Musical and electrical stimulation as intervention in disorder of consciousness (DOC) patients: A randomised cross-over trial.

BACKGROUND: Disorders of consciousness (DOC), i.e., unresponsive wakefulness syndrome (UWS) or vegetative state (VS) and minimally conscious state (MCS), are conditions that can arise from severe brain injury, inducing widespread functional changes. Given the damaging implications resulting from these conditions, there is an increasing need for rehabilitation treatments aimed at enhancing the level of consciousness, the quality of life, and creating new recovery perspectives for the patients. Music may represent an additional rehabilitative tool in contexts where cognition and language are severely compromised, such as among DOC patients. A further type of rehabilitation strategies for DOC patients consists of Non-Invasive Brain Stimulation techniques (NIBS), including transcranial electrical stimulation (tES), affecting neural excitability and promoting brain plasticity. OBJECTIVE: We here propose a novel rehabilitation protocol for DOC patients that combines music-based intervention and NIBS in neurological patients. The main objectives are (i) to assess the residual neuroplastic processes in DOC patients exposed to music, (ii) to determine the putative neural modulation and the clinical outcome in DOC patients of non-pharmacological strategies, i.e., tES(control condition), and music stimulation, and (iii) to evaluate the putative positive impact of this intervention on caregiver's burden and psychological distress. METHODS: This is a randomised cross-over trial in which a total of 30 participants will be randomly allocated to one of three different combinations of conditions: (i) Music only, (ii) tES only (control condition), (iii) Music + tES. The music intervention will consist of listening to an individually tailored playlist including familiar and self-relevant music together with fixed songs; concerning NIBS, tES will be applied for 20 minutes every day, 5 times a week, for two weeks. After these stimulations two weeks of placebo treatments will follow, with sham stimulation combined with noise for other two weeks. The primary outcomes will be clinical, i.e., based on the differences in the scores obtained on the neuropsychological tests, such as Coma Recovery Scale-Revised, and neurophysiological measures as EEG, collected pre-intervention, post-intervention and post-placebo. DISCUSSION: This study proposes a novel rehabilitation protocol for patients with DOC including a combined intervention of music and NIBS. Considering the need for rigorous longitudinal randomised controlled trials for people with severe brain injury disease, the results of this study will be highly informative for highlighting and implementing the putative beneficial role of music and NIBS in rehabilitation treatments. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05706831, registered on January 30, 2023.

Pragmatic Communication Deficit and Functional Outcome in Patients with Right- and Left-Brain Damage: A Pilot Study.

Pragmatic communication abilities refer to the capacity to use language in a social context. Despite evidence to the contrary, the left cerebral hemisphere of the majority of right handers has been considered exclusively specialized for control of language phonology, syntax and semantics, whereas the right hemisphere has been specialized for the control of language pragmatics. Many studies have shown the non-exclusivity of the left hemisphere for language skills. Communication deficits observed in these studies for patients with right hemisphere damage confirmed the necessity for integrity of the right hemisphere across a number of language components. The aim of this study is to investigate the specific role of the right and left hemispheres across several aspects of communication deficits, with particular attention given to the influence of these deficits on functional outcome. The second aim is to characterize possible correlations between pragmatic and other cognitive deficits. We evaluated 22 patients, 15 with left- and 7 with right-brain ischemic or hemorrhagic damage, using cognitive, pragmatic and language tests. We deployed the Right Hemisphere Language Battery-Santa Lucia and Montreal d'Evaluation de la Communication to assess pragmatic abilities. The results showed no statistically significant differences between patients with left- and right-brain damage, highlighting the importance of integration between the two hemispheres in the communication process. Multiple significant correlations were found between pragmatic abilities and cognitive tests assessing global cognitive functioning, pantomime expression and comprehension. Pragmatic deficits were also shown to correlate with functional cognitive outcome. It is important to assess pragmatic abilities in patients with cognitive deficits after both left and right stroke for tailoring neuropsychological intervention to mitigate pragmatic disabilities in functional outcomes.

The impact of cognitive function deficits and their recovery on functional outcome in subjects affected by ischemic subacute stroke: results from the Italian multicenter longitudinal study CogniReMo.

