Action observation combined with gait training to improve gait and cognition in elderly with mild cognitive impairment A randomized controlled trial / Observação da ação e treinamento da marcha para melhorar a marcha e a cognição em idosos com comprometimento cognitivo leve: um estudo controlado randomizado

Abstract. Owing to advancement of medical technology and current knowledge, the population has a longer life expectancy, leading to an increase in the proportion of elderly. Objective: The study aimed to investigate the effect of action observation (AO) combined with gait training on gait and cognition in elderly with mild cognitive impairment (MCI). Methods: Thirty-three participants were randomly allocated to action observation with gait training (AOGT), gait training (GT), and control (CT) groups. The AOGT and GT groups received a program of observation and gait training protocol with the same total duration of 65 min for 12 sessions. For the observation, the AGOT group watched a video of normal gait movement, while the GT group watched an abstract picture and the CT group received no training program. All participants were assessed for gait parameters during single- and dual-tasks using an electronic gait mat system and were assessed for cognitive level using the Montreal Cognitive Assessment (MoCA) at baseline, after training and at 1-month follow-up. Results: The results showed that the AOGT group had significant improvements in gait speeds during single- and dual-tasks, as well as better MoCA score, while the GT group had significant improvement only in gait speed. Conclusion: The adjunct treatment of AO with gait training provides greater benefits for both gait and cognitive performances in elderly with MCI.

Resumo. Com o avanço da tecnologia médica e do conhecimento atual, a população tem uma expectativa de vida mais longa, levando a um aumento na proporção de idosos. Objetivo: O estudo teve como objetivo investigar o efeito da observação de ação (AO) combinada com o treinamento da marcha na marcha e cognição em idosos com comprometimento cognitivo leve (CCL). Métodos: Trinta e três participantes foram alocados aleatoriamente para observação de ação com grupos de treinamento de marcha (AOGT), treinamento de marcha (GT) e controle (CT). Os grupos AOGT e GT receberam um programa de observação e protocolo de treinamento de marcha com a mesma duração total de 65 minutos por 12 sessões. Na observação, o grupo AGOT assistiu a um vídeo de movimento normal da marcha, enquanto o grupo GT assistiu a uma figura abstrata e o grupo CT não recebeu nenhum programa de treinamento. Todos os participantes foram avaliados quanto aos parâmetros da marcha durante tarefas simples e duplas, utilizando um sistema eletrônico de esteira da marcha e avaliados quanto ao nível cognitivo, utilizando a Avaliação Cognitiva de Montreal (MoCA) na linha de base, após o treinamento e 1 mês de acompanhamento. Resultados: Os resultados mostraram que o grupo AOGT apresentou melhorias significativas nas velocidades da marcha durante tarefas simples e duplas, além do escore MoCA, enquanto o grupo GT teve melhora significativa apenas na velocidade da marcha. Conclusão: O tratamento adjunto da AO com o treinamento da marcha proporciona maiores benefícios tanto do desempenho da marcha quanto do desempenho cognitivo em idosos com CCL.

The effect of Galantamine on sleep quality in Thai Alzheimer's disease patients.

OBJECTIVE: To study the effect of Galantamine on sleep quality in Thai Alzheimer's disease (AD) patients with or without cerebrovascular disease. MATERIAL AND METHOD: A 6 month, multicenter open-label, uncontrolled trial was undertaken in 75 mild to moderate Alzheimer's disease patients with or without cerebrovascular disease. Eligible patients received a flexible-dose of Galantamine 16 or 24 mg/day for 24 weeks. The Pittsburgh Sleep Quality Index (PSQI) with self-analysis questionnaires were used to evaluate sleep quality. Analyses were based on the intent-to-treat population. RESULTS: Seventy-five eligible patients with mild to moderate Alzheimer's disease with or without cerebrovascular disease (male:female = 32:43, age range 74.5 +/- 0.9) were included and 58 patients (79%) completed the present study. The global PSQI scores showed some improvement over baseline (week 0 = 5.10 +/- 3.08, week 4 = 4.37 +/- 2.48, week 8 = 4.65 +/- 2.71, week 24 = 3.70 +/- 2.12) but were not yet statistical significant. In contrast, most of each component scores such as sleep quality, sleep latency, sleep duration, sleep disturbances, sleep medication, and daytime dysfunction except sleep efficiency, showed significant differences from baseline after week 8. Moreover, there were no significant differences in global PSQI and component scores between mild and moderate stages of Thai AD patients or between men and women patients. CONCLUSION: The result of the present study may be consistent with Galantamine being safe and can maintain good sleep quality for mild to moderate Thai AD patients with or without VaD. Galantamine doses of 16-24 mg/day were well tolerated.

Patterns of single photon emission tomography (SPECT) among patients with dementia in the memory clinic at Siriraj Hospital.

