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Telehealth and telemedicine have encountered explosive growth since the beginning of the COVID-19 pandemic, resulting in increased access to care for patients located far from medical centers and clinics. Subspecialty clinicians in behavioral neurology & neuropsychiatry (BNNP) have implemented the use of telemedicine platforms to perform cognitive examinations that were previously office based. In this perspective article, BNNP clinicians at Massachusetts General Hospital (MGH) describe their experience performing cognitive examinations via telemedicine. The article reviews the goals, prerequisites, advantages, and potential limitations of performing a video- or telephone-based telemedicine cognitive examination. The article shares the approaches used by MGH BNNP clinicians to examine cognitive and behavioral areas, such as orientation, attention and executive functions, language, verbal learning and memory, visual learning and memory, visuospatial function, praxis, and abstract abilities, as well as to survey for neuropsychiatric symptoms and assess activities of daily living. Limitations of telemedicine-based cognitive examinations include limited access to and familiarity with telecommunication technologies on the patient side, limitations of the technology itself on the clinician side, and the limited psychometric validation of virtual assessments. Therefore, an in-person examination with a BNNP clinician or a formal in-person neuropsychological examination with a neuropsychologist may be recommended. Overall, this article emphasizes the use of standardized cognitive and behavioral assessment instruments that are either in the public domain or, if copyrighted, are nonproprietary and do not require a fee to be used by the practicing BNNP clinician.
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COVID-19 , Neurologia , Neuropsiquiatria , Telemedicina , Humanos , Hospitais Gerais , Pandemias , Atividades Cotidianas , Massachusetts , CogniçãoRESUMO
Many returning military service members and veterans who were deployed following the September 11, 2001, terrorist attacks (9/11) suffer from posttraumatic stress disorder (PTSD) and insomnia. Although intensive treatment programs for PTSD have shown promise in the treatment of PTSD symptoms, recent research has demonstrated that sleep disturbance shows little improvement following intensive trauma-focused treatment. The aim of the present study was to evaluate changes in self-reported insomnia symptoms among veterans and service members following participation in a 2-week intensive program for PTSD. We further aimed to investigate if residual PTSD symptoms, specifically hyperarousal, were associated with residual insomnia symptoms. Participants (N = 326) completed self-report assessments of insomnia, PTSD symptoms, and depressive symptoms at pre- and posttreatment. At pretreatment, 73.9% of participants (n = 241) met the criteria for moderate or severe insomnia, whereas at posttreatment 67.7% of participants (n = 203) met the criteria. Results of paired t tests demonstrated statistically significant differences between pre- and posttreatment Insomnia Severity Index scores; however, the effect size was small, d = 0.34. Analyses revealed that posttreatment hyperarousal symptoms were associated with posttreatment insomnia. These findings suggest that although an intensive program for service members and veterans with PTSD may significantly reduce insomnia symptoms, clinically meaningful residual insomnia symptoms remain. Further research is warranted to elucidate the association between residual hyperarousal and insomnia symptoms following intensive trauma-focused treatment.
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Distúrbios do Início e da Manutenção do Sono , Transtornos de Estresse Pós-Traumáticos , Veteranos , Nível de Alerta , Progressão da Doença , Humanos , Pacientes Ambulatoriais , Distúrbios do Início e da Manutenção do Sono/complicações , Distúrbios do Início e da Manutenção do Sono/terapia , Transtornos de Estresse Pós-Traumáticos/complicações , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/terapiaRESUMO
OBJECTIVE: Approximately 5%-20% of U.S. troops returning from Iraq and Afghanistan have posttraumatic stress disorder (PTSD), and another 11%-23% have traumatic brain injury (TBI). Cognitive-behavioral therapies (CBTs) are empirically validated treatment strategies for PTSD. However, cognitive limitations may interfere with an individual's ability to adhere to as well as benefit from such therapies. Comorbid TBI has not been systematically taken into consideration in PTSD outcome research or in treatment planning guidance. The authors hypothesized that poorer pretreatment cognitive abilities would be associated with poorer treatment outcomes from CBTs for PTSD. METHODS: This study was designed as a naturalistic examination of treatment as usual in an outpatient clinic that provides manualized CBTs for PTSD to military service members and veterans. Participants were 23 veterans, aged 18-50 years, with combat-related PTSD and a symptom duration of more than 1 year. Of these, 16 participants had mild TBI (mTBI). Predictor variables were well-normed objective tests of cognitive ability measured at baseline. Outcome variables were individual slopes of change of the PTSD Checklist for DSM-5 (PCL-5) and the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) over weeks of treatment, and of pretreatment-to-posttreatment change in PCL-5 and CAPS-5 (ΔPCL-5 and ΔCAPS-5, respectively). RESULTS: Contrary to prediction, neither pretreatment cognitive performance nor the presence of comorbid mTBI predicted poorer response to CBTs for PTSD. CONCLUSIONS: These results discourage any notion of excluding patients with PTSD and poorer cognitive ability from CBTs.
