Hypnotherapy as a Nonpharmacological Treatment for the Psychological Symptoms of Multiple Sclerosis.

Context: Stress and chronic pain are the factors that most influence the quality of life and well-being of people with MS, and 90% of adults with MS suffer from persistent fatigue. These symptoms can be associated with other disorders such as depression, and drug treatments provide inadequate comfort for most people with them. Objective: The study intended to examine the impact of hypnosis and hypnotherapy in the management of symptoms of people with multiple sclerosis (MS), such as stress, chronic pain, an inferior quality of life, and a lack of psychological well-being. Design: The research team performed a systematic narrative review by searching the PubMed and Web of Science databases, including review articles and other studies for additional citations. Setting: The study was conducted at our Scientific Institute for Research (IRCCS) in Messina. Results: Only 14 of 121 publications met the inclusion criteria and were selected. Hypnotic treatment is an effective therapy that has beneficial impacts on the intensity of perceived pain, psychological well-being, mood disorders, and fatigue, and in addition, it significantly improves physical functioning in MS patients. The same effects haven't been obtained with other nonpharmacological techniques. Conclusion: Hypnosis is an appropriate psychological therapy for the management of MS patients' symptoms.

Alzheimer cafè: toward bridging the gap between cure and care in patients with dementia.

BACKGROUND: Alzheimer's disease (AD) is the most common form of degenerative dementia, whose symptoms usually appear in the pre-senile age. In the early stages, patients present social difficulties due to the general cognitive decline in memory, language and executive domains. These problems also affect patients' quality of life, emotions, and mood, leading to social isolation. OBJECTIVE: The aim of this study is to evaluate the effects of Alzheimer's Cafè (AC) on the cognitive and behavioral outcomes of AD patients. METHODS: Twenty patients diagnosed with AD, who attended the Cognitive and Behavioral Rehabilitation Laboratory of the IRCCS Centro Neurolesi 'Bonino-Pulejo' of Messina, Italy, from December 2017 to December 2018, were enrolled in this study. As these patients belonged to the experimental group (EG: n = 20), they received specific cognitive-behavior training using the AC modality. The patients were assessed by a neuropsychological evaluation at the beginning and at the end of the program. Their outcomes were compared to a matched group of patients with neurodegenerative dementia (CG: 20) receiving conventional cognitive training. RESULTS: The pre-post comparisons showed that both CG and EG had a significant improvement in global cognitive functioning (MoCA p < 0.001) and in perceived quality of life (<0.001). However, only in the EG, we observed a significant increase in social functioning (SASS p < 0.00), the perception of mental well-being (SF-12 Mental p < 0.00), and a reduction in the depressive state (GDS p < 0.00). CONCLUSIONS: The present study suggests the importance of AC for patients with AD and the potential effect on psychological and social well-being.

Traumatic Brain Injury and Related Antisocial Behavioral Outcomes: A Systematic Review.

Background and Objectives: Higher level of aggression and antisocial behavior have been found in the period following head trauma. These changes are attributable to specific brain alterations that generally involved frontal lobe, insula and limbic system. A descriptive review was conducted on the specificity of aggressive behavior in relation to traumatic brain injury by evaluating numerous variables, focusing on age at the time of trauma and neuroimaging studies. Materials and Methods: We searched on PubMed and the Web of Science databases to screen references of included studies and review articles for additional citations. From an initial 738 publications, only 27 met the search criteria of describing the relationship between aggression, brain alterations and traumatic brain injury. Results: These findings showed that traumatic brain injury (TBI) is related to changes in behavior, personality and mood. Conclusions: The development of aggressive and criminal behavior is associated with multiple factors, including the etiology of injury, environmental, psychosocial and personality factors and age at the time of trauma.

Feasibility, Usability, and Customer Satisfaction of the Tele-COVID19 Project, Sicilian Model.

