Interprofessional education: a necessity in Alzheimer's dementia care-a pilot study.

Introduction: Interprofessional collaboration is seen as an indispensable prerequisite for high-quality health services and patient care, especially for complex diseases such as dementia. Thus, the current project aimed to extend interprofessional and competency-based education in the field of dementia care to the previously understudied therapy professions of nutrition, speech-language pathology, and physiotherapy. Methods: A three-day workshop was designed to provide specific learning objectives related to patient-centered dementia care, as well as competences for interprofessional collaboration. Teaching and learning approaches included case-based learning in simulated interprofessional case-conferences and peer-teaching. A total of 42 students (n = 20 nutrition therapy and counseling, n = 8 speech-language pathology, n = 14 physiotherapy), ranging from first to seventh semester, finished the whole workshop and were considered in data analysis. Changes in self-perceived attitudes toward interprofessional collaboration and education were measured by the German version of the UWE-IP. An in-house questionnaire was developed to evaluate knowledge and skills in the field of dementia, dementia management and interprofessional collaboration. Results: Participation in the workshop led to significant improvements in the total scores of the UWE-IP-D and the in-house questionnaire, as well as their respective subscales. Moderate to large effect sizes were achieved. All professions improved significantly in both questionnaires with large effect sizes. Significant differences between professions were found in the UWE-IP-D total score between students of speech-language pathology and physiotherapy in the posttest. Students of nutrition therapy and counseling revealed a significant lower level of self-perceived knowledge and skills in the in-house questionnaire pre- and post-testing. Discussion: The pilot-study confirms the effectiveness of interprofessional education to promote generic and interprofessional dementia care competencies and to develop positive attitudes toward interprofessional learning and collaboration in the therapy professions, thus increasing professional diversity in interprofessional education research. Differences between professions were confounded by heterogenous semester numbers and participation conditions. To achieve a curricular implementation, interprofessional education should be expanded to include a larger group of participants belonging to different professions, start early in the study program, and be evaluated over the long term.

Interdisciplinary Approaches to Deal with Alzheimer's Disease-From Bench to Bedside: What Feasible Options Do Already Exist Today?

Alzheimer's disease is one of the most common neurodegenerative diseases in the western population. The incidence of this disease increases with age. Rising life expectancy and the resulting increase in the ratio of elderly in the population are likely to exacerbate socioeconomic problems. Alzheimer's disease is a multifactorial disease. In addition to amyloidogenic processing leading to plaques, and tau pathology, but also other molecular causes such as oxidative stress or inflammation play a crucial role. We summarize the molecular mechanisms leading to Alzheimer's disease and which potential interventions are known to interfere with these mechanisms, focusing on nutritional approaches and physical activity but also the beneficial effects of cognition-oriented treatments with a focus on language and communication. Interestingly, recent findings also suggest a causal link between oral conditions, such as periodontitis or edentulism, and Alzheimer's disease, raising the question of whether dental intervention in Alzheimer's patients can be beneficial as well. Unfortunately, all previous single-domain interventions have been shown to have limited benefit to patients. However, the latest studies indicate that combining these efforts into multidomain approaches may have increased preventive or therapeutic potential. Therefore, as another emphasis in this review, we provide an overview of current literature dealing with studies combining the above-mentioned approaches and discuss potential advantages compared to monotherapies. Considering current literature and intervention options, we also propose a multidomain interdisciplinary approach for the treatment of Alzheimer's disease patients that synergistically links the individual approaches. In conclusion, this review highlights the need to combine different approaches in an interdisciplinary manner, to address the future challenges of Alzheimer's disease.

Patterns of linguistic and numerical performance in aphasia.

BACKGROUND: Empirical research on the relationship between linguistic and numerical processing revealed inconsistent results for different levels of cognitive processing (e.g., lexical, semantic) as well as different stimulus materials (e.g., Arabic digits, number words, letters, non-number words). Information of dissociation patterns in aphasic patients was used in order to investigate the dissociability of linguistic and numerical processes. The aim of the present prospective study was a comprehensive, specific, and systematic investigation of relationships between linguistic and numerical processing, considering the impact of asemantic vs. semantic processing and the type of material employed (numbers compared to letters vs. words). METHODS: A sample of aphasic patients (n = 60) was assessed with a battery of linguistic and numerical tasks directly comparable for their cognitive processing levels (e.g., perceptual, morpho-lexical, semantic). RESULTS AND CONCLUSIONS: Mean performance differences and frequencies of (complementary) dissociations in individual patients revealed the most prominent numerical advantage for asemantic tasks when comparing the processing of numbers vs. letters, whereas the least numerical advantage was found for semantic tasks when comparing the processing of numbers vs. words. Different patient subgroups showing differential dissociation patterns were further analysed and discussed. A comprehensive model of linguistic and numerical processing should take these findings into account.

Longitudinal cerebral diffusion changes reflect progressive decline of language and cognition.

