No abstract

No abstract

No abstract

Mrs. E, a 72-year-old woman in your practice who has experienced clear and progressive memory decline over the past 3 years, finally agrees to come and see you with her daughter and husband for an assessment. The patient is English speaking and has a bachelor's degree. Her medical history includes hypertension, a 20-pack-year history of smoking and a previous transient ischemic attack. Her family says that she is unable to currently handle her own banking and has become lost when driving. Mrs. E is increasingly anxious when left alone. Her husband is concerned that she might be depressed, but he adds

There have been several newly proposed sets of diagnostic criteria for Alzheimer's disease/mild cognitive impairment, advanced by the National Institute of Aging/Alzheimer's Association working groups in 2011 and by the International Working Group in 2007 and 2010. These sets each aim to provide broader disease stage coverage with incorporation of disease biomarkers into the diagnostic process. They have focused particular attention on the earlier identification of disease with focus on the preclinical and predementia stages. This paper reviews these diagnostic criteria and provides 2012 consensus recommendations from the Canadian Consensus Conference on the Diagnosis and Treatment of Dementia on their applications in both clinical and research settings.

Background The primary outcome results for the Secondary Prevention of Small Subcortical Strokes (SPS3) trial suggested that a lower target blood pressure may be beneficial (19% nonsignificant reduction) for reducing risk of recurrent stroke but that addition of clopidogrel to aspirinwas not. Whether blood pressure (BP) reduction and dual antiplatelet therapy affectchanges in cognition over time in patients with cerebral small vessel disease is unclear. Methods Pre-specified secondary endpoint analyses of the SPS3 trial involving 3020 patients, mean age 63 years, with recent symptomatic lacunar infarcts randomized 1:1 to two target levels of systolic BP (130-149 mm Hg vs. <130 mm Hg, open-label) and 1:1 to aonce-dailyantiplatelet therapy (75 mg clopidogrel plus 325 mg aspirin vs. 325 mg aspirin alone, double-blind) during 2003-2011 at 81 centers. The primary cognitive outcome was change in Cognitive Abilities Screening Instrument (CASI) during follow-up. Patients were tested annually (median 3 years of follow-up, maximum5)during which the mean difference in systolic BP averaged 11 mmHg between the two target (138 mm Hg vs 127 mm Hg at 1 year). This study is registered with ClinicalTrials.gov, number NCT 00059306. Findings The 2916 participants with CASI scores at study entry are included in the analysis.Mean (SD) changes in CASI z-scores from study entry to assessment at years1 (n=2699), 2 (n=2251), 3 (n=1785), 4( n=1134) and 5 (n=803) were 0.11 (0.84), 0.15 (0.85), 0.15 (0.97), 0.19 (1.0), and 0.16 (1.2), respectively. Changes in CASI z-scores over time did not differ between assigned antiplatelet groups (p=0.9) or between assigned blood pressure control groups (p=0.5).There was no interaction between assigned antiplatelet groups and assigned blood pressure control groups and change over time. (p=0.2) Interpretation Cognitivefunctionis not influenced by short-term treatment with dual antiplatelet therapy or blood pressure reduction in relatively young patients with recent lacunar stroke. Future studies of the effects of blood pressure reduction on cognition should focus on patients with higher rates of cognitive decline.

Objective: To assess the efficacy of a progressive aerobic exercise training program on cognitive and everyday function among adults with mild subcortical ischemic vascular cognitive impairment (SIVCI).Methods: This was a proof-of-concept single-blind randomized controlled trial comparing a 6-month, thrice-weekly, progressive aerobic exercise training program (AT) with usual care plus education on cognitive and everyday function with a follow-up assessment 6 months after the formal cessation of aerobic exercise training. Primary outcomes assessed were general cognitive function (Alzheimer Results: Seventy adults randomized to aerobic exercise training or usual care were included in intention-to-treat analyses (mean age 74 years, 51% female, n 5 35 per group). At the end of the intervention, the aerobic exercise training group had significantly improved ADAS-Cog performance compared with the usual care plus education group (21.71 point difference, 95% confidence interval [CI] 23.15 to 20.26, p 5 0.02); however, this difference was not significant at the 6-month follow-up (20.63 point difference, 95% CI 22.34 to 1.07, p 5 0.46). There were no significant between-group differences at intervention completion and at the 6-month follow-up in EXIT-25 or ADCS-ADL performance. Examination of secondary measures showed between-group differences at intervention completion favoring the AT group in 6-minute walk distance (30.35 meter difference, 95% CI 5.82 to 54.86, p 5 0.02) and in diastolic blood pressure (26.89 mm Hg difference, 95% CI 212.52 to 21.26, p 5 0.02). Conclusions:This study provides preliminary evidence for the efficacy of 6 months of thriceweekly progressive aerobic training in community-dwelling adults with mild SIVCI, relative to usual care plus education. ClinicalTrials.gov identifier: NCT01027858.Classification of evidence: This study provides Class II evidence that for adults with mild SIVCI, an aerobic exercise program for 6 months results in a small, significant improvement in ADAS-Cog performance. Vascular cognitive impairment (VCI) is the second most common cause of dementia after Alzheimer disease (AD).1 Cerebral small vessel disease plays a critical role in covert ischemia and the development of sub-cortical ischemic vascular cognitive impairment (SIVCI), 2 the most common form of VCI. SIVCI is defined by the presence of white matter lesions (WMLs) and lacunar infarcts, and has the clinical consequence of increased dementia risk.3,4 Aerobic exercise

Objective Lacunar strokes are a leading cause of cognitive impairment and vascular dementia. However, adequate characterization of cognitive impairment is lacking. The aim of this study was to estimate the prevalence and characterize the neuropsychological impairment in lacunar stroke patients. Methods All English-speaking participants in the SPS3 trial (NCT: 00059306) underwent neuropsychological testing at baseline. Raw scores were converted to z-scores using published norms. Those with impairment (z≤-1.5) in memory and/or non-memory domains were classified as having Mild Cognitive Impairment (MCI). Results Among the 1636 participants, average z scores on all tests were below zero with the largest deficits seen on tests of episodic memory (range of means -0.65 to -0.92), verbal fluency (mean -0.89), and motor dexterity (mean -2.5). Forty-seven percent were classified as having MCI: 36% amnestic, 37% amnestic multidomain, 28% non-amnestic. Of those with Rankin score 0-1 and Barthel score=100, 41% had MCI. Younger age [odds ratio (OR) per 10-yr increase=0.87], male sex (OR 1.3), less education (OR 0.13-0.66 compared to 0-4 yrs education), post-stroke disability (OR 1.4), and impaired activities of daily living (OR 1.8) were independently associated with MCI. Conclusions In this large, well characterized cohort of lacunar stroke patients, MCI was present in nearly half, including many with minimal or no physical disabilities. Cognitive dysfunction in lacunar stroke patients may commonly be overlooked in clinical practice but may be as important as motor and sensory sequelae.