Background and Objectives: In March 2020, COVID-19 pandemic affected the world. All countries, to limit viral transmission, imposed quarantine. This emergency exerted personal, social, economic, and psychological impact on people. For health systems, was needed to create alternative care pathways. Telemedicine can be helpful to reduce isolation, provide health care services, and monitor virus infections. Italian regions, including Sicily, have activated telemedicine services for management of patients with COVID-19. Objective: The purpose of study is to describe a Sicilian telemedicine model for management of COVID-19 patients, showing results on feasibility, usability and quality of service and patient satisfaction. Materials and Methods: This is a descriptive exploratory study on a telemedicine service for residents in Messina infected by COVID-19. It included monitoring of vital signs and specialist consultations (i.e., doctor, psychologists, social workers, and nutritionist biologists). Results: More than twenty percent (23.8%) of participants used tele-monitoring and tele-counselling services; 14.3% were only telemonitored. Participants judged positively telemedicine service (30% were quiet and 50% were very satisfied), as well as tool (70% were quiet and 10% were very satisfied). Telemonitoring had a low agreement (10% were slightly satisfied and 50% were neutral); tele-counselling had a high rate of satisfaction (40% quiet and 60% were very satisfied). Conclusions: This study showed that telemedicine model for Sicilian population affected by COVID-19 was feasible, easy to use and appreciated by patients. Our promising results allow us to assume that if in Sicily there was a return of the emergency, we would be ready to manage it This system can be the solution to remote management of these patients, to reduce isolation, provide health services, and monitor virus infections. The use of this technology should encourage future research to change the health care system and provides opportunities to ensure health and care for oneself and others.

Effects of Robotic Neurorehabilitation on Body Representation in Individuals with Stroke: A Preliminary Study Focusing on an EEG-Based Approach.

Patients with stroke can experience a drastic change in their body representation (BR), beyond the physical and psychological consequences of stroke itself. Noteworthy, the misperception of BR could affect patients' motor performance even more. Our study aimed at evaluating the usefulness of a robot-aided gait training (RAGT) equipped with augmented visuomotor feedback, expected to target BR (RAGT + VR) in improving lower limb sensorimotor function, gait performance (using Fugl-Meyer Assessment scale for lower extremities, FMA-LE), and BR (using the Body Esteem Scale-BES- and the Body Uneasiness Test-BUT), as compared to RAGT - VR. We also assessed the neurophysiologic basis putatively subtending the BR-based motor function recovery, using EEG recording during RAGT. Forty-five patients with stroke were enrolled in this study and randomized with a 1:2 ratio into either the RAGT + VR (n = 30) or the RAGT - VR (n = 15) group. The former group carried out rehabilitation training with the Lokomat©Pro; whereas, the latter used the Lokomat©Nanos. The rehabilitation protocol consisted of 40 one-hour training sessions. At the end of the training, the RAGT + VR improved in FMA-LE (p < 0.001) and BR (as per BES, (p < 0.001), and BUT, (p < 0.001)) more than the RAGT- did (p < 0.001). These differences in clinical outcomes were paralleled by a greater strengthening of visuomotor connectivity and corticomotor excitability (as detected at the EEG analyses) in the RAGT + VR than in the RAGT - VR (all comparisons p < 0.001), corresponding to an improved motor programming and execution in the former group.We may argue that BR recovery was important concerning functional motor improvement by its integration with the motor control system. This likely occurred through the activation of the Mirror Neuron System secondary to the visuomotor feedback provision, resembling virtual reality. Last, our data further confirm the important role of visuomotor feedback in post-stroke rehabilitation, which can achieve better patient-tailored improvement in functional gait by means of RAGT + VR targeting BR.

Neuropsychological assessment in Niemann-Pick disease type C: a systematic review.

BACKGROUND: The neuropsychological profile of Niemann-Pick type C (NP-C) patients is characterized by an early deterioration in executive functions and attention. There are few studies on cognitive impairment and on neuropsychological assessment of NP-C disease. The purpose of this review is to analyze the studies on a psychological assessment for NP-C patients. METHOD: This review aims to identify a neuropsychological assessment to evaluate cognitive domains and neuropsychological changes in these patients. There were a total of 73 articles. The search terms were identified as titles and abstracts. All articles were evaluated by title, abstract, and text. RESULTS: Only four of the 73 articles were included because they met the criteria of our review. Furthermore, in these studies, possible diagnostic protocols are proposed on NP-C subjects. DISCUSSION AND CONCLUSION: The cognitive impairment in NP-C has a negative impact on daily functioning and quality of life. Early diagnosis could identify cognitive deficits and promote cognitive interventions to improve the neuropsychological profile. The management of NP-C disease should be based on a multidisciplinary approach, to treating symptoms, preserving neurological functions, and guaranteeing the best possible quality of life. Early identification of neurological and psychological symptoms of the disease is necessary in order to decrease the progression of neurological disease and improve patient care and treatment outcomes. Furthermore, research should focus more on cognitive aspects, not only in the diagnostic process but also in the rehabilitation process.

