A randomized controlled trial to evaluate the effectiveness and safety of electro acupuncture and transcranial direct current stimulation with computerized cognitive rehabilitation in patients with vascular cognitive impairment.

BACKGROUND: Vascular cognitive impairment (VCI) refers to all cognitive disorders caused by cerebrovascular disorders. For the treatment, many types of pharmacologic and nonpharmacologic treatments are used but their underlying mechanisms and effects are unclear. Regarding nonpharmacologic treatment, electroacupuncture (EA), transcranial direct current stimulation (tDCS), and computerized cognitive rehabilitation treatment (CCRT) are effective. Here, we report the protocol for a randomized controlled trial of the effect and safety of combination therapy of EA or tDCS and CCRT in patients with VCI. METHODS: This study will be a prospective, outcome assessor-blinded, parallel-arm, randomized controlled clinical trial. Participants with cognitive impairment caused by stroke after 3 months of onset (n = 45) will be randomly assigned to a CCRT, combination therapy with EA and computerized cognitive rehabilitation treatment, or combination therapy with tDCS and computerized cognitive rehabilitation treatment group. All groups will receive treatment 3 times per week for 8 weeks, giving a total of 24 treatments. The CCRT group will perform a training task like shopping, calculating, and others and involving computerized cognitive assessment and brain training system (RehaCom) for 30 minutes. The combination therapy with EA and computerized cognitive rehabilitation treatment group will receive EA using 8 acupuncture points - baekhoe, sinjeong, both sides of pungji, 4 sites of sishencong - and will be applied using an EA stimulator and receive CCRT for 30 minutes at the same time. The combination therapy with tDCS and computerized cognitive rehabilitation treatment group will receive tDCS treatment and receive CCRT for 30 minutes at the same time. The primary outcome will be evaluated using the Lowenstein occupational therapy cognitive assessment, while other scales assessing walking ability, activities of daily living, and quality of life are considered secondary outcome measures. Outcomes will be evaluated before intervention, at the end of intervention 8 weeks after the first intervention, and 4 weeks after completion of the intervention program. DISCUSSION: This study aims to examine the effect and safety of combination therapy with EA or tDCS and CCRT in patients with VCI. This study can be useful in developing new treatment technologies using collaborative research with combined traditional Korean and conventional medicines. TRIAL REGISTRATION: This trial has been registered with cris.nih.go.kr (registration number, KCT 0003644 Registered 01 April 2019, http://cris.nih.go.kr).

VaD - An Integrated Framework for Cognitive Rehabilitation.

BACKGROUND & OBJECTIVE: Vascular dementia is the second most common cause of dementia, with clinical features that depend on neural substrates affected by the vascular lesions. Like most neurological disorders, it involves alterations that range from the molecular level to neuronal networks. Such alterations begin as compensatory mechanisms that reshape every subsystem involved in the brain's homeostasis. Although there have been recent huge advances in understanding the pathophysiology of cognitive dysfunction, a suitable therapeutic approach to vascular dementia remains elusive. Pharmacological interventions have failed to sustainably improve cognitive function, and it is a well-known fact that there is a need to change the current view for providing neuroprotection and enhancing neurorecovery after stroke. Studies regarding cognitive training are also faced with the difficulty of drawing up protocols that can embrace a holistic approach in cognitively impaired patients. CONCLUSION: This review will present a brief synthesis of current results from basic research data and clinical studies regarding pharmacological and non-pharmacological interventions in vascular dementia and will offer an integrated view from the perspective of systems biology.

Exercise improves recognition memory and synaptic plasticity in the prefrontal cortex for rats modelling vascular dementia.

