[Self and informant perception of clinical manifestations of Alzheimer dementia: results of a structured interview (CAMDEX)]. / Die Selbst-und Fremdeinschätzung klinischer Störungen bei der Alzheimer-Demenz: Ergebnisse eines strukturierten Interviews (CAMDEX).

The correlations between (a) the patients' memory complaints, (b) the informants' rating of the patients' cognitive impairment, and (c) cognitive performance according to the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX) were examined in 163 patients with probable or possible Alzheimer's disease. The patients' complaints were weakly correlated with informants' view (p < 0.05), closely correlated with depressive mood (p < 0.0001), but not with cognitive performance or the stage of dementia. The results of Clinical Dementia Rating, Mini-Mental State Examination and the Cambridge Cognitive Examination were significantly correlated with the informants' rating of cognitive impairment (p < 0.0001). These results are in line with previous studies and confirm (1) the suitability of CAMDEX for the structured examination of dementia patients and their caregivers, (2) the association between affective disturbances and the perception of cognitive deficits, and (3) the importance informants' rating for the valid evaluation of demented patients.

Senile dementia of Alzheimer type and multi-infarct dementia investigated by transcranial Doppler sonography.

Dementia of the Alzheimer type, senile onset (SDAT), and multi-infarct dementia (MID) exhibit differences in cerebrovascular blood flow velocity profiles, which were investigated by means of transcranial Doppler sonography. The pulsatility indices (PI), as angle-independent parameters of peripheral vascular resistance measured in the basal cerebral arteries, were significantly increased in MID patients with respect to SDAT cases. In an analysis of the correlations between several variables and the magnitude of PI, we found strong inverse correlations of the CAMCOG score, and strong direct correlations of the blood pressure and the duration of illness, with the PI of all basal cerebral arteries only in MID patients. In SDAT patients, we found a direct correlation between the Hachinski ischemia score and the PI of all basal cerebral arteries. All 3 ischemia scores (Hachinski, Rosen, Loeb and Gandolfo) were significantly correlated with the PI of the middle cerebral and basilar arteries. By analyzing the correlations of the single items of the 3 different ischemia scores with the PI values obtained, we only found a clearcut correlation with the item focal neurological signs. Thus, our findings stress the relative importance of a concomitant cerebrovascular factor in the development of dementia in old age, even in patients with probable SDAT. A raise of the PI in the basal cerebral arteries allows early suspicion of a cerebrovascular factor even in only slight dementia so that possible risk factors for further aggravation of this type of vascular dementia might be detected and treated early in the course of disease.

Multiinfarct dementia vs Alzheimer's disease: sonographic criteria.

Primary degenerative dementia of the Alzheimer type (DAT) and multiinfarct dementia (MID) exhibit differences in cerebrovascular blood flow velocity profiles, which were investigated by means of transcranial Doppler sonography. The pulsatility indices, as angle-independent parameters of peripheral vascular resistance, measured in middle cerebral and basilar arteries of patients with MID, were significantly increased (P < 0.005) with respect to cases of primary DAT and to healthy age-matched controls. Approximately 75% of all MID patients exhibited small-vessel disease rather than thromboembolism from the extracranial arteries and the heart, as judged by extracranial and transcranial Doppler sonographies, computerized cerebral tomographies, EEGs, and, if necessary, 2-D echocardiographies.

[Extraventricular obstructive hydrocephalus]. / Der extraventrikuläre obstruktive Hydrozephalus.

In extraventricular obstructive hydrocephalus (EVOH) there is an impaired outflow from the subarachnoid space usually at the level of the basal cisterns or arachnoid granulations. Subarachnoid haemorrhage, suppurative meningitis, and neoplastic or inflammatory exudates may fibrose or occlude the subarachnoid space. Following early reports that the response to shunt procedures was universally excellent, CSF shunting operations were performed on a large scale. Presence of the typical clinical triad, identified underlying aetiology, predominance of gait disorder, short duration of illness, absence of atrophy on CCT scan, typical lumboventricular perfusion picture, and improvement after high-volume lumbar puncture usually predict a beneficial response to surgery. The case presented here, however, indicates a favourable outcome of shunt surgery even in idiopathic EVOH with long duration of illness and without substantial clinical improvement after high-volume lumbar puncture. Thus, in clinically progressive idiopathic EVOH, shunt surgery should be considered in spite of a high complication rate, since there are no promising therapeutic alternatives for this syndrome.

