[Frontotemporal dementia diagnoses within the psychiatric practice: pitfalls and practical tools]. / Diagnostiek van frontotemporale dementie in de psychiatrische praktijk: handvatten en valkuilen.

BACKGROUND: The behavioural variant of frontotemporal dementia (bvFTD) strongly resembles primary psychiatric disorders. Furthermore, a bvFTD mimic may occur, without neurodegenerative aetiology. AIM: To offer psychiatrist clinical tools for making or ruling out a bvFTD diagnosis. METHOD: To present the results of the first prospective cohort study on bvFTD patients and primary psychiatric patients. Results are discussed within the context of the international literature. RESULTS: Frontotemporal atrophy on imaging confirms a suspected bvFTD diagnosis. Merely fulfilling the bvFTD clinical criteria, with or without frontotemporal hypometabolism on functional imaging, may also result from primary psychiatric disorders or the bvFTD-phenocopy syndrome. A high level of stereotypy, hyperorality, a low level of depressive symptoms, impaired social cognition or absent insight increases the probability of bvFTD. Biomarker or genetic tests and follow-up are recommended. CONCLUSIONS A bvFTD diagnosis should be made multidisciplinary. Without the confirmation of atrophy or genetics, great reserve in making the diagnosis is in place and careful analyses for psychiatric aetiologies is advised.

Psychiatric diagnoses underlying the phenocopy syndrome of behavioural variant frontotemporal dementia.

INTRODUCTION: The frontotemporal dementia (FTD) consortium criteria (2011) emphasise the importance of distinguishing possible and probable behavioural variant FTD (bvFTD). A significant number of possible patients with bvFTD do not show functional decline and remain with normal neuroimaging over time, thus exhibiting the bvFTD phenocopy syndrome. A neurodegenerative nature is unlikely but an alternative explanation is missing. Our aim was to detect psychiatric conditions underlying the bvFTD phenocopy syndrome after extensive evaluation. METHODS: We included patients with the bvFTD phenocopy syndrome whereby patients with probable bvFTD served as a control group. Patients had to have undergone both neurological and psychiatric evaluation. Their charts were reviewed retrospectively. Using both qualitative and quantitative methods, psychiatric and psychological conditions associated with the clinical syndrome were determined in both groups and their relative frequencies were compared. RESULTS: Of 181 suspected bvFTD cases, 33 patients with bvFTD phenocopy syndrome and 19 with probable bvFTD were included. Recent life events, relationship problems and cluster C personality traits were the most prevalent psychiatric/psychological conditions. The frequency of these conditions was higher in the group of patients with the bvFTD phenocopy syndrome (n=28) compared to the probable bvFTD group (n=9) (χ(2) p<0.05). CONCLUSIONS: This is the first study thoroughly exploring psychiatric causes of the bvFTD phenocopy syndrome, revealing that in most cases multiple factors played a contributory role. Our study gives arguments for neurological and psychiatric collaboration when diagnosing bvFTD. Prompt diagnosis of treatable psychiatric conditions is to be gained.

[Frontotemporal dementia and schizophrenia in later life: a comparison of executive and general cognitive functioning]. / Frontotemporale dementie en schizofrenie op oudere leeftijd: een verkenning van executief en globaal cognitief functioneren.

BACKGROUND: Frontotemporal dementia (FTD) is characterised clinically by progressive changes in behaviour and personality; these changes are followed by cognitive disorder. FTD needs to be differentiated from other forms of dementia and from psychiatric conditions such as schizophrenia. Both FTD and schizophrenia lead to cognitive disorders and particularly to executive impairments. AIM: To compare executive and general cognitive functioning in patients with FTD and in patients with schizophrenia in later life. METHOD: As cognitive screening instruments we used the 'Frontal Assessment Battery' (FAB) and the 'Mini-Mental State Examination' (MMSE). The FAB en MMSE test results (retrieved from the database of the Alzheimer centre of the VU medical centre) for 25 outpatients diagnosed as having FTD were compared with the test results (retrieved from the 'SOUL' study database) for 31 elderly schizophrenia patients. RESULTS: In both the fab and the MMSE tests the scores for the patients with FTD were significantly lower than the scores for the patients with schizophrenia. CONCLUSION: Our study suggests that, despite the clinical similarities, there are differences between patients with FTD and elderly patients with schizophrenia with regard to executive and general cognitive functioning. Further studies are needed in order to differentiate between the two illnesses.

