Background and Purpose--The study aimed to investigate the predictive value of neurobiochemical markers of brain damage (protein S-100B and neuron-specific enolase [NSE]) with respect to early neurobehavioral outcome after stroke. Methods--We investigated 58 patients with completed stroke who were admitted to the stroke unit of the Department of Neurology at Magdeburg University. Serial venous blood samples were taken after admission and during the first 4 days, and protein S-100B and NSE were analyzed by the use of immunoluminometric assays. In all patients, lesion topography and vascular supply were analyzed and volume of infarcted brain areas was calculated. The neurological status was evaluated by a standardized neurological examination and the National Institutes of Health Stroke Scale (NIHSS) on admission, at days 1 and 4 on the stroke unit, at day 10, and at discharge from the hospital. Comprehensive neuropsychological examinations were performed in all patients with first-ever stroke event and supratentorial brain infarctions. Functional outcome was measured with the Barthel score at discharge from the hospital. Results--NSE and protein S-100B concentrations were significantly correlated with both volume of infarcted brain areas and NIHSS scores. Patients with an adverse neurological outcome had a significantly higher and significantly longer release of both markers. Neuropsychological impairment was associated with higher protein S-100B release, but this did not reach statistical significance. Conclusions--Serum concentrations and kinetics of protein S-100B and NSE have a high predictive value for early neurobehavioral outcome after acute stroke. Protein S-100B concentrations at days 2 to 4 after acute stroke may provide valuable information for both neurological status and functional impairment at discharge from the acute care hospital.

This study aimed at the investigation of release patterns of neuron specific enolase (NSE) and protein S-100B after traumatic brain injury (TBI) and their association with intracranial pathologic changes as demonstrated in computerized tomography (CT). We analyzed NSE and S-100B concentrations in serial venous blood samples taken one to three days after TBI in 66 patients by the use of immunoluminometric assays. These markers are considered to be specific neurobiochemical indicators of damage to glial (S-100B) or neuronal (NSE) brain tissue. Standardized neurological examination and plani- and volumetric evaluation of computerized tomography scans were performed in all patients. Patients with medium severe to severe TBI [Glasgow Coma Scale (GCS) score at the site of accident < or =12] exhibited significantly higher NSE and S-100B concentrations and a significantly longer release compared to patients with minor head injury (GCS: 13-15). Both, patients with and without visible intracerebral pathology in CT scans exhibited elevated concentrations of NSE and S-100B after TBI and a significant decrease in the follow-up blood samples. Release patterns of S-100B and NSE differed in patients with primary cortical contusions, diffuse axonal injury (DAI), and signs of cerebral edema (ICP) without focal mass lesions. All serum concentrations of NSE and S-100B were significantly correlated with the volume of contusions. The data of the present study indicate that the early release patterns of NSE and S-100 may mirror different pathophysiological consequences of traumatic brain injury.

The frequency of postoperative delirium in elderly patients with cognitive deficits can be lowered with nursing measures carried out by a specially trained nurse, close postoperative supervision, and cognitive activation.

Background: As the elderly population increases, so, too, does the number of multimorbid patients and the risk of polypharmacy. The consequences include drug interactions, undesired side effects of medication, health impairment, and the need for hospitalization. 5-10% of hospital admissions among the elderly are attributable to undesired side effects of medication. Methods: This review is based on publications retrieved by a selective search in PubMed and the Cochrane Library that employed the search terms "drug interaction," "undesired side effect," "polypharmacy," "pharmacokinetics," and "pharmacodynamics." Results: Elderly patients are particularly at risk of polypharmacy, both because of the prevalence of multimorbidity in old age and because of physicians' uncritical implementation of guidelines. The more drugs a person takes, the greater the risk of drug interactions and undesired side effects. Age-associated changes in pharmacokinetics and pharmacodynamics elevate this risk as well. Physicians prescribing drugs for elderly patients need to know about the drugs' catabolic pathways, protein binding, and inductive and inhibitory effects on cytochrome P450 in order to avoid drug interactions and polypharmacy. Conclusion: Multiple aids and instruments are available to ensure practical and reasonable drug monitoring, so that the risks of drug interactions and undesired side effects can be detected early and avoided.

SUMMARYBackground: Behavioral disorders such as aggressiveness, agitation, delusions, disinhibition, affect lability, and apathy arise in more than 90% of patients with dementia. Behavioral disorders are a major challenge and the greatest stress factor in everyday life for nursing personnel and for family members caring for the patient.

ObjectiveDelirium is a frequent postoperative complication in older and cognitively impaired patients in general hospitals. Delirium is associated with prolonged hospital stay as well as with an increased risk of nursing home placement after discharge. We wanted to study whether the implementation of a specialized delirium nurse on a surgical ward leads to a reduction in the frequency of postoperative delirium.MethodsIn an open-label study on two surgical wards of a general hospital, first the prevalence rate of postoperative delirium in patients older than 70 years was assessed (March to August 2011). During the following intervention phase (September 2011 to June 2012), a trained geriatric nurse implemented delirium-preventative measures in accordance with the Hospital Elder Life Program (HELP). The second surgical ward provided standard treatment as usual as an in-house control.ResultsOverall 20.2%, 95% CI [14.6, 26.4] of patients on both wards without special intervention developed postoperative delirium. By implementing preoperative screening measures and specific interventions by a delirium nurse, the incidence of postoperative delirium was reduced to 4.9%, 95% CI [0.0, 11.5]. The interventions were validation, improving sleep quality, cognitive activation, early mobilisation, improving sensory perception and optimising food and fluid intake. Most important predictors of postoperative delirium were Mini Mental Status Exam results, age and preoperative infection.ConclusionThe establishment of a specialised delirium nurse as well as the implementation of simple preoperative care measures increased postoperative attention, cognitive activation and is associated significantly with reducing risk of postoperative delirium in older and cognitively impaired inpatients.Disclosure of interestThe authors have not supplied their declaration of competing interest.

The classic literature on pathological laughter and crying emphasizes the difference between incontinence and lability of affect. Pathological laughter and crying as key symptoms of affect incontinence are viewed as the effects of disinhibition of motor synergisms without congruent affect, which is the crucial difference to affect lability. The interpretation as a disinhibitory phenomenon is supported by clinical and electromyographic observations, which found a lack of modulation of intensity in pathological laughter and crying. In 1924, Wilson postulated a supranuclear pontobulbar center for affective synergisms that is controlled by cortex and thalamus. Accordingly, Kleist viewed a combined lesion of thalamic or brainstem structures and corticofugal motor projection systems as the pathoanatomic basis of affect incontinence. Recent work reported the frequent occurrence of affect incontinence with stroke and dementia of the Alzheimer type and thus disagrees with the classical theory. However, the methods used cannot rule out a confounding between affect lability and incontinence.

In the past the concept of delirium was associated with different diseases. Even today numerous synonyms of delirium exist. The author gives an overview of the definition of delirium in the past and today. The paper presents epidemiological data, diagnostic criteria and differential diagnoses of delirium for patients suffering from dementia. Pathological mechanisms, risk factors and triggers as well as different forms of delirium for patients suffering from dementia are discussed. Diagnostics and differential diagnostics are discussed and possible medicamentous and non-medicamentous therapy procedures as well as the prevention of delirium are shown. The author points out the necessity of education and training of medical staff to prevent or to diagnose early delirium for patients suffering from dementia and to start therapy as early as possible.