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Concussão Encefálica/epidemiologia , Cognição , Terapia Cognitivo-Comportamental , Disfunção Cognitiva/epidemiologia , Avaliação de Resultados em Cuidados de Saúde , Transtornos de Estresse Pós-Traumáticos/terapia , Adolescente , Adulto , Distúrbios de Guerra/epidemiologia , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Militares , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Veteranos , Adulto JovemRESUMO
Coronavirus 2019 (COVID-19) has profoundly impacted the well-being of society and the practice of medicine across health care systems worldwide. As with many other subspecialties, the clinical paradigm in behavioral neurology and neuropsychiatry (BN-NP) was transformed abruptly, transitioning to real-time telemedicine for the assessment and management of the vast majorities of patient populations served by our subspecialty. In this commentary, we outline themes from the BN-NP perspective that reflect the emerging lessons we learned using telemedicine during the COVID-19 pandemic. Positive developments include the ability to extend consultations and management to patients in our high-demand field, maintenance of continuity of care, enhanced ecological validity, greater access to a variety of well-reimbursed telemedicine options (telephone and video) that help bridge the digital divide, and educational and research opportunities. Challenges include the need to adapt the mental state examination to the telemedicine environment, the ability to perform detailed motor neurologic examinations in patients where motor features are important diagnostic considerations, appreciating nonverbal cues, managing acute safety and behavioral concerns in less controlled environments, and navigating intervention-based (neuromodulation) clinics requiring in-person contact. We hope that our reflections help to catalyze discussions that should take place within the Society for Behavioral and Cognitive Neurology, the American Neuropsychiatric Association, and allied organizations regarding how to optimize real-time telemedicine practices for our subspecialty now and into the future.
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Betacoronavirus , Infecções por Coronavirus , Doenças do Sistema Nervoso/diagnóstico , Exame Neurológico , Pandemias , Pneumonia Viral , Telemedicina/organização & administração , COVID-19 , Humanos , Massachusetts , Neurologia , Neuropsiquiatria , SARS-CoV-2RESUMO
OBJECTIVE: This study examined whether objectively measured pretreatment cognitive impairment predicted worse response to treatment for posttraumatic stress disorder. Participants were 113 veterans and active duty service members who participated in a new multidisciplinary 2-week intensive clinical program that included individual trauma-focused cognitive-behavioral therapy, group psychotherapy, psychoeducation, skills-building groups, and complementary and alternative medicine treatments (mean age: 39.7 years [SD=8.5]; 20% women). METHODS: Prior to treatment, participants completed a brief computerized cognitive battery (CNS Vital Signs) and were operationalized as having cognitive impairment if they scored in the ≤5th percentile on two or more of five core cognitive domains. Participants completed measures of traumatic stress, depression, cognitive self-efficacy, and satisfaction with their ability to participate in social roles before and after treatment. RESULTS: There were no significant correlations between pretreatment individual cognitive test scores and change in the clinical outcome measures. One-half of the study sample (49.6%) met criteria for cognitive impairment. In a mixed multivariate analysis of variance, the interaction between cognitive impairment and time was not significant (F=0.83, df=4, 108, p=0.51), indicating that the pre- to posttreatment changes in outcome scores were not significantly different for the cognitively impaired group compared with the cognitively intact group. The multivariate main effect for time was significant (F=36.75, df=4, 108, p<0.001). Follow-up univariate tests revealed significant improvement in traumatic stress, depression, cognitive self-efficacy, and satisfaction with social roles after treatment. CONCLUSIONS: Cognitive impairment was not associated with worse response to treatment in veterans with severe and complex mental health problems. Veterans with and without cognitive impairment reported large improvements in symptoms and functioning after treatment.
