Reversible Causes Of Dementia Research Articles

Cognitive Safety is Largely Ignored in Clinical Drug Trials: A Study of Registered Study Protocols.

The number of reports on suspected drug-induced memory impairment submitted to the US Food and Drug Administration increased 30-fold from 2000 to 2022. Drugs are the most common cause of reversible dementia. However, there is very little research on drug-induced cognitive impairment. The aim of this study was to investigate if and how an assessment of cognitive safety was included in recent, registered, controlled, clinical drug trials. The clinical trials registry ( www. gov ) was searched for randomized controlled clinical trials with available study protocols. After excluding irrelevant trials such as surgical procedures, local or short-term treatment, and dietary supplements, 803 trials were included in this study. The protocols were manually reviewed for information on if, and how, cognitive safety had been assessed. Trial drugs were categorized into those targeting the central nervous system or not, as well as older and newer drugs. Methods used for the assessment of cognitive function were categorized into questionnaires, screening instruments, and neuropsychological tests. If the trial results were published, we examined whether the publication contained any data on cognitive safety that had emerged from the trial. The start dates of the screened trials ranged from 31 July, 2009, to 4 April, 2021. Out of the 803 trials, 52 (6.5%) actively assessed cognitive safety. The remaining trials relied solely on spontaneous reporting. Of 429 trials studying a new drug, 32 (7.5%) actively assessed cognitive safety. One hundred and fifty-eight trials examined drugs intended to, or known to have, pharmacological effects on the central nervous system. Of these, 21 (13.5%) assessed cognitive safety. Most of the trials that assessed cognitive safety used either crude screening tools or questionnaires. Cognitive safety is largely ignored by recent controlled clinical trials. This applies even to trials assessing new drugs and trials assessing central nervous system drugs. There is an urgent need for drug manufacturers, regulatory authorities, and the medical profession to address the cognitive safety of drugs.

111 Normal Pressure Hydrocephalus—a disease made for frailty clinics

Abstract Background NPH is one of the few reversible causes of dementia and gait disturbance. Multidisciplinary assessment is vital for diagnosis. CT findings are variable but scoring systems are available. Trial of high volume CSF drainage can be technically difficult in this population and even if there is measurable improvement after CSF drainage, referral for VP shunting can take months to years. Methods We present a Case Series of 10 cases of Probable NPH presenting to RFIT (Roscommon Frailty Intervention Team) over a 1 year period. Diagnosis was based on ‘Radscale’ CT Brain criteria (1) (used to differentiate from ventriculomegaly ex-vacuo) with presenting Gait and Cognitive deficits and positive response to high volume CSF drainage. Pre- and post-LP (up to 40 mL CSF drained) Gait and Cognitive findings are presented. Results Ten patients were diagnosed as having probable NPH using the Imperial College London diagnostic pathway. Three patients were deemed not to be fit for VP shunt. One elected to have a trail of CSF drainage for diagnostic reasons. Seven patients had high volume CSF drainage. Five patients showed improvement of >15% in timed up and go. Two patients showed no improvement post-LP. Five patients were referred for VP shunt. Three patients have had shunts inserted and have improved. Two still await VP shunt insertion. Conclusion 10 cases of probable NPH were diagnosed by the RFIT team in 1 year. We feel that as one of the very few reversible causes of progressive cognitive impairment and gait disturbance it is imperative that NPH be diagnosed as early and as definitively as possible. We highlight the utility of the Radscale CT Brain scoring system as an initial diagnostic prompt. We feel that this can be used by non-radiologist doctors, Frailty CNS or ANP, Physiotherapists in order to prompt teams to consider NPH in the differential diagnosis of Gait and cognitive abnormalities.

Association of Anemia with Dementia and Cognitive Decline among Community-Dwelling Elderly