Hypersexuality in neurological diseases: do we see only the tip of the iceberg?

The purpose of this commentary is to investigate the pathophysiological mechanisms underlying hypersexuality and its manifestation in neurological diseases through a meta-analysis. Studies were identified by searching on PubMed, Web of Science and Cochrane databases. All results of each database between 2014 and 2020 were evaluated for possible inclusion. After an accurate revision of complete manuscripts, forty articles satisfied the inclusion/exclusion criteria. Data from our meta-analysis indicated hypersexuality to be a frequent sexual disorder in patients with neurological disorders, especially neurodegenerative ones. Hypersexuality could negatively affect a patient's management and outcomes. This commentary discusses studies that are often incomplete for evaluation measures or sample selection. In our opinion, it is necessary to consider hypersexuality with particular attention, so more extensive sample studies are needed to find the most appropriate treatment to improve the quality of life for both the patient and the caregiver.

Rehabilitation of somatoparaphrenia with misoplegia: insights from a single case-pilot study.

Somatoparaphrenia lacka ownership of a paralyzed limb, i.e., the illusion that one's limbs belong to someone else. Somatoparaphrenia is one of the many forms of body misperceptions. We report a case of somatoparaphrenia with misoplegia, characterized by the absence of anosognosia for hemiplegia and personal neglect, following a surgical operation for left parietal meningioma. The patient received a novel multidisciplinary treatment, including motor rehabilitation training, traditional physiotherapy and robotic rehabilitation using the Hunova Movendo Technology and psychological counseling. At the end of the training, the patient improved in global cognitive functioning, mood, motor abilities, and the perception of herself and her body, reducing the sense of estrangement and repulsion in the lower right limb. Our result showed the importance of a specific neuropsychological assessment in patients with parietal brain lesions and the usefulness of an integrated psychological and motor approach in rehabilitating patients with somatoparaphrenia, primarily when associated with misoplegia.

Do patients with PD benefit from music assisted therapy plus treadmill-based gait training? An exploratory study focused on behavioral outcomes.

Purpose: Parkinson's disease (PD) is the second most common age-related neurodegenerative disorder, presenting not only with motor symptoms (resting tremor, bradykinesia, and muscular rigidity), but also with cognitive and behavioral problems that need to be addressed in a rehabilitation setting. Aim of the study was to evaluate the effects of a combined rehabilitative approach, using gait training coupled to music-based therapy, on cognitive and behavioral function in a sample of patients with PD.Materials and Methods: Forty patients, meeting the inclusion criteria, were enrolled in this study and were randomly divided into two groups. The control group (CG) underwent traditional over ground gait training, whilst the experimental group (EG) underwent gait training with the Biodex Gait Trainer 3 (a treadmill integrated with music therapy). Each subject was evaluated at baseline (T0) and after the training (T1), using specific neuropsychological and motor function tests.Results: The EG presented higher outcomes scores concerning mood and quality of life in all subscales of Psychological General Well-Being Index (i.e. anxiety, depression, health, vitality and positivity) and subscales of Brief-COPE, with regard to behavioral disengagement, positive reframing, planning, acceptance and use of emotional support, as compared to the CG. Moreover, a significant improvement in motor functioning, with regard to static and dynamic balance, was found in the EG.Conclusion: Music-based gait training rehabilitation may be considered an effective strategy to improve behavioral performances, coping strategies and rehabilitation outcomes in patients with PD.

Can robotic gait rehabilitation plus Virtual Reality affect cognitive and behavioural outcomes in patients with chronic stroke? A randomized controlled trial involving three different protocols.