BACKGROUND: The recovery of independence in activities of daily living is a fundamental goal of rehabilitation programs in subjects affected by subacute stroke. Rehabilitation is focused both on motor and cognitive aspects, and some evidence has reported cognitive deficits as prognostic factors of motor recovery. However, rehabilitation is a dynamic process during which executive functions and motor functions should be improved. AIM: The aim of the study is to evaluate the relationships between impairments in cognitive functions and recovery of functional independence in stroke patients during the subacute phase. DESIGN: Multicenter observational study. SETTING: Intensive rehabilitation units. POPULATION: A sample of 319 stroke patients in subacute phase (70.6±11.6 years, 40.4% females), consecutively admitted from November 2019 to July 2021 at sixteen rehabilitation centers were enrolled in this observational, prospective and multicentric study with longitudinal assessments. METHODS: Cognitive and functional assessments were performed at hospital admission and discharge, including Oxford Cognitive Screen, modified Barthel Index, Functional Independent Measure, Fugl-Meyer assessment scale and National Institutes of Health Stroke Scale. RESULTS: A regression analysis identified five predictors (out of about 200 tested variables) of functional recovery related to four aspects assessed at admission: functional status (P<0.001), lower limb functioning (P=0.002), attention (P=0.011), and executive functions (P=0.017). Furthermore, patients who recovered deficits in executive functions had the same recovery of those without deficits, whereas those who maintained deficits had a smaller recovery (P=0.019). CONCLUSIONS: The relationship between cognitive and motor deficits is increasingly highlighted and the recovery of executive functions deficits seems to contribute to motor recovery. CLINICAL REHABILITATION IMPACT: Our results suggest that the recovery of executive functions may promote the recovery of the functional outcome of the patient with subacute stroke. Future treatment protocols may benefit from paying more attention to the recovery of executive functions.

Prevalence of Psychopathological Symptoms and Their Determinants in Four Healthcare Workers' Categories during the Second Year of COVID-19 Pandemic.

Highly stressful situations, such as the current COVID-19 pandemic, induce constant changes in the mental state of people who experience them. In the present study, we analyzed the prevalence of some psychological symptoms and their determinants in four different categories of healthcare workers during the second year of the pandemic. A total of 265 physicians, 176 nurses, 184 other healthcare professionals, and 48 administrative employees, working in different Italian healthcare contexts, answered a questionnaire including variables about their mental status and experience with the pandemic. The mean scores for anxiety and depressive symptoms measured more than one year after the onset of the pandemic did not reach the pathological threshold. In contrast, post-traumatic and burnout symptoms tended toward the critical threshold, especially in physicians. The main determinant of psychological distress was perceived stress, followed by job satisfaction, the impact of COVID-19 on daily work, and a lack of recreational activities. These results increase the knowledge of which determinants of mental distress would be important to act on when particularly stressful conditions exist in the workplace that persist over time. If well-implemented, specific interventions focused on these determinants could lead to an improvement in employee well-being and in the quality of care provided.

Effects of computer-based therapy versus therapist-mediated therapy in stroke-related aphasia: Pilot non-inferiority study.

PURPOSE: The burgeoning growth of computer-based rehabilitation technologies has led to a paradigm shift in the delivery of aphasia intervention. The aim of this study was to conduct a pilot non-inferiority study comparing computer-based training for people with aphasia versus traditional therapist-mediated training on language skills, functional communication and quality of life outcomes in the hospital setting. METHODS: Twenty-two fluent, monolingual Italian speakers with stroke-related aphasia in the acute phase of recovery were enrolled in the study. Participants were assigned randomly to computer-based or therapist-mediated aphasia treatment. Both groups received one, 50-minute session for 5 days per week over a period of 8 weeks. During the training, they were administered words and sentence comprehension, written naming, word completion, fluency, word and sentence reorganization tasks. The complexity of each task was increased progressively based on the severity of each person's language deficits. RESULTS: Participants in both computer-based and traditional therapist-mediated aphasia intervention showed significant gains in language skills, functional communication and quality of life from pre- to post-treatment. Statistically significant within-group differences were found across all outcome measures. In contrast, no significant between-group and group x time interaction effects were found across language skills, functional communication and quality-of-life measures. CONCLUSIONS: The overall pattern of findings suggested computer-based intervention was not inferior to traditional therapist-based intervention for enhancing functional communication deficits in stroke-related aphasia during the acute phase of recovery. A follow-up, fully-powered clinical trial is needed to confirm the reliability of these results.