The value of transcranial Doppler sonography in the differential diagnosis of Alzheimer disease vs multi-infarct dementia.

Primary degenerative dementia of the Alzheimer type and multi-infarct dementia exhibit differences in cerebrovascular blood flow velocity profiles, which were investigated by means of transcranial Doppler sonography. The pulsatility indices, as angle-independent parameters of peripheral vascular resistance, measured in middle cerebral and basilar arteries of patients with multi-infarct dementia (MID), were significantly increased (p < 0.005) with respect to cases of primary degenerative dementia of the Alzheimer type and to healthy age-matched controls. Approximately 75% of all MID patients exhibited small vessel disease rather than thromboembolism from the extracranial arteries and the heart, as judged by extracranial and transcranial Doppler sonographies, computerized cerebral tomographies, EEGs, and, if necessary, 2-D echocardiographies.

[Normal and frequent neurologic findings in elderly patients]. / Normale bzw. häufige neurologische Befunde bei älteren Menschen.

Numerous normal age-related changes that occur in the nervous system differ more quantitatively than qualitatively from certain common neurological diseases of elder individuals. Changes in the cranial nerve examination primarily relate to an age-related decline in sensory functions, especially of vision and hearing, and to a restriction in the range of eye movements, especially vertically. A progressive decline in the bulk and strength of muscles and in the speed and coordination of movements has long been recognised as an accompaniment of aging. Posture and gait show conspicuous changes with advancing age, partially correlating with diminished sensation in the legs and/or with a nonspecific bradykinetic senile gait. The distal depression of deep tendon reflexes and sensory function is primarily due to distal degeneration of sensory axons. Among the release signs, only the reappearance of the grasp reflex is a reliable sign for indicating pathology of the nervous system. Senile tremor, a decline in the maintenance of thermal homoeostasis, an increasing frequency of orthostatic hypotension, and disorders of sleep are also commonly associated with aging.

[Undetected physical diseases in new psychiatric admission]. / Unentdeckte körperliche Erkrankungen bei psychiatrischen Neuaufnahmen.

We report on clinical observations from a 10-bed psychiatric acute ward where predominantly patients with concurrent physical diseases are treated. Of 287 patients admitted within 18 months we detected serious physical illness previously unrecognized or at least not sufficiently diagnosed in 15 cases (5.2%; age 17-88 years; 4 m, 11 f). Six patients suffered from acute neurological disease. One or more extracerebral disorders were found in nine cases. 14 of the 15 patients presented with organic mental syndromes classified according to ICD-9 (acute organic psychosis: n = 8, chronic organic psychosis: n = 6). The physical diseases unknown at admission were the only cause of the acute organic psychoses while they were contributing to the development of psychiatric symptoms in the majority of the other patients. In 14 patients the diagnosis of the previously unrecognized illnesses led to a significant change of therapy. At discharge 10 patients had improved with regard to their somatic and mental state while in two cases only the physical symptoms had remitted. One patient remained completely unchanged and two patients died from their serious diseases. Our case studies illustrate the fact that a relevant proportion of newly admitted psychiatric patients suffers from life-threatening medical illnesses. These require prompt and specific interventions and can only be detected by early and thorough physical examination.

[Neurogenic impotence]. / Neurogene Impotenz.

Until recently, the management of impotence was mainly concerned with the distinction of psychogenic from organic causes of erectile failure. Patients with the former were offered psychosexual counselling, while surgery, principally in the form of prosthesis implantation, was reserved for those with organic impotence. With the identification of pharmacologic regimes that can successfully induce erection, it has become necessary to distinguish between vascular and neurogenic causes of erectile failure, since it is mainly the latter patient group that can profit from an intracavernosal injection therapy with papaverine and phentolamine. Neurogenic erectile failure is further classified according to lesion localization and underlying disease.

Multiinfarct and Alzheimer-type dementia investigated by transcranial Doppler sonography.

Primary degenerative dementia of the Alzheimer type and multiinfarct dementia exhibit differences in cerebrovascular blood flow velocity profiles, which were investigated by transcranial Doppler sonography. The pulsatility indices, as angle-independent parameters of peripheral vascular resistence, measured in middle cerebral and basilar arteries of patients with multiinfarct dementia were significantly increased (p less than 0.005) compared with cases of primary degenerative dementia of the Alzheimer type and with healthy age-matched controls.