OBJECTIVES: Functional electrical stimulation (FES) may induce involuntary exercise and make beneficial effects on vascular dementia (VD) by strengthening the BDNF-pCREB-mediated pathway and hippocampal plasticity. Whether FES improves recognition memory and synaptic plasticity in the prefrontal cortex (PFC) was investigated by establishing a VD model. METHODS: The VD rats were administered with two weeks of voluntary exercise, forced exercise, or involuntary exercise induced with FES. Sham-operated and control groups were also included. The behavioral changes were assessed with the novel object recognition test and novel object location test. The expression levels of key proteins related to synaptic plasticity in the PFC were also detected. RESULTS: All types of exercise improved the rats' novel object recognition index, but only voluntary exercise and involuntary exercise induced with FES improved the novel object location index. Any sort of exercise enhanced the expression of key proteins in the PFC. CONCLUSION: Involuntary exercise induced with FES can improve recognition memory in VD better than forced exercise. The mechanism is associated with increased synaptic plasticity in the PFC. FES may be a useful alternative tool for cognitive rehabilitation.

Individual and group psychotherapy with people diagnosed with dementia: a systematic review of the literature.

OBJECTIVES: Psychotherapy provides a means of helping participants to resolve emotional threats and play an active role in their lives. Consequently, psychotherapy is increasingly used within dementia care. This paper reviews the existing evidence base for individual and group psychotherapy with people affected by dementia. DESIGN: The protocol was registered. We searched electronic databases, relevant websites and reference lists for records of psychotherapy with people affected by Alzheimer's Disease, Vascular dementia, Lewy-body dementia or a mixed condition between 1997 and 2015. We included studies of therapies which met British Association of Counselling and Psychotherapy definitions (e.g. occurs regularly, focuses on talking about life events and facilitates understand of the illness). Art therapy, Cognitive Stimulation and Rehabilitation, Life Review, Reminiscence Therapy and family therapy were excluded. Studies which included people with frontal-temporal dementia and mild cognitive impairment were excluded. Data was extracted using a bespoke form, and risk of bias assessments were carried out independently by both authors. Meta-analysis was not possible because of the heterogeneity of data. RESULTS: A total of 1397 papers were screened with 26 papers using randomised, non-randomised controlled trials or repeated measured designs being included. A broad mix of therapeutic modalities, types, lengths and settings were described, focussing largely on people with mild levels of cognitive impairment living in the community. CONCLUSIONS: This study was limited to only those studies published in English. The strongest evidence supported the use of short-term group therapy after diagnosis and an intensive, multi-faceted intervention for Nursing Home residents. Many areas of psychotherapy need further research. Copyright © 2016 John Wiley & Sons, Ltd.

Effect of exercise-induced neurogenesis on cognitive function deficit in a rat model of vascular dementia.

Chronic cerebral hypoperfusion (CCH) is strongly correlated with progressive cognitive decline in neurological diseases, such as vascular dementia (VaD) and Alzheimer's disease. Exercise can enhance learning and memory, and delay age-related cognitive decline. However, exercise-induced hippocampal neurogenesis in experimental animals submitted to CCH has not been investigated. The present study aimed to investigate whether hippocampal neurogenesis induced by exercise can improve cognitive deficit in a rat model of VaD. Male Wistar rats (age, 8 weeks; weight, 292±3.05 g; n=12-13/group) were subjected to bilateral common carotid artery occlusion (2VO) or sham­surgery and each group was then subdivided randomly into no exercise and treadmill exercise groups. Exercise groups performed treadmill exercise daily at 15 m/min for 30 min for 4 weeks from the third to the seventh week after 2VO. It was demonstrated that the number of neural progenitor cells and mature neurons in the subgranular zone of 2VO rats was increased by exercise, and cognitive impairment in 2VO rats was attenuated by treadmill exercise. In addition, mature brain­derived neurotrophic factor (BDNF) levels in the hippocampus were increased in the exercise groups. Thus the present study suggests that exercise delays cognitive decline by the enhancing neurogenesis and increasing BDNF expression in the context of VaD.

Quantitative EEG Neurometric Analysis-Guided Neurofeedback Treatment in Dementia: 20 Cases. How Neurometric Analysis Is Important for the Treatment of Dementia and as a Biomarker?