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Disfunção Cognitiva/terapia , Militares/estatística & dados numéricos , Ataques Terroristas de 11 de Setembro , Transtornos de Estresse Pós-Traumáticos/terapia , Veteranos/estatística & dados numéricos , Adulto , Terapia Cognitivo-Comportamental , Feminino , Humanos , Masculino , Testes Neuropsicológicos/estatística & dados numéricos , Avaliação de Resultados em Cuidados de SaúdeRESUMO
The authors examined 28 dementia inpatients receiving treatment as usual. Beginning-to-end differences in neuropsychiatric symptoms and actigraphic sleep patterns were measured. Using a mixed-model, the authors regressed neuropsychiatric symptoms on average sleep minutes (between-subjects effect) and each night's deviation from average (within-subject effect). Sleep did not significantly differ from beginning to end of participation, whereas neuropsychiatric symptoms did. Average sleep minutes predicted average neuropsychiatric symptoms (p=0.002), but each night's deviation from the average did not predict next day's symptoms (p=0.90). These findings raise questions about the immediate benefits of treating sleep-wake disturbances on neuropsychiatric symptoms in hospitalized inpatients with dementias.
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Demência/psicologia , Demência/terapia , Hospitalização , Sono , Actigrafia , Idoso de 80 Anos ou mais , Demência/fisiopatologia , Feminino , Humanos , Pacientes Internados , Masculino , Escalas de Graduação Psiquiátrica , Análise de Regressão , Sono/fisiologiaRESUMO
Seventy-three women with posttraumatic stress disorder (PTSD) resulting from rape or physical assault participated in a loud-tone procedure, while skin conductance (SC), heart rate, and electromyogram responses were recorded. Pearson correlations were examined between each psychophysiological response and Clinician-Administered PTSD Scale (CAPS) symptom scores. Significant correlations were adjusted for each remaining individual PTSD symptom score. Heart rate response (HRR) significantly correlated with CAPS total score and with CAPS nightmares. The relationship between HRR and nightmares remained significant after controlling for each of the other 16 individual PTSD symptoms, for the remaining reexperiencing cluster, and for CAPS total score. The zero-order correlations between SC response and nightmares and between electromyography response and nightmares were both not significant. The association of nightmares with larger HRR in the absence of an association with larger SC response likely reflects reduced parasympathetic tone. Thus, our findings indirectly support a role for reduced parasympathetic tone in PTSD nightmares.
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Doenças do Sistema Nervoso Autônomo/fisiopatologia , Vítimas de Crime , Sonhos/fisiologia , Frequência Cardíaca/fisiologia , Transtornos do Sono-Vigília/fisiopatologia , Transtornos de Estresse Pós-Traumáticos/fisiopatologia , Violência , Adulto , Doenças do Sistema Nervoso Autônomo/etiologia , Eletromiografia , Feminino , Resposta Galvânica da Pele , Humanos , Pessoa de Meia-Idade , Estupro , Transtornos do Sono-Vigília/etiologia , Transtornos de Estresse Pós-Traumáticos/complicações , Adulto JovemRESUMO
This study evaluated the degree of mixed-handedness in predominantly right-handed Vietnam combat veteran twins and their identical, combat-unexposed cotwins. The "high-risk" cotwins of combat veterans with combat-related posttraumatic stress disorder (PTSD) had more mixed-handedness (i.e., less right-handedness) than the "low-risk" cotwins of combat veterans without PTSD. Self-reported combat exposure in combat-exposed twins was a mediator of the association between handedness in their unexposed cotwins and PTSD in the twins themselves. We conclude that mixed-handedness is a familial risk factor for combat-related PTSD. This risk may be mediated in part by a proclivity for mixed-handed soldiers and Marines to experience heavier combat.
