Rehabilitation after head injury--1: Cognitive problems.
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Adolescent↗
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Tacrine (tetrahydroaminoacridine; THA) and lecithin in senile dementia of the Alzheimer type: a multicentre trial. Groupe Français d'Etude de la Tetrahydroaminoacridine.
OBJECTIVE: To see whether combined treatment with oral tacrine (tetrahydroaminoacridine; THA) and lecithin improves the symptoms of patients with Alzheimer's disease. DESIGN: Multicentre double blind, placebo controlled, random order crossover trial with individual determination of maximum tolerated dosage and four month follow up. SETTING: Outpatient departments at six university neurological centres. PATIENTS: 67 Outpatients (24 men, 43 women) aged 53-81 (mean 66 (SD 7.3)) selected according to the following criteria: probable Alzheimer's disease as defined by the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association; absence of mood disorder; mini mental state score lower than 26; availability of a close relative able to complete questionnaires; and informed consent of the patient or his or her closest relative, or both. INTERVENTIONS: Mean of 114 mg tacrine or placebo daily plus 1200 mg lecithin daily given in three divided doses for one four week active treatment period and one four week control period without washout at crossover. MAIN OUTCOME MEASURES: Cognitive state as assessed by Folstein's mini mental state rating scale, behavioural state as assessed by the Stockton geriatric rating scale, and overall state as assessed with a visual analogue scale rated by both the relative and the physician. RESULTS: Compared with placebo tacrine did not improve either the mini mental state score (mean 14.9 (SD 7.3) v 14.8 (7.3)) or the Stockton geriatric score (28.2 (15.7) v 28.7 (17.8)), but a slight and statistically significant improvement occurred in the physician's score on the visual analogue scale (6.3 (10.2) v 11.6 (17.9)). Seven patients dropped out. Six patients were excluded because of acute hepatitis and one withdrew for personal reasons not related to treatment. Two other patients developed acute hepatitis at the end of the eight week crossover trial and another during the follow up study. Twenty patients complained of gastrointestinal side effects. CONCLUSIONS: Neither short term nor long term treatment with oral tacrine at dosages lower than 125 mg/day improves the symptoms of Alzheimer's disease. Moreover, these dosages may induce hepatitis (nine of 67 patients in this series).
Aged↗
Epidemiology of Alzheimer's presenile dementia in Scotland, 1974-88.
OBJECTIVE: To describe the epidemiology of presenile Alzheimer's disease in Scotland from 1974 to 1988. DESIGN: Retrospective review of hospital records of patients aged less than 73 years admitted to psychiatric hospital with various diagnoses of dementia. Diagnoses were classified by National Institute for Communicative Disorders and Stroke and Alzheimer's Disease and Related Disorders Association Criteria and the Hachinski score. Completeness of the study sample was evaluated by scrutiny of neurology outpatient and general hospital records. SETTING: All general psychiatric hospitals in Scotland. SUBJECTS: All patients with onset of dementia aged 40-64. MAIN OUTCOME MEASURES: Probable and broad Alzheimer's disease, sex of patient, age at onset. RESULTS: 5874 psychiatric hospital records, 129 neurology outpatient records, and 89 records from non-psychiatric hospitals were examined. 317 patients met criteria for probable Alzheimer's disease, 569 met criteria for broad Alzheimer's disease, and 267 met those for multi-infarct dementia. Minimal incidences per 100,000 population aged 40-64 years were 22.6 (95% confidence interval, 20.2 to 25.2) and 40.5 (38.9 to 42.3) per 100,000 for probable and broad Alzheimer's disease. In the 1981 census year the annual incidence of probable Alzheimer's disease was 1.6 (1.0 to 2.6). Women were at greater risk with incidence rates for probable Alzheimer's disease of 28.2 (24.5 to 32.4) per 100,000 compared with 16.5 (13.8 to 19.8) per 100,000 for men. The incidence per 100,000 for multi-infarct dementia was greater in men (25.1, 23.3 to 27.1) than women (13.4, 12.1 to 14.8). CONCLUSION: Female sex seems to be positively associated with development of Alzheimer's disease before age 65 years.
Adult↗
Blindness and loss of other sensory and cognitive functions.
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Acute Disease↗
Is smoking a communicable disease? Effect of exposure to ever smokers in school tutor groups on the risk of incident smoking in the first year of secondary school.