The Italian validation of the Communicative Effectiveness Index Questionnaire: a multicentric study.

INTRODUCTION: Common assessment tools for aphasia evaluate single language impairments but not their functional impact on patient's communication skills in daily life. The lack of tools focused on ecological aspects might affect the choice of rehabilitative trainings. The Communicative Effectiveness Index (CETI) represents an attempt to assess the communicative abilities in "ecologic" context. This study aimed to explore psychometrics properties of the Italian translation and adaptation of CETI (I-CETI). METHODS: Sixty-eight patients with aphasia due to left hemispheric stroke admitted to post-acute rehabilitation units and their relatives were included in the study. Data were collected in three different sessions. At study entry, patients were assessed for language, depression, and functional abilities, while their caregivers and speech therapists independently completed the I-CETI to assess inter-rater agreement (baseline). One week later, caregivers and speech therapists completed again I-CETI, to assess test-retest reliability (T1). Last, at discharge, patients completed again the evaluation protocol, and caregivers and speech therapists completed I-CETI (T2). RESULTS: I-CETI showed high internal validity, excellent reliability, and good correlation between scores obtained by speech therapists and caregivers. Moreover, scores of I-CETI had quite good correlations with a traditional tool to assess language, and with measures of functional independence both at study entry and at discharge. DISCUSSION: I-CETI showed good psychometric proprieties. These results allowed considering I-CETI as a reliable tool to assess effects of speech treatments on the communicative abilities in patients with aphasia. Furthermore, I-CETI might help clinicians to develop treatments more tailored on the "ecologic" difficulties of patients.

Association Between Malnutrition and Outcomes in Patients With Severe Ischemic Stroke Undergoing Rehabilitation.

OBJECTIVE: To investigate the incremental prognostic significance of malnutrition in patients with severe poststroke disability. DESIGN: Retrospective cohort study. The patients were recruited from 3 specialized inpatient rehabilitation facilities. Nutritional status was assessed using the Prognostic Nutritional Index (PNI), which is calculated from serum albumin and total lymphocyte count. Scores >38 points reflect normal nutrition status, scores of 35-38 indicate moderate malnutrition, and scores <35 indicate severe malnutrition. The association of PNI categories with outcomes was assessed using multivariable regression analyses. SETTING: Inpatient rehabilitation facility. PARTICIPANTS: Patients (N=668) with ischemic stroke admitted to inpatient rehabilitation within 90 days from stroke occurrence and classified as Case-Mix Groups 0108, 0109, and 0110 of the current Medicare case-mix classification system. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Three outcomes were examined: (1) the combined outcome of transfer to acute care and death within 90 days from admission to rehabilitation; (2) 2-year mortality; and (3) FIM motor effectiveness, calculated as (FIM motor change/maximum FIM motor-admission FIM motor score)×100. RESULTS: Overall, the median time to rehabilitation admission was 18 days (range, 12-26 days). The prevalence of moderate and severe malnutrition was 12.7% and 11.5%, respectively. Ninety-one patients (13.6%) experienced the combined outcome. After adjusting for independent predictors including sex, atrial fibrillation, dysphagia, FIM cognitive score, and hemoglobin levels, neither moderate (P=.280) nor severe malnutrition (P=.482) were associated with the combined outcome. Similar results were observed when looking at 2-year mortality. Overall, FIM motor effectiveness was 30%±24%. After adjusting for independent predictors, severe malnutrition (ß coefficient -0.458±0.216; P=.034) was associated with FIM motor effectiveness. CONCLUSIONS: Approximately 1 in every 9 patients presented severe malnutrition. On top of the independent predictors, severe malnutrition did not provide additional prognostic information concerning risk of the combined outcome or 2-year mortality. Conversely, severe malnutrition was associated with poorer functional outcome as expressed by FIM motor effectiveness.

Attention Deficits in Stroke Patients: The Role of Lesion Characteristics, Time from Stroke, and Concomitant Neuropsychological Deficits.

