4 hour over night periods.

Conclusion

Calculation of DC might contribute to a better monitoring and identification of an increased risk of cardiac mortality in patients with schizophrenia undergoing antipsychotic treatment.

Validation of the German revised Addenbrooke's cognitive examination for detecting mild cognitive impairment, mild dementia in alzheimer's disease and frontotemporal lobar degeneration

BACKGROUND/AIMS

The diagnostic accuracy of the German version of the revised Addenbrooke's Cognitive Examination (ACE-R) in identifying mild cognitive impairment (MCI), mild dementia in Alzheimer's disease (AD) and mild dementia in frontotemporal lobar degeneration (FTLD) in comparison with the conventional Mini Mental State Examination (MMSE) was assessed.

METHODS

The study encompasses 76 cognitively healthy elderly individuals, 75 patients with MCI, 56 with AD and 22 with FTLD. ACE-R and MMSE were validated against an expert diagnosis based on a comprehensive diagnostic procedure. Statistical analysis was performed using the receiver operating characteristic method and regression analyses.

RESULTS

The optimal cut-off score for the ACE-R for detecting MCI, AD, and FTLD was 86/87, 82/83 and 83/84, respectively. ACE-R was superior to MMSE only in the detection of patients with FTLD [area under the curve (AUC): 0.97 vs. 0.92], whilst the accuracy of the two instruments did not differ in identifying MCI and AD. The ratio of the scores of the memory ACE-R subtest to verbal fluency subtest contributed significantly to the discrimination between AD and FTLD (optimal cut-off score: 2.30/2.31, AUC: 0.77), whereas the MMSE and ACE-R total scores did not.

CONCLUSION

The German ACE-R is superior to the most commonly employed MMSE in detecting mild dementia in FTLD and in the differential diagnosis between AD and FTLD. Thus it might serve as a valuable instrument as part of a comprehensive diagnostic workup in specialist centres/clinics contributing to the diagnosis and differential diagnosis of the cause of dementia.

[SSRI - treatment and bleeding. What risks do we take?]

Treatment with selective serotonin reuptake inhibitors (SSRI) increases the risk of gastrointestinal bleeding. The combination with non-steroidal anti-inflammatory drugs (NSAIDs) further augments this hazard. Particular precaution is also necessary in patients on platelet aggregation inhibitors, with a known bleeding disorder or preceding gastrointestinal lesions. The incidence of bleeding events apart from the gastrointestinal tract, e.g. intracerebral hemorrhages, is not cumulated under SSRI treatment. This also applies for the combination of SSRI and coumarin or aspirin. Prescribing doctors have to be aware of the bleeding risks of SSRI and should explain this to their patients. High-risk patients have to be followed up closely and an SSRI with a low potential for drug interaction should be used. The prescription of gastroprotective agents and a change of the antidepressant should be considered in particular cases. We provide a literature survey and recommendations for the clinical routine.

Turning principles into practice in Alzheimer's disease

The prevalence of dementia is reaching epidemic proportions globally, but there remain a number of issues that prevent people with dementia, their families and caregivers, from taking control of their condition. In 2008, Alzheimer's Disease International (ADI) launched a Global Alzheimer's Disease Charter, which comprises six principles that underscore the urgency for a more ambitious approach to diagnosis, treatment and care. This review highlights some of the most important aspects and challenges of dementia diagnosis and treatment. These issues are reviewed in light of the six principles of the recent ADI Charter: promoting dementia awareness and understanding; respecting human rights; recognizing the key role of families and caregivers; providing access to health and social care; stressing the importance of optimal diagnosis and treatment; and preventing dementia through improvements in public health. The authors continue to hope that, one day, a cure for Alzheimer's disease will be found. Meanwhile, healthcare professionals need to unite in rising to the challenge of managing all cases of dementia, using the tools available to us now to work toward improved patient care.

[The German Study on the Epidemiology of Parkinson's Disease with Dementia (GEPAD): more than Parkinson]

It is unknown, how frequently Parkinson's disease (PD) is complicated by dementia, depression and other neuropsychiatric conditions. An epidemiologic characterisation of the situation in specialised neurologic settings is lacking. The Geman Study on the Epidemiology of Parkinson's Disease with Dementia (GEPAD) isa national representative epidemiological study of n=1449 PD patients in n=315 office-based neurological settings, designed to estimate the prevalence of dementia, depression and other neuropsychiatric conditions in patients with PD of all stages by using standardized clinical assessments.

RESULTS

28.6% met DSM-IV criteria for dementia. 33.6% met criteria for depression and 61% additionally had other clinically significant psychopathological syndromes. Only 29.4% had no neuropsychiatric conditions. GEPAD reveals for the first time comprehensively that the neuropsychiatric burden of PD patients in all stages and even early stages is considerable, posing challenging questions for research and clinical management.

