Treating Agitation in Patients with Dementia with a Therapy Dog in a Milieu Therapy Setting on a Geropsychiatric Ward

<b><i>Background:</i></b> Animal-assisted intervention has become a common therapeutic practice used for patients with dementia in home-dwelling and institutions. The most established procedure is a visiting service by specially trained dogs and their owners to improve social interactions and reduce symptoms of agitation. <b><i>Objectives:</i></b> The study aims to investigate the effects of a therapy dog on agitation of inpatients with dementia in a gerontopsychiatric ward. <b><i>Materials and Methods:</i></b> The severity of agitation was assessed by a rater blinded for the presence of the dog via the Overt Agitation Severity Scale (OASS). The scale was conducted on 1 day with the dog and his handler present (resident doctor on the ward) and on another day with only the handler present. Each patient was his/her own control. Heart rate variability (HRV) and serum level of brain-derived neurotrophic factor (BDNF) of the patients were measured on both days. 26 patients with the Mini-Mental Status Examination (MMSE) score &#x3c;21 and the diagnosis of dementia were included in the study. <b><i>Results:</i></b> A significant reduction of agitation in the OASS could be shown when the dog was present (<i>p</i> = 0.006). The data neither demonstrated a difference in the HRV for the parameters mean heart rate (<i>p</i> = 0.65), root mean square of successive differences (<i>p</i> = 0.63), and high frequencies (<i>p</i> = 0.27) nor in serum BDNF concentrations (<i>p</i> = 0.42). <b><i>Discussion:</i></b> Therapy dogs can be implemented as a therapeutic tool in a gerontopsychiatric ward to reduce symptoms of agitation in patients with dementia. The study was registered in the German Clinical Trials Register (DRKS00024093).

P.015 What Happens to the Worried Well? – Follow-up of Subjective Cognitive Impairment

Background: Concern around perceived neurocognitive decline is increasing, leading to increased number of referrals and anxiety for patients. We aimed to explore the likelihood of the “worried well” experiencing neurocognitive decline. Methods: 166 “worried well” patients who attended the Rural and Remote Memory Clinic between 2004 and 2019 were included. Mini Mental Status Examination, Center for Epidemiologic Studies Depression Scale, and Functional Assessment Questionnaire scores were measured and compared at initial assessment and at 1-year follow-up. MMSE scores over time were assessed with a mean follow-up of 2.95 years (SD 2.87). Results: There was no statistically significant difference in MMSE, CESD, or FAQ scores between clinic day and one-year follow-up, and no consistent pattern of MMSE score over time. Of the 166 patients with SCI on initial assessment, nine were eventually given a neurological diagnosis. Conclusions: There is no pattern of neurologic decline observed in the “worried well”. Though the likelihood of a patient with SCI developing a neurological diagnosis is reassuringly low, (9/166), it is not irrelevant. This, along with the benefits of early diagnosis and treatment for dementia, leads us to believe that patients with SCI should still be seen in follow-up at least at the one-year mark.

Naloxone Alleviate the Severity of Delirium in Hospitalized Patients With Parkinsonism: Three Case Reports

Purpose: Delirium is common in geriatric with Parkinson's disease (PD). Treatments for delirium have generally been neuroleptics; however, antipsychotics have potential effect to block striatal dopamine D2 receptors and worsen symptom of parkinsonism. We explored whether naloxone can alleviate delirium in PD and other forms of parkinsonism.Patients and Methods: Patients with parkinsonism who met the delirium criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) received naloxone infusions once or twice daily. Treatment effects were evaluated by the delirium rating scale–revised 98 (DRS-R98), including non-cognitive and cognitive subscales; the Richmond agitation–sedation scale (RASS); and the mini mental status examination (MMSE).Results: Two patients with primary parkinsonism, one with vascular PD were observed. The daily dose of naloxone was 2.08 ± 0.64 mg (range: 1–4 mg). Medication time last from 1 h to 7 days without side effects observed. Following with naloxone infusions, DRS-R98 scores decreased within 12 h and MMSE scores increased. The psychotic symptoms, disorientation, and attention deficits were alleviated significantly, while RASS scores decreased with naloxone treatment.Conclusion: Naloxone alleviated psychotic symptoms, improved cognitive dysfunction, and irritability in patients with delirium in the context of PD. The preliminary findings point out that the opioid system may be involved in the pathophysiology of delirium, which may be one of potential treat targets for delirium of PD.