Attention impairments are frequent in stroke patients with important consequences on the rehabilitation outcomes and quality of life. The aim of the study was to perform a comprehensive assessment of selective and intensive attention processes in a large population of brain-damaged patients, evaluating the influence of the side and site of the brain lesion, the time from stroke, and the concomitant presence of aphasia or neglect. We assessed 204 patients with a first unilateral brain lesion and 42 healthy individuals with three subtests of the Test of Attentional Performance (TAP): Alertness, Go-No Go, and Divided Attention. 44.4% of patients had an impairment in both intensive and selective aspects of attention, 5.6% had deficits only in the intensive component, and 31.8% had deficits only in selective tasks. More than 80% of the patients fell below the cut-off point on at least one task. Patients with a right hemispheric lesion (RHL) were more impaired than patients with a left hemispheric lesion (LHL) especially in tonic and phasic alertness. Patients with total anterior infarcts (TACI) presented the worst profile compared to other stroke subtypes, with a difference between total and lacunar subtypes in the Alertness test, independent of the presence of warning. Patients in the chronic phase had shorter RTs than acute patients only in the Alertness test. In patients with LHL, the presence of aphasia was associated with a greater deficit in selective attention. In patients with RHL, the presence of unilateral neglect was associated with impaired alertness and selective attention. Attention deficits are common after a unilateral first stroke. In keeping with the hierarchical organization of attention functions, results confirm the important role of the right hemisphere for the intensive components of attention, also highlighting the involvement of left hemisphere functioning for the selective aspects, possibly indicating a role of its linguistic functions.

Rehabilitation Outcomes of Patients With Severe Disability Poststroke.

OBJECTIVE: To characterize rehabilitation outcomes of patients with severe poststroke motor impairment (MI) and develop a predictive model for treatment failure. DESIGN: Retrospective cohort study. Correlates of treatment failure, defined as the persistence of severe MI after rehabilitation, were identified using logistic regression analysis. Then, an integer-based scoring rule was developed from the logistic model. SETTING: Three specialized inpatient rehabilitation facilities. PARTICIPANTS: Patients (N=1265) classified as case-mix groups (CMGs) 0108, 0109, and 0110 of the Medicare classification system. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Change in the severity of MI, as assessed by the FIM, from admission to discharge. RESULTS: Median FIM-motor (FIM-M) score increased from 17 (interquartile range [IQR] 14-23) to 38 (IQR, 25-55) points. Median proportional recovery, as expressed by FIM-M effectiveness, was 26% (IQR, 12-47). Median FIM-M change was 18 (IQR, 9-34) points. About 38.5% patients achieved the minimal clinically important difference. Eighteen point six percent and 32.0% of the patients recovered to a stage of either mild (FIM-M ≥62) or moderate (FIM-M 38-61) MI, respectively. All between-CMG differences were statistically significant. Outcomes have also been analyzed according to classification systems used in Australia and Canada. The scoring rule had an area under the curve of 0.833 (95% confidence interval, 0.808-0.858). Decision curve analysis displayed large net benefit of using the risk score compared with the treat all strategy. CONCLUSIONS: This study provides a snapshot of rehabilitation outcomes in a large cohort of patients with severe poststroke MI, thus filling a gap in knowledge. The scoring rule accurately identified the patients at risk for treatment failure.

Italian adaptation of the functional outcome questionnaire - aphasia: initial psychometric evaluation.

