Lower Preoperative Verbal Memory Performance Is Associated with Delirium after Coronary Artery Bypass Graft Surgery: A Prospective Cohort Study.

OBJECTIVE: Cognitive impairment constitutes one of the major risk factors of delirium after coronary artery bypass graft (CABG) surgery; however, it is unclear whether only patients with global cognitive decline are at increased risk for delirium or if individuals with preserved global cognitive functions but impairments in specific cognitive domains are also more vulnerable to developing delirium. Thus, this study aimed to analyze the neurocognitive status of patients scheduled for CABG surgery with the use of an advanced computerized cognitive battery (CNS Vital Signs) and to investigate possible associations between impaired performance in selective cognitive areas and the risk of postoperative delirium development. METHODS: The study enrolled 127 participants with a median age of 67 years (IQR: 63-71). Postoperative delirium developed in 32 (25%) patients.Before surgery, the patients were screened for global cognitive impairment with the use of the Mini-Mental State Examination Test, and the individuals were asked to perform the CNS Vital Signs battery to investigate 12 specific cognitive domains. The Confusion Assessment Method and the Memorial Delirium Assessment Scale were used to screen for a diagnosis of delirium postoperatively. RESULTS: In multivariate models, a lower score of verbal memory-assessed preoperatively was independently associated with the risk of postoperative delirium development. Other independent predictors of delirium included more advanced age, gender female, depression, postoperative pyrexia, and the presence of extracorporeal circulation. CONCLUSIONS: As decreased verbal memory constitutes an independent risk factor for postoperative delirium, a verbal memory test may be a useful predictor of postoperative delirium development.

Pharmacotherapy of Behavioral and Psychological Symptoms of Dementia: State of the Art and Future Progress.

The core symptoms of different dementia subtypes are the behavioral and psychological symptoms of dementia (BPSD) and its neuropsychiatric symptoms (NPS). BPSD symptoms may occur at any stage in the case of dementia due to Alzheimer's disease (AD), whereas they tend to occur early on in the case of its behavioral variant frontotemporal dementia or dementia with Lewy bodies and are essential for diagnosis. BPSD treatment consists of non-pharmacological as well as pharmacological interventions, with non-pharmacological interactions being suggested as first-line treatment. Agitation, psychotic features, apathy, depression, and anxiety may not respond to acetylcholinesterase inhibitors or memantine in AD cases; therefore, antipsychotics, antidepressants, sedative drugs or anxiolytics, and antiepileptic drugs are typically prescribed. However, such management of BPSD can be complicated by hypersensitivity to antipsychotic drugs, as observed in DLB, and a lack of effective pro-cognitive treatment in the case of frontotemporal dementia. The present paper reviews current knowledge of the management of BPSD and its limitations and discusses on-going clinical trials and future therapeutic options.

Neutrophil-lymphocyte ratio is increased in elderly patients with first episode depression, but not in recurrent depression.

Association between inflammation and depression, especially in elderly patients, leads to conclusions about their shared influence on risk of cardiovascular disease and death. It might be found useful to predict those issues by monitoring inflammatory parameters, such as neutrophil/lymphocyte ratio (NLR). The aim of this study was to determine the NLR in elderly patients with unipolar depression compared with non-depressed elderly patients. NLR was measured in 684 Caucasian subjects (depressed: n = 465, non-depressed: n = 219), aged ≥ 60 (depressed: mean age 74.8 ±â€¯7.8 years, non-depressed: mean age: 71.1 ±â€¯5.7 years). There were two subgroups within depressed patients: first episode depression (n = 138, 29.6%) and recurrent depression (n = 328, 70.3%). NLR was calculated as ratio between absolute neutrophil count to absolute lymphocyte count. NLR was significantly higher in unmedicated patients with depression compared with healthy control (2.10 ±â€¯2.13 vs. 2.01 ±â€¯0.75, p = 0.004). It was higher in first episode depression compared with recurrent depression (2.11 ±â€¯1.76 vs 1.64 ±â€¯1.04, p < 0.05). There was a positive correlation with severity of symptoms. We found non-specific effect of treatment with antidepressants or antipsychotics on lower NLR. Increased NLR in patients with first episode of depression compared to recurrent depression and healthy control may have important clinical consequences. Severity of symptoms are positively correlated with NLR, which may indicate that with increasing severity of depression, the risk of cardiovascular events is also rising, which leads to higher mortality. In elderly patients with depression even a small reduction of such risk may translate into better prognosis and improve quality of live. The difference between first episode and recurrent depression in terms of inflammatory biomarkers requires further studies.

Serotonergic drugs for the treatment of neuropsychiatric symptoms in dementia.