OBJECTIVE: The authors hypothesized that there is a pattern difference in cerebralperfusion of the 99-Technitium L, L-ethyl cysteinate dimer Single Photon Emission Computer Tomography (99-Tc ECD SPECT) between mild and moderate to severe dementia. MATERIAL AND METHOD: The authors reported a retrospective study in the Memory Clinic, Siriraj Hospital between January 2001 and October 2003 including only patients with Alzheimer's disease, vascular dementia, and mixed dementia. Clinical dementia rating (CDR) was used to document dementia severity. Patterns of hypoperfusion were classified into no definite hypoperfusion, regional hypoperfusion, and diffused hypoperfusion. RESULTS: One hundred and seven patients were included in the present study. Only mean Thai Mental State Examination (TMSE) score was different between the two groups. There was no significant correlation between pattern of hypoperfusion in brain SPECT and severity of dementia. CONCLUSION: The authors cannot demonstrate the pattern of hypoperfusion of 99-Tc ECD SPECT among patients' difference in dementia severity.

Use of Hachinski Ischemic Score in the memory clinic: Thai experience.

BACKGROUND: The validity ofHachinski Ischemic Score (HIS) in differentiating between Alzheimer's disease (AD) and Vascular dementia (VaD) has been questioned and compared with the gold standard autopsy. OBJECTIVE: To confirm that the HIS can be used to differentiate related VaD from AD in a Thai population. MATERIAL AND METHOD: A prospective study of 398 patients who were attending the Memory Clinic, at Siriraj Hospital between January 2001 and October 2003. RESULTS: The 214 patients, with a mean age of 71.15 + 10.20 years, were classified as AD, VaD or mixed dementia (AD with cerebrovascular disease) in proportion of 60.2%, 30.4%, and 9.3% respectively. The authors propose HIS at 5 as a cut off point to differentiate patients with AD and those with VaD or AD with cerebrovascular disease with sensitivity of 85.3% and specificity of 72.9%. CONCLUSION: The HIS can be applied to differentiate dementia related vascular etiology from AD in a Thai population.

CT criteria in vascular dementia: A study in Thai population.

Objective: To evaluate CT criteria for diagnosis of vascular dementia (VaD) in Thai population. Methods: Cranial CT was performed in the elderly from an urban community in the west of Bangkok. The evaluation of infarction (number, location and volume of infarction), white matter low attenuation, and atrophy were performed by neuroradiologists; and, the final diagnoses of dementia were done by neurologists. Results: Ninety-one patients were recruited into the study with their mean age of 70.16 years old (range = 53-90). Twenty-seven patients were males and 64 were females. The final diagnoses were, namely: normal cognition (10=11%), vascular dementia (30=33%), Alzheimer’s disease (AD) (41=45.1%), and mixed VaD and AD (10=11%). On CT, most patients had infarction of less than two lesions and the volume of infarction was less than 25 ml. Two (2.2%) patients who were diagnosed as AD and one who was diagnosed as normal had lesions more than one lesion; whereas 11 (12.1%) patients who were diagnosed as VaD had more than one lesion. No patients who were diagnosed with AD or those who were normal had infarction volume more than 25 ml, except two patients who were diagnosed with VaD had infarction volume more than 25 ml. Most patients who had white matter scale more than 2 were VaD (52%). No significant difference between atrophy and dementia was found. With the CT grading criteria of 0 for non-VaD and combined 1, 2 and 3 for VaD, the sensitivity, specificity and accuracy for diagnosis of VaD were 96%, 64.7%, and 76.5%, respectively. Conclusion: Modified CT criteria for VaD established by reducing volume of infarction regardless of the atrophy are helpful to identify VaD patients with improved diagnostic performance.

SPECT as an aid for clinicians in the diagnosis of alzheimer's disease: A case report and review of current diagnostic approaches and the need forearly accurate diagnosis to optimize treatment.

A case of 66 year-old male with Alzheimer's dementia with classical 99mTc-ECD SPECT imaging findings is reported. The history, physical examination, and investigation, are described. Biological markers which are new used for the diagnosis of Alzheimer's dementia and current treatment are discussed.

Hemifacial spasm treated with botulinum toxin injection: A ten-year experience at Siriraj Hospital.