PURPOSE: To evaluate the psychometric properties of the Italian version of Functional Outcome Questionnaire - Aphasia. METHODS: Two hundred and five persons with stroke-related aphasia and right hemiparesis who received ongoing assistance from a family caregiver were assessed using the Functional Outcome Questionnaire - Aphasia, Aachener Aphasie Test, Token Test, Raven's Coloured Progressive Matrices, Functional Independence Measure (FIM), Functional Assessment Measure (FAM), and Quality of Life Questionnaire for Aphasics (QLQA). The Functional Outcome Questionnaire - Aphasia was translated into the Italian language using a translation and back-translation method. Reliability and construct validity of the Functional Outcome Questionnaire - Aphasia were evaluated. RESULTS: The Italian version of the Functional Outcome Questionnaire - Aphasia showed good internal consistency and test-retest reliability for the overall scale (α = 0.98; ICC = 0.95) and subscales (α = 0.89 for the communicating basic needs (CBN), α = 0.92 for the making routine requests (MRR), α = 0.96 for the communicating new information (CNI), α = 0.93 for the attention/other communication skills (AO); ICC = 0.95 for CBN, ICC = 0.96 for MRR, ICC = 0.97 for CNI and ICC = 0.92 for AO). Significant correlations were found between the Functional Outcome Questionnaire - Aphasia and Token Test, QLQA, Aachener Aphasie Test scores, and FAM linguistic scores, indicating good convergent validity. Low correlations were found between Functional Outcome Questionnaire - Aphasia and Raven's Coloured Progressive Matrices and FIM motor scores, showing good discriminant validity. CONCLUSIONS: The overall findings of this study supported the reliability and construct validity of the Italian version of the Functional Outcome Questionnaire - Aphasia. This measure holds considerable promise in assessing the functional outcomes of aphasia rehabilitation in Italian-speaking persons with aphasia. Implications for Rehabilitation Functional Outcome Questionnaire - Aphasia is a reliable and valid questionnaire in assessing functional communication of Italian-speaking people with aphasia. This measure provides critical information about people with aphasia's functional and pragmatic communication in home and community settings, contributing significantly to overall quality of life. Since the use of measures of functional communication is recommended in the clinical evaluation of language disease, the Italian version of Functional Outcome Questionnaire - Aphasia may be effective in tailoring rehabilitation treatment to the presenting communication problems of people with aphasia and their caregivers.

Effect of subtypes of neglect on functional outcome in stroke patients.

OBJECTIVE: Because of the loss of autonomy in daily-life activities, spatial neglect after stroke is one of the main causes of disability. According to the spatial domains, neglect can be divided into personal (body), peripersonal (reaching) and extrapersonal (far) space. We evaluated the effect of these subtypes of neglect on functional outcome of rehabilitation in stroke patients. METHODS: A total of 1350 stroke patients were consecutively admitted into our neurorehabilitation unit from 2002 to 2016. We analyzed data for patients with a first ischemic or hemorrhagic right-hemispheric stroke in this observational retrospective study. The presence of neglect was evaluated by using structured tests for specific spatial domains. Patients underwent individual physical and occupational therapy, and those with neglect received specific therapy for 8 consecutive weeks consisting of visual scanning, reading and copying, copying line drawings on a dot matrix and describing scenes. The Functional Independence Measure (FIM) instrument was administered at both admission and discharge to assess functional autonomy. Rehabilitation effectiveness for FIM (percentage of potential improvement achieved) was calculated. Multiple regression analyses were performed. RESULTS: Among 359 patients with right-brain damage, 130 showed left neglect, or unilateral spatial neglect (USN), and 229 only left hemiparesis, without neglect. Overall, 90 patients (69%) with USN showed peripersonal neglect, 89 (68%) extrapersonal neglect and 60 (46%) personal neglect. Functional motor and cognitive impairment was greater with than without USN as measured by FIM at admission and discharge and the rehabilitation hospital stay was longer. USN affected functional status at admission and rehabilitation effectiveness for FIM. Extrapersonal and peripersonal neglect significantly affected both function at admission and effectiveness. CONCLUSIONS: Our data confirm the negative prognostic effect of neglect on functional outcome in a large sample. We also show the importance of evaluating and training according to neglect subtype to improve functional independence.

Different Cognitive Profiles of Patients with Severe Aphasia.

Cognitive dysfunction frequently occurs in aphasic patients and primarily compromises linguistic skills. However, patients suffering from severe aphasia show heterogeneous performance in basic cognition. Our aim was to characterize the cognitive profiles of patients with severe aphasia and to determine whether they also differ as to residual linguistic abilities. We examined 189 patients with severe aphasia with standard language tests and with the CoBaGA (Cognitive Test Battery for Global Aphasia), a battery of nonverbal tests that assesses a wide range of cognitive domains such as attention, executive functions, intelligence, memory, visual-auditory recognition, and visual-spatial abilities. Twenty patients were also followed longitudinally in order to assess their improvement in cognitive skills after speech therapy. Three different subgroups of patients with different types and severity of cognitive impairment were evidenced. Subgroups differed as to residual linguistic skills, in particular comprehension and reading-writing abilities. Attention, reasoning, and executive functions improved after language rehabilitation. This study highlights the importance of an extensive evaluation of cognitive functions in patients with severe aphasia.