[Acute and subacute organic psychoses with altered consciousness. Attempt at classifying severity]. / Akute und subakute organische Psychosen mit Bewusstseinsstörung. Versuch einer Schweregradeinteilung.

We have retrospectively investigated 71 patients with ICD-9 diagnoses 293.0 or 293.1, who were treated in our clinic in 1987, with respect to the maximum severity of altered consciousness. On the basis of an available neurological grading into "clouding of consciousness", "confusional state", "delirium", "stupor", and "coma", and from knowledge of the underlying somatic disease, we have developed prognostic criteria: Disorders of heart and circulation associated with acute organic mental disorder (with altered consciousness) carry a fair prognosis for recovery of the mental disorder in approximately two-thirds of all patients affected, even in advanced age. The same statement is valid with respect to drug-induced acute organic mental disorders, whereas most cases of cerebrovascular disorders with mental disturbances proceed to chronic forms of organic mental disorder. We believe that the clinical descriptive terms referred to above allow easy grading of states of acutely/subacutely altered consciousness, thereby providing prognostic criteria for the course of the disease.

[Neurogenic bladder disorders]. / Neurogene Blasenstörungen.

The past 15 years have witnessed an explosion of new knowledge concerning the anatomy, neurophysiology, and pharmacology of the lower urinary tract. Knowledge of the localization of a neurologic lesion-suprapontine, suprasacral, cauda equina, or peripheral nerves-rather than the type of disease allows a more "rational approach" to the diagnosis and therapy of neurogenic voiding disorders. More specifically, advances in pharmacological understanding enable us, at least in theory, to treat voiding disorders according to their types of dysfunction: drugs to promote bladder emptying that exert their predominant effect on bladder and bladder outlet respectively, and those promoting bladder storage with the corresponding objectives. We discuss the problem that many theoretically sound drugs are, in fact, not clinically efficacious, probably due to incomplete understanding of the physiology of normal micturition and its neurogenic disorders.

[Delirium syndrome in biperiden poisoning]. / Delirantes Syndrom bei Biperiden-Intoxikation.

We report on two cases of self-induced intoxication with the anticholinergic agent biperiden (oral ingestion of at least 200 mgs. in case 1, and of 60 mgs. in combination with 300-400 mgs levomepromazine in case 2). An acute delirious state and other somatic symptoms of a toxic anticholinergic action dominated the clinical picture. Serial measurements of biperiden serum levels revealed values up to 50-fold (case 1) and 15-fold (case 2) of those usually observed under therapeutic doses of biperiden. In both cases, the intoxication was controlled by the application of physostigmine and general therapeutic measures. We discuss the prognosis of biperiden intoxications, and the clinical symptomatology and therapy of drug-induced anticholinergic syndromes.

Basilar artery disease--clinical outcome and Doppler sonographical follow-up.

In the past 5 years we have investigated 29 patients with symptomatic basilar artery stenoses (14 cases) and occlusions (14) and a patent primitive trigeminal artery with thin-calibered basilar and vertebral arteries (1) using directional continuous-wave Doppler sonography of the vertebral arteries. A total of 19 patients survived, and 17 of them were clinically and sonographically reexamined after 40.4 +/- 15.8 months (mean +/- SD). Among the 8 patients with basilar stenoses, 6--with no further transient ischemic attacks (TIAs) in the interval--exhibited an increase in the summed modified Pourcelot indices (relative end-diastolic flow velocities) of the vertebrals by 0.18 +/- 0.16; the other 2 showed a decrease by 0.26 each, in 1 case temporally related to a TIA, in the 2nd case without further clinical deterioration. In the 8 survivors with basilar occlusions, 5 remained--by sonographic criteria--unchanged with summed modified Pourcelot indices of the vertebrals of 0.00, while 3 patients exhibited a slight increase in the summed modified Pourcelot indices of 0.13 +/- 0.03. While the difference between the outcome of subsets of patients treated with regimens of 30,000-40,000 units heparin/day or phenprocoumon and less radical drugs were statistically not significant, the former regimen appeared clinically more efficacious in preventing further deterioration in approximately two-thirds of the patients affected. Due to the potential recurrence of neurological symptoms, a treatment period with phenprocoumon of 6 months after discharge from hospital appears justified. Due to these therapeutic efforts, approximately half of the patients initially affected survived with no or only a mild neurological deficit.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy of EC-IC anastomoses: evaluation by directional c-w Doppler sonography.

