[Joint crisis plans in mental health hospitals-Real practice in an association of psychiatric hospitals]. / Behandlungsvereinbarungen in der Psychiatrie ­ reale Praxis in einem Verbund psychiatrischer Kliniken.

BACKGROUND: Joint crisis plans (JCPs) are offered in many psychiatric hospitals, but patients only rarely make use of them. OBJECTIVE: To assess the rates of JCPs among inpatients of mental health hospitals and to analyze the clinical characteristics of patients who make use of a JCP. MATERIAL AND METHODS: We carried out a retrospective analysis of routine data from the statistical database/basis documentation of the LVR hospital association, which consists of nine psychiatric hospitals. The basis documentation is consistent in the nine hospitals. All admissions between 2016 and 2020 were considered. We recorded the existence of a JCP, age, gender and main diagnosis at release, as well as previous hospital stays, detention under the Mental Health Act of the Federal State of NRW and experiences with compulsory measures (seclusion/restraint) in the previous 24 months before index admission. RESULTS: Out of a total of 117,662 inpatients 467 (0.4%) had completed a JCP. Patients with JCP were more likely to be diagnosed with schizophrenia, bipolar disorder, or emotionally unstable personality disorder. Patients with a JCP had more previous inpatient stays and they had more frequently experienced detentions and compulsory measures. However, 50% of the patients with a JCP had other diagnoses and the vast majority of them had experienced no detention or compulsory measure in the 24 months preceding the first documentation of a JCP. CONCLUSIONS: Overall, the use of JCPs is limited. The targeted group of patients with severe mental illness and previous experience with involuntary placements and compulsory measures make use of the offer of a JCP but so do other patients as well. Additional qualitative analyses are required in order to analyze the content and objectives of JCPs in more detail.

[Potentials and limits of aging cohort studies for geriatric psychiatry]. / Potenziale und Grenzen von Alternskohortenstudien für die Gerontopsychiatrie.

The sizeable number of population-based cohort studies of aging in Germany have provided highly valuable contributions for the specification of risk factors and predictors for frequent mental disorders in old age, especially dementia and depression. The results from these cohort studies enable the specification of mechanisms for the development of and preventative interventions for common mental disorders in old age. On the other hand, there is a significant paucity of clinical cohort studies investigating disease trajectories and possible markers for specific individualized interventions of frequent mental disorders in old age. In this article, we report selected key findings from cohort studies of aging and discuss novel approaches for the integration and harmonization of population-based and clinical cohort studies.

[Collation of word retrieval disorders in patients with Alzheimer's dementia]. / Erfassung von Wortfindungsstörungen bei Patienten mit Alzheimer-Demenz.

BACKGROUND: One of the first symptoms of Alzheimer's disease (AD) is word retrieval deficits. A systematic evaluation of word retrieval deficits can have an important predictive value for developing Alzheimer's disease. OBJECTIVE: Is the test for finding word retrieval deficits (word finding = WoFi) able to detect deficits in word retrieval and does it correlate with other dementia tests? METHODS: A word retrieval test called WoFi was developed. It is an instrument that tests word retrieval deficits based on 50 questions. A maximum of 100 points can be scored. RESULTS: The control group scored significantly better than the AD group. Using a cut-off score of 84 points WoFi could discriminate controls from subjects with a sensitivity of 95% and a specificity of 92%. CONCLUSION: The use of WoFi was able to test for word retrieval deficits. Application required less than 15 min and test instructions are very simple. This instrument might be useful in telehealth.

[Geriatric psychiatric home counseling for people with dementia and anosognosia : Results of a model project]. / Gerontopsychiatrische Hausbesuche bei Menschen mit Demenz und Anosognosie : Ergebnisse eines Modellprojekts.

BACKGROUND: Lack of awareness of an illness (anosognosia) is a common symptom in dementia and has a significant impact on the course of the disease. It is associated with dysfunctional interaction with caregivers. Due to unawareness patients are not able to accept diagnostic procedures or medical treatment and refuse any kind of support. Thus, they are not integrated into psychosocial networks and medical support. This has a significant impact on patient-centered care in a domestic environment. In this article a model project with home visits to patients with dementia and anosognosia is described. METHOD: A total of 55 home visits were carried out. The aim of this project was the integration into the existing healthcare services in order to safeguard the domestic environment. These visits focused on advice and information for the patients and their caregivers initiating the visits. Sociodemographic data of the patient cohort and the satisfaction of the caregiving relatives and general practitioners are presented. RESULTS: Subjects with dementia were found to be in advanced stages of the disease, caring situations were complex and required assistance. Caregivers showed a substantial burden in accordance with previous reports. CONCLUSION: New strategies are required to cope with anosognosia in patients with dementia and their caregivers. Even single home visits seem to be sufficient to initiate support for subjects with dementia and their relatives.