Dementia is a debilitating degenerative disorder where the sufferer's cognitive abilities decline over time, depending on the type of dementia. The more common types of dementia include Alzheimer's disease and vascular or multi-infarct dementia. In this study, 20 subjects with dementia (9 of Alzheimer's type, and 11 with vascular dementia) were treated using qEEG-guided neurofeedback training. The Mini Mental Status Examination (MMSE) was used as the primary outcome measure. The results showed an increase of the MMSE scores for all subjects regardless of dementia type with an average MMSE score increase of 6 points, which was found to be significant. To our knowledge this is the first time the same modality was shown to be beneficial in both dementia groups.

Lokomat training in vascular dementia: motor improvement and beyond!

Vascular dementia (VaD) is a general term describing problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to the brain. Cognitive rehabilitation and physical therapy are the mainstays of dementia treatment, although often ineffective because of the scarce collaboration of the patients. However, emerging data suggest that physical activity may reduce the risk of cognitive impairment, mainly VaD, in older people living independently. Herein, we describe a 72-year-old male affected by VaD, in which traditional cognitive training in addition to intensive gait robotic rehabilitation (by using Lokomat device) led to a significant improvement in the motor and cognitive function. This promising finding may be related either to the intensive and repetitive aerobic exercises or to the task-oriented training with computerized visual feedback, which can be considered as a relevant tool to increase patients' motor output, involvement, and motivation during robotic training.

Reliability and validity of the upper-body dressing scale in Japanese patients with vascular dementia with hemiparesis.

The purpose of this study was to examine the reliability and validity of the Upper-body Dressing Scale (UBDS) for buttoned shirt dressing, which evaluates the learning process of new component actions of upper-body dressing in patients diagnosed with dementia and hemiparesis. This was a preliminary correlational study of concurrent validity and reliability in which 10 vascular dementia patients with hemiparesis were enrolled and assessed repeatedly by six occupational therapists by means of the UBDS and the dressing item of the Functional Independence Measure (FIM). Intraclass correlation coefficient was 0.97 for intra-rater reliability and 0.99 for inter-rater reliability. The level of correlation between UBDS score and FIM dressing item scores was -0.93. UBDS scores for paralytic hand passed into the sleeve and sleeve pulled up beyond the shoulder joint were worse than the scores for the other components of the task. The UBDS has good reliability and validity for vascular dementia patients with hemiparesis. Further research is needed to investigate the relation between UBDS score and the effect of intervention and to clarify sensitivity or responsiveness of the scale to clinical change.

A cognitive rehabilitation paradigm effective in male rats lacks efficacy in female rats.

Cognitive dysfunction, as a consequence of dementia, is a significant cause of morbidity lacking efficacious treatment. Females comprise at least half of this demographic but have been vastly underrepresented in preclinical studies. The current study addressed this gap by assessing the protective efficacy of physical exercise and cognitive activity on learning and memory outcomes in a rat model of vascular dementia. Forty ovariectomized Sprague-Dawley rats (∼6 months old) were exposed to either a diet high in saturated fats and refined sugars or standard laboratory chow and underwent either chronic bilateral carotid occlusion or Sham surgery. Learning and memory abilities were evaluated using standard cognitive outcomes over the ensuing 6 months, followed by histologic analyses of hippocampal CA1 neurons. In Experiment 1, we confirmed hypoperfusion-induced cognitive dysfunction using a 2 × 2 (Surgery × Diet) experimental design, without alterations in hippocampal architecture. In Experiment 2, hypoperfused animals were either exposed to alternating days of physical (wheel running) and cognitive activity (modified Hebb-Williams maze) or sedentary housing. In contrast to males, this combination rehabilitation paradigm did not improve cognition or histopathologic outcomes in hypoperfused animals. These findings, highlighting differences between female and male animals, show the necessity of including both sexes in preclinical experimentation.

Training and maintenance of a picture-based communication response in older adults with dementia.

We examined whether adults with dementia could learn to emit a picture-based communication response and if this skill would maintain over time. Three women with moderate to severe dementia were taught to exchange a picture card for a highly preferred activity. All participants quickly learned to exchange the picture card and maintained this response without practice.

[Prevention of cognitive impairments in patients after stroke].