Introduction: The association of anemia with dementia in elders is controversial. We examined the potential association of anemia with dementia in a large population of elders. Methods: Historical-prospective registry-based study. Included 36,951 community-dwelling elders (65–113 years) that were followed during 2002–2012. Anemia of all kinds was defined according to Clalit Health Services (CHS) definitions: hemoglobin (HGB) <14 g/dL men, <12 g/dL women; and World Health Organization (WHO): HGB <13 g/dL men, <12 g/dL women. Anemia was categorized as mild (HGB 11–13 g/dL men, 11–12 g/dL women) or moderate-severe (HGB <8–10.9 g/dL men and women). Background data, laboratory values, and diagnosis of dementia and cognitive decline (DCD) were reviewed. Results: During the 10-year follow-up period, DCD was newly diagnosed in 7,180 subjects (19.4%). Subjects with DCD had a higher rate of anemia than those without DCD. Time to development of DCD was 1.5 years shorter in those with than without anemia. On multivariate Cox regression analysis adjusted for age and sex, the hazard ratio (HR) for DCD was 1.45 (95% CI: 1.37–1.54) by CHS and 1.51 (95% CI: 1.41–1.61) WHO anemia criteria. The more severe the anemia, the greater the risk of DCD development (HGB 13–14 g/dL [men only], HR = 1.20 [95% CI: 1.09–1.32]; mild anemia, HR = 1.38 [95% CI: 1.28–1.49]; moderate-severe anemia, HR = 1.64 [CI: 1.41–1.90]). Every decrease in 1 standard deviation of HGB (1.4 g/dL) increased the DCD risk by 15%. A competing risk model has weakened the association of anemia with DCD risk. Conclusions and implications: Anemia in community-dwelling elders appears to be associated with an increased DCD risk in a dose-response manner. Application of the WHO anemia criteria in men may miss patients with mild anemia that places them at DCD risk. Further research should look at anemia as a cause of reversible dementia.

Normal pressure hydrocephalus associated with COVID-19 infection: a case report

BackgroundCOVID-19 is a pandemic disease responsible for many deaths worldwide. Many neurological manifestations have been described. We report a case of normal pressure hydrocephalus (NPH) 2 months after acute COVID19 infection, in a patient without other risk factors.Case presentationA 45-year-old male patient presented an 8-month history of progressive gait disorder and cognitive impairment after being hospitalized for SARS-CoV-2 infection. Magnetic resonance imaging (MRI) was compatible with NPH. A spinal tap test was positive and there was progressive improvement after shunting, with complete resolution of symptoms.ConclusionOther infections such as syphilis, cryptococcosis and Lyme disease have been associated with NPH. Possible mechanisms for NPH after COVID include disruption of choroid plexus cells by direct viral invasion or as a result of neuroinflammation and cytokine release and hypercoagulability leading to venous congestion and abnormalities of CSF flow. Given the significance of NPH as a cause of reversible dementia, it is important to consider the possibility of a causal association with COVID19 and understand the mechanisms behind this association.

Normal-pressure hydrocephalus: A rare cause of reversible dementia.

Normal-pressure hydrocephalus (NPH) is characterized by the clinical triad of dementia, gait instability, and urinary incontinence. The estimated annual incidence is 1.8 cases in 100,000 persons, making NPH a rare diagnosis and uncommon cause of dementia. NPH is a form of communicating hydrocephalus that can easily be missed in older adults with multiple comorbidities, so clinicians must exclude reversible causes of dementia before diagnosing irreversible causes such as Alzheimer disease.

Proposal for a normal pressure hydrocephalus syndrome center of excellence

Normal pressure hydrocephalus syndrome, characterized by ventriculomegaly and the classic triad of symmetric gait disturbance, cognitive decline, and urinary incontinence, is the most common cause of hydrocephalus in the adult population and a significant cause of reversible dementia among older adults. The only effective treatment for this syndrome, to date, is a cerebrospinal fluid shunting procedure, commonly a ventriculoperitoneal, ventriculoatrial, or lumboperitoneal shunt. The shunting success rate ranges between 73 and 96%. Hence, early identification, proper diagnosis, and treatment are paramount.We designed a protocol-based program supported on the best available evidence for an integral approach of patients with normal pressure hydrocephalus syndrome. The protocol consists of a series of patient-centered tests and interventions performed on adults with clinical suspicion, leading to optimized and sustainable outcomes for patients living with this condition.The program obtained the recognition of the Joint Commission International as an accredited center of excellence. The objectives of our center are increasing awareness and knowledge of normal pressure hydrocephalus syndrome within the community, delivering optimized interdisciplinary care, mitigating risks, improving quality of life to patients and their families, and ultimately saving from oblivion a significant number of patients who would be otherwise condemned.