OBJECTIVE: To estimate the effect of joining a first year secondary school tutor group with a high prevalence of ever smoking on the risk of incident smoking in schoolchildren. DESIGN: Cross-sectional questionnaire survey. SETTING: 10 randomly selected secondary schools in Nottinghamshire, UK. PARTICIPANTS: Pupils in years (grades) 7-11 (aged 11-16 years). MAIN OUTCOME MEASURE: Incident smoking in the first year of secondary education, defined as pupils who reported smoking their first cigarette during year 7. RESULTS: Of 6522 pupils (75% of those eligible) who completed the questionnaire, 17% were current smokers and 49% had ever smoked, of whom 23% had started smoking in year 7. Incident smoking in year 7 was more common in girls, in children with parents or siblings who smoke, and in more deprived children, and was independently increased in relation to the proportion of ever smokers in the year 7 tutor group joined by the child (adjusted odds ratio of incident smoking for a child joining a year 7 tutor group in the highest relative to the lowest quartile of ever smoking prevalence 1.45, 95% confidence interval (CI) 1.11 to 1.89). Exposure to ever smokers in year 7 tutor groups also accounted for most of the increased risk of incident smoking associated with socioeconomic deprivation. CONCLUSIONS: The risk of incident smoking in children entering secondary education is independently increased by exposure to other ever smokers in school tutor groups. Incident smoking in adolescents is thus to some extent a communicable disorder, and may be partly preventable by policies that reduce exposure to smoking at school.
Adolescent↗
Aphasia, depression, and non-verbal cognitive impairment in ischaemic stroke.
Aphasia, depression, and cognitive dysfunction are common consequences of stroke, but knowledge of their interrelationship is limited. This 1-year prospective study was designed to evaluate prevalence and course of post-stroke aphasia and to study its psychiatric, neurological, and cognitive correlates. We studied a series of 106 consecutive patients (46 women and 60 men, mean age 65. 8 years) with first-ever ischaemic brain infarction. The patients were clinically examined, and presence and type of aphasia were evaluated during the 1st week after stroke and 3 and 12 months later. Psychiatric and neuropsychological evaluations were performed 3 and 12 months after stroke. Aphasia was diagnosed in 34% of the patients during the acute phase, and two thirds of them remained so 12 months later. Seventy percent of the aphasic patients fulfilled the DSM-III-R criteria of depression 3 months and 62% 12 months after stroke. The prevalence of major depression increased from 11 to 33% during the 12-month follow-up period. The non-verbal neuropsychological test performance in the aphasic patients was significantly inferior to that of the patients with dominant hemisphere lesion without aphasia. One third of the patients with ischaemic stroke suffer from communicative disorders which seem to increase the risk of depression and non-verbal cognitive deficits. Although the prevalence of depression in aphasic patients decreases in the long term, the proportion of patients suffering from major depression seems to increase. We emphasize the importance of the multidimensional evaluation of aphasic stroke patients.
Adult↗
A 6-month, double-blind, placebo-controlled trial of eptastigmine in Alzheimer's disease.
OBJECTIVES: To evaluate the efficacy and safety of eptastigmine as a treatment for patients with mild-to-moderate Alzheimer's disease (AD). PATIENTS AND METHODS: The study was designed as a randomized, double-blind, placebo-controlled, parallel-group study. It was performed in 26 Italian and American geriatric and neurological centers. The study group comprised 349 outpatients with a diagnosis of probable AD according to the criteria of the National Institute of Neurological and Communicative Disorders and Stroke and the AD and Related Disorders Association. Patients were assigned to one of the three study groups: placebo (n = 119), eptastigmine 10 mg t.i.d. (n = 115) or eptastigmine 12 mg t.i.d. (n = 115) for 25 weeks. The AD Assessment Cognitive Subscale (ADAS-Cog) and the Clinical Dementia Rating Scale-Sum of the Boxes (CDR-SB) were the primary outcome measures for efficacy. RESULTS: The two doses of eptastigmine produced similar results and are presented together. Percentages of patients completing double-blind treatment were 82 and 87% in the placebo and eptastigmine groups, respectively. At the end of treatment, the intent to-treat analysis on 342 patients showed a statistically significant effect of eptastigmine compared to placebo on both ADAS-Cog (p = 0.047) and CDR-SB (p = 0.010). Patients on eptastigmine performed significantly better than placebo-treated patients also on the Mini-Mental State Examination (p < 0.001). The drug was well tolerated with 5% of patients withdrawing due to adverse events versus 3% on placebo. Adverse events were recorded in 46% of the patients on placebo compared to 52% of the patients taking eptastigmine. Cholinergic side effects (nausea, vomiting, diarrhea and abdominal pain) were reported with similar frequency in the eptastigmine and placebo-treated patients. CONCLUSION: Eptastigmine doses up to 12 mg t.i.d. for 25 weeks are well tolerated. The drug positively affects cognitive performance and global function of patients with mild-to-moderate AD.
