Perspectives on the diagnosis and management of functional cognitive disorder: An international Delphi study.

BACKGROUND: Current proposed criteria for functional cognitive disorder (FCD) have not been externally validated. We sought to analyse the current perspectives of cognitive specialists in the diagnosis and management of FCD in comparison with neurodegenerative conditions. METHODS: International experts in cognitive disorders were invited to assess seven illustrative clinical vignettes containing history and bedside characteristics alone. Participants assigned a probable diagnosis and selected the appropriate investigation and treatment. Qualitative, quantitative and inter-rater agreement analyses were undertaken. RESULTS: Eighteen diagnostic terminologies were assigned by 45 cognitive experts from 12 countries with a median of 13 years of experience, across the seven scenarios. Accurate discrimination between FCD and neurodegeneration was observed, independently of background and years of experience: 100% of the neurodegenerative vignettes were correctly classified and 75%-88% of the FCD diagnoses were attributed to non-neurodegenerative causes. There was <50% agreement in the terminology used for FCD, in comparison with 87%-92% agreement for neurodegenerative syndromes. Blood tests and neuropsychological evaluation were the leading diagnostic modalities for FCD. Diagnostic communication, psychotherapy and psychiatry referral were the main suggested management strategies in FCD. CONCLUSIONS: Our study demonstrates the feasibility of distinguishing between FCD and neurodegeneration based on relevant patient characteristics and history details. These characteristics need further validation and operationalisation. Heterogeneous labelling and framing pose clinical and research challenges reflecting a lack of agreement in the field. Careful consideration of FCD diagnosis is advised, particularly in the presence of comorbidities. This study informs future research on diagnostic tools and evidence-based interventions.

Treatment of Post-Stroke Depression.

PURPOSE OF REVIEW: This review presents a critical appraisal of current therapeutic strategies for patients with post-stroke depression (PSD). We present the reader with the most recent evidence to support pharmacological, psychosocial, and neuromodulation interventions in PSD. We also discuss the relevance of using antidepressants and psychotherapy to prevent PSD and discuss evidence that antidepressant treatment may reduce mortality after stroke. RECENT FINDINGS: Neuroinflammation and decrease neurogenesis and plasticity may play an important role in the mechanism of PSD. The strongest predictors of PSD are stroke severity, early physical disability, and severity of loss of functioning. Nevertheless, populations at risk for PSD are yet to be identified. Recent meta-analysis examined the efficacy of pharmacotherapy and psychotherapy. There is consensus that antidepressants such as escitalopram and paroxetine produce a significantly greater response and remission rate of PSD than placebo. Randomised controlled trials (RCTs) using psychotherapy are fewer, but recent meta-analysis tend to suggest efficacy for this treatment modality. Neuromodulation using repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS), as well as novel psychosocial interventions are potentially useful treatments in need of further research. Pharmacological therapy with antidepressants and psychotherapy should be considered as first line of treatment for PSD. The most effective antidepressants are the selective serotonin reuptake inhibitors escitalopram and paroxetine, whereas cognitive behavioural therapy is the most effective psychotherapeutic intervention.

The neuropsychiatry of hyperkinetic movement disorders: insights from neuroimaging into the neural circuit bases of dysfunction.

BACKGROUND: Movement disorders, particularly those associated with basal ganglia disease, have a high rate of comorbid neuropsychiatric illness. METHODS: We consider the pathophysiological basis of the comorbidity between movement disorders and neuropsychiatric illness by 1) reviewing the epidemiology of neuropsychiatric illness in a range of hyperkinetic movement disorders, and 2) correlating findings to evidence from studies that have utilized modern neuroimaging techniques to investigate these disorders. In addition to diseases classically associated with basal ganglia pathology, such as Huntington disease, Wilson disease, the neuroacanthocytoses, and diseases of brain iron accumulation, we include diseases associated with pathology of subcortical white matter tracts, brain stem nuclei, and the cerebellum, such as metachromatic leukodystrophy, dentatorubropallidoluysian atrophy, and the spinocerebellar ataxias. CONCLUSIONS: Neuropsychiatric symptoms are integral to a thorough phenomenological account of hyperkinetic movement disorders. Drawing on modern theories of cortico-subcortical circuits, we argue that these disorders can be conceptualized as disorders of complex subcortical networks with distinct functional architectures. Damage to any component of these complex information-processing networks can have variable and often profound consequences for the function of more remote neural structures, creating a diverse but nonetheless rational pattern of clinical symptomatology.