Vascular intracranial malformations and dementia: An under-estimated cause and clinical correlation. Clinical note

Cerebrovascular malformations (CVMs) such as arteriovenous malformations (AVMs) or dural arteriovenous fistulas (DAVFs) represent a possible source of intracranial hemorrhage, but these malformations can also manifest with neurologic disorders secondary to ischemic penumbra from vascular steal. In the latter case, the clinical manifestations are less obvious and characteristic, and may include a varied clinical spectrum ranging from focal deficits to generalized malfunction of the brain parenchyma resulting in dementia. Dementias secondary to CVMs constitute a probably underestimated subpopulation of patients of great interest because they present with devastating but potentially reversible cognitive impairment. We examined the pertinent literature regarding the clinical manifestations of CVMs characterized by cognitive impairment and describe the distinctive clinical features. Our results confirm that cognitive impairment is one of the clinical manifestations of CVMs and is a frequently misrecognized and often late-diagnosed cause of reversible dementia.

Dural arteriovenous fistula presenting as reversible dementia

DAVF is an abnormal connection between arteries and veins, where supply is mainly through branches arising from the external carotid artery. A 30 years old male had multiple episodes of seizures and progressive behavioral and cognitive decline, inattention and disorientation to time, place and person, along with ptosis and ophthalmoplegia in the right eye. DSA provided a definitive diagnosis of hypervascular Dural AV fistula at the right transverse sigmoid junction with significant cortical venous hypertension. Through femoral access, both underwent transarterial embolization through the Middle Meningeal branch of the right external carotid artery using onyx, resulting in complete occlusion of fistula and resolution of venous hypertension. Post embolisation, cognitive function assessment revealed increased attention span and improved orientation with time, place and person. Thus, DAVF can be one of the rare but reversible causes of dementia. Early diagnosis and treatment may help to dramatically improve patients’ clinical condition and minimize long-term disability.

Normal pressure hydrocephalus

Normal pressure hydrocephalus – NPH is one of the potentially reversible causes of dementia. In this work, we provide the clinical tools for the management of NPH to the Primary Health Care – PHC physicians. The PubMed and Cochrane databases were reviewed, and 40 articles were chosen, which include randomized clinical trials, metanalysis and systematic reviews. The symptoms of the classic triad are nonspecific and found in the elderly with other diseases. Gait apraxia is the earliest symptom, followed by cognitive impairment and urinary incontinence. The concomitance of the three symptoms occurs in about 60% of the cases in the advanced stages. Apraxia of gait is presented with short steps, without sensorial, vestibulocerebellar or muscle strength changes, which allows it to be distinguished from other pathological marches. Cognitive impairment is subcortical – psychomotor slowliness, inattention, loss of working memory and executive function and preservation of episodic memory – unlike cortical dementias, such as Alzheimer's disease. Urinary incontinence must be distinguished from overflow by prostatism and stress incontinence in women. The PHC physician, when faced with the triad, should request a CT scan or brain MRI and, in the presence of one or two symptoms, rule out other diagnoses. Patients with NPH seek help from the physician in the PHC who must know how to identify and differentiate their symptoms. In the case of suspicion, the study of neuroimaging is mandatory and referral to neurosurgery or neurology is recommended.

Dementia screening: an audit of screening for reversible causes of dementia

AimsThis audit aimed to assess to what extent patients being referred for assessment of memory problems were receiving appropriate screening for reversible causes. We considered the blood tests recommended by the National Institute for Clinical Excellence (NICE).BackgroundResearch into ‘reversible dementias’ identified numerous common underlying causes. As a result of this NICE complied comprehensive guidance on investigations which should be performed in the initial stages of assessing patients with memory problems, ideally at a primary care level. These investigations are also crucial at the point of secondary care assessment in order to make a confident diagnosis.MethodDetails of patients referred by their GP to the Older Adult CMHT with memory problems over a one month period were collected. We then used the local laboratory database to note whether each of the eight recommended blood tests had been performed in the preceding 6 months. We measured this against an agreed standard of 95%.After the first cycle of data collection we prepared business-card sized ‘aide memoirs’ for GPs that could serve as a quick reminder. These were sent out to all GPs in the area along with a letter outlining the audit findings.ResultOverall 31 patients were included in the first cycle. 15 patients had all 8 dementia blood screens (48%), 13 (42%) had some of the recommended tests and 3 patients had no screening tests at all (10%). On average patients had 76.6% of the recommended bloods completed. The most commonly completed tests were Full Blood Count (FBC) and Urea &amp; Electrolytes (U&amp;Es), with blood Glucose being the most frequently omitted.In cycle 2, 20 patients were included. Of these patients, 10 had the full complement of screening bloods (50%); 8 had some tests completed (40%) and 2 patients had no screening tests complete (10%). On average 76% of tests were completed. There was an improvement in the rate of completion of both Glucose and Liver Function Tests from cycle1.ConclusionThis audit demonstrated that current practice does not meet the national standard in general. Our intervention produced a modest improvement in the proportion of patients who received a full complement of dementia screening tests, as well as increasing the rate of patients receiving a blood glucose as part of their screening. It would likely be beneficial to consider further intervention and a 3rd audit cycle in due course.