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Lateralidade Funcional/genética , Transtornos de Estresse Pós-Traumáticos/genética , Transtornos de Estresse Pós-Traumáticos/psicologia , Gêmeos Monozigóticos/genética , Veteranos/psicologia , Guerra do Vietnã , Distúrbios de Guerra/diagnóstico , Distúrbios de Guerra/genética , Distúrbios de Guerra/psicologia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Transtornos de Estresse Pós-Traumáticos/diagnósticoRESUMO
PRIMARY OBJECTIVE: To summarize the literature on post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) and their co-morbidity, focusing on diagnosis, clinical symptoms and treatment issues relevant to the clinician. RESEARCH DESIGN: Review of the literature. METHODS AND PROCEDURES: Pubmed searches were performed using the terms post-traumatic stress disorder, traumatic brain injury, sleep, cognitive, depression, anxiety, treatment and combinations of these terms. Those articles relevant to the objective were included. MAIN OUTCOMES AND RESULTS: This study presents pathophysiological, neuroimaging and clinical data on co-morbid PTSD and TBI. It reviews associated conditions, emphasizing the impact of cognitive and sleep problems. It summarizes the emerging literature on treatment effectiveness for co-morbid PTSD and TBI, including psychotherapy, pharmacotherapy and cognitive rehabilitation. CONCLUSIONS: Both PTSD and TBI commonly occur in the general population, both share some pathophysiological characteristics and both are associated with cognitive impairment and sleep disruption. PTSD and TBI present with a number of overlapping symptoms, which can lead to over-diagnosis or misdiagnosis. Both conditions are associated with co-morbidities important in diagnosis and treatment planning. More research is needed to elucidate what treatments are effective in PTSD and TBI co-morbidity and on factors predictive of treatment success.
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Lesões Encefálicas/diagnóstico , Lesões Encefálicas/terapia , Transtornos Cognitivos/epidemiologia , Terapia Cognitivo-Comportamental , Distúrbios de Guerra/diagnóstico , Transtornos do Sono-Vigília/epidemiologia , Transtornos de Estresse Pós-Traumáticos/diagnóstico , Transtornos de Estresse Pós-Traumáticos/terapia , Lesões Encefálicas/epidemiologia , Lesões Encefálicas/fisiopatologia , Fator Neurotrófico Derivado do Encéfalo/sangue , Transtornos Cognitivos/diagnóstico , Transtornos Cognitivos/terapia , Terapia Cognitivo-Comportamental/métodos , Distúrbios de Guerra/epidemiologia , Distúrbios de Guerra/fisiopatologia , Comorbidade , Diagnóstico Diferencial , Feminino , Neuroimagem Funcional , Humanos , Masculino , Militares/estatística & dados numéricos , Plasticidade Neuronal , Transdução de Sinais , Transtornos do Sono-Vigília/diagnóstico , Transtornos do Sono-Vigília/terapia , Transtornos de Estresse Pós-Traumáticos/epidemiologia , Transtornos de Estresse Pós-Traumáticos/fisiopatologia , Resultado do Tratamento , Estados UnidosRESUMO
Posttraumatic stress disorder (PTSD) is a debilitating condition affecting military populations, with a higher prevalence compared to the general population. Despite the development of first-line trauma-focused treatments such as Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE), a significant proportion of patients continue to experience persistent PTSD symptoms following treatment. This study utilized network analysis to explore the PTSD symptom network's dynamics pre- and post- trauma-focused treatment and investigated the role of military sexual trauma (MST) history in shaping the network. Network analysis is a novel approach that can guide treatment target areas. The sample was comprised of 1648 service members and veterans who participated in a two-week intensive PTSD treatment program, which included completion of evidenced-based individual therapy as well as skill-building focused group therapy. PTSD severity was assessed using the PTSD Checklist for DSM-5 at baseline and post-treatment. Network analyses revealed strong connections within symptom clusters, with negative emotions emerging as one of the most central symptoms. Interestingly, the symptom network's overall structure remained stable following treatment, whereas global strength significantly increased. MST history did not significantly impact the network's structure or its change relative to treatment. Future research should further examine whether targeting negative emotions optimizes PTSD treatment outcomes for military populations.
