Impairment in cognitive function in patients with axial spondyloarthritis and psoriatic arthritis.

Spondyloarthritis may contribute to deficits in cognition. The objective of this study was to compare cognitive abilities in patients with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA) with matched reference groups. This investigator-initiated, cross-sectional, exploratory study of adults with axSpA or PsA was conducted at two German rheumatology centres (November 2018-September 2019). All data on patient and disease characteristics and cognitive abilities were collected at a single visit. Cognitive function was assessed by the previously validated Memory and Attention Test subscores of selective attention, episodic working memory, and episodic short-term memory and compared with subscores from healthy age-, sex-, and education-matched reference subjects. The mean patient age was 51.1 and 55.8 years in the axSpA (n = 101) and PsA (n = 117) groups, respectively, and mean symptom duration was 13.7 and 10.3 years. Compared with matched reference subjects, axSpA and PsA patients showed significant impairments in selective attention (mean difference of -6.5 and -4.5, respectively, on a 45-point scale; P < 0.001 for both) and no significant differences in episodic working memory. The PsA cohort, but not the axSpA cohort, had significantly better episodic short-term memory subscores compared with matched reference subjects (mean change of 2.0 on a 15-point scale; P < 0.001). Explorative subgroup analyses were unable to identify factors influencing cognitive changes, including disease activity, pain, and function, but may have been underpowered. We conclude that impairments in selective attention may impact the ability of axSpA and PsA patients to process information. These findings warrant additional studies, including longitudinal analyses, in patients with spondyloarthritis.

Memory and selective attention in multiple sclerosis: cross-sectional computer-based assessment in a large outpatient sample.

Cognitive impairments may have a severe impact on everyday functioning and quality of life of patients with multiple sclerosis (MS). However, there are some methodological problems in the assessment and only a few studies allow a representative estimate of the prevalence and severity of cognitive impairments in MS patients. We applied a computer-based method, the memory and attention test (MAT), in 531 outpatients with MS, who were assessed at nine neurological practices or specialized outpatient clinics. The findings were compared with those obtained in an age-, sex- and education-matched control group of 84 healthy subjects. Episodic short-term memory was substantially decreased in the MS patients. About 20% of them reached a score of only less than two standard deviations below the mean of the control group. The episodic short-term memory score was negatively correlated with the EDSS score. Minor but also significant impairments in the MS patients were found for verbal short-term memory, episodic working memory and selective attention. The computer-based MAT was found to be useful for a routine assessment of cognition in MS outpatients.

[Anaesthesiological management of patients with dementia]. / Der demenzkranke Patient--Was ist beim anästhesiologischen Management zu beachten?

The aging society challenges anaesthesiologists with a growing number of patients with dementia. These and their relatives worry about an aggravation of an already existing dementia or even the postoperative evocation of one. Common volatile anaesthetics and propofol are suspected to increase dementia - associated protein tau and amyloid-betalevels in the brain. Perioperative complications such as cognitive dysfunction and delirium occur more frequently in dementia patients. For anaesthesiologists, it seems prudent toassess the grade of dementia in the elderly to adjust anaesthesia drug doses and monitoring intra- and postoperatively. Pharmacological interactions with antidementic andneuroleptic current medications affectanaesthetic and analgesic effects.In dementia, perioperative malfunction of cognition, memory, attention, information processing, communication and social interaction abilities is of profound influence on the perioperative management.This review mentions actual knowledge about dementia forms and symptoms in brief. Recommendations for the anaesthesia care are given in more detail.

[Recommendations for individual comorbidity risk assessment in adult patients with psoriasis]. / Handlungsempfehlungen zur individuellen Risikoermittlung von Komorbidität bei erwachsenen Patienten mit Psoriasis.

It has long been known that chronic inflammatory systemic diseases, such as psoriasis, pose a high risk of developing comorbidities. In everyday clinical practice, it is therefore of particular importance to identify patients who have an individually increased risk profile. In patients with psoriasis, the comorbidity patterns "metabolic syndrome", "cardiovascular comorbidity" and "mental illness" were identified as particularly relevant in epidemiological studies depending on the duration and severity of the disease. In the everyday care of patients with psoriasis in dermatological practice, the use of an interdisciplinary checklist for risk analysis and the initiation of professional follow-up care has proven valuable. On the basis of an existing checklist, the contents were critically evaluated by an interdisciplinary group of experts and a guideline-oriented update was prepared. In the opinion of the authors, the new analysis sheet represents a practicable, factually focused and updated tool for comorbidity risk assessment in patients with moderate and severe psoriasis.