[Late-onset schizophrenia: is it a dementia nonpraecox? Review article with advice on differential diagnosis]. / Laat-ontstane schizofrenie: een dementia non-praecox?

BACKGROUND: For many years now researchers have been discussing whether late-onset schizophrenia (LOS) is in fact a separate subgroup of schizophrenia. They also want to find out whether LOS has a neurodegenerative aetiology and is a progressive illness. AIM: To obtain insight into the clinical aspects, aetiological factors and the course of late-onset schizophrenia. In addition, advice is given about better ways of diagnosing LOS in clinical practice and about differentiating LOS from dementia. METHOD: The literature was searched via Medline and the Cochrane Library on the basis of the key words '(very) late-onset schizophrenia' and 'paraphrenia' combined with 'course', 'outcome', 'cognition', 'decline', 'white matter hyperintensities', 'MRI', and 'neuropsychological', 'postmortem' and cerebrospinal fluid'. The period studied was from 1960 to November 2004. RESULTS: Clinical parameters andfunctional and structural brain research point to differences from and similarities to the early form of schizophrenia (EOS). In cases of 'very-late-onset schizophrenia-like psychosis' (VLOS) the clinical differences vis-à-vis EOS are even more marked. It is not known to what extent neurodegenerative factors play a role. There is no clear consensus about the course of (V)LOS either. CONCLUSION: In view of the aetiologial and physiopathological factors it is still not clear whether (V)LOS can be differentiated from EOS on a neurobiological basis. There is insufficient proof about the extent to which (V)LOS is a dementia nonpraecox with neurodegenerative aetiology. To achieve clear differentiation between the various forms of dementia it is essential that the clinical diagnosis of LOS is supported as strongly as possible and is evaluated continually.

[The development of psychotic symptoms in later life: late-onset schizophrenia or frontotemporal dementia? A case study]. / Het ontstaan van psychotische verschijnselen op latere leeftijd. Laat onstane schizofrenie of froontotemporale dementia?

The diagnosis of psychotic disorders that develop later in life is complicated, as can be seen from the case of a 65-year-old woman. Initially she was admitted to hospital for psychotic depression, but after some time doubts arose regarding the diagnosis. The most striking symptoms were bizarre delusions with acoustic, haptic and gustatory hallucinations. In addition, she showed behavioral and personality changes. It is difficult to establish whether a patient has late-onset schizophrenia or frontotemporal dementia. The similarities and differences between the symptoms of these two disorders are discussed and advice is given to assist with clinicians with diagnosis in the future.

Shedding consistency of strongyle-type eggs in Dutch boarding horses.

Faeces of 484 horses were sampled twice with an interval of 6 weeks while anthelmintic therapy was halted. Faecal eggs counts revealed that 267 (55.2%) horses had consistently low numbers of eggs per gram faeces (EPG) (EPG < 100 or = 100), 155 (32.0%) horses had consistently high EPGs (EPG > 100). Horses with consistently high EPGs were more often mares with access to pasture, aged less than 6 or more than 23 years, that were dewormed at intervals longer than 6 months, and were treated for the last time more than 3 months before the start of the study. Horses with consistently low EPGs were more often male horses with no or limited access to pasture, that were dewormed at maximally 6-month intervals, and were aged between 6 and 23 years. The results are an indication that some horses have consistently low EPGs and perhaps could be used as non-treated animals in a selective anthelmintic treatment scheme aimed at the prevention of the development of anthelmintic resistance.

Auditory information processing during adequate propofol anesthesia monitored by electroencephalogram bispectral index.