Study rationale and baseline data for pilot trial of dronabinol adjunctive treatment of agitation in Alzheimer’s dementia (THC-AD)

Agitation is a common complication of Alzheimer’s dementia (Agit-AD) associated with substantial morbidity, high healthcare service utilization, and adverse emotional and physical impact on care partners. There are currently no FDA-approved pharmacological treatments for Agit-AD. We present the study design and baseline data for an ongoing multisite, three-week, double-blind, placebo-controlled, randomized clinical trial of dronabinol (synthetic tetrahydrocannabinol [THC]), titrated to a dose of 10 mg daily, in 80 participants to examine the safety and efficacy of dronabinol as an adjunctive treatment for Agit-AD. Preliminary findings for 44 participants enrolled thus far show a predominately female, white sample with advanced cognitive impairment (Mini Mental Status Examination mean 7.8) and agitation (Neuropsychiatric Inventory-Clinician Agitation subscale mean 14.1). Adjustments to study design in light of the COVID-19 pandemic are described. Findings from this study will provide guidance for the clinical utility of dronabinol for Agit-AD. ClinicalTrials.gov Identifier: NCT02792257.

Efficacy of Donepezil in Improving Cognitive Impairment Induced by Electroconvulsive Therapy in Patients with Mood Disorders: A Randomized, Double-blind, Placebo-Controlled Trial

Background: Electroconvulsive therapy (ECT) is an effective strategy in the treatment of mood disorders; however, it is associated with some cognitive complications. Objectives: This study aimed to evaluate the efficacy of donepezil as an acetylcholinesterase inhibitor in improving cognitive impairment induced by ECT in mood disorder patients. Methods: Ninety-six mood disorder patients were randomly assigned to the donepezil (5mg/day) or placebo groups. The Persian versions of the Mini-Mental Status examination (MMSE) and Addenbrooke’s Cognitive Examination Revised (ACE-R) were used to evaluate cognitive performance before the first ECT session, after the fourth ECT session, and four weeks after the last ECT session. Results: The mean scores of MMSE and ACE-R revealed significant improvement in the donepezil group over time (P < 0.001). All ACE-R subscales increased significantly following the intervention implementation in the donepezil group (P < 0.001). Furthermore, the donepezil group reported no remarkable complications and completed the study. Conclusions: Donepezil co-administration with ECT may improve the ECT-induced cognitive disturbances.

The Neurocognitive Study for the Aging: Longitudinal Analysis on the Contribution of Sex, Age, Education and APOE ɛ4 on Cognitive Performance

Objective: The effects of normal cognitive aging on executive functions (EF), Verbal Episodic Memory (VEM) and the contribution of age, sex, education, and APOΕ ε4 in a group of old Greek Cypriots across a five-year period were investigated.Design: NEUROAGE, the first project on cognitive aging in Cyprus, is a prospective longitudinal study with a rolling admission process. Participants are assessed at baseline and retested every 24–30 months.Subjects: 170 participants completed all three testing cycles; 86 men and 84 women with ages ranging between 60 and 88 years (mean = 73.21, SD = 5.84); education, 2–20 years (mean = 9.07, SD = 4.27).Results: Α Repeated Measures Multivariate Analysis of Covariance was conducted with one between-subject factor: sex; two covariates: age and education, while Time (time 1, time 2, time 3) served as a within – subject factor. Time did not have an effect on mini mental status examination in Greek (MMSE), EF or VEM. Also, sex had no effect on MMSE, EF and VEM. There was no time by sex interaction. Age and Education significantly predicted the EF performance, F(1, 168) = 11.23, p &lt; 0.05; F(1, 158) = 90.03, p &lt; 0.001 and VEM performance, F(1, 171) = 17.22, p &lt; 0.001; F(1, 171) = 61.25, p &lt; 0.001. Furthermore, there was a significant interaction effect between time and education, for EF, F(2, 167) = 7.02, p &lt; 0.001. Performance of the APOE ε4 carriers did not differ on any of the above measures as compared to performance of non-carriers in this older adult group.Conclusion: Cognitively healthy adults maintained overall cognitive performance across the five-year period. Male and female participants performed similarly and the pattern of change over time was similar across the two sexes. Education was predictive of VEM and EF performance across time. Furthermore, those with higher education maintained higher levels of EF performance. APOE results did not differentiate performance at baseline. Implications of findings are discussed.

Cluster seizures and status epilepticus in new onset seizures among adult Egyptians

Background New onset seizure (NOS) is defined as the first seizure within a 24-h period ever experienced by the patient. Cluster seizures (CS) or status epilepticus (SE) can be the first manifestation of epilepsy or it may be a symptom of a brain tumor, a systemic disorder, an infection, or a syndrome. This study aims to determine the etiology of CS and SE in NOS among adult Egyptians. One hundred twenty adult Egyptian patients presented with NOS were enrolled in a hospital-based cross-sectional observational study within a time period of 6 months from March till September 2018. All patients were subjected to neurological examination including mini mental status examination, laboratory, neuroimaging, and electroencephalogram. Results Among 120 adult patients presented with NOS, males were prevalent (63%). Older adults (> 55 years) were prevalent (60%). Of the patients, 25% presented by CS, while 11% presented by SE. Post-stroke epilepsy (41%) was the predominant etiology of NOS. Cerebrovascular diseases (CVDs) were the prevalent etiology of SE in NOS (35%). NOS presented by CS were more prevalent among patients with brain tumors (29%) in comparison to CVDs (25%). Conclusion CS represented 25% of NOS in adult Egyptian patients. SE is prevalent among 11% of NOS. Despite CVDs being the most prevalent etiology of NOS in adult population (41%) including those presented with SE (35%), brain tumors are the most prevalent etiology of new onset CS (29%).