Attention and CERAD test performances in cognitively impaired elderly subjects.

OBJECTIVES: Attention plays a fundamental role in cognitive performance and is closely interrelated with all major cognitive domains. In this retrospective study, we correlated different measures of attention with standard cognitive parameters in 85 cognitively impaired elderly individuals presenting with cognitive complaints to a memory clinic. MATERIALS AND METHODS: Z-scores of all relevant cognitive parameters of a extended Consortium to Establish a Registry for Alzheimer's disease (CERAD-Plus) neuropsychological battery were correlated with tonic and phasic alertness, inhibition, and divided attention, assessed by a computerized test battery of attention. The pooled sample consisted of 36 patients with the diagnosis of mild AD, 30 patients with mild cognitive impairment, and 19 patients with major depressive disorder. RESULTS: Subjects of all diagnostic groups exhibited normal results in all subtests of attention. Reaction times of neither the tonic nor the phasic alertness task were correlated with any parameter of memory and global cognition. However, significant correlations were obtained between reaction times in the alertness tasks and the trail-making tests. Omissions in the divided attention task yielded the strongest correlations with deficits in cognitive performance, particularly in the verbal learning tasks, the Boston naming test, and the trail-making tests. CONCLUSIONS: Our data demonstrate the relative independency of the CERAD-Plus on the variability of attention and particularly alertness suggesting its robustness in psychiatric memory clinic settings. Moreover, CERAD-Plus subtests correlated considerably with failure rates in divided attention, suggesting that impairment in divided attention tasks may be early markers of cognitive impairment.

Cognition in older offenders in North Rhine-Westphalia: A comparison of prisoners and patients in forensic psychiatry hospitals.

The number of elderly delinquent individuals living in prisons and forensic hospitals is increasing. For both settings, complex needs have been described for the elderly related to age-related changes and frequent somatic disorders as well as mental disorders, primarily depressive symptoms.. One of the biggest challenges are cognitive impairments which have been described for both groups, probably not least due to frequent risk factors (e.g., substance abuse, depressive symptoms). Given that the group of forensic patients has a manifest mental illness, which is usually treated with psychopharmaceuticals, the question arises as to what extent cognitive deficits are more frequent here. For both groups, the detection of cognitive deficits with regard to therapy and release planning is of relevance. In sum, studies on cognitive function in both populations are rare, and the results are hard to compare due to different instruments to assess cognition. Sociodemographic, health-, and incarceration-related data were collected as well as neuropsychological functions using established instruments to evaluate global cognitive functioning (Mini-Mental State Examination [MMSE], DemTect), executive function (Frontal Assessment Battery [FAB], and Trail Making Test [TMT]). In the final sample, 57 prisoners and 34 forensic inpatients from North Rhine Westphalia, Germany being 60 years and older were included. The groups were comparable in age (prisoners: M = 66.5 years, SD ± 5.3; forensic inpatients: M = 66.8 years, SD ± 7.5) and education (prisoners: M = 11.47, SD ± 2.91; forensic inpatients: M = 11.39, SD ± 3.64), but the offenders in forensic psychiatry had spent significantly more time in the correctional setting than prisoners (prisoners: M = 8.6, SD ± 10.8; forensic inpatients: M = 15.6 years, SD ± 11.9). In both groups cognitive deficits were frequent. Depending on the tests and population, between 42% and 64% showed impairments in global cognition, and between 22% and 70% were classified with impaired executive functioning. We found no significant differences in global cognition or executive functions assessed with the TMT between the two groups. However, forensic inpatients were significantly more impaired in the FAB compared to the prisoners. The results emphasize the high frequency of cognitive dysfunction in both settings and a possibly higher frequency of "frontal" dysfunction in forensic inpatients, and, thus, indicate the relevance of routine neuropsychological diagnostic and treatment procedures in these settings.

A novel MRI-biomarker candidate for Alzheimer's disease composed of regional brain volume and perfusion variables.