Aged↗
Efficacy of the accent method of voice therapy.
There is an increasing need for studies of efficacy of behavior readjustment therapy procedures in human communicative disorders. Legal, social, scientific and professional considerations point up the need for more careful documentation of the effects of treatment techniques used by phoniatricians and speech-language pathologists. This study is conducted in order to evaluate the efficacy of the accent method of voice therapy (AM). The AM is one of the holistic approaches for behavior readjustment voice therapy. It tackles collectively and simultaneously the various parameters of voice such as pitch, loudness and timbre. The results of intervention utilizing the AM in this clinical trial are assessed in a relatively controlled setup. Patients with voice problems resulting from various etiologic vocal pathologies are distributed randomly into two groups. Group 1 (G1) is given the full aspect of the AM, that is, voice hygiene advice plus the accent exercises to correct the faulty vocal technique (habit). Group 2 (G2) receives only voice hygiene advice. The AM is administered in individual sessions 20 min each, twice a week, while the voice hygiene advice counseling is given once a week. The assessment of the vocal pathology is done following a diagnostic protocol utilizing subjective as well as quasi-objective measures of evaluation. The initial assessment presents the baseline (pretest) data for both groups. The follow-up evaluations are done at mid intervention (mid-test), that is, 10 sessions for G1 and 5 sessions for G2, and at the termination of intervention/therapy (post-test). The difference in improvement between G1 and G2 at the end of the observation was generally significant in favor of G1. There were significant improvements in G1 in certain items specific for the various etiologic categories. The improvement from pretest to mid-test to post-test values followed a linear tendency. The significance of the results is discussed and the conclusions are outlined and criticized.
Adult↗
Augmentative and alternative communication in logopedics.
Like logopedics, augmentative and alternative communication (AAC) has a short history and a long past. In the 1950s and 60s the field of AAC emerged as a response to the need of individuals who, despite years of 'traditional speech therapy', had not developed adequate oral communication skills, and for whom compensatory rather than remedial approaches were thus deemed advisable. Various trends like the shift from form to function in language development research, dissemination of sign language, use of non-speech graphic symbols, advances in computer technology, and international collaboration have all contributed to AAC's present-day status as a multidisciplinary enterprise involving speech-language therapists and an array of other professions. Clinical experience, for lack of comprehensive empirical studies, seems to indicate that AAC is warranted for congenital as well as acquired communication disorders.
Humans↗
Update on diagnostic methods, natural history and outcome variables in Alzheimer's disease.
The diagnosis of Alzheimer's disease (AD) currently relies on history obtained from family or friends and on mental status assessment matched to National Institute of Neurological and Communicative Disorders and Stroke criteria. Progression over time may or may not be typical, suggesting alternate diagnoses such as Lewy body or frontotemporal dementias. Apolipoprotein E genotype does not appear to be useful as a diagnostic marker. The usefulness of brain imaging in AD must be reexamined. Critical events in the natural history of AD, such as institutionalization and loss of ability for self-care, could be used as end points. Loss of ability for instrumental tasks, such as driving, traveling alone, or managing finances, would be preferable for early-stage stabilization studies. Different symptomatic domains of AD (mood, cognition, functional autonomy, behavior, motoricity) can be quantified using specific outcome measures. Although cognitive loss has been considered a core symptom of AD from a regulatory perspective, loss of functional autonomy and behavioral disinhibition are considered more important by clinicians and families. Recently, the availability of new scales has led to an interest in all of these domains. Results from symptomatic drug studies suggest a differential effect of cholinesterase inhibitors on cognition versus muscarinic agonists on functional autonomy and behavior. Hence there is a need to measure these domains separately and, eventually, to attempt combination therapy. Quality of life is a difficult but important dimension of AD therapeutic research, and it requires further methodological research.
Alzheimer Disease↗
Speech-language pathology in Malta: meeting local needs in a global perspective.
Education in logopaedics and patterns of service delivery for the communication-disordered have expanded over the past decade in the Maltese Islands to address local needs, culture and circumstances. This paper provides an overview of the expansion of trained staff, caseloads and mode of service delivery. Various strategies are reported as having been adopted by the relatively underresourced training establishment to ensure the preparation and maintenance of competent and accountable practitioners, as recommended by the International Association of Logopedics and Phoniatrics. The success in training is perceived as being the result of the collaborative approach adopted with local service providers and expatriate colleagues. Strategic plans to strengthen the profession and service provision are also discussed.