We report the results obtained by means of directional c-w Doppler sonography on 33 patients with superficial temporal-to-middle cerebral artery anastomoses. The efficiency of the anastomosis was evaluated by the modified Pourcelot indices (relative end-diastolic flow velocities) of the preauricular superficial temporal artery and of the bypass-supplying branch at the edge of the burr-hole. The influence of intermittent compression of the bypass-supplying branch on the modified Pourcelot index of the ipsilateral common carotid was used as a further criterion in the sonographic evaluation. All efficient anastomoses, defined by a modified Pourcelot index of at least 0.20 at the edge of the burr-hole, exhibited a reduction of the relative end-diastolic flow velocity of 0.08 on the average in the common carotid during compression. In the 18 cases with unilateral occlusion of the internal carotid, bypass surgery was predominantly efficacious in those patients who showed a reduction in the sum of the modified Pourcelot indices of the remaining brain-supplying arteries of at least two standard deviations with respect to the mean of age-matched controls. The subgroups of patent and absent collaterals through the ophthalmic artery did not show any difference with respect to the percentage of efficient anastomoses. In all 4 patients with bilateral internal carotid artery occlusion, bypass surgery was effective, while 50% of the patients with intracranial carotid artery disease exhibited an insufficient anastomosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatable dementia syndromes]. / Behandelbare dementielle Syndrome.

Dementia--a syndrome of acquired intellectual deterioration--is an etiologically non-specific condition which is permanent, progressive, or reversible. In the evaluation of demented patients, a careful exposure history will determine the possible role of drugs, metals, or toxins. The physical examination may reveal focal deficits in cases of intracranial mass lesions and spasticity or ataxia of the lower limbs if hydrocephalus is present. Coexistance of dementia and peripheral neuropathy usually indicates a toxic or metabolic disorder. Asterixis, myoclonus, and postural tremor are common in toxic-metabolic dementias, while resting tremor, choreoathetosis, and rigidity occur in progressive extrapyramidal disorders. EEG is focally abnormal in cases of cerebral mass lesions and exhibits generalized slowing in toxic-metabolic encephalopathies. CT will aid in the identification of hydrocephalus, subdural hematomas, and intracranial mass lesions. A thorough laboratory evaluation including complete blood count, erythrocyte sedimentation rate, electrolytes, blood urea nitrogen and blood sugar, liver and thyroid tests, calcium and phosphorus levels, B12 and folate levels, serum copper and ceruloplasmin, VDRL, chest X-ray, electrocardiogram, and lumbar puncture may demonstrate treatable disorders that are adversely affecting intellectual function. Elderly individuals are particularly susceptible to the effects of toxic or metabolic disorders, and a mild dementia might be exaggerated by relatively minor fluctuations in metabolic status. Treatable causes of dementia should be considered in all demented patients.

Directional C-W Doppler sonography in the diagnosis of basilar artery disease.

Using directional continuous-wave Doppler sonography of the vertebral arteries, we have investigated 1,540 patients during the past 5 years. On the basis of unilateral and bilateral retrograde brachial angiograms in the same patients (a total of 1,989 angiograms) we have developed sonographic criteria for demonstrating a significant increase in the peripheral resistance of both distal vertebral arteries and/or the basilar artery. All 11 cases of basilar artery stenosis of at least 60% reduction in lumen diameter (as shown by angiography) exhibited an approximately 40% or higher reduction in the sum of the modified Pourcelot indices of both vertebral arteries with respect to age-matched controls. All 3 stenoses of less than 60% reduction in lumen diameter were not detected by sonography. Even a good collateral circulation through rete mirabile anastomoses did not normalize the modified Pourcelot indices. One case of a persistent primitive trigeminal artery with thin-calibered vertebral arteries was also detected by sonography. The high percent of patients with one hypoplastic vertebral artery in the group with basilar artery stenoses indicates an increased risk for atherosclerosis of the basilar and/or distal vertebral artery in these patients. All 14 angiographically verified occlusions of the basilar artery were detected by sonographic criteria independent of the occlusion localization. Thus, we believe that directional continuous-wave Doppler sonography is a reliable technique for detecting basilar artery stenoses of at least 60% reduction in lumen diameter and basilar artery occlusions.

Vertebral artery Doppler sonography.

