Multidomain intervention for the prevention of cognitive decline after stroke - a pooled patient-level data analysis.

BACKGROUND AND PURPOSE: The aim of this pooled patient-level data analysis was to test if multidomain interventions, addressing several modifiable vascular risk factors simultaneously, are more effective than usual post-stroke care for the prevention of cognitive decline after stroke. METHODS: This pooled patient-level data analysis included two randomized controlled trials using a multidomain approach to target vascular risk factors in stroke patients and cognition as primary outcome. Changes from baseline to 12 months in the trail making test (TMT)-A, TMT-B and 10-words test were analysed using stepwise backward linear mixed models with study as random factor. Two analyses were based on the intention-to-treat (ITT) principle using different imputation approaches and one was based on complete cases. RESULTS: Data from 322 patients (157 assigned to multidomain intervention and 165 to standard care) were analysed. Differences between randomization groups for TMT-A scores were found in one ITT model (P = 0.014) and approached significance in the second ITT model (P = 0.087) and for complete cases (P = 0.091). No significant intervention effects were found for any of the other cognitive variables. CONCLUSION: We found indications that multidomain interventions compared with standard care can improve the scores in TMT-A at 1 year after stroke but not those for TMT-B or the 10-words test. These results have to be interpreted with caution due to the small number of patients.

Lack of accuracy for the proposed 'Dubois criteria' in Alzheimer's disease: a validation study from the Swedish brain power initiative.

BACKGROUND/AIMS: Our purpose was to investigate whether the new research criteria for Alzheimer's disease proposed in 2007 by Dubois et al. are valid in a naturalistic memory clinic sample. METHOD: Retrospective diagnostic analyses were carried out to compare the traditional diagnostic criteria for dementia with the new criteria suggested by Dubois et al. No patient had gone through all procedures postulated as additional features in the proposed new Dubois criteria. MATERIAL: Two independent experienced geriatricians re-examined 150 complete patients' records. The study physicians were blinded to any of the results of the core and additional features suggested by Dubois et al. to avoid circular diagnostic bias. RESULTS: Among our 96 patients with a clinical diagnosis of subjective cognitive impairment and/or mild cognitive impairment, 2 of the patients with subjective cognitive impairment and 5 patients with mild cognitive impairment would classify as pre-dementia Alzheimer's disease according to the Dubois criteria. In our 23 Alzheimer patients diagnosed clinically, only 12 of the cases fulfilled the criteria for Alzheimer's disease suggested by Dubois et al. INTERPRETATION: The proposed new criteria for Alzheimer's disease are valid in 55% of our patients clinically diagnosed as having full-blown Alzheimer dementia. Additionally, 7.3% 'true' Alzheimer cases will be identified in a group of 96 clinically non-demented patients. Our results show that there is a large heterogeneity in a clinical naturalistic sample of patients with an Alzheimer phenotype. CONCLUSION: There is a need to further validate the currently existing biomarkers in large unselected samples and avoid the pitfall of workup bias and circular diagnostic processes. Additionally, valid age-specific cut-off values for the diagnostic markers in question have to be defined.

Voxel-based correlation between coregistered single-photon emission computed tomography and dynamic susceptibility contrast magnetic resonance imaging in subjects with suspected Alzheimer disease.

BACKGROUND: Current diagnosis of Alzheimer disease is made by clinical, neuropsychologic, and neuroimaging assessments. Neuroimaging techniques such as magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT) could be valuable in the differential diagnosis of Alzheimer disease, as well as in assessing prognosis. PURPOSE: To compare SPECT and MRI in a cohort of patients examined for suspected dementia, including patients with no objective cognitive impairment (control group), mild cognitive impairment (MCI), and Alzheimer disease (AD). MATERIAL AND METHODS: 24 patients, eight with AD, 10 with MCI, and six controls, were investigated with SPECT using (99m)Tc-hexamethylpropyleneamine oxime (HMPAO, Ceretec; GE Healthcare Ltd., Little Chalsont UK) and dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) with a contrast-enhancing gadobutrol formula (Gadovist; Bayer Schering Pharma, Berlin, Germany). Voxel-based correlation between coregistered SPECT and DSC-MR images was calculated. Region-of-interest (ROI) analyses were then performed in 24 different brain areas using brain registration and analysis of SPECT studies (BRASS; Nuclear Diagnostics AB, Stockholm, Sweden) on both SPECT and DSC-MRI. RESULTS: Voxel-based correlation between coregistered SPECT and DSC-MR showed a high correlation, with a mean correlation coefficient of 0.94. ROI analyses of 24 regions showed significant differences between the control group and AD patients in 10 regions using SPECT and five regions in DSC-MR. CONCLUSION: SPECT remains superior to DSC-MRI in differentiating normal from pathological perfusion, and DSC-MRI could not replace SPECT in the diagnosis of patients with Alzheimer disease.