Background : Hemifacial spasm is a common movement disorder in Thailand. Botulinum toxin has been introduced as an advanced treatment for this condition recently. Objective: To evaluate the efficacy and complication of botulinum toxin in the treatment of hemifacial spasm. Methods: We reviewed all files of patients with hemifacial spasm in the Movement Disorders Clinic at Siriraj Hospital, Mahidol University, who were treated with botulinum toxin injection from January, 1989 until September, 1999. Sex, age, duration of treatment, times of injection, treatment outcome, and complications were analysed. Results: There were 913 patients of which 38 patients were excluded because they were loss to follow up. 875 patients were analysed, (269 males, 606 females sex ratio 1:2.25). The mean age of all patients was 50.86+12.53 years with a range of 18 to 81 years. The follow up period ranged from 1-130 months (mean = 32.5+35.05 months). The outcome were classified as excellent (improvement >50%) in 58.9%, good (improvement >25%) in 37.3%, fair (improvement <25%) in 3.1%, and no improvement in 0.8%. Thus the efficacy of this treatment (improvement >25%) was 96.2 percent. There were complications of mild facial paresis in 80 patients (9.1%), ptosis in 39 patients (4.5%), excessive lacrimation in 7 patients (0.8%), and others (including pain and itching at the injection sites and double vision) in 7 patients (0.8%). All of the complications ere transient. ? Conclusion: Botulinum toxin A injection is a safe and effective way with no long term systemic complications (of treating patients with hemifacial spasm).

Neurosarcoidosis: First reported case in Thailand.

Sarcoidosis is a chronic multisystem granulomatous disease of unknown aetiology, which has a propensity to affect the lungs and rarely the nervous system; neurosarcoidosis may be an enigmatic diagnosis which is often entertained but rarely made with conviction. Prevalence rates for intrathoracic sarcoidosis vary from greater than 50 per 100, 000 e.g. in New York African-Americans, to under 10 per 100,0002. Much higher prevalence rates were obtained when consecutive postmortems were performed on approximately 60% of all deaths in an area of Sweden, of known to have sarcoidosis during life, yielding a prevalence of 641 per 100,0003. Previous data from large series of patients with sarcoidosis have estimated that approximately 5% of such patients will have clinical involvement of the nervous system4-7, although post-mortem studies suggest that ante-mortem diagnosis is only made in 50% with nervous system involvement. Therefore one can estimate that about 5 to 10 patients per million population will have clinical neurosarcoidosis. In Thailand there has been no previous report of neurosarcoidosis, thus our patient is the first documented case in the Kingdom.

Do physicians recognise dementia.

Background : Recognition and diagnosis of dementia is frequently overlooked by attending physicians both in the community and hospital settings. Objective : To determine the ability of attending physicians to recognise dementia. Methods : A cross-sectional survey of cognitive impairment in 150 medical inpatients at Siriraj Hospital, Bangkok, Thailand was done from May to November 1999. Inclusion criteria were patients aged over 50 year-old with Glasgow coma score over 12/15, no delirium and no active medical problems. Cognitive assessment was done before the discharge date by means of clinical evaluation, neurological examination and mental state examination. Dementia was diagnosed by DSM-IV criteria. The severity of dementia was classified by using the degree of dependency. Diagnosis of dementia in the medical records was categorised as whether dementia was recognised by the attending physicians. Results : Forty nine patients out of a total of 150 patients (32.67 per cent) were demented of which thirty three patients had mild dementia, thirteen patients had moderate dementia and three patients had severe dementia. The attending physicians recognised two patients out of forty nine dementia patients (4%). However, both of them had previously been diagnosed as having dementia before the admission. Conclusion : Delayed diagnosis of dementia is frequently due to attending physicians not recognising this condition. Early recognition of dementia usually leads to its proper management, thus internists should be more alert for this condition.

Rapidly reversible generalised weakness and slow nerve conduction velocity: A case report.

Generalised weakness from neuropathy, requiring respiratory support combined with slow nerve conduction velocity, is usually concomitant with acute inflammatory demyelinating polydiculoneuropathy (AIDP). In AIDP, the weakness usually reaches its peak within two to four weeks. The clinical symptoms and the measurable abnormalities in nerve conduction studies (NCS) take several weeks to resolve. We describe a case misdiagnosed as AIDP where the patient’s rapidly progressive weakness and slow nerve conduction studies (NCS) take several weeks to resolve. We describe a case misdiagnosed as AIDP where the patient’s rapidly progressive weakness and slow nerve conduction velocity reversed spontaneously to a near normal state within one week. From a literature review, this case was found to be similar to the tetrodotoxication and saxitoxin poisoning case reported. However, there was no evidence to support intoxication in this case.

Comparative study of Thai mini-mental state examination and chula mental test.

Thai Mini-mental State Examination (TMSE) and Chula Mental Test (CMT) have been widely used in Thailand. Both of them are screening test for cognitive impairment. However there are some differences in subsets of the tests. We conducted a comparative study between these 2 tests in 82 Thai elderly admitted in Siriraj Hospital. We found significant relationship between these 2 tests (correlation coefficient 0.78, Chi-square test p<0.05). They are best fitted in a reciprocating hyperbolar curve [ CMT = TMSE / (0.03444xTMSE+0.6287) ].