Carotid- intima media thickness is independently associated with cognitive decline. The INVADE study

OBJECTIVES

Increased carotid intima-media thickness (C-IMT) is a non-invasive marker of atherosclerosis and predicts vascular events. Moreover, increasing evidence suggests an association between carotid atherosclerosis and cognitive decline. The purpose of this study is to investigate the relationship between C-IMT and the development of cognitive impairment in a large population-based sample.

METHODS

This study was based on the data of the participants of the INVADE (Intervention project on cerebrovascular diseases and dementia in the district of Ebersberg, Bavaria) project. Vascular risk factors, Geriatric depression scale (GDS) and "6 Item Cognitive Impairment Test" (6CIT) were evaluated at baseline and after 2 years. The relationship between C-IMT and cognitive impairment was analysed using multivariate logistic regression.

RESULTS

Complete baseline data were available in 3386 subjects (mean age 67.7 [95% confidence interval (CI): 67.5, 68.0] years, 41% male). During follow-up, 174 subjects developed a new cognitive impairment. In the subgroup without cognitive impairment at baseline a significant association between cognitive decline after 2 years and elevated C-IMT at baseline could be detected with a significantly higher baseline C-IMT in those with cognitive decline (0.87 mm vs. 0.78 mm; p < 0.0001). After adjustment for various risk factors only age, GDS baseline 6CIT and C-IMT were independently associated with the development of a new cognitive impairment.

CONCLUSIONS

Our data indicate that an increased carotid intima-media thickness predicts a cognitive decline in an elderly population without prevalent cognitive impairment.

[Personality in old age]

Modern developmental psychology tends to draw a positive, resource-based picture of human aging. We will however focus on more difficult aspects of personality in old age which are of psychiatric relevance: the persistence of cluster A and C personality disorders, antisocial personality in the elderly; the interaction of personality and a detection of mild cognitive impairment (MCI); personality features as risk or protective factors or early signs of Alzheimer's dementia; changes of personality in Parkinson's disease and frontotemporal dementia. We will briefly mention recent neuroimaging studies which appear to suggest a functional neuroanatomy of personality. A quote from Cicero's cato major, de senectute indicates that some of his perceptions regarding classic personality characteristics of the elderly can be recognized in our patients and can be prevented or treated with modern interventions.

[Somatic factors in cognitive impairment]

Mild cognitive impairment describes a cognitive decline greater than expected for an individual's age and education level that does not interfere significantly with activities of daily life. In the recent years concepts of "mild cognitive impairment" with divergent definitions have been discussed as potential preclinical forms of dementia. The etiology of cognitive impairment is heterogeneous and it can be promoted or caused by numerous somatic factors. Relevant somatic factors include hypertension, diabetes mellitus, heart failure, chronic obstructive airways disease and bronchial asthma. Cognitive impairment may be facilitated by hypercholesterolemia, chronic renal failure, hypothyroidism, testosterone deficiency, minimal hepatic encephalopathy, HIV- and hepatitis C-infection. Knowledge and diagnosis of these somatic factors is essential in cognitive impairment, as diligent treatment may lead to improve cognitive performance and postpone the manifestation of dementia.

No association of lipase C polymorphisms with Alzheimer's disease

Hepatic lipase, also known as hepatic triglyceride lipase (LIPC), much like the major genetic risk factor for Alzheimer's disease (AD), apolipoprotein E (APOE), is associated with altered lipid metabolism. As such this link makes LIPC a potential functional candidate for AD risk. Previously, three single nucleotide polymorphisms (SNPs) have been investigated in AD with a lack of association reported. To rule out a possible contribution of other variants in LIPC, located at 15q21-q23, we used a detailed fine mapping approach in a German case-control sample. Genotyping of 25 single nucleotide polymorphisms covering the complete LIPC gene and haplotypic analysis revealed no association with AD. Thus, we conclude that LIPC can be excluded as a major functional candidate gene conferring risk to AD.

[MCI-plus: mild cognitive impairment with rapid progression. Part II: Biomarkers and research methods]

Long-term studies will be pivotal in order to examine the efficacy of preventive and early therapeutic interventions during the preclinical phase of dementia. Biomarkers will be of importance due to the large sample sizes and the necessary logistic efforts, high drop-out rates and slow clinical progression. The validity of functional and even structural imaging methods is currently investigated with early and promising results; it is presently unclear whether conventional csf-markers of Alzheimer's disease (beta-amyloid and tau-proteins) are sufficiently sensitive to monitor the effects of early interventions. It also remains doubtful whether modifications of these methods will ever be useful and available for practical purposes.

[MCI-plus: mild cognitive impairment with rapid progression. Part I: prevention and therapy]

Mild Cognitive Impairment (MCI) is a prevalent problem in the elderly and many patients show predictors of rapid cognitive decline ("MCI-plus"). MCI-plus represents a syndrome with growing importance in an ageing society, which will increasingly affect primary medicine and most other clinical specialties. We will have to face the dilemma of fast progress in the field of neurodiagnostics with innovative therapeutic strategies lagging behind. Psychological and medical co-morbidity in MCI-plus will therefore offer important opportunities to delay and to avoid the manifestation of dementia. We will review and discuss current training and treatment options including symptomatic and causal interventions.