861 Vascular dementia presenting as rapidly progressive dementia secondary to zolpidem

Abstract Introduction Rapidly progressive dementia is a condition with a wide differential which remains difficult to accurately diagnose. The potential pathologies responsible include thyroid, vitamin, and electrolytes abnormalities, infectious, and malignant causes. Vascular dementia, however, typically has a slow and insidious presentation. Zolpidem (Ambien) is among the top 50 prescribed medications in the US. Report of case(s) An 84-year-old Caucasian male with a past medical history of insomnia, and sleep apnea who is noncompliant with CPAP presented after a fall associated with altered mental status. He has taken zolpidem 10 mg nightly for over six years. The patient and wife reported notable personality changes beginning six months prior, as well as four months of progressively worsening auditory and visual hallucinations. Additionally, the patient noted developing urinary incontinence, and worsening gait steadiness with recurrent falls. The patient then developed sleep-wake inversion during the three weeks prior to his fall, and an outpatient referral to neurology was subsequently sent for dementia evaluation. On the night prior to his presentation, the patient took his usual nighttime zolpidem at 22:00 and later fell and was unable to get up. Subsequent testing was negative for reversible causes of dementia and MRI Brain revealed only chronic microvascular disease. His zolpidem dose was decreased to 5 mg and scheduled earlier which resulted in the resolution of his hallucinations, gait abnormalities, and acute encephalopathy. Conclusion One month later, the patient presented to the hospital after a repeat fall secondary to taking his zolpidem at his previously scheduled time. Once more, his dosage was further decreased to 2.5 mg and scheduling earlier, resulting again, in the complete resolution of his symptoms. Zolpidem, has an increased potential for delirium in elderly patients and especially those with dementia. Chronic use of zolpidem with insidiously progressive vascular dementia led to a worsening delirium which resolved after adjustment of timing and reduction of zolpidem dosing. Support (if any):

Prevalence of Vitamin B12 deficiency in elderly population (>60 years) presenting with dementia to outpatient department

BackgroundVitamin B12 deficiency is an easily treatable cause of reversible dementia. It is likely to be more common in Indian population due to traditionally vegetarian culture. This study was conducted to estimate the prevalence of Vitamin B12 deficiency in elderly patients (>60 years) with dementia attending outpatient department. MethodsThis study was conducted in two phases. The first phase was a cross sectional observational study to estimate the prevalence of Vitamin B12 deficiency in the elderly population with dementia. The second phase was a pilot study done in subjects with Vitamin B12 deficiency to assess the change in cognition following Vitamin B12 supplementation. ResultsOut of 2920 study eligible subjects, 200 were diagnosed as dementia with Mini Mental Status Examination (MMSE) score of ≤ 24. Vitamin B12 deficiency was seen in 7.5% of patients. Vitamin B12 deficiency was associated with shorter and more severe dementia. Macrocytosis was more common in Vitamin B12 deficiency (p value < 0.001) where as vegetarian diet did not show significant correlation (p value 0.69). There was significant improvement in the median MMSE score in the intervention group with increase in MMSE by 2 points at 6-8 weeks and 3 points at 12 weeks (p value 0.009 and 0.003 by Mann Whitney test). ConclusionPrevalence of Vitamin B12 deficiency in dementia was 7.5%. It was associated with macrocytosis, shorter duration and more severe dementia. There was a significant improvement in median MMSE score at 6 weeks and 12 weeks following Vitamin B12 supplementation.

Dynamic functional networks in idiopathic normal pressure hydrocephalus: Alterations and reversibility by CSF tap test.