Behavioral and psychological symptoms of dementia (known also as neuropsychiatric symptoms) are essential features of Alzheimer's disease and related dementias. The near universal presence of neuropsychiatric symptoms in dementia (up to 90% of cases) has brought significant attention of clinicians and experts to the field. Non-pharmacological and pharmacological interventions are recommended for various types of neuropsychiatric symptoms. However, most pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia are used off-label in many countries. Cognitive decline and neuropsychiatric symptoms can be linked to alterations in multiple neurotransmitter systems, so modification of abnormalities in specific systems may improve clinical status of patients with neuropsychiatric symptoms. Use of serotonergic compounds (novel particles acting on specific receptors and widely acting drugs) in the treatment of neuropsychiatric symptoms is reviewed.

Benefits and risks of add-on therapies for Alzheimer's disease.

Despite three decades of intensive research, the efforts of scientific society and industry and the expenditures, numerous attempts to develop effective treatments for Alzheimer's disease have failed. Currently, approved and widely used medications to treat cognitive deficits in Alzheimer's disease are symptomatic only and show at best modest efficacy. In this context, the need to develop a successful, disease-modifying treatment is loudly expressed. One way to achieve this goal is the use of add-on therapies or various combinations of existing 'conventional' drugs. Results of several clinical studies and post hoc analyses of combination therapy with all cholinesterase inhibitors and memantine are published. Moreover, there is a need for studies on long-term efficacy of combination therapy in Alzheimer's.

Magnetic resonance spectroscopy in the diagnosis of dementia with Lewy bodies.

Dementia with Lewy bodies (DLB) is considered to be the second most frequent primary degenerative dementing illness after Alzheimer's disease (AD). DLB, together with Parkinson's disease (PD), Parkinson's disease with dementia (PDD) belong to α-synucleinopathies--a group of neurodegenerative diseases associated with pathological accumulation of the α-synuclein protein. Dementia due to PD and DLB shares clinical symptoms and neuropsychological profiles. Moreover, the core features and additional clinical signs and symptoms for these two very similar diseases are largely the same. Neuroimaging seems to be a promising method in differential diagnosis of dementia studies. The development of imaging methods or other objective measures to supplement clinical criteria for DLB is needed and a method which would accurately facilitate diagnosis of DLB prior to death is still being searched. Proton magnetic resonance spectroscopy ((1)H-MRS) provides a noninvasive method of assessing an in vivo biochemistry of brain tissue. This review summarizes the main results obtained from the application of neuroimaging techniques in DLB cases focusing on (1)H-MRS.

Clinical application of the Polish adaptation of the Montreal Cognitive Assessment (MoCA) test in screening for cognitive impairment.

MATERIAL AND METHODS: A group of 115 subjects (36 meeting DSM-IV criteria for Alzheimer disease (AD) [Clinical Dementia Rating (CDR) = 1], 42 meeting Petersen's criteria for MCI [CDR = 0.5], and 37 cognitively intact controls [CDR = 0]) was recruited for the study in the university-based Alzheimer out-patient clinic. All participants underwent general medical, neurological, and psychiatric examinations. The MoCA, the MMSE, CDR and the short (15-item) version of the Geriatric Depression Scale were also applied. RESULTS: Both MCI and AD groups exhibited impaired performance on MoCA compared to controls. Polish versions of the MMSE and MoCA tests were comparable in discriminating mild dementia from both MCI and control groups. The Polish version of the MoCA test performed marginally better than MMSE in discriminating MCI from controls. We propose to use the MoCA test to screen for MCI using an optimal cut-off score of 24 and to screen for dementia using a cut-off score of 19. CONCLUSIONS: The Polish version of the MoCA seems effective in the detection of deteriorated cognitive performance and appropriate for differentiating impaired from preserved cognitive function in a Polish population.

The influence of vascular risk factors on the survival rate of patients with dementia with Lewy bodies and Alzheimer disease.

BACKGROUND AND PURPOSE: The aim of this study was to determine whether dementia with Lewy bodies (DLB) progres-ses more rapidly than Alzheimer disease (AD) and to compare survival after dementia onset and mortality in both dementia groups. MATERIAL AND METHODS: A medical records analysis of AD (n = 183) and DLB (n = 51) patients was performed to determine age at onset of symptoms, the date of first presentation to the psychiatric services, dementia severity at diagnosis (MMSE score), and mean disease duration before diagnosis. Categorical data regarding vascular risk factors were collected. Projected decline rate (MMSE/year), survival rate after the diagnosis of dementia, mean survival time after diagnosis and mortality rate were calculated and compared between DLB and AD groups. RESULTS: The comparison of clinical and demographic parameters revealed no significant differences between groups, apart from a more pronounced decline rate in the DLB group. Diabetes, and to a lesser extent hypertension, influenced survival in AD, but not in DLB subjects. Overall, however, the difference in mortality rates and survival time between DLB and AD subjects cannot be attributed to the presence of any vascular risk factor analysed. DLB, independently of the presence of vascular risk factors, seems to be a more aggressive disorder than AD, when mortality and survival time are taken into account. CONCLUSIONS: More rapid progression of cognitive decline and shorter duration of dementia were found in DLB in this naturalistic study. The findings may have important implications for the management and treatment of DLB and should be confirmed in prospective studies.