Dermatology and medical law: the effect of legal issues on the treatment of patients in dermatological practices in southern Germany

Background: Usage of modern therapies in the treatment of chronic dermatological diseases has proven to be effective but associated with high costs. High therapy costs might raise legal issues and even lead to recourse claims. Objectives: To evaluate dermatologists' interests and knowledge in medical law and the occurrence of recourse claims, and to assess the impact of medical law on clinical practice. Materials & Methods: Dermatologists of the "Psoriasis-Praxisnetz Süd-West e.V." participated in a web-based questionnaire study investigating the relationship between medical law and usage of modern therapies. The questionnaire was separated in two sub-polls carried out from 11/2016 to 12/2016 and 02/2017 to 03/2017, respectively. The first addressed general topics of medical law and the second specific legal topics, particularly recourse claims. Results: Overall, 76 dermatologists participated in the first and 66 in the second sub-poll. In the first sub-poll, 27.6% of participants attended a seminar on medical law within the last 12 months. Furthermore, 28.8% of the participants of the second sub-poll already experienced a previous recourse claim, and 26.3% of those stated feeling confident or rather confident on legal topics. This proportion was lower among those who had not experienced a recourse claim (17.0%). Overall, 73.7% of those who had a previous recourse claim changed their prescription behaviour as a direct consequence thereof. Conclusion: The study demonstrates a close relationship between medical law issues and the prescription behaviour of dermatologists working in private practices in southern Germany. Regular legal education would thus be beneficial for patient-centred care.

[Validity Study of the Cookie Theft Picture Test - Early Detection of Dementia Based on Linguistic Abnormalities]. / Validierungsstudie zum Cookie Theft Picture Test.

OBJECTIVE: Previous studies have provided inconsistent results regarding discriminatory language variables between subjects with dementia and healthy controls. In this study, using the Cookie Theft Picture Test (CTP), selected language variables are tested for predicting actual diagnoses. METHODS: 24 healthy subjects and 24 subjects with mild dementia were included in the present study. RESULTS: All language variables except repetitions, word finding difficulties and paraphasias showed significant differences between the groups. The variables pause length and clues increase significantly the likelihood of AD, while the variable sentence length decreases it. CONCLUSION: Due to the small sample size and insufficient standardization, the study can only be interpreted to a limited extent. Nevertheless, the results indicate that the CTP appears to be suitable for practical use.

Cognitive Blackouts in Mild Cognitive Impairment and Alzheimer's Dementia.

BACKGROUND: Cognitive blackouts, e.g. moments of amnesia, disorientation, or perplexity may be an early sign of incipient Alzheimer's dementia (AD). A short questionnaire, the checklist for cognitive blackouts (CCB), was evaluated cross-sectionally in users of a memory clinic. METHODS: The CCB was performed in 130 subjects, who further underwent a neuropsychological and clinical examination. Subjective memory impairment and depressive symptoms were assessed. Differences in the CCB score between diagnostic groups and relationships with cognitive performance, depression, and subjective memory impairment were analyzed. RESULTS: The CCB score was increased in mild cognitive impairment of the amnestic type or mild AD and correctly predicted 69.2% of the respective subjects. It was negatively correlated with cognitive performance, positively correlated with depressive symptoms, and substantially increased in subjects who estimated their memory poorer than that of other persons of their age. DISCUSSION: The CCB may be a helpful screening tool for the early recognition of AD.

Adding memantine to rivastigmine therapy in patients with mild-to-moderate alzheimer's disease: results of a 12-week, open-label pilot study.