Efficacy of visual-scanning training and prism adaptation for neglect rehabilitation.

Unilateral spatial neglect consists of the inability of a patient to respond, orient, and attend to stimuli on the left side of a space following a right-hemisphere lesion. Many rehabilitation approaches have been proposed to reduce neglect. The aim of our study was to compare the effect of visual-scanning training (VST) and prismatic adaptation (PA) on patients with neglect following a right-hemisphere lesion. Twenty patients with left neglect were enrolled in the study. Before and after training, a comprehensive neuropsychological assessment of visuospatial abilities, evaluating personal, peripersonal, and extrapersonal neglect, was performed. After assessment, patients were alternately assigned to 1 of 2 groups, VST or PA. Both trainings consisted of 20 sessions, 1 per day, 5 days a week for 4 weeks. The results showed that both treatments improved patient neglect, especially in personal and peripersonal spaces. No difference between pretreatment and posttreatment was found in extrapersonal subscales. This finding could be due to the fact that there were no exercises requiring the use of objects within reach in either training. In conclusion, no difference between the 2 approaches was found, and both are useful rehabilitation techniques that appear to improve neglect.

A case of atypical progressive supranuclear palsy.

BACKGROUND: Progressive supranuclear palsy (PSP) is a neurodegenerative extrapyramidal syndrome. Studies have demonstrated that PSP can present clinically as an atypical dementing syndrome dominated by a progressive apraxia of speech (AOS) and aphasia. AIM: We aimed to investigate the clinical presentation of PSP, using a comprehensive multidimensional evaluation, and the disease response to various pharmacological treatments. METHODS: A 72-year-old right-handed male, with 17 years education, who first presented with aphasia, AOS, depression, apathy, and postural instability at 69 years; a complete neuropsychological evaluation, tapping the different cognitive domains, was performed. RESULTS: Testing revealed a moderate global cognitive deficit (Mini-Mental State Examination test score =20), low memory test scores (story recall, Rey's 15-word Immediate and Delayed Recall), and poor phonemic and semantic fluency. The patient's language was characterized by AOS, with slow speech rate, prolonged intervals between syllables and words, decreased articulatory accuracy, sound distortions, and anomia. Behavioral changes, such as depression, anxiety, apathy, and irritability, were reported. The neurological examination revealed supranuclear vertical gaze palsy, poor face miming, and a mild balance deficit. Magnetic resonance imaging showed only widespread cortical atrophy. Single photon emission computed tomography demonstrated left > right frontotemporal cortical abnormalities. After 6 months, a further neuropsychological assessment showed a progression in cognitive deficits, with additional attention deficits. The patient reported frequent falls, but the neurological deficits remained unchanged. Neuroimaging tests showed the same brain involvement. CONCLUSION: Our case highlights the heterogeneity of the clinical features in this syndrome, demonstrating that atypical PSP can present as AOS and aphasia, without the classical features or involvement of the subcortical gray and brainstem region, commonly affected in typical PSP.

Quality of life measurement and outcome in aphasia.

BACKGROUND: Quality of life (QL) can be defined as the individual's perception of their own well-being. Aphasia is the most important potential consequence of stroke and has a profound effect on a patient's life, causing emotional distress, depression, and social isolation, due to loss of language functions. AIMS: To draw up a QL questionnaire for aphasics (QLQA) focusing particularly on difficulties in interpersonal relationships and on the loss of independence as a result of language disorders. We reported the results of a psychometric evaluation of this measure. Moreover, we experimentally focused on the differences in QLQA between patients affected only by neurological motor impairment and hemiparetic patients with aphasia (PWA) in order to verify the specific role of aphasia on QL. We also explored if the QLQA is sensitive to the severity of aphasia and to the time elapsing from the stroke. METHODS: A total of 146 consecutive PWA and 37 control subjects were enrolled to evaluate the reliability (internal consistency and test-retest reliability) and validity of the QLQA, using standard psychometric methods. Patients were divided into acute (within 3 months since stroke) and chronic (beyond 3 months) groups, and into mild and severe according to the severity of aphasia. The experimental group of only acute PWA was compared to control subjects, with right hemispherical lesion and without aphasia in QLQA total and partial scores. RESULTS: The QLQA had good internal consistency and test-retest reliability. Acute and chronic PWA and mild and severe ones differed in QLQA total, communication, and autonomy subscales. No differences were found in psychological condition. Between aphasic and control patients, significant differences were found in all QLQA subscales. CONCLUSION: The QLQA is a valid measure of QL in PWA, contributing to a better distinction between severe and mild aphasia, and it is sensitive also to the variations in QL depending on the time interval from stroke.