BACKGROUND: Earlier evidence indicates that regional cerebral volume (rVOL) and blood flow (rCBF) variables carry independent information on incipient and early Alzheimer's disease (AD) and combining these modalities may increase discriminant performance. We compared single variables and combinations regarding their power for optimizing diagnostic accuracy. METHODS: Twelve cognitively normal elderly controls (CN), 30 subjects with mild cognitive impairment (MCI) and 15 with mild AD were examined by structural and perfusion-weighted magnetic resonance imaging (MRI) in single sessions at 1.5 Tesla. rVOLs were measured by manual volumetry, and rCBFs were calculated with a ROI-based co-localization technique. RESULTS: Applying single MRI variables for the differentiation of AD versus CN, the area under curve (AUC) of receiver operating characteristic curves (ROCCs) was highest for rVOL variables (maximum of 0.972 for right amygdala). A composite marker selected and weighted by logistic regression containing left amygdalar rCBF, left hippocampal and right amygdalar rVOLs gave a diagnostic accuracy for AD versus CN of 100%. Internal cross-validation revealed a reliability of 88.9%. CONCLUSIONS: Whilst external revalidation is mandatory employing a naturalistic sample containing disease controls, our phase I/II findings demonstrate that deducing composite markers from multimodal MRI acquisitions can optimize diagnostic accuracy for AD.

Lenticular nucleus lesion in idiopathic dystonia detected by transcranial sonography.

We report the transcranial sonography (TCS) findings of the basal ganglia in 86 patients with dystonic disorders including idiopathic dystonia (facial, cervical, upper limb, and generalized dystonia), drug-induced tardive dystonia, dopa-responsive dystonia, and kinesigenic dystonia. The TCS was focused on alterations of the lenticular, caudate, raphe nuclei, and the thalamus. Seventy-five percent of patient with idiopathic cervical and 83% of those with idiopathic upper limb dystonia had a hyperechogenic lesion of the middle segment of the lenticular nucleus on the side opposite to the clinical dystonic symptoms. The ipsilateral side was also affected in 20%. In facial dystonia, only one-third of the patients revealed lenticular nucleus lesions. The mean area of the lenticular nucleus lesion opposite to the clinically affected side was 30 mm2 in cervical dystonia, 17 mm2 in upper limb dystonia, and 7.5 mm2 in facial dystonia. These lenticular abnormalities were significantly more frequent (p < 0.001) and their areas were significantly greater (p < 0.001) compared with a control group of 50 patients afflicted with radiculopathy. There was a significant correlation of the severity of symptoms with the intensity of lenticular nucleus hyperechogenicity in patients with cervical and upper limb dystonia (p < 0.05). Increased caudate nucleus echogenicity was present in 20% of patients with cervical and upper limb dystonia, mostly contralateral to the clinically affected side and raphe abnormalities were present in 7% of all patients with idiopathic dystonia. In contrast, there were no abnormalities of the lenticular nucleus or thalamus in nonidiopathic dystonias. We conclude that idiopathic dystonia is associated with lesions in the basal ganglia, particularly the lenticular nucleus, that can be visualized by TCS. An alteration of the basal ganglia matrix may be the pathologic basis of idiopathic dystonia with secondary affliction of striatopallidothalamic pathways.

Cerebellar vermis area in schizophrenic patients - a post-mortem study.

Neuroimaging studies of cerebellar atrophy in schizophrenia have yielded contradictory results. In computer-tomography (CT) studies, cerebellar atrophy was found in up to 40% of schizophrenic patients. However, several recent magnetic resonance imaging (MRI) studies could not replicate these early findings; in addition, contradictory observations of enlargement of vermal structures were reported. In contrast to the number of CT and MRI studies, there are only a few neuropathological reports on this subject. In a post-mortem study we analyzed the midsagittal vermal area of formaldehyde-fixed cerebella of 12 deceased schizophrenic patients and 12 age- and gender-matched control subjects by using morphometrical methods. Statistical analysis using ANOVA revealed no significant group effects, but there were interactions with gender and cerebellar brain weight. In view of the present results, the common concept of cerebellar atrophy in schizophrenic patients appears premature. Gender effects and secondary processes (e.g., relevant alcohol or drug abuse) cannot be excluded as possible factors causing decrease of vermal areas in schizophrenic patients.

Depression in Parkinson's disease: brainstem midline alteration on transcranial sonography and magnetic resonance imaging.