OBJECTIVE: At present, inhibition of cholines-terase is the treatment of choice for subjects with mild-to-moderate Alzheimer's disease (AD). Memantine, a noncompetitive antagonist at N-methyl-d-aspartate receptors, is currently used to treat subjects with moderate-to-severe AD. The goal of this multicenter, open-label pilot study was to investigate whether combination therapy with memantine added to rivastigmine is safe and beneficial in subjects with mild-to-moderate AD. METHOD: Patients with a DSM-IV diagnosis of dementia of the Alzheimer's type (N = 95), who were treated with rivastigmine (6-12 mg/day) for a maximum duration of 24 weeks prior to baseline, received memantine (5-20 mg/day) in combination with rivastigmine for 12 weeks. The primary efficacy variable was the change in the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog) total score at the end of 12 weeks compared with baseline. The study was conducted between September 15, 2003, and May 27, 2004. RESULTS: There was a statistically significant difference between baseline and week 12 for the ADAS-cog total score, showing a positive effect of combination therapy. Combination therapy did not evidence any unexpected safety concerns and was well-tolerated by most patients. CONCLUSION: Memantine in combination with rivastigmine appears to be safe and beneficial in patients with mild-to-moderate AD. Our results need to be confirmed in a large, long-term, randomized, double-blind, placebo-controlled clinical trial.

Six-month course of mild cognitive impairment and affective symptoms in late-life depression.

Mild cognitive impairment (MCI) is frequent in patients with late-life depression. Previous studies indicate that cognitive performance in these patients is not or only marginally improved when they recover from depression. However, recovery from cognitive impairments due to depression may have a longer time course than recovery from affective symptoms. In a group of 34 elderly depressed patients (mean age: 73.4 years) admitted to a gerontopsychiatric day-clinic, severity of depression and cognitive performance were assessed before the initiation of treatment and were reassessed 6 months later. At admission, 18 of 34 patients (53%) fulfilled the criteria for MCI, with a preponderance of impairments in short-term memory and visuospatial capabilities. At the 6-month follow-up, cognitive performance had not significantly improved for the entire group; 12 of 27 patients (44%) still were fulfilling the criteria for MCI. No relationships could be ascertained between cognitive impairment or functional level and severity or course of depression. Patients with diurnal variations of the depressive symptomatology were less likely to fully recover from depression.

[Computer-based assessment of memory and attention: evaluation of the memory and attention test (MAT)]. / Die computergestützte Untersuchung von Gedächtnis und Aufmerksamkeit: Evaluation des Merkfähigkeits- und Aufmerksamkeitstests (MAT).

Objective A computer-based test for the assessment of working and short-term memory and selective attention was evaluated in Alzheimer patients and controls.Methods By means of the MAT, working and short-term memory for verbal, figural and episodic material are assessed through recognition tasks. Selective attention is tested through visual samples in an oddball paradigm. In 42 Alzheimer patients and 42 controls, we applied the MAT and usual reference methods for the assessment of attention and the respective memory domains.Results The correlations of the scores of the MAT memory subtests with the scores of the reference tests were moderate to high (r: 0.63-0.84). Test-retest correlations were between 0.79 and 0.90. Differentiation of Alzheimer patients and controls was good, particularly in episodic and figural short-term memory (p < 0,01). Nearly all of the probands reported that they could see and hear everything well and felt at ease during the MAT assessment.Conclusions High correlations of the MAT subtests with the reference tests indicate an acceptable construct validity. The test-retest correlations show a good reliabilty. Differentiation of Alzheimer patients and controls is fairly well. The computer-based assessment was readily accepted by the elderly probands.

Rationale for transdermal drug administration in Alzheimer disease.

Transdermal patches are used for the treatment of various diseases including neurologic and psychiatric disorders such as Parkinson disease (PD), major depression, and attention deficit hyperactivity disorder. They are believed to offer many advantages over conventional oral therapies. By providing smoother, continuous drug delivery and steadier plasma levels, patches may reduce the incidence of side effects, thus making optimal therapeutic doses easier to attain and potentially improving treatment efficacy and compliance. Drug delivery systems such as patches that are more patient- and caregiver-friendly may enable patients to continue treatment for longer periods and to attain greater, more sustained treatment benefits. To date, approved therapies for Alzheimer disease (AD), including cholinesterase inhibitors and memantine, are orally administered. Potential advantages associated with patches provide a therapeutic rationale to offer additional benefits in AD patients. Rivastigmine is well suited to patch administration because it is a small, potent molecule that is both lipophilic and hydrophilic. A rivastigmine patch has been developed and may provide a promising new approach to dementia therapy.

Domain-specific improvement of cognition on memantine in patients with Alzheimer's disease treated with rivastigmine.