UNLABELLED: Memory for intraoperative events may arise from inadequate anesthesia when the hypnotic state is not continuously monitored. Electroencephalogram bispectral index (BIS) enables monitoring of the hypnotic state and titration of anesthesia to an adequate level (BIS 40 to 60). At this level, preserved memory function has been observed in trauma patients. We investigated memory formation in elective surgical outpatients during target-controlled propofol anesthesia supplemented with alfentanil. While BIS remained between 40 and 60, patients listened to a tape with either familiar instances (exemplars) from two categories (Experimental [E] group, n = 41) or bird sounds (Control [C] group, n = 41). After recovery, memory was tested directly and indirectly. BIS during audio presentation was on average (+/- SD) 44 +/- 5 and 46 +/- 5 for Groups E and C, respectively. No patient consciously recalled the intraoperative period, nor were presented words recognized reliably (Group E, 0.9 +/- 0.8 hits; Group C, 0.8 +/- 0.8 hits) (P = 0.7). When asked to generate category exemplars, Group E named 2.10 +/- 1.0 hits versus 1.98 +/- 1.0 in Group C (P = 0.9). We found no explicit or implicit memory effect of familiar words presented during adequate propofol anesthesia at BIS levels between 40 and 60 in elective surgical patients. IMPLICATIONS: This study suggests that stable levels of adequate hypnosis may prevent information processing and memory formation during general anesthesia and supports the feasibility of electroencephalogram bispectral index as a monitor of adequate anesthesia.

Memory formation during general anesthesia for emergency cesarean sections.

BACKGROUND: Occurrence of explicit memory (i.e., conscious recall) has been reported especially after surgical procedures in which anesthesia is considered to be "light." In addition, previous research has shown that implicit memory (e.g., improved memory test performance in absence of conscious recall) decreases with increasing hypnotic state. The current study investigated explicit and implicit memory during emergency cesarean sections with consistently light levels of hypnotic state. METHOD: Words were presented via headphones, and the bispectral index was recorded throughout surgery. Memory for the presented words was tested after recovery with a word-stem completion test. Using both parts of the process dissociation procedure allowed separation of explicit and implicit memory. In the "inclusion" part of the process dissociation procedure, patients are asked to complete word stems, if possible, with the corresponding words recalled from the intraoperative presentation. In the "exclusion" part, patients are instructed to avoid the words presented intraoperatively and to use other words instead. In the absence of recall, patients are asked to use the first word that comes to mind. RESULTS: The mean bispectral index during word presentation was 76.3 (+/-3.0). On average, the 24 patients were able to make correct inclusion-exclusion decisions: In the inclusion part, hit rates (i.e., the probability of responding with a word presented during surgery) were higher than base rates (0.37 vs. 0.31), whereas in the exclusion part hit rates were lower (0.23 vs. 0.28). Importantly, the patients made these inclusion-exclusion decisions without being able to consciously recall the words presented during surgery. CONCLUSIONS: This study shows that if words are presented at relatively light levels of anesthesia, patients are able to control their inclusion-exclusion decisions. This weak form of explicit memory can occur in the absence of conscious recall.

Dependence of explicit and implicit memory on hypnotic state in trauma patients.

BACKGROUND: It is still unclear whether memory of intraoperative events results entirely from moments of inadequate anesthesia. The current study was designed to determine whether the probability of memory declines with increasing depth of the hypnotic state. METHOD: A list of words was played via headphones during surgery to patients who had suffered acute trauma. Several commonly used indicators of anesthetic effect, including the bispectral index, were recorded during word presentation. First, these indicators served as predictors of the memory performance in a postoperative word stem completion test. Second, general memory performance observed in the first part was separated into explicit and implicit memory using the process dissociation procedure, and then two models of memory were compared: One model assumed that the probability of explicit and implicit memory decreases with increasing depth of hypnotic state (individual differences model), whereas the other assumed equal memory performance for all patients regardless of their level of hypnotic state. RESULTS: General memory performance declined with decreasing bispectral index values. None of the other indicators of hypnotic state were related to general memory performance. Memory was still significant at bispectral index levels between 60 and 40. A comparison of the two models of memory resulted in a better fit of the individual differences model, thus providing evidence of a dependence of explicit and implicit memory on the hypnotic state. Quantification of explicit and implicit memory revealed a significant implicit but no reliable explicit memory performance. CONCLUSIONS: This study clearly indicates that memory is related to the depth of hypnosis. The observed memory performance should be interpreted in terms of implicit memory. Auditory information processing occurred at bispectral index levels between 60 and 40.