Delirium: actualización en manejo no farmacológico / Delirium: update on nonpharmacological management

Delirium is a neuropsychiatric syndrome of acute onset and fluctuating course, with involvement of the attention and cognition, particularly common in older people. Increases morbidity and mortality, implies a high cost for health services and can be significantly prevented with adequate control of their risk factors. The use of drugs should not be the first line strategy in the patient with delirium, except in cases of significant psychomotor agitation or disruptive hallucinations because psychotropic drugs in general often cause serious side effects in this age group. Non-pharmacological multicomponent interventions are cost-effective in preventing delirium and reduce its severity and duration. Interventions such as reality orientation, adequate hydration and nutrition, sleep hygiene, early mobility, visual and hearing aids, environmental suitability and limitation of unnecessary physical intervention or physical restraint produce consistent clinical benefits.

El delirium es un síndrome neuropsiquiátrico de aparición aguda y curso fluctuante, con compromiso de la atención y cognición, particularmente frecuente en personas mayores. Incrementa la morbilidad y mortalidad, implica un alto costo para los dispositivos de salud y puede ser prevenido en un significativo porcentaje con adecuado control de sus factores predisponentes. El uso de medicamentos no debiera ser la estrategia de primera línea en el paciente con delirium, excepto en los casos de importante agitación psicomotora o alucinaciones disruptivas, ya que los psicofármacos, en general, suelen producir serios efectos secundarios en este grupo etario. Las intervenciones multicomponentes no farmacológicas, son costo-efectivas en prevenir delirium y también en reducir su severidad y duración. Medidas como la orientación en realidad, adecuada hidratación y nutrición, higiene de sueño, movilización precoz, ayudas visuales y auditivas, adecuación física ambiental y limitación de intervenciones innecesarias o restricciones físicas producen beneficios consistentes en la evolución del cuadro.

Tratamiento de la enfermedad de Alzheimer: rol de agentes neurotróficos / Alzheimer's disease treatment: neurotrophic agents role

Dementia and mainly Alzheimer's disease is a very serious and frequent clinical problem. So far, the pharmacological treatment with approved drugs has been essentially symptomatic. Although the aetiology of AD is not yet fully understood, new therapy approaches are primarily based on the amyloidal hypothesis. Unfortunately, the new drugs with amyloidal target have had difficulties to show consistence in efficacy and safety On the other hand, neurotrophic factors such as NGF and BDNF are small, versatile proteins that maintain survival and function to specific neuronal populations, for instance cholinergic neurons, on which they have a trophic and protective effect. Cerebrolysin is a peptidergic drug, approved for Alzheimer 's disease in some countries, containing biologically active peptides that exert nerve growth factor like activity and it has interesting data about pleiotropic properties of the compound. Some clinical trials with cerebrolysin have demonstrated cognitive and functional benefits when comparing with placebo. In a complex therapeutic scene appears necessary to explore with more clinical trials the neurotrophic way.

Las demencias y especialmente la enfermedad de Alzheimer (EA) se han transformado en un problema clínico muy frecuente y grave. En la actualidad, los fármacos aprobados como tratamiento convencional de esta enfermedad, han demostrado esencialmente beneficios sintomáticos. Aún cuando su etiopatogenia no ha sido completamente precisada, la mayor parte de nuevas moléculas terapéuticas investigadas están basadas en la hipótesis amiloídea, pero los resultados de los estudios no han sido suficientes o en eficacia o en seguridad. Por otra parte, se ha establecido que factores neurotróficos como NGF o BDNF, poseen propiedades neuroprotectoras de poblaciones celulares específicas como las neuronas colinérgicas, severamente afectadas en la EA. Cerebrolisina, un compuesto polipeptídico aprobado en algunos países para su uso en EA, estudiado in vitro e in vivo, ha demostrado poseer valiosas propiedades pleiotrópicas similares a neurotróficos. Asimismo, algunos ensayos clínicos randomizados han demostrado beneficios clínicos en cognición y funcionalidad al comparar con placebo. En un escenario terapéutico presente complejo para la EA, existen muchas expectativas de que nuevos estudios clínicos ratifiquen las propiedades multimodales de este agente neurotrófico.