Psychiatric syndromes in Parkinson's disease.

PURPOSE OF REVIEW: To examine progress about relevant behavioural and psychiatric disorders in Parkinson's disease, such as depression, apathy, psychosis, and impulse control disorder. RECENT FINDINGS: Several recent studies have characterized the phenomenology of depression in Parkinson's disease, and randomized controlled trials have demonstrated the efficacy of tricyclics, selective serotonin reuptake inhibitors and psychotherapy for depression in Parkinson's disease. Apathy is a valid behavioural syndrome in Parkinson's disease and is associated with depression and cognitive deficits. Psychosis is highly prevalent in the late stages of the disease, but there are few effective therapeutic modalities for this psychiatric condition. Impulse control disorders are also relatively frequent in Parkinson's disease, and are associated with comorbid psychiatric disorders. SUMMARY: Standardized criteria should be used to diagnose depression and apathy in Parkinson's disease. Psychotherapy and pharmacotherapy are useful treatment modalities for affective disorders in Parkinson's disease. Clozapine is still the most effective, albeit rarely used, treatment for psychosis in Parkinson's disease. Impulse control disorders are relatively frequent in Parkinson's disease and all patients should be screened for this complex disorder.

Point-of-care testing of capillary glucose in the exclusion and diagnosis of diabetes in remote Australia.

OBJECTIVES: To determine the utility of point-of-care (POC) capillary blood glucose measurements in the diagnosis and exclusion of diabetes in usual practice in primary health care in remote areas. DESIGN: Cross-sectional study comparing POC capillary glucose results with corresponding venous glucose levels measured in a reference laboratory. PARTICIPANTS: 200 participants aged 16-65 years enrolled: 198 had POC capillary glucose measurements; 164 also had acceptable venous glucose laboratory results. SETTING: Seven health care sites in the Kimberley region of Western Australia from May to November 2006. MAIN OUTCOME MEASURES: Concordance and mean differences between POC capillary blood glucose measurement and laboratory measurement of venous blood glucose level; POC capillary blood glucose equivalence values for excluding and diagnosing diabetes, and their sensitivity, specificity and positive-predictive value. RESULTS: The concordance between POC and laboratory results was high (rho=0.93, P<0.001). The mean difference in results was 0.48 mmol/L (95% CI, 0.23-0.73; limits of agreement, - 2.6 to 3.6 mmol/L). The POC capillary glucose equivalence values for excluding and diagnosing diabetes were < 5.5 mmol/L (sensitivity, 53.3%; specificity, 94.4%; positive-predictive value, 88.9%; for a venous value of < 5.5 mmol/L) and >or= 12.2 mmol/L (sensitivity, 83.3%; specificity, 99.3%; positive-predictive value, 95.2%; for a venous value of >or= 11.1 mmol/L), respectively. While the choice of glucometer and whether or not patients were fasting altered these results, they did not have a significant influence on the diagnostic utility of POC glucose measurement in this setting. CONCLUSION: POC capillary blood glucose analysers can be used as part of the process of diagnosing and excluding diabetes in remote rural communities using these locally established capillary equivalence values.

Addicted to the good life: harm reduction in chronic disease management.

Individual values sometimes lead patients to make lifestyle choices that have negative effects on their health. Doctors tend to feel responsible for delivering best-practice health outcomes to such patients, but also feel inclined to respect their patients' values. The adoption of a harm reduction model may provide a strategy for delivering the best care that is compatible with each patient's chosen lifestyle.