Protecting the Health and Finances of the Elderly With Early Cognitive Impairment.

The projected expansion of the nation's elderly population necessitates the revision of health care and policy strategies for safeguarding the health and assets of this community. The elderly are at greatly increased risk for developing mild cognitive impairment and Alzheimer's disease. These conditions are associated with diminished complex decision-making abilities that adversely affect patients, their families, and society, even during early stages of Alzheimer's disease. We present three composite patient histories that demonstrate problems routinely encountered by families, health care providers, and legal professionals during the course of early AD and MCI. We review the prevalence of cognitive and behavioral symptoms associated with MCI and early AD. Obstacles to early detection of cognitive decline, limitations of current testing modalities and benefits of earlier detection are discussed. Central themes common to medical and judicial approaches toward capacity assessment are discussed. We argue that an emphasis on earlier detection will result in benefits for patient health and result in financial savings to patients and the country as a whole. Finally, we recommend national guidelines for the evaluation of task-specific decision-making capacities to reduce the variability of outcome and improve quality of evaluations found among medical professionals, forensic evaluators, and legal actors.

Retrospective Analysis of the Short-Term Safety of ECT in Patients With Neurological Comorbidities: A Guide for Pre-ECT Neurological Evaluations.

Pre-ECT neurology consultations are often requested to determine the relative risk of the procedure in patients with neurological comorbidities, but there is limited data to guide clinicians. The authors performed a retrospective chart review of all consecutive inpatients at McLean Hospital who underwent a pre-ECT neurological evaluation between January 2012 and June 2014 (N=68). ECT was safe and effective in patients with a wide variety of neurological diseases. Only one minor event was related to a neurological comorbidity, and there were no serious neurological complications. Based on the latest evidence, the authors provide guidance on the pre-ECT evaluation with respect to neurologic status.

Bapineuzumab and solanezumab for Alzheimer's disease: is the 'amyloid cascade hypothesis' still alive?

INTRODUCTION: The 'amyloid cascade hypothesis' remains the leading hypothesis to explain the pathophysiology of Alzheimer's disease (AD). Immunotherapeutic agents have been developed to remove the neurotoxic amyloid ß42 protein and prevent the hypothesized amyloid ß42-induced neurotoxicity and neurodegeneration. The most notable of these immunotherapies are bapineuzumab and solanezumab. AREAS COVERED: This article briefly reviews the experimental agents in development for treatment of AD and then discusses the results of bapineuzumab and solanezumab in AD patients, as reported in preclinical studies, clinical trials and press releases. EXPERT OPINION: Phase III trials showed that bapineuzumab failed to improve cognitive and functional performances in AD patients, and was associated with a high incidence of amyloid-related imaging abnormalities (ARIA). Solanezumab's two Phase III trials in AD patients failed to meet endpoints when analyzed independently. However, analysis of pooled data from both trials showed a significant reduction in cognitive decline in mild AD patients. The improvement was associated with an increase in plasma amyloid-ß (Aß) levels and a low incidence of ARIA in solanezumab-treated patients. The marginal benefits of solanezumab are encouraging to support continued evaluation in future studies, and offer small support in favor of the ongoing viability of the 'amyloid cascade hypothesis' of AD.

The role of psychotic disorders in religious history considered.

The authors have analyzed the religious figures Abraham, Moses, Jesus, and St. Paul from a behavioral, neurologic, and neuropsychiatric perspective to determine whether new insights can be achieved about the nature of their revelations. Analysis reveals that these individuals had experiences that resemble those now defined as psychotic symptoms, suggesting that their experiences may have been manifestations of primary or mood disorder-associated psychotic disorders. The rationale for this proposal is discussed in each case with a differential diagnosis. Limitations inherent to a retrospective diagnostic examination are assessed. Social models of psychopathology and group dynamics are proposed as explanations for how followers were attracted and new belief systems emerged and were perpetuated. The authors suggest a new DSM diagnostic subcategory as a way to distinguish this type of psychiatric presentation. These findings support the possibility that persons with primary and mood disorder-associated psychotic symptoms have had a monumental influence on the shaping of Western civilization. It is hoped that these findings will translate into increased compassion and understanding for persons living with mental illness.

Cold elbow syndrome: spurious slowing of ulnar nerve conduction velocity.

Low temperature decreases nerve conduction velocity (NCV). The across-elbow segment of the ulnar nerve is superficial and may be particularly susceptible to decreased temperature. We evaluated patients without clinical ulnar neuropathy at the elbow (UNE) but with isolated slowing of the across-elbow ulnar NCV (normal group), and patients with clinical and electrodiagnostic findings of UNE (UNE group). All subjects had ulnar motor nerve studies completed before and after warming. The mean across-elbow NCV was 43.4 m/s and 48.6 m/s (P < 0.0001) in the normal group, and 37.4 m/s and 37.7 m/s (P = 0.90) in the UNE group, before and after warming, respectively. There was no change in the forearm segment NCV in either group. Seventeen of 32 subjects in the normal group had completely normal studies after warming. No patients with UNE developed normal across-elbow NCV with warming. Low temperature slows across-elbow ulnar NCV in normal subjects without impact on the forearm segment. Warming of the elbow improves across-elbow ulnar NCV in normals, but does not reverse the abnormalities in patients with UNE. Elbow warming should become a routine part of ulnar nerve conduction studies, especially when there is isolated conduction slowing in the across-elbow segment.