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Militares , Trauma Sexual Militar , Transtornos de Estresse Pós-Traumáticos , Veteranos , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto Jovem , Terapia Cognitivo-Comportamental/métodos , Estudos Longitudinais , Militares/psicologia , Militares/estatística & dados numéricos , Trauma Sexual Militar/terapia , Transtornos de Estresse Pós-Traumáticos/terapia , Veteranos/psicologia , Veteranos/estatística & dados numéricosRESUMO
The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Prim Care Companion CNS Disord 2024;26(3):23f03667. Author affiliations are listed at the end of this article.
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Lesões Encefálicas Traumáticas , Humanos , Lesões Encefálicas Traumáticas/terapia , Lesões Encefálicas Traumáticas/diagnóstico , Lesões Encefálicas Traumáticas/complicações , Transtornos Mentais/terapia , Transtornos Mentais/diagnósticoRESUMO
In 2009, Massachusetts General Hospital and the Red Sox Foundation launched Home Base, a nonprofit dedicated to providing care to veterans, service members, and their loved ones who struggle with the invisible wounds of war free of charge. Significant needs exist for mental health services in each of these populations, and a need for innovative approaches to address shortcomings in existing treatment models. Three inventive components of our programming are highlighted herein: a Veteran Outreach Team, which helps to engage patients in care, programming, and services specifically for family members, and an intensive outpatient substance use treatment program. More than 4,000 patients, 3,031 veterans and service members, and 1,025 family members have engaged in treatment at Home Base. Patients were asked to complete post-treatment self-measures, including a satisfaction questionnaire via an electronic data collection system. The vast majority of individuals who engaged in our treatment model were satisfied with the care they received (>92%) and would refer their peers to the Home Base program (>75%). Data from 78 individuals who completed the dual diagnosis services demonstrated large effect sizes in reductions in alcohol use and comorbid mental health symptoms. These data suggest that novel components to the standard outpatient mental health model might provide substantive benefits for the patients served. While internal data is prone to a lack of generalizability, these additional offerings help ameliorate patients' expressed shortcomings with existing models; present literature that describes the benefits that these additions provide is also reviewed. The lessons learned and limitations are discussed.
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Posterior circulation infarctions (PCI) constitute 5-25% of ischemic strokes. PCI of the occipital lobe present with a panoply of symptoms including quadrantanopsia, topographical disorientation, and executive dysfunction. Long-term cognitive recovery after PCI is not well described. However, the adult brain is remarkably plastic, capable of adapting and remodeling. We describe a 43-year-old right-handed woman who complained of black spots in both eyes, headaches, photophobia, and a feeling she would faint. Initial neurological exam and a CT scan were normal; she was diagnosed with ocular migraine. A second neurological exam a week later showed left superior quadrantopsia; an MRI scan suggested right occipito-temporal infarct. In subsequent months, the patient complained of fatigue, quadrantanopsia, memory problems, and topographical disorientation. The patient participated in multi-modality treatment, and in self-directed arts projects and physical activities. Six years later, she reported noticeable improvements in cognition and daily functioning, which were documented on neurocognitive testing. Comparison between initial and subsequent MRIs using FreeSurfer 5.3 identified neuroplastic brain changes in areas serving similar functions to the areas injured from the stroke. The case illustrates the neuropsychiatric presentation after right occipito-temporal stroke, the value of formal and self-directed cognitive rehabilitation, the extended time to cognitive recovery, and the ability of the brain to undergo neuroplastic changes.
