Barriers and Best Practices in Disclosing a Dementia Diagnosis: A Clinician Interview Study.

The vast majority of individuals with dementia want to receive a diagnosis. Research suggests, however, that only a fraction of individuals with dementia receive a diagnosis and patients and families often feel the information is poorly explained. We thus aimed to assess clinician-reported barriers to dementia disclosure and recommendations for giving a dementia diagnosis. To accomplish this, we performed telephone interviews with 15 clinicians from different specialties using a semi-structured interview guide. Transcripts were analyzed thematically. Clinician-reported barriers fit 3 categories: patient and caregiver-related barriers, clinician-related barriers, and barriers related to the triadic interaction. Patient and caregiver-related barriers included lack of social support, misunderstanding the diagnosis, and denial. Clinician barriers included difficulty giving bad news, difficulty communicating uncertainty, and lack of time. Triadic interaction barriers included challenges meeting multiple goals or needs and family requests for non-disclosure. Recommendations for best practice included for clinicians to foster relationships, educate patients and family, and take a family-centered approach. Clinicians described recommendations for fostering relationships such as using empathic communication and developing and maintaining connection. Educating patients and families included tailoring communication, explaining how the diagnosis was reached, and following up. Family approaches included meeting with family members prior to delivering the diagnosis and involving the caregiver in the discussion. Findings may inform updated recommendations for best practices when communicating a dementia diagnosis.

Afasia primaria progresiva y sus variantes: diagnóstico, evolución, características imagenológicas y manejo / Progressive primary aphasia and its variants: diagnosis, evolution, imaging characteristics and management

RESUMEN INTRODUCCIÓN: Las demencias son un conjunto de trastornos neurocognitivos, en personas con edad menor a 65 años sobresale la demencia frontotemporal, síndrome neurodegenerativo heterogéneo que tiene dos grandes variantes: conductual y afasia primaria progresiva. En esta última se describen tres variantes: no fluente, semántica y logopénica, que exigen en la práctica conocimientos actualizados para su diferenciación y comprensión. El objetivo de este escrito es hacer una revisión narrativa sobre las tres variantes clínicas de la afasia primaria progresiva, profundizando en diagnóstico, evolución, características imagenológicas y manejo. MATERIALES Y MÉTODOS: Artículo de revisión narrativa a partir del estado del arte en literatura biomédica sobre demencia frontotemporal, afasia primaria progresiva y sus variantes. RESULTADOS: El compromiso del lenguaje y de otras funciones cognitivas, así como los hallazgos imagenológicos, son heterogéneos en las tres variantes. Semiológicamente, la afasia primaria progresiva no fluente se caracteriza por apraxia del habla, la variante logopénica por fallas en la nominación y la variante semántica por fallas en el significado del mensaje. El compromiso imagenológico en la afasia primaria progresiva no fluente es más frontoinsular y corticosubcortical; en la variante semántica es habitualmente temporal del lado dominante; y en la variante logopénica priman alteraciones temporoparietales. No hay tratamiento específico, pero se puede vincular algunas opciones farmacológicas con procesos/técnicas de rehabilitación del lenguaje. CONCLUSIÓN: Si bien se trata de una forma heterogénea de demencia, tiene características clínicas (síntomas, signos y evolución) e imagenológicas importantes a la hora de su detección y diagnóstico en ambientes clínicos.

ABSTRACT INTRODUCTION: Dementias are a group of neurocognitive disorders, and in people under 65 years of age, frontotemporal dementia stands out, a heterogeneous neurodegenerative syndrome that has two major variants: behavioral and primary progressive aphasia. In the latter, three variants are described: non-fluent, semantic and logopenic, which require up-to-date knowledge in practice for their differentiation and understanding. The objective is to carry out a narrative review on the three clinical variants of primary progressive aphasia, delving into diagnosis, evolution, imaging characteristics and management. MATERIALS AND METHODS: Narrative review article based on the state of the art in biomedical literature on frontotemporal dementia, primary progressive aphasia and its variants. RESULTS: The compromise of language and other cognitive functions, as well as the imaging findings, are heterogeneous in the three variants. Semiologically, non-fluent progressive primary aphasia is characterized by apraxia of speech, the logopenic variant by failures in the nomination and the semantic variant by failures in the meaning of the message. Imaging involvement in non-fluent progressive primary aphasia is mainly frontoinsular and cortico-subcortical; in the semantic variant it is usually temporary on the dominant side; and in the logopenic variant, temporo-parietal alterations prevail. There is no specific treatment, but some pharmacological options can be linked with language rehabilitation processes / techniques. CONCLUSION: although Frontotemporal dementia is an heterogenous disorder, there are important clinical and imagenologic features that are useful to the diagnostic approach in the clinical field.