Recent studies using transcranial sonography (TCS) have provided evidence of alterations in the mesencephalic midline structures in patients with unipolar depression and depression in Parkinson's disease (PD), suggesting an involvement of the basal limbic system in primary and secondary mood disorders. This study tested the hypothesis of brainstem midline abnormality in depression and investigated 31 PD patients by magnetic resonance imaging (MRI) and TCS. Signal intensity of the pontine and mesencephalic brainstem midline was rated on T2-weighted images and measured by relaxometry. In addition, two blinded investigators assessed the echogenicity of the brainstem midline by TCS. The severity of motor symptoms and depression were graded independently using standard research scales. Rating of signal intensity and T2 relaxometry of the pontomesencephalic midline structures revealed significant difference between depressed and nondepressed PD patients (P < 0.05). This corresponded to a significant reduction in mesencephalic midline echogenicity of depressed PD patients on TCS images. No correlation was found between raphe signal intensity, T2 relaxation times, or TCS echogenicity and the severity of motor symptoms or depression. This study is the first to show changes in signal intensity and T2 relaxation time of the pontomesencephalic midline structures on MRI in depressed PD patients confirming previous TCS findings. As these midline structures comprise fiber tracts and nuclei of the basal limbic system, the findings may support the hypothesis of an alteration in the basal limbic system in mood disorders.

MRI T2 relaxation times of brain regions in schizophrenic patients and control subjects.

In this MRI investigation T2 relaxation times were studied in schizophrenic patients compared to normal control subjects. Approximate T2 relaxation times were calculated using signal intensity at two echo times in several brain regions of 25 male schizophrenic patients and 25 age-matched, normal male control subjects. The schizophrenic patients showed significantly longer T2 relaxation times as compared to normal control subjects in the left anterior column of the fornix. This is a small structure, prone to partial volume effects and this may account for these findings. There was a trend towards longer T2 times in the left frontal cortex and shorter T2 times in [corrected] right temporal cortex in schizophrenic patients as compared to control subjects. There were right/left differences in relaxation times within each group. In both patients and control subjects, frontal lobe white matter T2 was longer on the right than on the left side. This finding is probably due to brain asymmetry and unrelated to the presence or absence of psychiatric illness. In schizophrenic patients only the left temporal cortex showed longer T2 times than the right side. This observation could indicate left sided temporal lobe pathology in schizophrenia.

[How the mind impairs healing of the body. Properly diagnosing organic psychosyndrome]. / Wie die Seele die Heilung des Körpers stört. Organische Psychosyndrome richtig diagnostizieren.

Psychological comorbidity is patients with systemic diseases is common and clinically relevant: mental disturbances can complicate the course of treatment of such diseases, and may aggravate somatic morbidity. The duration of hospital stay may be increased and thus has a negative economic impact. In the last resort, mortality is also increased by the appreciably elevated risk of suicide among patients with severe somatic illnesses. The evaluation of psychiatric problems in patients hospitalized for the treatment of internal illnesses is undertaken mainly by a consultant specialist. In addition to the diagnostic categorization of the psychological disorder presenting, and recommendations for treatment, an evaluation of potential suicidal intent is of central importance.

[Pharmacological treatment options in frontotemporal dementia]. / Pharmakologische Behandlungsansätze bei der frontotemporalen Demenz.

In contrast to Alzheimer's disease, there are only few systematic trials for drug therapy of frontotemporal dementia (FTD). Neurochemically, a strong serotonergic deficit is supposed in FTD. This is the rationale for treatment, especially of behavioral abnormalities, with serotonergic antidepressants. However, only paroxetine and trazodone have been studied in trials with class I and II evidence so far. The results of paroxetine are inconsistent; and for trazodone a number of potential side-effects must be considered. Moreover, there is class II evidence for rivastigmine in FTD, even though a cholinergic deficit in this type of dementia is questionable. There are no published data from controlled trials for the use of memantine in FTD so far.

Cognitive changes after carotid artery stenting.

INTRODUCTION: We aimed to test changes in cognitive performance after carotid artery stenting (CAS). METHOD: Ten patients were neuropsychologically tested at least 24 h before and 48 h after CAS. To diminish thromboembolic events, we used a proximal protection device. The following neuropsychological tests were selected: The Mini Mental State Examination (MMSE), symbol digit test and subtests of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) battery (verbal fluency, constructional practice, word list memory and delayed recall). Affective state was determined by the Beck Depression Score (BDS). RESULTS: No patient suffered from depression (BDS <1) or dementia (MMSE 29.9+/-1.5). Nine of the ten patients (P=0.12) showed increased speed in the Number Connection Test (NCT) (corresponding to trail making test). Most patients showed better or similar results concerning delayed recall (P=0.31). No change was observed in the symbol digit test, word list memory, verbal fluency or constructional practice. Better results concerning NCT and delayed recall after carotid stenting might be due to improved brain perfusion. CONCLUSION: After CAS, cognitive and memory performance seem to improve. Further studies with different time intervals and more refined testing, as well as perfusion-weighted imaging, are needed.

Cerebrospinal fluid diagnostic markers correlate with lower plasma copper and ceruloplasmin in patients with Alzheimer's disease.