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Hemianopsia , Lobo Occipital , Adulto , Feminino , Humanos , Infarto , Imageamento por Ressonância Magnética , Transtornos da Memória , Lobo Occipital/diagnóstico por imagemRESUMO
OBJECTIVE: While the comparative efficacy of prolonged exposure (PE) and cognitive processing therapy (CPT) has been examined in outpatient settings, there is a dearth of literature on the relative effectiveness of these interventions when adapted for an intensive treatment format. In an expanded secondary analysis of a previous study, we sought to examine the comparative effectiveness of PE and CPT delivered in the naturalistic setting of an intensive treatment format including maintenance of outcomes through a 6-month follow-up period. METHOD: A sample of 296 veterans with posttraumatic stress disorder (PTSD) received either PE (n = 186) or CPT (n = 90), alongside other trauma-informed interventions, in a 2-week intensive clinical program. Treatment selection was determined collaboratively between patient and therapist. Our primary outcome was self-reported PTSD symptom severity (i.e., PTSD Checklist for DSM-5, PCL-5); secondarily, we examined self-reported depression (i.e., Patient Health Questionnaire) symptom severity outcomes. RESULTS: A mixed-model regression controlling for age and gender revealed a significant effect of time from baseline to endpoint (p < .001), 3-month (p < .001), and 6-month follow-up (p < .001) on PCL-5 scores but no significant effect of treatment or effect of treatment by time interaction (all ps > .05; model: Wald's χ² = 232.38, p < .001). Results were similar for depression outcomes. Attrition at posttreatment was not significantly different between groups: 7.2% for CPT and 6.5% PE (z score = 0.22). CONCLUSIONS: Both PE and CPT are associated with comparable improvements when delivered as part of a 2-week intensive outpatient program. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Terapia Cognitivo-Comportamental , Militares , Transtornos de Estresse Pós-Traumáticos , Veteranos , Terapia Cognitivo-Comportamental/métodos , Manual Diagnóstico e Estatístico de Transtornos Mentais , Humanos , Processos Mentais , Transtornos de Estresse Pós-Traumáticos/psicologia , Transtornos de Estresse Pós-Traumáticos/terapia , Veteranos/psicologiaRESUMO
Hypnosis has primarily been used to treat individual problems. Occasionally, it has been applied to couples' problems such as infertility. We present a transcript of a treatment session of Dr. Milton Erickson in which he works with a married couple and interpret his techniques. We emphasize the following principles. Dr. Erickson's assessment was brief, just long enough to determine a general target. He used hypnotic induction to build responsiveness. He used evocative communication. He seeded ideas that, when presented later, had a powerful impact. He moved in small, strategic steps. The main intervention was designed to elicit dormant resources and adaptive states. He followed through, providing suggestions on how to use these resources. In presenting this case and our analysis of it, we highlight some of Dr. Erickson's methods and conceptualization of several intervention techniques.
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Hipnose , Terapia Conjugal , Comunicação , Feminino , Humanos , Hipnose/métodos , Masculino , Terapia Conjugal/métodos , Disfunções Sexuais Psicogênicas/psicologia , Disfunções Sexuais Psicogênicas/terapiaRESUMO
Wernicke's encephalopathy and Korsakoff's psychosis in alcoholics are thought to be due to thiamine deficiency. When the process goes untreated, patients may develop alcohol-induced persisting dementia. We review the literature on thermal dysregulation and the place of thiamine treatment in Wernicke's encephalopathy, Korsakoff's psychosis, and alcohol-induced persisting dementia. We describe a patient with alcohol-induced persisting dementia who showed thermal dysregulation which responded to parenteral but not oral thiamine. Subsequently, he developed aspiration pneumonia with associated fever reaction and expired. We describe the neuroimaging findings--diffuse cortical atrophy, ventricular dilatation, atrophy of the corpus callosum, hypothalamus, and medulla, and a probable arachnoid cyst in the left temporal tip. We conclude that thermal dysregulation was likely related to dysfunction of temperature regulatory brain centers, that thermal dysregulation was stabilized with parenteral but not oral thiamine, and that parenteral thiamine may have a role even in chronic cases of alcohol-induced persisting dementia.
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Alcoolismo/complicações , Demência/patologia , Deficiência de Tiamina/tratamento farmacológico , Tiamina/uso terapêutico , Idoso , Atrofia , Regulação da Temperatura Corporal/efeitos dos fármacos , Córtex Cerebral/patologia , Demência/etiologia , Demência/fisiopatologia , Evolução Fatal , Febre/tratamento farmacológico , Febre/etiologia , Febre/fisiopatologia , Humanos , Hipotálamo/patologia , Imageamento por Ressonância Magnética , Masculino , Tiamina/administração & dosagem , Deficiência de Tiamina/etiologia , Complexo Vitamínico B/administração & dosagem , Complexo Vitamínico B/uso terapêuticoRESUMO
Frontotemporal dementia (FTD) is second only to Alzheimer's disease in individuals younger than 65 years of age. Behavioral variant FTD (bvFTD) presents with nonspecific symptoms such as disinhibition, apathy, or emotional blunting. Although neuropsychological testing and structural neuroimaging are not very helpful in diagnosing bvFTD in its initial stages, newer quantitative structural methods and functional neuroimaging have better sensitivity and specificity. Ms L presented with blunted affect, disinhibition, impairments in insight, planning ability and social comportment, changed dietary habits, and episodes of mutism. Her brain magnetic resonance imaging was normal whereas her single-photon emission computed tomography (SPECT) pattern was consistent with FTD. Her clinical presentation was consistent with bvFTD yet both the symptoms and SPECT findings reversed after 2 years of follow-up. We suggest that Ms L had a reversible phenotypic and brain function equivalent of bvFTD. The case highlights the limitations of our diagnostic tools and the complex relationship between clinical symptoms, neuroimaging, and etiology.