We have examined the vertebral and subclavian arteries in 1,205 patients using directional continuous-wave (c-w) Doppler sonography, and compared the sonographic findings with the results of unilateral or bilateral retrograde brachial arteriographies in the same patients. Doppler sonography revealed 33 false positives among 909 cases with normal angiographic findings. Some types of vertebral artery (VA) lesions allowed an excellent, others a fairly good differentiation by Doppler sonography: the complete subclavian steal syndrome with constant reversal of VA flow was reliably detected (16 cases). In the incomplete steal syndrome (5 cases) sonography was superior to angiography. Two bilateral distal VA occlusions and seven basilar artery occlusions - six in the proximal third and one in the rostral third - were detected sonographically; four basilar occlusions sparing the caudal third and one case exhibiting rete mirabile anastomoses were not identified by Doppler sonography. Our acoustically defined sonographic criteria did not permit an unequivocal assignment to an anatomical variant or a vascular lesion. The sensitivity in the detection of a severe stenosis at the VA origin amounted to 16 out of 31, and to 12 of 25 in cases with a proximal VA occlusion and reconstitution of the distal VA through cervical collaterals. Our results confirm that the conventional hand-held c-w Doppler sonography cannot replace angiography in the evaluation of vertebro-basilar insufficiency. It rather serves as an aid to the decision for or against angiography, and in the follow-up of angiographically proven lesions. However, several therapeutically important lesions are readily diagnosed by sonography.

[Doppler sonographic diagnosis of basilar stenoses and obliterations]. / Die Doppler-sonographische Diagnose von Basilarisstenosen und -obliterationen.

We have examined 10,162 patients during the past 5 years using directional continuous-wave Doppler sonography of the vertebral arteries. On the basis of 1,989 retrograde brachial angiograms, we have developed sonographic criteria for demonstrating a significant increase in the peripheral resistance of both distal vertebral arteries and/or the basilar artery. All 11 cases of basilar artery stenosis of at least 60% reduction in lumen diameter (as shown by angiography) exhibited an approximately 40% or higher reduction in the sum of the modified Pourcelot indices of both vertebral arteries in comparison with age-matched controls. The 3 stenoses below 60% reduction in lumen diameter were not detected by sonography. Even a good collateral circulation through rete-mirabile anastomoses did not normalize the modified Pourcelot indices. One case of persistent primitive trigeminal artery with thin-calibred vertebral arteries was also detected by sonography. The high percentage of patients with one hypoplastic vertebral artery in the group of basilar artery stenoses indicates an increased risk for atherosclerosis of the basilar and/or the distal vertebral artery in these patients. All 14 angiographically verified occlusions of the basilar artery were detected by sonographic criteria independent of the occlusive localization. Thus, we believe that directional continuous-wave Doppler sonography is a reliable technique for detecting basilar artery stenoses of at least 60% reduction in lumen diameter and basilar artery occlusions.

[Doppler ultrasonic evaluation of the efficiency of extra-intracranial anastomoses]. / Die Doppler-sonographische Beurteilung der Funktionsfähigkeit extra-intracranieller Anastomosen.

We report on the results obtained by means of directional continuous-wave Doppler sonography in 33 patients with superficial temporal-to-middle cerebral artery anastomoses. Recurrent transient ischaemic attacks or a recent mild neurological deficit were considered as justification for bypass surgery in cases of angiographically proven occlusions of one or both internal carotids, severe intracranial carotid artery disease, or stenoses and occlusions of the M-1 segment of the middle cerebral artery. The efficiency of the anastomosis was evaluated by the modified Pourcelot indices (relative end-diastolic flow velocity) of the preauricular superficial temporal artery and of the bypass-supplying branch at the edge of the burr-hole. The influence of intermittent compression of the bypass-supplying branch on the modified Pourcelot index of the ipsilateral common carotid was used as a further criterion for sonographic evaluation. All efficient anastomoses, defined by a modified Pourcelot index of at least 0.20 at the edge of the burr-hole, exhibited an average reduction of 0.08 in the relative end-diastolic flow velocity in the common carotid during compression. In the 18 patients with unilateral occlusion of the internal carotid, bypass surgery was predominantly efficacious (by the above criterion) in those patients who showed a reduction in the sum of the modified Pourcelot indices of the remaining brain-supplying arteries of at least 10% as compared with age-matched controls. The subgroups of existing and absent collaterals through the ophthalmic artery did not show any differences with respect to the percentage of efficient anastomoses.(ABSTRACT TRUNCATED AT 250 WORDS)