Health Services Needs and Demand↗
The validity and reliability of 6 sets of clinical criteria to classify Alzheimer's disease and vascular dementia in cases confirmed post-mortem: added value of a decision tree approach.
Data from 204 participants from the Oxford Project to Investigate Memory and Ageing, who were diagnosed post-mortem using the histopathological criteria of the Consortium to Establish a Registry for Alzheimer's Disease (CERAD), were used to assess the validity of the clinical criteria for Alzheimer's disease (AD) of the 'National Institute of Neurological and Communicative Disorders and Stroke/the Alzheimer's Disease and Related Disorders Association' (NINCDS/ADRDA). Cases who had been diagnosed as NINCDS/ADRDA 'probable AD' in life were usually confirmed at autopsy, but half of the NINCDS/ADRDA 'negative' cases were not (low specificity). It was hypothesized that the overall clinical impression may have taken precedence over the use of the actual criteria. We therefore investigated the validity and reliability of the clinical criteria using a computerized 'dementia diagnosis system' for each of 6 sets of criteria [Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), NINCDS/ADRDA and three sets of criteria specifically for vascular dementia (VaD): NINCDS-AIREN, State of California Alzheimer's Disease Diagnostic and Treatment Centers (ADDTC), and Vascular Cognitive Impairment (VCI)] to classify a subset (n = 96) of the cases confirmed post-mortem. The use of the computerized system significantly (p = 0.01) increased the specificity (81%, similar to sensitivity) of the NINCDS/ADRDA diagnoses, which were shown to have 'moderate' inter-rater reliability. The DSM-IV criteria had good validity for AD when compared with post-mortem confirmation and showed 'substantial' inter-rater reliability. The ADDTC and VCI criteria for VaD had good specificity (88%) and sensitivity (75%), but only for one rater. The DSM-IV and NINCDS-AIREN criteria for VaD showed poor validity and inter-rater reliability. We conclude that the forced use of decision trees through a computerized system enhances the accuracy of the clinical diagnoses of dementia.
Aged↗
Education of speech-language pathologists and audiologists in Brazil.
The field of speech-language pathology (SLP) in Brazil, named 'fonoaudiologia', comprises both a therapeutic approach to communication disorders and audiology and was officially recognized on December 9, 1981 (law No. 6965). University programs exist since the 1960s. The undergraduate level is a 4-year honors Bachelor of Science program and requires at least a 3,700 h of coursework. Since 1996 four areas of specialization were established: language, audiology, voice and oral myology, requiring a minimum of 500 h of course. Graduate programs in the narrower sense,master's degree and doctorate, exist since the 1970s. Brazil is a 180-million inhabitant country with approximately 25,000 speech-language pathologists, of which 2,700 are specialists, 800 masters and 210 doctors. There are almost 100 undergraduate programs and 70 specialization courses; however, for master's degree and doctorate purposes there are only 8.
Audiology↗
Education in logopaedics in the Maltese Islands.
The Communication Therapy (CT) Division of the University of Malta is relatively small and young and is the only local training establishment of speech-language pathologists (SLPs) in the Maltese Islands. It aims to achieve a distinctive profile of excellence and international standing in the education and training of caring, accountable and autonomous SLPs. Various strategies are adopted by the CT Division in order to reach its goals and to overcome its limitations and challenges. These include running its own Teaching and Research Clinic, engaging in European staff/student exchange and conducting research projects with other organizations to develop scientific data and tools for use with the Maltese communication-disordered population.
Curriculum↗
The effect on risk estimates of excluding cases from a case-control study of ischemic stroke.
There is limited information about the effect on stroke risk estimates of excluding cases who are unable to respond to interviews. A case-control study of ischemic stroke between 1988 and 1990 in Shreveport, La., USA, provided a basis for studying this question. Of 197 consecutively admitted cases of ischemic stroke, 77 were excluded due to dementia, aphasia or impaired consciousness. Information about risk factors and stroke characteristics was obtained from hospital records. Excluded cases had more left hemispheric (52 versus 19%) and fewer vertebrobasilar (12 versus 29%) and lacunar (5 versus 13%) infarcts than included cases. Excluded cases were also older (p < 0.01), and they had larger infarcts (p < 0.01), multiple strokes (p < 0.01) and congestive heart failure (p < 0.01) more often than included cases. Cases were matched to hospital controls by age, sex, race, and date of admission. Odds ratios (ORs) were higher for excluded cases for 5 of 6 exposures with a significantly higher OR for congestive heart failure (p < 0.01). The ORs changed by as much as 63% when excluded cases were added. These results emphasize the importance of acquiring information about excluded cases and considering selection bias when interpreting stroke studies that exclude cases who are unable to respond to interviews.