Language deficits are regularly found in cortical neurodegenerative diseases. The progression of language deficits shows a considerable inter-individual variability even within one diagnostic group. We aimed at detecting patterns of altered diffusion as well as atrophy of cerebral gray and white matter which underlie ongoing language-related deterioration in patients with cortical neurodegenerative diseases. Diffusion tensor imaging and T1-weighted MRI data of 26 patients with clinically diagnosed neurodegenerative disorders were acquired at baseline and 14 months later in this prospective study. Language functions were assessed with a confrontation naming test and the Token Test. Diffusion and voxel-based morphometric measures were calculated and correlates of language performance were evaluated. Across all patients, the naming impairment was related to diffusion (false discovery rate-corrected P<0.05 at baseline) and atrophy abnormalities (family-wise error (FWE)-corrected P<0.05 at follow-up) primarily in the left temporal lobe. Deficits in the Token Test were correlated with predominantly left frontal MRI abnormalities (FWE-corrected P<0.05). The Token Test performance decline over 14 months was accompanied by further increasing abnormalities in the frontal cortex, left caudate, parietal cortex (all FWE-corrected P<0.05), and posterior callosal body (FWE-corrected P=0.055). Both diffusion and structural MRI were apt to elucidate the underpinnings of inter-individual differences in language-related deficits and to detect longitudinal changes that accompanied ongoing cognition and language decline, with mean diffusivity appearing most sensitive. This might indicate the usefulness of diffusion measures as markers for successful intervention in therapy studies.

Enhancement and suppression in a lexical interference fMRI-paradigm.

Previous picture-word interference (PWI) fMRI-paradigms revealed ambiguous mechanisms underlying facilitation and inhibition in healthy subjects. Lexical distractors revealed increased (enhancement) or decreased (suppression) activation in language and monitoring/control areas. Performing a secondary examination and data analysis, we aimed to illuminate the relation between behavioral and neural interference effects comparing target-related distractors (REL) with unrelated distractors (UNREL). We hypothesized that interference involves both (A) suppression due to priming and (B) enhancement due to simultaneous distractor and target processing. Comparisons to UNREL should remain distractor unspecific even at a low threshold. (C) Distractor types with common characteristics should reveal overlapping brain areas. In a 3T MRI scanner, participants were asked to name pictures while auditory words were presented (stimulus onset asynchrony [SOA] = -200 msec). Associatively and phonologically related distractors speeded responses (facilitation), while categorically related distractors slowed them down (inhibition) compared to UNREL. As a result, (A) reduced brain activations indeed resembled previously reported patterns of neural priming. Each target-related distractor yielded suppressions at least in areas associated with vision and conflict/competition monitoring (anterior cingulate cortex [ACC]), revealing least priming for inhibitors. (B) Enhancements concerned language-related but distractor-unspecific regions. (C) Some wider brain regions were commonly suppressed for combinations of distractor types. Overlapping areas associated with conceptual priming were found for facilitatory distractors (inferior frontal gyri), and areas related to phonetic/articulatory processing (precentral gyri and left parietal operculum/insula) for distractors sharing feature overlap. Each distractor with semantic relatedness revealed nonoverlapping suppressions in lexical-phonological areas (superior temporal regions). To conclude, interference combines suppression of areas well known from neural priming and enhancement of language-related areas caused by dual activation from target and distractor. Differences between interference and priming need to be taken into account. The present interference paradigm has the potential to reveal the functioning of word-processing stages, cognitive control, and responsiveness to priming at the same time.

Categorical and continuous--disentangling the neural correlates of the carry effect in multi-digit addition.

BACKGROUND: Recently it was suggested that the carry effect observed in addition involves both categorical and continuous processing characteristics. METHODS: In the present study, we aimed at identifying the specific neural correlates associated with processing either categorical or continuous aspects of the carry effect in an fMRI study on multi-digit addition. RESULTS: In line with our expectations, we observed two distinct parts of the fronto-parietal network subserving numerical cognition to be associated with either one of these two characteristics. On the one hand, the categorical aspect of the carry effect was associated with left-hemispheric language areas and the basal ganglia probably reflecting increased demands on procedural and problem solving processes. Complementarily, the continuous aspect of the carry effect was associated with increased intraparietal activation indicating increasing demands on magnitude processing as well as place-value integration with increasing unit sum. CONCLUSIONS: In summary, the findings suggest representations and processes underlying the carry effect in multi-digit addition to be more complex and interactive than assumed previously.

Reduced precuneus deactivation during object naming in patients with mild cognitive impairment, Alzheimer's disease, and frontotemporal lobar degeneration.

The precuneus is part of the default network of the human brain, which exhibits a high level of activity during the resting state and lower activity during task-related behavior. Typically, the posterior midline areas show this characteristic response in functional magnetic resonance imaging (fMRI) studies. In Alzheimer's disease (AD) and mild cognitive impairment (MCI), subjects exhibit a lack of this typical deactivation. The interpretation of these findings, however, is obfuscated by the presence of local pathology and atrophy in AD. In contrast to AD, in patients with early frontotemporal lobar degeneration (FTLD), the precuneus is virtually free of local neuropathology. In this study, we demonstrate reduced fMRI signal in the precuneus in a group of patients with FTLD during a confrontation naming task. We show that this effect in FTLD patients was (1) similar to that observed in AD and MCI and (2) not related to the degree of gray matter atrophy in the precuneus. We hypothesize that reduced deactivation of the default network is not related to local pathology but to a lack of connectivity, which decreases in both FTLD and AD, the major cortical dementias.