Previous studies demonstrated that 78.3%-81.6% of patients after stroke have cognitive impairments. In order to prevent vascular cognitive impairments in patients with stroke after discharge from hospital, we have proposed a comprehensive program of activities.

Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer's disease and vascular dementia.

BACKGROUND: Cognitive impairments, particularly memory problems, are a defining feature of the early stages of Alzheimer's disease (AD) and vascular dementia. Cognitive training and cognitive rehabilitation are specific interventional approaches designed to address difficulties with memory and other aspects of cognitive functioning. The present review is an update of previous versions of this review. OBJECTIVES: The main aim of the current review was to evaluate the effectiveness and impact of cognitive training and cognitive rehabilitation for people with mild Alzheimer's disease or vascular dementia in relation to important cognitive and non-cognitive outcomes for the person with dementia and the primary caregiver in the short, medium and long term. SEARCH METHODS: The CDCIG Specialized Register, ALOIS, which contains records from MEDLINE, EMBASE, CINAHL, PsycINFO, LILACS and many other clinical trial databases and grey literature sources, was most recently searched on 2 November 2012. SELECTION CRITERIA: Randomised controlled trials (RCTs), published in English, comparing cognitive rehabilitation or cognitive training interventions with control conditions, and reporting relevant outcomes for the person with dementia and/or the family caregiver, were considered for inclusion. DATA COLLECTION AND ANALYSIS: Eleven RCTs reporting cognitive training interventions were included in the review. A large number of measures were used in the different studies, and meta-analysis could be conducted for 11 of the primary and secondary outcomes of interest. Several outcomes were not measured in any of the studies. The unit of analysis in the meta-analysis was the change from baseline score. Overall estimates of treatment effect were calculated using a fixed-effect model, and statistical heterogeneity was measured using a standard Chi(2) statistic. One RCT of cognitive rehabilitation was identified, allowing examination of effect sizes, but no meta-analysis could be conducted. MAIN RESULTS: Cognitive training was not associated with positive or negative effects in relation to any reported outcomes. The overall quality of the trials was low to moderate. The single RCT of cognitive rehabilitation found promising results in relation to a number of participant and caregiver outcomes, and was generally of high quality. AUTHORS' CONCLUSIONS: Available evidence regarding cognitive training remains limited, and the quality of the evidence needs to improve. However, there is still no indication of any significant benefit derived from cognitive training. Trial reports indicate that some gains resulting from intervention may not be captured adequately by available standardised outcome measures. The results of the single RCT of cognitive rehabilitation show promise but are preliminary in nature. Further, well-designed studies of cognitive training and cognitive rehabilitation are required to obtain more definitive evidence. Researchers should describe and classify their interventions appropriately using available terminology.

Improved functional status by comprehensive physical and psychosocial approach through right insula activation in poststroke vascular dementia.

The aim is to investigate the effect of a comprehensive physical and psychosocial approach on functional outcome and cerebral glucose metabolism in poststroke vascular dementia (PSVaD). Ten PSVaD patients participated in the study. They were diagnosed according to the National Institute of Neurological Disorders and Stroke and Association Internationale pour la Recherché et l'Enseignement en Neurosciences (NINDS-AIREN) criteria and needed physical assistance in sit-to-stand transfer activities. Six were enrolled in a comprehensive program consisted of an individualized task-specific exercise regimen of transfer training and a psychosocial intervention program. The other 4 patients participated in the control group. The programs were undertaken over a period of 2 months. Outcomes were the scores on the Mini-Mental State Examination and the Functional Independence Measure (FIM), and on cerebral glucose metabolism determined by (18)F-fluorodeoxyglucose positron emission tomography performed before and at the end of the program. The score on the transfer mobility subscale of the FIM increased at the end of the program in all patients who received the comprehensive program. Regional glucose metabolism was increased in the right insular cortex at the end of the combined program. Control patients showed no change in FIM score or regional cerebral metabolism. A combined approach may be associated with an increase in glucose metabolism of the right insula cortex in PSVaD patients.

Cognitive rehabilitation reduces cognitive impairment and normalizes hippocampal CA1 architecture in a rat model of vascular dementia.