Lewy Body Dementias: Controversies and Drug Development.

Lewy body dementia (LBD) is one of the most common neurodegenerative dementias. Clinical trials for symptomatic and disease-modifying therapies in LBD remain a national research priority, but there are many challenges in both past and active drug developments in LBD. This review highlights the controversies in picking the appropriate populations, interventions, target selections, and outcome measures, which are all critical components of clinical trial implementation in LBD. The heterogeneity of LBD neuropathology and clinical presentations, limited understanding of core features such as cognitive fluctuations, and lack of validated LBD-specific outcome measures and biomarkers represent some of the major challenges in LBD trials.

Vitamin B-Can it prevent cognitive decline? A systematic review and meta-analysis.

BACKGROUND: Development of cognitive decline represents substantial issues in today's society, steadily gaining importance with increasing life expectancy. One potential approach to preventing cognitive decline is to lower homocysteine by administering vitamin B. In this systematic review and meta-analysis, we address this topic and investigate whether oral supplementation of vitamin B can successfully prevent cognitive decline in cognitively unimpaired individuals. METHODS: A computerized systematic literature search was conducted using the electronic databases PubMed, Embase, and the Cochrane Library. Eligibility criteria included oral supplementation with vitamin B (B1, B6, folic acid, and B12) and the absence of cognitive impairment. A meta-analysis was conducted with "global cognition" as the primary outcome of this review. Secondary outcomes were changes in cognitive function in other cognitive domains reported in the included studies. Risk of bias was assessed according to the Cochrane Risk of Bias tool and the GRADE approach to establish the overall certainty of the evidence. RESULTS: The meta-analysis did not yield a significant overall effect of supplementation with vitamin B on cognitive function (Z = 0.87; p = 0.39; SMD, 0.02; 95% CI, - 0.034, 0.08). A sensitivity analysis focusing on specific risk factors did not alter this result. Some studies reported isolated significant effects of the intervention on secondary outcomes. However, these findings were outnumbered by the number of cognitive tests that did not yield significant effects. DISCUSSION: We found no overall evidence that oral vitamin B supplementation prevented cognitive decline. The isolated significant effects that were reported could be attributed to methodological issues. The results of this review do not provide evidence that population groups with certain risk factors would profit more from the intervention than others. Our findings do not apply to forms of administration other than oral supplementation nor do they offer information regarding the treatment of cognitively impaired individuals via the administration of vitamin B. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017071692.

Espectro clínico y tratamiento del trastorno cognoscitivo y demencia asociada a la enfermedad de Parkinson / Clinical spectrum, evaluation and treatment of cognitive disorder and dementia associated with Parkinson's disease

RESUMEN La prevalencia del deterioro cognitivo mínimo en pacientes con EP está en un rango de 20-50 %. La prevalen-cia puntual de la demencia asociada a la enfermedad se estima en alrededor del 25-30 °% con un incremento proporcional en relación con la edad y el tiempo de evolución de la enfermedad. El perfil clínico puede ser heterogéneo y hace referencia a la alteración en los diferentes dominios que supone un substrato neurobiológico diferente. La disfunción ejecutiva suele ser más frecuente en etapas tempranas de la enfermedad, aunque también hay perfiles clínicos corticales. Hay síntomas neuropsiquiátricos como la depresión, la ansiedad y el discontrol de impulsos que pueden afectar la cognición. La valoración rutinaria de las actividades de la vida diaria y el desempeño funcional se ha relacionado con el grado de compromiso así como con el rendimiento cognitivo global. Pacientes en estadios avanzados y candidatos a la cirugía de estimulación cerebral profunda requieren la evaluación neuropsicológica para seguimiento e identificación de potenciales riesgos o contraindicaciones cognitivas, comportamentales y/o emocionales. Las conclusiones del consenso de cognición son: 1) el deterioro cognitivo mínimo es común en los pacientes, incluso en estadios tempranos; 2) el perfil clínico es heterogéneo, aunque la disfunción ejecutiva es más frecuente; 3) la valoración inicial permite detectar perfiles de riesgo a demencia; 4) deben usarse instrumentos validados para esta población; 5) los síntomas neuropsiquiátricos pueden afectar el desempeño del paciente, y 6) la valoración de la independencia funcional permite explorar el impacto de la cognición en la cotidianidad.