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Encéfalo/patologia , Demência Frontotemporal/diagnóstico , Interpretação de Imagem Assistida por Computador , Neuroimagem , Tomografia Computadorizada de Emissão de Fóton Único , Encéfalo/fisiopatologia , Feminino , Demência Frontotemporal/fisiopatologia , Humanos , Processamento de Imagem Assistida por Computador , Pessoa de Meia-Idade , Testes NeuropsicológicosRESUMO
Creutzfeldt-Jakob disease (CJD) is a rapidly progressive neurodegenerative disease caused by prions. Typically CJD presents with a triad of rapidly progressive dementia, abnormal movements (e.g., myoclonus) and electroencephalographic (EEG) changes. Recently, CJD has been subdivided into subtypes based on host genetic polymorphisms and the characteristics of the pathological prion protein. Different subtypes likely have different clinical and laboratory presentations. We describe a case of sporadic CJD of the VV1 subtype. We describe our patient's clinical symptoms, time course, laboratory workup, structural and functional neuroimaging data, EEG data and CJD biomarkers. Our patient presented with clinical symptoms atypical for CJD. Because of that, her clinical symptoms were initially attributed to psychiatric reasons. After extensive clinical and laboratory investigation, we concluded that the patient probably had CJD. Postmortem neuropathological results confirmed this clinical hypothesis. We compare our patient's clinical, laboratory and neuroimaging data to the data on typical CJD as well as the data on the few CJD VV1 cases described in the literature. We discuss our case's relevance to the diagnosis of CJD.
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Encéfalo/patologia , Encéfalo/fisiopatologia , Síndrome de Creutzfeldt-Jakob/diagnóstico , Demência/etiologia , Espasticidade Muscular/etiologia , Príons/metabolismo , Adulto , Síndrome de Creutzfeldt-Jakob/complicações , Síndrome de Creutzfeldt-Jakob/fisiopatologia , Demência/diagnóstico , Demência/fisiopatologia , Diagnóstico Diferencial , Eletroencefalografia , Evolução Fatal , Feminino , Hipocampo/patologia , Hipocampo/fisiopatologia , Humanos , Imageamento por Ressonância Magnética , Espasticidade Muscular/fisiopatologia , Príons/genéticaAssuntos
Antipsicóticos/efeitos adversos , Transtorno Bipolar/tratamento farmacológico , Eletrocardiografia/efeitos dos fármacos , Haloperidol/efeitos adversos , Síndrome do QT Longo/induzido quimicamente , Idoso , Antipsicóticos/uso terapêutico , Aripiprazol , Bloqueio de Ramo/complicações , Terapia Combinada , Comportamento Cooperativo , Eletroconvulsoterapia , Feminino , Haloperidol/uso terapêutico , Humanos , Comunicação Interdisciplinar , Piperazinas/uso terapêutico , Quinolonas/uso terapêutico , Fatores de Risco , Torsades de Pointes/induzido quimicamente , Torsades de Pointes/prevenção & controleRESUMO
Traumatic brain injury (TBI) is a serious health risk for older adults, and the consequences of TBI range from full recovery to death. For many who survive, there is a legacy of cognitive, physical, and emotional disability. Falls are the major cause of head injury in older adults. There are many risk factors including pre-existing brain disease, other diseases, and, sometimes, iatrogenic factors. Efforts directed at prevention are of great importance. Outcome studies indicate that outcome is generally worse for older people than for younger people with similar injuries, but older individuals also deserve aggressive rehabilitation directed at the best possible recovery. This review will discuss the symptoms and syndromes that commonly result from TBI with comments about treatment.