Dementia is a major cause of morbidity in the western society. Pharmacological therapies to delay the progression of cognitive impairments are modestly successful. Consequently, new therapies are urgently required to improve cognitive deficits associated with dementia. We evaluated the effects of physical and cognitive activity on learning and memory in a rat model of vascular dementia (VasD). Male Sprague-Dawley rats (6 months old) were exposed to either regular chow or a diet rich in saturated fats and sucrose and chronic bilateral common carotid artery occlusion or sham surgery. First, this model of VasD was validated using a 2 × 2 experimental design (surgery × diet) and standard cognitive outcomes. Next, using identical surgical procedures, we exposed animals to a paradigm of cognitive rehabilitation or a sedentary condition. At 16 weeks post surgery, VasD animals demonstrated significant learning and memory deficits in the Morris water maze, independent of diet. Rehabilitation significantly attenuated these cognitive deficits at this time point as well as at 24 weeks. Further, rehabilitation normalized hippocampal CA1 soma size (area and volume) to that of control animals, independent of cell number. Importantly, these findings demonstrate beneficial neuroplasticity in early middle-aged rats that promoted cognitive recovery, an area rarely explored in preclinical studies.

Adherence to Canadian Best Practice Recommendations for Stroke Care: vascular cognitive impairment screening and assessment practices in an Ontario inpatient stroke rehabilitation facility.

BACKGROUND: The Canadian Best Practice Recommendations for Stroke Care suggest that (1) all patients with stroke should be screened for cognitive impairment and (2) persons who are detected as having cognitive impairment on a screening test should receive additional cognitive assessment. The purpose of this study is to determine whether care in an Ontario inpatient stroke rehabilitation facility is consistent with these recommendations. METHODS: Stroke patients discharged from an inpatient stroke rehabilitation program located in Southwestern Ontario, Canada, from May to October 2009 were included in this study. Charts were reviewed to identify current screening and assessment practices. The percentages of patients formally screened and/or assessed as well as differences between those who were and were not screened are reported. RESULTS: The study included 123 patients (62 male; mean age = 67.3,SD 15.1). During inpatient rehabilitation, 82.9% of patients were screened using a formal cognitive screening instrument. Patients with cognitive and/or communication deficits were significantly less likely to be screened than those with intact cognitive and communicative abilities. Although 77.5% of those screened scored below the threshold for cognitive impairment, evidence of referral for a comprehensive cognitive assessment was found for only 3 patients. CONCLUSIONS: Although the majority of patients were screened for cognitive impairment while in inpatient rehabilitation, few patients were referred for a comprehensive diagnostic examination. On the basis of these results from a single inpatient stroke rehabilitation unit, it appears that specific cognitive deficits are likely underidentified in stroke rehabilitation patients in Ontario.

Improved social interaction and increased anterior cingulate metabolism after group reminiscence with reality orientation approach for vascular dementia.

A group reminiscence approach (GRA) with reality orientation (RO) is widely used as a psychosocial intervention for dementia. Since clinical effectiveness was reported for the intervention, interest has been directed toward areas of the neuronal network that might be being stimulated. We hypothesized that the frontal lobe associated with social interaction was being stimulated. To test this hypothesis, we studied 24 patients with vascular dementia. In addition to conventional care, a 1-h session of GRA with RO was provided once a week for 3 months in the GRA-RO arm (n=12). Only supportive care was provided in the control arm (n=12). Before and after the interventions, cognitive function, depressive state, and social activities were assessed. Since glucose metabolism is associated with brain function, cerebral glucose metabolism was measured by positron emission tomography (PET). Regarding behavioral improvement, 10 patients in the GRA-RO arm showed improvement compared with only two patients in the control arm, a significant difference. PET demonstrated that metabolism in the anterior cingulate was increased in the GRA-RO arm, whereas no significant changes were observed in the control arm. These results suggest that GRA-RO stimulates the anterior cingulate and has a positive effect on social interaction.

Tai Chi exercise versus rehabilitation for the elderly with cerebral vascular disorder: a single-blinded randomized controlled trial.