Increasing evidence links Alzheimer's disease (AD) with misbalanced Cu homeostasis. Recently, we have shown that dietary Cu supplementation in a transgenic mouse model for AD increases bioavailable brain Cu levels, restores Cu, Zn-super oxide-1 activity, prevents premature death, and lowers A beta levels. In the present report we investigated AD patients with normal levels of A beta 42, Tau and Phospho-Tau in the cerebrospinal fluid (CSF) in comparison with AD patients exhibiting aberrant levels in these CSF biomarkers. The influence of these cerebrospinal fluid (CSF) diagnostic markers with primary dependent variables blood Cu, Zn and ceruloplasmin (CB) and secondary with CSF profiles of Cu, Zn and neurotransmitters was determined. Multivariate tests revealed a significant effect of factor diagnostic group (no AD diagnosis in CSF or AD diagnosis in CSF) for variables plasma Cu and CB (F=4.80; df=2, 23; p=0.018). Subsequent univariate tests revealed significantly reduced plasma Cu (-12.7%; F=7.05; df=1, 25; p=0.014) and CB (-14.1%; F=9.44; df=1, 24; p=0.005) levels in patients with aberrant CSF biomarker concentrations. Although only AD patients were included, the reduced plasma Cu and CB levels in patients with a CSF diagnosis of advanced AD supports previous observations that a mild Cu deficiency might contribute to AD progression.

[Alzheimer's disease versus vascular dementia -- dichotomy or interaction?]. / Alzheimer Demenz versus vaskuläre Demenz -- Dichotomie oder Interaktion?

Alzheimer's dementia (AD) and vascular dementia (VD) are the two major forms of dementia in the elderly. They have been separated categorically on the basis of pathophysiological findings and clinical operationalized criteria. However, this strict separation has to be reevaluated in the light of recent data. The risk to develop a neurodegenerative dementia in old age is determined by various susceptibility genes and correlated with aging. In AD, the current understanding of pathophysiology focuses on the amyloid cascade hypothesis as the major endpoint of the complex cellular pathology. In VD, incomplete microangiopathic infarcts due to fibrohyalinosis are regarded as the major pathophysiological event. A controversial discussion exists about the coincidence or interaction of genetically determined risk factors of AD and/or VD. Further interactions between AD and VD exist with regard to perivascular mediators and those factors which impair cerebral blood flow. Based on these and other recent neuropathological and therapeutic findings the hypothesis is proposed that the two specific etiopathologies of AD and VD interact to precipitate clinical dementia in the individual and that the individual phenomenology of these dementias is modified by vascular risk factors. Neither, a categorical separation of AD and VD nor the recent idea to regard AD as a distinct form of vascular dementia, do appear convincing.

Dementia of frontal lobe type in Kennedy's disease.

The pathomorphological correlate of Kennedy's disease (KD) is a degeneration of spinal and bulbar alpha-motor neurons. The disease is caused by a CAG repeat expansion in the first exon of the X-chromosomal androgene receptor gene. Contrary to the common belief that cognitive disorders in motor neuron diseases (MND) are either rare or only mild, there is now an increasing number of case reports on dementia in amyotrophic lateral sclerosis (ALS). In ALS, dementia of the frontal lobe type (frontotemporal dementia, FTD) seems to be the characteristic pattern. However, in KD cognitive dysfunction has not been studied systematically. Here we present a case with clinical characteristics of FTD in a patient with genetically confirmed KD. It remains speculative whether there is an association between KD and FTD comparable to a genetic linkage between ALS and FTD, which has been proposed in recent years. However, we suggest that cognitive dysfunction may be more common in KD than reported until today.

[Awareness of memory deficits in patients with probable Alzheimer's disease]. / Metagedächtnisleistungen bei Alzheimerpatienten.

Thirty-eight patients with Alzheimer's disease were asked to give a qualitative (estimation of memory changes) and quantitative assessment of their own performance on memory tasks and also of their relatives' performance. Qualitative assessment showed to be independent from measured memory-deficits, while the precision of quantitative prediction of performance deteriorated with increased cognitive impairment. Cognitive impairment of the demented patients did not influence the prediction of the performance of their relatives. Both, qualitative and quantitative assessment of memory performance were influenced by premorbid coping-strategies. Patients, who were attributed to use strategies of cognitive avoidance, more often claimed to have no changes in memory function or over-estimated their memory performance. The results of this investigation reveal that methodological issues influence studies on the association of meta-cognitive abilities with the severity of dementia to a great extent. They also suggest that awareness of deficits should be based on a complex, multi-dimensional concept.