Can dynamic susceptibility contrast magnetic resonance imaging replace single-photon emission computed tomography in the diagnosis of patients with Alzheimer's disease? A pilot study.

PURPOSE: To compare single-photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI) in a cohort of patients examined for suspected dementia, including patients with no objective cognitive impairment (control group), mild cognitive impairment (MCI), and Alzheimer's disease (AD). MATERIAL AND METHODS: Twenty-four patients, eight with AD, 10 with MCI, and six controls were investigated with SPECT using 99mTc-hexamethylpropyleneamine oxime (HMPAO) and dynamic susceptibility contrast magnetic resonance imaging (DSC-MRI) with gadobutrol. Three observers performed a visual interpretation of the SPECT and MR images using a four-point visual scale. RESULTS: SPECT was superior to DSC-MRI in differentiating normal from pathological. All three observers showed statistically significant results in discriminating between the control group, AD, and MCI by SPECT, with a P value of 0.0006, 0.04, and 0.01 for each observer. The statistical results were not significant for MR (P values 0.8, 0.1, and 0.2, respectively). CONCLUSION: DSC-MRI could not replace SPECT in the diagnosis of patients with Alzheimer's disease. Several patient- and method-related improvements should be made before this method can be recommended for clinical practice.

Social and depressive stress suffered by spouses of patients with mild dementia.

OBJECTIVE: To identify stressors and their correlates in spouses of patients with mild dementia. DESIGN: Retrospective study of patient records. SETTING: Patients attending a Memory Clinic at Ullevaal Hospital in Oslo. SUBJECTS: 92 mildly demented patients living at home (mean age 75.7 years, 51% women, mean MMSE score 22.3) and their spouses. MAIN OUTCOME MEASURES: Frequency and types of stress suffered by spouses using validated and factor-analyzed instruments as measures. RESULTS: Twenty-five per cent or more of the spouses reported often/always having problems with the following: being depressed by the situation, having difficulties getting away on holiday, social life being affected, household routines being upset, and sleep being interrupted. Factor analysis of the Greene Caregiver Stress Scale (15 items) identified two factors; 'Social stress' and 'Depressive stress'. Social stress was associated with the patient's I-ADL level, and depressive stress with mood and behaviour of the patient. The depressive symptomatology of the patient as expressed by the spouses was related to both depressive and social stress, whereas cognitive function, as measured by the MMSE, was not an independent predictor of carer strain. CONCLUSION: Even in mildly demented patients, symptoms of carer stress are frequent. Supportive strategies such as early diagnosis, information for carers and intervention strategies are discussed.

[Memory clinic--ambulatory examination in suspected dementia]. / Hukommelsesklinikk--poliklinisk utredning ved mistanke om demens.

Dementia and confusion are frequently overlooked by general practitioners. A memory clinic was established at the Department of Geriatric Medicine, Ullevål Hospital in September 1990 with the intention of creating a standardized programme for diagnosing dementia and cognitive impairment in the elderly in an out-patient setting. The activities and services offered by the clinic are described: diagnoses, information to patients, their family and staff in the primary health care system about the symptoms and treatment of dementia. In addition, advice is given on follow-up care and how to apply for care through the national health service. There has been a great demand for the services of the Memory Clinic, and we believe that the methods used are adequate in an out-patient setting. The concept could easily be transferred to other specialist clinics involved with the elderly, and parts of the programme could also be used by general practitioners.