SUMMARY The prevalence of minimal cognitive impairment in patients with PD is between 20-50 °%. The prevalence of dementia associated with the disease is estimated at around 25-30 °% with a proportional increase in relation to age and time of disease progression. The clinical profile can be heterogeneous and refers to the alteration in the different domains that a different neurobiological substrate supposes. Executive dysfunction is usually more frequent in the early stages of the disease, although there are also clinical cortical profiles. There are neuropsychiatric symptoms such as depression, anxiety and impulse control disorders that can affect cognition. The routine assessment of activities of daily living and functional performance has been related to the degree of commitment as well as to the overall cognitive performance. Patients in advanced stages and candidates for deep brain stimulation surgery require neuropsychological evaluation to monitor and identify potential risks or cognitive, behavioral and/or emotional contraindications. The conclusions of the consensus of cognition are 1. Minimal cognitive deterioration is common in patients even in early stages, 2. The clinical profile is heterogeneous, although executive dysfunction is more frequent, 3. An initial assessment allows detecting risk profiles to dementia, 4. Validated instruments should be used for this population, 5. Neuropsychiatric symptoms can affect the patient's performance and 6. The assessment of functional independence allows for exploring the impact of cognition in everyday life.

Deterioro cognoscitivo en trastorno afectivo bipolar de larga evolución y demencia frontotemporal variante conductual / Cognitive impairment in long-standing bipolar disorder and behavioral variant of frontotemporal dementia

RESUMEN INTRODUCCIÓN: Los pacientes con trastorno afectivo bipolar pueden presentar alteraciones cognoscitivas que en algunos casos tienen un curso progresivo, por lo cual se ha cuestionado si la evolución de esta enfermedad se asocia a demencia, particularmente aquellas pertenecientes al espectro de la degeneración lobar frontotemporal. En este contexto, discriminar si un paciente presenta una demencia secundaria a la enfermedad psiquiátrica de base o si cursa una enfermedad neurodegenerativa además del trastorno afectivo bipolar, es un desafío para el diagnóstico diferencial. OBJETIVO: Comparar los desempeños cognoscitivos en pacientes con trastorno afectivo bipolar, con veinte años o más de evolución de la enfermedad y pacientes con demencia frontotemporal variante conductual. MATERIALES Y MÉTODOS: Estudio exploratorio, descriptivo y transversal en una cohorte seleccionada de casos por método no probabilístico. Los datos se analizan por medio de estadísticos no paramétricos. RESULTADOS: Eespecto al grupo control (N:27), los pacientes con demencia frontotemporal (N:24) presentan desempeños significativamente bajos en memoria verbal, funciones ejecutivas, praxias visoconstruccionales y atención (p <0,01). El grupo de trastorno bipolar (N:17) tiene bajos desempeños en estos procesos, pero no presenta fenómenos patológicos significativos asociados a intrusiones y perseveraciones. Entre los grupos clínicos no se identifican diferencias significativas. CONCLUSIÓN: Aunque los grupos clínicos comparten el compromiso en los procesos cognoscitivos evaluados, los desempeños son más bajos en el grupo de demencia frontotemporal, lo que sugiere que en una enfermedad degenerativa de menor tiempo de evolución y aparición en etapa presenil el déficit cognitivo es mayor que en una enfermedad psiquiátrica crónica.

SUMMARY INTRODUCTION: Patients with Bipolar Disorder may present cognitive alterations that in some cases have a progressive course, whereby it has been questioned if the evolution of this disease is associated with dementia, in particular those that belong to the spectrum of frontotemporal lobar degeneration. Thereby, discriminate if a patient has a dementia secondary to the underlying psychiatric illness or if the patient presents a neurode-generative disease besides the bipolar disorder is a challenge for the differential diagnosis. OBJECTIVE: To compare the cognitive performance in a sample of patients with Bipolar Disorder and twenty years or more of disease progression, and patients with behavioral variant of frontotemporal dementia. MATERIALS AND METHODS: Exploratory, descriptive and transversal study in a cohort of cases selected with a non probabilistic method. Dates are compared through non parametric statistics. RESULTS: Relative to Control group (N:27), Frontotemporal Dementia Patients (N:24) have significantly lower performances in verbal memory, executive functions, visoconstructional praxis and attention tasks (p <0,01). Bipolar Disorder group (N:17) has lower performances in this processes but don't present pathological markers such as intrusions and perseverative responses. There are no significant differences when comparing between clinical groups. CONCLUSION: Although clinical groups share the compromise in most of the cognitive process evaluated, the performances are lower in Frontotemporal dementia group, which suggests that in a degenerative disease of less evolution time and onset in presenile stage, the cognitive deficit is greater than in a chronic psychiatric illness.