BACKGROUND: The rehabilitation of cognitive and behavioral abnormalities in individuals with stroke is essential for promoting patient's recovery and autonomy. The aim of our study is to evaluate the effects of robotic neurorehabilitation using Lokomat with and without VR on cognitive functioning and psychological well-being in stroke patients, as compared to traditional therapy. METHODS: Ninety stroke patients were included in this randomized controlled clinical trial. The patients were assigned to one of the three treatment groups, i.e. the Robotic Rehabilitation group undergoing robotic rehab with VR (RRG+VR), the Robotic Rehabilitation Group (RRG-VR) using robotics without VR, and the Conventional Rehabilitation group (CRG) submitted to conventional physiotherapy and cognitive treatment. RESULTS: The analysis showed that either the robotic training (with and without VR) or the conventional rehabilitation led to significant improvements in the global cognitive functioning, mood, and executive functions, as well as in activities of daily living. However, only in the RRG+VR we observed a significant improvement in cognitive flexibility and shifting skills, selective attention/visual research, and quality of life, with regard to the perception of the mental and physical state. CONCLUSION: Our study shows that robotic treatment, especially if associated with VR, may positively affect cognitive recovery and psychological well-being in patients with chronic stroke, thanks to the complex interation between movement and cognition.

Toward Improving Poststroke Aphasia: A Pilot Study on the Growing Use of Telerehabilitation for the Continuity of Care.

BACKGROUND: Aphasia is a quite common and very disabling symptom following stroke, negatively affecting patient's quality of life. Aim of the study is to evaluate the effectiveness of a rehabilitation training for aphasia that employ a touch-screen tablet using a virtual reality rehabilitation system (VRRS-Tablet). MATERIAL AND METHODS: Thirty patients with aphasia due to ischemic or hemorrhagic stroke were randomized into either the control or the experimental group and assessed by means of a specific neuropsychological evaluation. The study lasted 6 months and included 2 phases. During the former, the experimental group underwent an experimental linguistic treatment performed using the VRRS-Tablet, while the control group was trained with a traditional linguistic treatment. In the latter, the control groups were delivered to territorial services, while the experimental group was provided with the VRRS-Tablet. RESULTS: The experimental group improves in all the investigated areas, except for writing, while the control group only improves in comprehension, depression, and quality of life. CONCLUSIONS: Our study has demonstrated the effectiveness of a home-based telerehabilitation program specific for poststroke aphasia. The use of telerehabilitation by means of VRRS-Tablet could be one of the best solutions to treat aphasic patients after their discharge, promoting continuity of care by monitoring functional outcomes, maintaining preserved abilities, reducing depression, and improving linguistic functions, besides the psychological well-being.

What About the Role of Virtual Reality in Parkinson Disease's Cognitive Rehabilitation? Preliminary Findings From a Randomized Clinical Trial.

BACKGROUND: The purpose of this study is to evaluate the effects of a virtual reality training with BTS Nirvana (BTS-N) system in the cognitive and behavioral recovery in patients with Parkinson disease (PD). The BTS-N is a semi-immersive therapy system used for motor and cognitive rehabilitation of patients with neurological diseases, by creating virtual scenarios with which the patient may interact. METHODS: We enrolled 20 patients with PD undergoing neurorehabilitation. All the patients were randomized into 2 groups: experimental group performing semi-immersive virtual reality training with BTS-N and control group undergoing traditional cognitive training. Each participant was evaluated before and immediately after the end of the training. Each cognitive training consisted of 3 sessions a week, each lasting 60 minutes, for 8 weeks, for a total of 24 sessions in each group. RESULTS: Experimental group showed a greater improvement in cognitive functioning, with regard to executive and visuospatial abilities, as compared with the control group. CONCLUSION: Our findings suggest that rehabilitation through a new virtual reality instrument could be a valuable tool in improving cognitive and behavioral outcomes of patients with PD.

Personal computer-based cognitive training in Parkinson's disease: a case study.

Parkinson's disease (PD) is a neurodegenerative disorder that is best managed by a combination of medication and regular physiotherapy. PD's main symptoms involve the motor system, but cognitive disorders can be very severe as well. The aim of this study was to evaluate the effects of the computerized rehabilitative tool Esercizi di Riabilitazione Cognitiva (ERICA) in the cognitive recovery of a patient with PD. The patient was a 65-year-old man affected by PD with motor complications and severe cognitive and behavioural alterations. He underwent two different types of intensive rehabilitation training: standard cognitive rehabilitation alone and in combination with specific personal computer (PC)-based cognitive training. We evaluated his neuropsychological profile before and after the two types of training by using a specific psychometric battery. Only at the end of the PC training did we observe improvement in cognitive function as well as mood stabilization. When used in addition to standard cognitive rehabilitation, PC-based cognitive training may be a valuable tool in improving cognitive skills, with regard to attention, memory process, and executive functions. PC-based cognitive training may be able to help optimize managing the symptoms of PD.