BACKGROUND: Cerebral vascular disorder (CVD) might result in a quantifiable decrease in quality of life, which is determined not only by the neurological deficits but also by impairment of cognitive functions. There are few studies that report on the cognitive effect of Tai Chi exercise (Tai Chi) on the elderly with CVD. The purpose of the present study was to examine the cognitive effect of Tai Chi on the elderly with CVD using P300 measurement, in addition to the General Health Questionnaire (GHQ) and Pittsburgh Sleep Quality Index (PSQI). METHODS: A total of 34 patients with CVD were recruited from outpatient Akistu-Kounoike Hospital and randomly assigned to receive Tai Chi (n= 17) or rehabilitation (n= 17) in group sessions once a week for 12 weeks. To examine the time courses of each score (P300 amplitude, P300 latency, GHQ score and PSQI score), repeated-measures analysis of variance was carried out with groups and time as factors. RESULTS: For the time courses of P300 amplitudes and latencies, there were no significant effects of interaction between group and time. However, significant time-by-group interactions were found for Sleep Quality (P= 0.006), GHQ total score (P= 0.005), anxiety/insomnia score (P= 0.034), and severe depression score (P= 0.020). CONCLUSIONS: Tai Chi might therefore be considered a useful non-pharmacological approach, along with rehabilitation, for the maintenance of cognitive function in the elderly with CVD and might be a more useful non-pharmacological approach for the improvement of sleep quality and depressive symptoms in the elderly with CVD than rehabilitation.

The effects of modified spaced-retrieval training on learning and retention of face-name associations by individuals with dementia.

The purpose of this project was to assess the effects of spaced-retrieval training (SRT) on learning of new and previously known associations by individuals with dementia in two treatment conditions: one in which the recall intervals were filled with activities unrelated to the information being learned (unrelated condition) and one in which the intervals were filled with related activities (related condition). Thirty-two individuals with mild to moderate dementia (30 with a diagnosis of Alzheimer's disease; two with vascular dementia) participated in the study. On average, participants learned the associations in fewer than four sessions and retained the information for variable amounts of time, up to 6 weeks. Previously known associations were learned significantly faster than new associations. The modified SRT format, in which the within-session recall intervals were filled with information related to the target association, did not result in faster learning or longer retention of learned associations. Participants learned previously known associations in the standard SRT format (with unrelated information in the recall intervals) significantly faster than new associations taught in the modified SRT condition. Cognitive impairment, as measured by the Mini-Mental State Examination, was significantly correlated with time to learn new associations, but did not explain a large proportion of the variance in new learning. Theoretical and clinical implications are discussed.

Vascular dementia.

Vascular dementia (VaD) is the second most common form of dementia after Alzheimer's dementia (AD). It is characterized by loss of executive function with milder memory loss as compared with AD and is associated with cerebral brain infarction or hemorrhage. Treatment is predominantly focused on cardiovascular risk factor reduction, but anticholinesterase inhibitors and memantine may play a role. The data is most robust for donepezil.

Subcortical vascular lesions and functional recovery in older patients with gait disorders.

This study aimed to assess whether subcortical vascular lesions (SVLs) predict functional recovery after rehabilitation in elderly patients with gait disorders (GD) due to multiple etiology (GD-ME). All patients consecutively admitted with GD-ME (n=103) in our Rehabilitation and Aged Care Unit (RACU) underwent a standardized rehabilitative program. The outcome measure was the Barthel Index (BI) Relative Functional Gain (RFG), a measure of improvement adjusting for baseline functional level. Potential predictors included cognition, depression, functional and nutritional status, physical health, occurrence of adverse clinical events during hospital stay, and SVLs, assessed with a validated visual rating scale based on brain CT scans. Predictors were divided into quartiles and the association with RFG was assessed. In a multivariate linear regression model, SVLs maintained its predictive power on RFG after adjustment for age, gender, and adverse clinical events, which was the only variable associated to RFG in the bivariate model (adjusted p=0.002 for trend). The study shows that SVLs is a predictor of functional recovery in elderly patients with GD-ME.