OBJECTIVE: Cholinergic therapy is used in mild-to-moderate Alzheimer's disease (AD) and antiglutamatergic therapy in moderate-to-severe AD. Global scales, as commonly used in clinical trials, blur specifics of disease progression and drug effects. The objective was to assess combination therapy of rivastigmine plus memantine by specific neuropsychological tests in patients with mild-to-moderate AD. METHODS: 12-week-short multicenter open-label pilot study. Ninety patients with mild-to-moderate AD already on stable medication with rivastigmine (3-6 mg b.i.d.) additionally received memantine for 12 weeks. Subscales of the Alzheimer's Disease Assessment Scale (ADAS-cog), the Mini-Mental State Examination (MMSE) and additional neuropsychological tests (e.g. span tasks, semantic fluency) were assessed. RESULTS: The scores in the ADAS-cog memory subscale, the MMSE score, and digit span and semantic fluency significantly improved on combination therapy. CONCLUSION: Memory improvement was correlated with ADAS-cog memory score at baseline and inversely with age at onset of treatment. The data suggest that improvement on combination therapy results from an improvement of attention/executive function with secondary memory improvement, which will need to be confirmed in a subsequent double-blind study on a larger number of patients.

[Mnestic impairment under olanzapine overdosage in an elderly patient]. / Mnestische Störungen unter Olanzapinüberdosierung bei einem älteren Patienten.

Atypical antipsychotics are increasingly used for the treatment of elderly patients. However, there are only few studies on their efficacy and side effects in this patient group. The case of a 67-year old patient is presented, in whom under treatment with olanzapine in usual dosage, serum level increased into the toxic range. This olanzapine overdosage was accompanied by severe impairments in visual and verbal memory and by an increase of slow-frequency activity in the EEG. Both alterations may be attributed to the anticholinergic effects of olanzapine and reversed rapidly after dose reduction and normalization of the olanzapine serum level.

[The social situation of patients with late-life depression]. / Die soziale Situation von Patienten mit Altersdepressionen.

The social situation of patients with late-onset late-life depression admitted to a gerontopsychiatric day-clinic was assessed with respect to activities, social contacts, living conditions and finances. The patients were compared with an age- and sex-matched control group. Relationships of the social situation to life satisfaction and severity of depression were investigated. In the patients, there were significant deficits in activities and contacts, especially with respect to those features which directly depend on the patients' level of activity (e. g. frequency of activities outside the household). Social infrastructure (e. g. frequency of attendance) and living conditions were positively correlated with life satisfaction, but were not significantly impaired in the depressed patients, neither were there differences in the financial situation between patients and controls. Thus, the social situation of elderly depressed patients is mainly characterised by a decreased level of activities, to which special therapeutic attention should be given.

Pretreatment interhemispheric EEG coherence is related to seizure duration in right unilateral electroconvulsive therapy.

OBJECTIVE: The relationships between pretreatment EEG parameters and seizure duration in electroconvulsive therapy (ECT) were studied in order to provide information useful for the prediction of ECT-induced seizures. METHODS: In 16 depressed patients treated with right unilateral ECT, pretreatment absolute band powers and interhemispheric coherences were assessed and correlated with the duration of the first ECT-induced seizure. RESULTS: Interhemispheric coherence for the central electrodes in the fast alpha band was positively correlated with seizure duration. CONCLUSIONS: Interhemispheric coherence may reflect, in a quantitative manner, cortico-cortical transmission via commissural pathways required for the generation of a generalized seizure through right unilateral stimulation. It may represent a useful parameter with respect to seizure threshold with potential therapeutic implications for ECT.

Late-onset depression with mild cognitive deficits: electrophysiological evidences for a preclinical dementia syndrome.

Mild cognitive impairment (MCI) is present in up to 60% of patients with late-onset depression and constitutes a major diagnostic problem in geriatric psychiatry. Searching for sensitive markers for the detection of early brain changes suggestive of dementia, we compared this depressive risk population with mildly to moderately demented patients and cognitively unimpaired depressed patients using EEG power and coherence. We found a considerable similarity between Alzheimer's disease patients and cognitively impaired depressed patients regarding the cognitive profile and EEG pattern. Changes in EEG power and coherence at frontotemporal leads in depressive patients with MCI thereby allowed discrimination from cognitively unimpaired patients with a sensitivity of 88% and a specifity of 81%.