Neuroanatomical correlates of poststroke complex regional pain syndrome: a voxel-based lesion symptom-mapping study

Complex regional pain syndrome (CRPS) is a common poststroke complication. However, the neural substrates associated with CRPS remain unclear. We investigated the neural correlates associated with poststroke CRPS using voxel-based lesion‒symptom mapping (VLSM) analysis. Among 145 patients with ischemic stroke, 35 were diagnosed with CRPS and categorized into the poststroke CRPS group, and the remaining 110 into the control group. We compared the clinical characteristics between the groups. VLSM analysis was performed to identify the brain region associated with the development of poststroke CRPS. The clinical findings suggested that the poststroke CRPS group had lower muscle strength; lower scores on Fugl‒Meyer assessment, Manual Function Test, Mini-Mental Status Examination; and higher incidence of absent somatosensory evoked potentials in the median nerve than the control group. The head of the caudate nucleus, putamen, and white matter complexes in the corona radiata were significantly associated with poststroke CRPS development in ischemic stroke patients. These results facilitate an understanding of poststroke CRPS pathophysiology. Monitoring patients with lesions in these structures may aid the prevention and early treatment of poststroke CRPS.

Management Challenges and Outcomes of Traumatic Brain Injury due to Bear Maul in Tribal Areas of Chhattisgarh, India—Man versus Wild

Objectives Neurosurgeons working in the vicinity of tribal areas face traumatic brain injury (TBI) cases due to bear maul which is on the rise in Chhattisgarh. Most of the literature is focused on the management of maxillofacial injuries. This study intends to describe the challenges in management and outcomes of TBI due to bear maul. Materials and Methods A retrospective review was conducted from May 2018 to April 2020. The patients without TBI were excluded. The variables studied were age, gender, timing and mode of conflict, Glasgow coma scale (GCS) at arrival, injury spectrum, hospital stay, the modified Rankin score (MRS), mini mental status examination (MMSE), and surgical site infections (SSI). Results Twenty-eight patients were eligible for analysis. The mean age of presentation was 40.67 ± 13.99 years. There were 23 males (82.15%). Most common time of attack was during dawn (n = 11, 39.28%) followed by dusk (n = 9, 32.14%) and day (n = 8, 28.57%) time. Provoked conflicts were seen in 64.28%. The mean preoperative GCS was 11.07 ± 3.54 and hospital stay was 18.71 ± 9.51 days. Skull fractures were found in 24/28 (85.71%). The mean MRS was 1.67 ± 1.38 at a mean follow-up of 14.53 ± 6.59 months. Favorable outcome (MRS ≤ 2) was seen in 64.28% of patients. The mean MMSE score was 22.28 ± 5.36. Eight patients developed SSI (28.57%). Conclusion Outcomes of TBI due to bear maul depend on preoperative GCS. There are higher incidences of skull fractures and SSI. Humans need to avoid infiltration in wildlife territory to reduce the number of conflicts.

Neuroanatomical correlates of poststroke complex regional pain syndrome: A voxel-based lesion symptom- mapping study

Complex regional pain syndrome (CRPS) is a common poststroke complication. However, the neural substrates associated with CRPS remain unclear. We investigated the neural correlates associated with poststroke CRPS using voxel-based lesion‒symptom mapping (VLSM) analysis. Among 145 patients with ischemic stroke, 35 were diagnosed with CRPS and categorized into the poststroke CRPS group, and the remaining 110 into the control group. We compared the clinical characteristics between the groups. VLSM analysis was performed to identify the brain region associated with the development of poststroke CRPS. It suggested that damage to the caudate nucleus head, putamen, and white matter complexes in the corona radiata were significantly associated with poststroke CRPS development. The clinical findings suggested that the poststroke CRPS group had lower muscle strength; lower scores on Fugl‒Meyer assessment, Manual Function Test, Mini-Mental Status Examination; and higher incidence of absent somatosensory evoked potentials in the median nerve than the control group. The head of the caudate nucleus, putamen, and white matter complexes in the corona radiata were associated with poststroke CRPS development in ischemic stroke patients. These results facilitate an understanding of poststroke CRPS pathophysiology. Monitoring patients with lesions in these structures may aid the prevention and early treatment of poststroke CRPS.