Multiple system atrophy with early cognitive deficits: a case report.

We present the case of a patient with multiple system atrophy with predominant cerebellar ataxia (MSA-C) in the early stage of the disease, who was assessed using a comprehensive neuropsychological test battery. Many studies have found cognitive deficits in MSA patients assessed after 2-3 years, but not in the first stages of the disease. The aim of this paper is to stress the importance of a complete neuropsychological assessment, even at the initial stage of the disease, when instrumental examinations are not able to show cortical involvement and daily life activities have not been affected. The neuropsychological tests examined general cognition, verbal and visual memory, visuospatial and constructional ability, language, executive function, depression and functional autonomy. Results showed cognitive deficits in executive functions, above all in the control and inhibition of automatic response, planning and reasoning abilities, memory and visuoconstructional functions. However, these problems did not affect the patient's autonomy in everyday life. MRI scan showed the involvement of the cerebellum and the fibers of the pons and raphe, with normal cerebral ventricles and sulci. The cognitive deficits in our patient could be explained by a disruption in cerebrocerebellum connections between the frontal areas and the cerebellar structures. These results show that a more comprehensive cognitive evaluation is necessary to detect early the onset of neuropsychological deficits, also in order to begin in time adequate rehabilitation programs.

Neuropsychiatric symptoms and the APOE genotype in Alzheimer's disease.

The study aimed to characterize neuropsychiatric symptomatology in Alzheimer's disease (AD) and investigate the role of APOE genotype and other clinical variables in the onset of neuropsychiatric disorders. Moreover, an attempt to study the evolution of behavioral and psychiatric symptoms was made. Fifty-three consecutive outpatients with AD were enrolled. Twenty-four were followed longitudinally for 1 year. MMSE was used to evaluate cognitive functions. The neuropsychiatric inventory (NPI) was administered to assess behavioral and psychiatric symptoms. Genotyping was determined through laboratory testing. At baseline, no specific neuropsychiatric disorder was significantly associated with ApoE genotype, but associated with a peculiar neuropsychiatric profile. Patients with epsilon(4) allele showed a wider range of neuropsychiatric disturbances when compared to non-carriers and higher scores for hallucinations and aberrant motor behaviors. The longitudinal results suggest different trends in both groups: over time, epsilon(4) carriers showed an increase/delayed onset in some symptoms and a parallel decrease in others, while non-carriers presented an undifferentiated worsening of symptomatology. Clear relations with other clinical and demographic variables were also found. APOE epsilon(4) allele is associated to a peculiar neuropsychiatric profile characterizing the onset and evolution of Alzheimer's disease.

Influence of nutritional status on cognitive, functional and neuropsychiatric deficits in Alzheimer's disease.

Nutrition is an important issue for elderly people, especially in patients with dementia. It is also related to clinical outcome, such as cognition, autonomy and behavior. The present study investigated the role of nutritional status on cognitive, functional and neuropsychiatric deficits in patients with Alzheimer's disease (AD). Forty-nine patients underwent neuropsychological, nutritional and neuropsychiatric assessments. The sample was divided into at risk of malnutrition (21 patients) and well-nourished (28 patients) according to the Mini Nutritional Assessment (MNA) score. The groups were similar for clinical and demographic variables, except for MNA score and age. The mean body mass index (BMI) was higher than the normal range. Patients at risk of malnutrition showed greater impairment, both in simple and instrumental activities of daily living (ADL and IADL) and a more severe ideomotor praxis deficit than well-nourished patients. Neuropsychiatric symptoms showed significant differences in hallucination, apathy, aberrant motor behavior and night-time subscales of Neuropsychiatric Inventory (NPI). These symptoms were more severe in patients at risk of malnutrition. Logistic regression analysis showed that malnutrition was an important risk factor for the onset of apathy. We hypothesized that changes in dietary habits and intake and the onset of these disorders reflect the involvement of a common neuroanatomical network.