Sexual Functioning and Sexual Health in Female Patients following Stroke: A Scoping Review with Implications for Rehabilitation.

The impact of stroke on the sexual functioning of female survivors can arise from direct neurological effects or be triggered indirectly through various psychophysiological processes. Although an increasing number of publications exist, the topic of sexuality remains seldom discussed in the stroke literature, even though patients have expressed a need for sexual rehabilitation services. A literature review on sexual functioning in post-stroke females examining existing rehabilitation programs addressing patients' sexuality and exploring the perspectives of nurses and caregivers on sexual issues constitutes a novel approach. Therefore, we conducted a scoping review to better investigate this hot topic. Studies were identified by searching Scopus, PubMed, Web of Science, Cochrane Library, PsychINFO, and Embase databases. Current data indicates substantial connections between stroke and female sexual dysfunction (SD), including factors like desire/libido, sexual satisfaction, and sexual intercourse. Some intervention programs have been created to provide specific guidance to healthcare professionals in addressing patients' requirements for sexual recovery, although their adequacy remains uncertain. However, to date, there are neither specific rehabilitation programs for post-stroke female SD nor healthcare personnel trained to deal with post-stroke sexual issues adequately and efficiently. The incorporation of sexual rehabilitation into the overall rehabilitation process for stroke patients is crucial, ideally within an interdisciplinary framework. Despite being a fundamental aspect of post-stroke women's lives, sexuality remains taboo.

The Lack of Ad Hoc Neuropsychological Assessment in Adults with Neurofibromatosis: A Systematic Review.

Background: Neurofibromatosis Type 1 (NF1) is a genetic autosomal dominant disorder that affects both the central and peripheral nervous systems. Children and adolescents with NF1 commonly experience neuropsychological, motor, and behavioral deficits. The cognitive profile hallmark of this disorder includes visuospatial and executive function impairments. These cognitive disorders may persist into adulthood. This study aims to analyze previous research studies that have described cognitive dysfunctions in adults with NF1. The purpose of this analysis is to review the neuropsychological and psychological assessment methods used. Methods: A total of 327 articles were identified based on the search terms in their titles and abstracts. The evaluation was conducted by scrutinizing each article's title, abstract, and text. Results: Only 16 articles were found to be eligible for inclusion based on the pre-defined criteria. The selected studies primarily focus on the development of diagnostic protocols for individuals with NF1. Conclusions: The management of NF1 disease requires a multidisciplinary approach to address symptoms, preserve neurological functions, and ensure the best possible quality of life. However, cognitive impairment can negatively affect psychological well-being. This study suggested that cognitive functions in NF1 patients were not tested using specific measures, but rather were evaluated through intelligence scales. Additionally, the findings revealed that there is no standardized neuropsychological assessment for adults with NF1. To address this gap, it would be helpful to create a specific neuropsychological battery to study cognitive function in NF1 patients during clinical studies. This battery could also serve as a tool to design models for cognitive rehabilitation by using reliable and sensitive measures of cognitive outcomes.

The Effects of Home Automation on Personal and Social Autonomies in Spinal Cord Injury Patients: A Pilot Study.

Background: Spinal cord injury (SCI) is a severe and progressive neurological condition caused by trauma to the nervous system, resulting in lifelong disability and severe comorbidities. This condition imposes serious limitations on everyday life, interfering with patients' social lives and compromising their quality of life, psychological well-being, and daily living activities. Rehabilitation is essential to helping SCI patients gain more independence in their daily routines. Home automation (HA) systems provide personalized support to users, allowing them to manage various aspects of their living environment, promoting independence and well-being. This study aims to demonstrate the efficacy of an HA system in enhancing personal and social autonomies in SCI patients, resulting in improved cognitive function and reduced anxiety-depressive symptoms compared to traditional training. Methods: We enrolled 50 SCI patients undergoing neurorehabilitation at IRCCS Centro Neurolesi (Messina, Italy). These patients were randomly assigned to one of two groups: a control group (CG) and an experimental group (EG). The CG received traditional training, while the EG underwent HA training. We evaluated the patients before (T0) and after (T1) rehabilitation using various scales, including the Montreal Cognitive Assessment (MoCA), the Beck Depression Inventory (BDI), the Hamilton Rating Scale for Anxiety (HRS-A), the 12-Item Short-Form Survey (SF-12), the Functional Independence Measure (FIM), Activities of Daily Living (ADL), Instrumental Activities of Daily Living Scale (IADL), and the EQ-5D-5L. Results: The effect of the experimental treatment showed an improvement in all patients test scores in the EG, especially regarding cognitive functions, mood disorders, activities of daily living, and quality of life. Conclusion: Our findings suggest that HA may be effective in improving daily autonomy and, in turn, alleviating mood disorders and enhancing psychological well-being.