Ludwig II, King of Bavaria: a royal medical history

OBJECTIVE

The case of Ludwig II, King of Bavaria, had soon become synonymous with paranoia, after he had drowned at the age of 40 together with the neuropsychiatrist Gudden.

METHOD

We were granted access to the Secret Archive of the House of Wittelsbach to study documents on Ludwig's medical history.

RESULTS

The documents underlying Gudden's expert opinion which led to Ludwig being deposed would be insufficient for a diagnosis of schizophrenia according to contemporary standards. The autopsy revealed prominent prefrontal brain atrophy.

CONCLUSION

The evidence is compatible with a diagnosis of schizotypal personality and suspected frontotemporal degeneration.

Prevention of interferon-stimulated gene expression using microRNA-designed hairpins

RNA interference allows selective gene silencing, and is widely used for functional analysis of individual genes in vertebrate cells and represents an attractive therapeutic option for treating central nervous system diseases. However, growing evidence exists that the expression of short hairpin RNAs (shRNAs) can trigger cellular immune response resulting in unspecific cellular phenotypes and severe side effects. We found that lentiviral vector (LV)-mediated expression of shRNAs in primary cortical cultures resulted in strong expression of the interferon-stimulated gene oligoadenylate synthetase 1 (Oas1), which was accompanied by accelerated apoptosis and substantial net neuron loss. Modification of the shRNA construct by implementing features of the naturally occurring microRNA-30 (miR-30) precursor avoided Oas1 induction in transduced primary cultures, whereby modification of the passenger strand seems to be a crucial feature to circumvent interferon-stimulated gene expression. This work represents the first experimental study showing that an miR-30-based shRNA construct prevents Oas1 pathway associated off-target effects, which we consider as an essential prerequisite for shRNA use in future gene therapeutic approaches.

[Dementia with Lewy bodies and reduced dopamine transporter binding indicates significant acetylcholine deficiency]

Dementia with Lewy bodies (DLB) is the second most common form of neurodegenerative dementia. It is usually caused by a mixture of symptoms of Parkinson's and Alzheimer's disease leading to a significant impairment of nigro-striatal dopaminergic and baso-cortical cholinergic neurotransmission with typical clinical symptoms of a fluctuating course, hallucinations, parkinsonism, REM-sleep disorder and neuroleptic hypersensitivity. If the clinical presentation of DLB is uncharacteristic, the demonstration of reduced presynaptic striatal dopamine transporter (DaT) sites supports a suspicion of DLB and may lead to important therapeutic consequences. In these circumstances this evidence for compromised dopaminergic neurotransmission also indicates a significant cholinergic deficit: both require diligent therapeutic attention.

[The status of imaging methods for the treatment of patients with Parkinson's syndrome]

The accuracy of the diagnosis of Parkinson's disease early in the course of the disease remains a clinical challenge. Imaging of dopamine transporters with DatSCAN and SPEC tomography contributes to identifying patients without nigral degeneration and thus helps preventing unnecessary and potentially harmful treatments. The cost of these imaging procedures needs to be set against the cost of unnecessary medication.

Frühsymptome, Überlebenszeit und Todesursachen - Beobachtungen an 115 Patienten mit Demenz auf der Grundlage frontotemporaler lobärer Degenerationen

The early and differential diagnosis of the clinical phenotypes of frontotemporal lobar degeneration (FTLD), including frontotemporal dementia (FTD), semantic dementia (SD) and non-fluent progressive aphasia (NFPA), can be challenging. It may be difficult not only to differentiate these conditions from normal aging, psychiatric disorders, and other dementias, but also to distinguish between them. For early diagnosis, information on the initial and presenting symptoms of the FTLD phenotypes is essential. In the present study caregivers of 78 patients with FTD, 20 patients with SD and 17 patients with PA were interviewed about initial symptoms. In patients with FTD, the most frequent initial symptoms were alterations of personality, followed by forgetfulness and word finding difficulty. Patients with SD presented with word finding difficulty and behavioral disturbances. Almost all patients with PA developed word finding difficulty as the first manifestation of their disorder. Diagnostic latency - the time from disease onset to diagnosis was 4.1 years in FTD, 4.2 years in SD and 3.1 years in PA. Caregivers, and in some cases also patients, should be educated about the likely course and mortality of FTLD. To obtain information about survival time and cause of death associated with FTLD we analyzed follow-up data on 106 patients of whom 25 had died. The median survival time from the occurrence of first symptoms was 14 years. Mortality risk was significantly higher in patients with an early disease onset. Causes of death were varied, but pneumonia and sudden unexplained deaths were particularly frequent.