Funcionalidad y demencia / Functionality and dementia

The functionality, that ability permits the people to be able to face the basic and complex needs of the daily life, invariably will be affected in the dementias. This progressive functional limitation acquires importance because affects the quality of life of patients and caregivers and even increases the risk of mortality of the patient with dementia. The measurement of the function, with different neuropsychological tools, is an essential part of the clinical practice and it has been constituted in one of the main objectives in the follow up and in the evaluation of interventions in dementia. Cognitive training programs and antidementia drugs, like cholinesterase inhibitors or memantine, have shown modest but statistically significant benefits in some activities of daily living.

Síndrome de Charles Bonnet: presentación de tres casos y revisión de la literatura / Charles Bonnet syndrome: Report of three cases

Charles Bonnet syndrome is characterized by the presence of visual hallucinations associated with loss of vision. We report three patients aged 74, 84 and 80 years (two women) with a severe loss of vision due to ocular diseases and silent visual hallucinations, that they recognized as unreal. Two patients felt that the hallucinations were ominous. Years later, two suffered a probable Alzheimer's disease (AD). One of them had a mild cognitive impairment when the syndrome appeared, that evolved into an AD with psychosis. This syndrome is not uncommon in older patients with loss of vision and it is probably underdiagnosed. Its pathogenesis is probably a cortical deafferentation. The content of the visual hallucinations (faces, landscaped, and so on) coincides with the activation of different areas of the visual association cortices).

Síntomas psicológicos y conductuales asociados a demencias: actualización terapéutica / An update on the treatment of psychological and behavioral symptoms associated to dementia

Behavioral disturbances in dementias are relevant because they are very common, they worsen patients' medical and cognitive condition, increase the caregiver burden and accelerate the admission to nursing homes. The different behavioral disturbances in dementias can appear isolated, but in most cases, patients present a combination of disturbances producing one of two main syndromes: the psychotic or the affective syndrome. Proper handling of these behavioral disturbances requires a correct characterization of the syndrome, discarding medical or environmental causes and selecting the drug with the better effectiveness and safety profile for each patient. In spite of the important number of psychotropics available, there is not enough scientific evidence about their real effectiveness and security in patients with Alzheimer's disease. This article reviews recent advances in the treatment of most common and disruptive behavioral disturbances.

Enfermedad de Alzheimer: Actualización en terapia farmacológica / An update on the pharmacological treatment of Alzheimer disease

Dementia in general, especially Alzheimer disease and vascular dementia, are diseases of high prevalence with severe socio-economic consequences in all countries. In recent years, due to the obtention of new pharmaceutical products acting on different brain neurotransmitters, there has been important changes in the therapy of these diseases. Although these drugs do not stop disease progression, there is consistent evidence of their usefulness in cognitive, behavioral and functional domains and of their pharmaco-economical justification. This article reviews the main drugs available for Alzheimer disease and some future therapeutic perspectives.

Esclerosis lateral amiotrófica juvenil asociada a compromiso cócleo-vestibular, atrofia óptica, ptosis palpebral y fatigabilidad muscular / Juvenile amyotrophic lateral sclerosis associated with cocleo-vestibular disturbances, optic atrophy, palpebral ptosis and muscle weakness

Se comunica el caso de un paciente joven portador de un síndrome progresivo, caracterizado por compromiso de la motoneurona, de predominio bulbar, asociado a hipoacusia neurosensorial, disfunción vestibular central, atrofia óptica, ptosis palpebral y elementos cerebelosos. Se discute la nosología de la entidad, estableciéndose semejanzas con la parálisis bulbar en asociación con sordera y atrofia óptica, cuya primera descripción, corresponde a Brown a fines del siglo pasado. Este caso tratado con Nicergolina, y lográndose una mejoría aceptable, sugiere para este grupo de enfermos una definición mórbida distinta a la de otras atrofias espinales, postulándose un origen mitocondrial del daño.