Adult↗
Systemic lupus erythematosus presenting with recurrent acute demyelinating polyneuropathy.
We report a patient who in the course of 3 years developed 3 distinct episodes of an acute demyelinating neuropathy, each fulfilling the criteria set up by an ad hoc committee of the National Institute of Neurological and Communicative Disorders and Stroke for acute Guillain-Barré syndrome. Each episode was associated with strong serological evidence for lupus erythematosus. The episodes were separated by 1-2 years and each was followed by near complete clinical recovery. The only systemic feature was a pleural effusion during the last 2 episodes.
Acute Disease↗
Early dramatic recovery during intravenous tissue plasminogen activator infusion: clinical pattern and outcome in acute middle cerebral artery stroke.
BACKGROUND AND PURPOSE: Acute-stroke patients receiving standard intravenous tissue plasminogen activator (tPA) have been noted to experience early dramatic recoveries. The prevalence, clinical characteristics, and outcome of patients experiencing dramatic recovery is not well described. METHODS: We prospectively studied all patients presenting with acute middle cerebral artery (MCA) stroke syndromes and transcranial Doppler (TCD) evidence of an MCA obstruction. All patients received intravenous tPA per the National Institute of Neurological and Communicative Disorders and Stroke protocol, with serial National Institutes of Health Stroke Scale (NIHSS) scores and continuous TCD monitoring. Dramatic recovery was defined as an improvement of > or =10 NIHSS points or a decrease to an NIHSS score of < or =3 by the end of infusion. Outcome at the end of infusion, at 24 hours, and at long-term follow-up were obtained. The timing and pattern of deficit recovery during dramatic recovery was also studied. RESULTS: Dramatic recovery occurred in 22% of all patients. Compared with patients who did not experience dramatic recovery, those patients who did had significantly lower end-infusion NIHSS (median 2 and range 0 to 16 for dramatic-recovery patients versus median 17 and range 6 to 35 for non-dramatic-recovery patients, P<0.01) and 24-hour NIHSS (median 2 and range 0 to 16 for dramatic-recovery patients versus median 13 and range 2 to 35 for non-dramatic-recovery patients, P<0.01). A long-term modified Rankin Score benefit was noted (median 1 and range 0 to 6 for dramatic-recovery patients versus median 4 and range 0 to 6 for non-dramatic-recovery patients, P<0.01). Baseline clinical characteristics were similar. The only difference was improved TCD-determined flow values at the end of infusion (normal restoration of flow was 58% in dramatic-recovery patients versus 14% in non-dramatic-recovery patients, P<0.01). A characteristic pattern of recovery of deficit was noted. CONCLUSIONS: Early dramatic recovery in acute MCA stroke patients treated with intravenous tPA is relatively frequent. The benefit of dramatic recovery is maintained at 24 hours and over the long term. TCD monitoring suggests that dramatic recovery is a result of early restoration of MCA flow during the tPA infusion. The consistent pattern of early clinical recovery may help explain the mechanisms by which thrombolysis improves outcome and could suggest targets for enhancing the therapeutic effect of intravenous tPA.
Acute Disease↗
The Stroke Data Bank: design, methods, and baseline characteristics.
The National Institute of Neurological and Communicative Disorders and Stroke initiated the Stroke Data Bank, which is a multicenter project to prospectively collect data on the clinical course and sequelae of stroke. Additional objectives were to provide information that would enable a standard diagnostic clinical evaluation, to identify prognostic factors, and to provide planning data for future studies. A brief description of the structure and methods precede the baseline characterization of 1,805 patients enrolled in the Stroke Data Bank between July 1983 and June 1986. Two thirds of these patients were admitted within 24 hours after stroke onset. Medical history, neurologic history, and hospitalization summaries are presented separately for the following stroke subtypes: infarction, unknown cause; embolism from cardiac source; infarction due to atherosclerosis; lacune; parenchymatous or intracerebral hemorrhage; subarachnoid hemorrhage; and other. The utility and limitations of these data are discussed.
Cerebral Infarction↗