To carry or not to carry--is this the question? Disentangling the carry effect in multi-digit addition.

Recent research has suggested addition performance to be determined by both the need for a carry operation and problem size. Nevertheless, it has remained debatable, how these two factors are interrelated. In the current study, this question was pursued by orthogonally manipulating carry and problem size in two-digit addition verification. As the two factors interacted reliably, our results indicate that the carry effect is moderated by number magnitude processing rather than representing a purely procedural, asemantic sequence of processing steps. Moreover, it was found that the carry effect may not be a purely categorical effect but may be driven by continuous characteristics of the sum of the unit digits as well. Since the correct result of a carry problem can only be derived by integrating and updating the magnitudes of tens and units within the place-value structure of the Arabic number system, the present study provides evidence for the idea that decomposed processing of tens and units also transfers to mental arithmetic.

Correct and erroneous picture naming responses in healthy subjects.

In this functional magnetic resonance imaging study, brain activations of correct and erroneous picture naming responses were investigated in 34 healthy subjects using an event-related design. We regarded main effects comprising all (ALL), false (FAL), or correct (COR) responses only. Despite the rare error occurrence, activation maxima differed between all three main effects. To investigate the influence of naming accuracy on brain activations, we therefore (1) considered the number of errors as covariates, and (2) compared carefully matched sets of FAL and COR for subjects with higher error rates. As a result, activations in left middle/medial frontal gyrus were significantly correlated with number of errors. The neural substrate of naming errors appears to be separated in several subsystems of activation: first bilateral activations in anterior cingulate cortex (ACC), prefrontal, and premotor regions associated with monitoring processes; second the involvement of right (para)hippocampal gyrus most likely indicating post-error processes of retention; third perisylvian (especially inferior frontal) language areas. These activations were not restricted to false responses, but were with less intensity also recruited for correct responses. In contrast, there was no specific activation for successful name retrieval in correct trials. To conclude, the underlying processing mechanisms of erroneous and correct naming responses are strikingly similar; self-monitoring appears to be a general mechanism of the naming process.

Rehabilitation of arithmetic fact retrieval via extensive practice: a combined fMRI and behavioural case-study.

The present study investigates the effects of a training of arithmetic fact retrieval in a patient suffering from particular difficulties with multiplication facts. Over a period of four weeks simple multiplication facts were trained extensively. The outcome of the training was assessed behaviourally and changes in cerebral activation patterns were investigated using fMRI. The training led to a change in calculation strategies: Prior to training, the patient used predominantly time-consuming back-up strategies, after training he relied increasingly on the direct retrieval of arithmetic facts from long-term memory. Regarding the fMRI results, prefrontal activations were observed for untrained problems, which can be attributed to the application of back-up strategies strongly relying on fronto-executive functions. Interestingly, significant foci of activation for both trained and untrained items were found in the angular gyrus of the right hemisphere, which, however, differed in their exact localisation. For the trained condition, activations were observed in anterior parts of the angular gyrus which may be related to the training-based automatisation in fact retrieval. Activations in the untrained condition were found in a more posterior portion of the angular gyrus, that might be attributable to one of the patient's back-up strategies, namely to recite a whole multiplication row to get to the correct answer.

The separation of processing stages in a lexical interference fMRI-paradigm.

In picture-word interference paradigms, the picture naming process is influenced by an additional presentation of linguistic distractors. Naming response times (RTs) are speeded (facilitation) by associatively-related and phonologically-related words when compared to unrelated words, while they are slowed down by categorically-related words (inhibition), given that distractor onsets occur at appropriate stimulus onset asynchronies (SOAs). In the present study with healthy subjects, we for the first time integrated all four auditorily presented distractor types into a single paradigm at an SOA of -200 ms, in order to directly compare behavioral and neural interference effects between them. The behavioral study corroborated results of previous studies and revealed that associatively-related distractors speeded RTs even more than phonologically-related distractors, thereby becoming equally fast as naming without distractors. Distractors were assumed to specifically enhance activation of brain areas corresponding to processing stages as determined in a cognitive model of word production (Indefrey, P., Levelt, W.J.M., 2004. The spatial and temporal signatures of word production components. Cognition 92, 101-144.). Functional magnetic resonance imaging (fMRI) at 3 T revealed activation of left superior temporal gyrus exclusively for phonologically-related distractors, and activation of left or right lingual gyrus exclusively for associatively-related and categorically-related distractors, respectively. Moreover, phonologically-related distractors elicited phonological-phonetic networks, and both semantic distractors evoked areas associated with mental imagery, semantics, and episodic memory retrieval and associations. While processes involved in distractor inhibition (e.g., conflict/competition monitoring) and high articulatory demands were observed for categorically-related distractors, priming of articulatory planning was revealed for associatively-related distractors. We conclude that activations of neural networks as obtained by the fMRI interference paradigm can be predicted from a cognitive model.