The effect of Computer Assisted Rehabilitation Environment (CAREN) in cognitive impairment and coping strategies in Parkinson's disease: a preliminary study.

Parkinson's disease is a neurodegenerative disorder characterized by different motor, vegetative, behavioral, and cognitive impairments, with worsening quality of life. Virtual reality devices have given promising results in neurorehabilitation as they can provide multisensory stimulation in a realistic environment. This study aims to test the efficacy of virtual reality training by using Computer Assisted Rehabilitation Environment in cognitive impairment in a sample of PD. 31 patients affected by PD were enrolled. All PD patients underwent 24 sessions of Computer Assisted Rehabilitation Environment training. The participants were assessed at baseline (T0) and after two months (T1). Our results suggested that Computer Assisted Rehabilitation Environment training may be effective in the cognitive and emotional domains, particularly by improving executive function, anxiety, and depressive symptoms. These changes have helped to improve self-efficacy and coping strategies. These results indicate greater cognitive and physical effort to overcome stressors. Our results show that Computer Assisted Rehabilitation Environment training was beneficial in improving cognitive functions. Longer duration training may be especially beneficial for patients with mild cognitive impairment. Our findings open the door to tailored personalized treatments based on the patient's motor and cognitive profiles.

The Role of Telemedicine in the Treatment of Cognitive and Psychological Disorders in Parkinson's Disease: An Overview.

BACKGROUND: This literature review evaluates the use and efficacy of telemedicine in cognitive and psychological treatment in Parkinson's disease. METHODS: Studies performed between 2016 and 2021 that fulfilled inclusion criteria were selected from PubMed, Scopus, Cochrane, and Web of Science databases. All articles were evaluated by title, abstract, and text. All studies that examined the cognitive and psychological/psychotherapy treatment of patients with Parkinson's disease by telemedicine were included. RESULTS: Telehealth improved cognitive status and emotional/behavioral disorders in this population, and had positive effects on the patients' and caregivers' quality of life. CONCLUSIONS: Our literature review supports the development and efficacy of cognitive and psychological treatment with telemedicine, but the methodology of the study must be reviewed considering its limitations so as to highlight the benefits and risks of treatment via telemedicine.

Paving the Way for Predicting the Progression of Cognitive Decline: The Potential Role of Machine Learning Algorithms in the Clinical Management of Neurodegenerative Disorders.

Alzheimer's disease (AD) is the most common form of neurodegenerative disorder. The prodromal phase of AD is mild cognitive impairment (MCI). The capacity to predict the transitional phase from MCI to AD represents a challenge for the scientific community. The adoption of artificial intelligence (AI) is useful for diagnostic, predictive analysis starting from the clinical epidemiology of neurodegenerative disorders. We propose a Machine Learning Model (MLM) where the algorithms were trained on a set of neuropsychological, neurophysiological, and clinical data to predict the diagnosis of cognitive decline in both MCI and AD patients. METHODS: We built a dataset with clinical and neuropsychological data of 4848 patients, of which 2156 had a diagnosis of AD, and 2684 of MCI, for the Machine Learning Model, and 60 patients were enrolled for the test dataset. We trained an ML algorithm using RoboMate software based on the training dataset, and then calculated its accuracy using the test dataset. RESULTS: The Receiver Operating Characteristic (ROC) analysis revealed that diagnostic accuracy was 86%, with an appropriate cutoff value of 1.5; sensitivity was 72%; and specificity reached a value of 91% for clinical data prediction with MMSE. CONCLUSION: This method may support clinicians to provide a second opinion concerning high prognostic power in the progression of cognitive impairment. The MLM used in this study is based on big data that were confirmed in enrolled patients and given a credibility about the presence of determinant risk factors also supported by a cognitive test score.