Idiopathic Normal Pressure Hydrocephalus (iNPH)—the leading cause of reversible dementia in aging—is characterized by ventriculomegaly and gait, cognitive and urinary impairments. Despite its high prevalence estimated at 6% among the elderlies, iNPH remains underdiagnosed and undertreated due to the lack of iNPH‐specific diagnostic markers and limited understanding of pathophysiological mechanisms. INPH diagnosis is also complicated by the frequent occurrence of comorbidities, the most common one being Alzheimer's disease (AD). Here we investigate the resting‐state functional magnetic resonance imaging dynamics of 26 iNPH patients before and after a CSF tap test, and of 48 normal older adults. Alzheimer's pathology was evaluated by CSF biomarkers. We show that the interactions between the default mode, and the executive‐control, salience and attention networks are impaired in iNPH, explain gait and executive disturbances in patients, and are not driven by AD‐pathology. In particular, AD molecular biomarkers are associated with functional changes distinct from iNPH functional alterations. Finally, we demonstrate a partial normalization of brain dynamics 24 hr after a CSF tap test, indicating functional plasticity mechanisms. We conclude that functional changes involving the default mode cross‐network interactions reflect iNPH pathophysiological mechanisms and track treatment response, possibly contributing to iNPH differential diagnosis and better clinical management.

Characteristics and Real-Life Outcomes of Dementia and Cognitive Impairment at a Geriatric Clinic

Background: Various patterns of dementia care have been developed in different settings, depending on the availability of healthcare resources and facilities. The purpose of this study was to examine the epidemiology and characteristics of dementia care at a geriatric clinic, a field that has been subject to little prior evaluation. Methods: A retrospective chart review was undertaken of cohort patients with cognitive impairment who had received a diagnosis and were still on active follow-up at a geriatric clinic. A total of 892 patients were included. In addition, 203 geriatric patients with no cognitive impairment who attended the clinic during the study period were sampled as a control. Results: The main diagnoses of dementia were Alzheimer’s disease (AD) (40.1%), vascular dementia (16.9%), unspecified dementia (16.3%), mixed dementia (9.0%), AD with cerebrovascular disease (8.7%), and Parkinson’s disease dementia (6.1%). Atypical dementia was presented in 3.0% of cases. There were 178 patients with mild cognitive impairment, 20 with vascular cognitive impairment, and 18 with subjective cognitive decline. Other comorbidities were found in 97% of the subjects. Patients with cognitive impairment had a higher total number of other geriatric syndromes and higher percentages for delirium, falls, immobility, loss of appetite, and incontinence. Potentially reversible causes of dementia were found in 11.3% of the cases. Acetylcholinesterase inhibitors were administered to 61%, whereas 23.5% received an NMDA receptor antagonist. The need for a change in the antidementia medication was identified for 10.7% of the subjects; the major cause was adverse drug side effects. Nonpharmacological therapy only was administered to 52.4% of the people with dementia who had behavioral and psychological symptoms. Conclusions: Mixed brain pathologies, comorbidities, and the coexistence of other geriatric syndromes are common at geriatric clinics. Holistic, integrated, and continuous care are needed to improve the outcomes of patients with more complicated comorbidities.

Young onset dementia

HintergrundAufgrund des demographischen Wandels sind Demenzen ein häufiger und dramatisch zunehmender Grund für ärztliche Vorstellungen. In etwa 8 % der Fälle treten sie bereits vor dem 65. Lebensjahr auf. Gerade bei jüngeren Patienten sind die psychosozialen und ökonomischen Folgen oft gravierend. Die Behandler stehen vor großen diagnostischen Herausforderungen. Eine rasche Diagnose ist für das Patientenmanagement von zentraler Bedeutung.Ziel der Arbeit/FragestellungDieser Übersichtsartikel stellt die Besonderheiten der Demenzen bei jüngeren Menschen sowie die wichtigsten zugrunde liegenden Krankheitsbilder vor und vermittelt ein strukturiertes klinisch-diagnostisches Vorgehen.MethodenNarrativer Review. Die Literatursuche wurde in PubMed durchgeführt.ErgebnisseDas differenzialdiagnostische Spektrum von Demenzen bei jüngeren Menschen vor dem 65. Lebensjahr ist sehr breit. Die häufigsten Ursachen stellen die Alzheimer-Krankheit mit typischen oder atypischen klinischen Präsentationen sowie die frontotemporale Lobärdegeneration dar. Je jünger das Erkrankungsalter, desto höher ist der Anteil an behandelbaren und potenziell reversiblen Ursachen eines demenziellen Syndroms.DiskussionDie Diagnostik primär neurodegenerativer Erkrankungen hat sich zunehmend verbessert, insbesondere unter Berücksichtigung einer stetig steigenden Zahl an klinischen, molekularen und bildgebenden Biomarkern. Dennoch muss die Diagnostik der Demenzen mit frühem Erkrankungsbeginn hypothesengeleitet erfolgen, d. h. nach einer präzisen klinisch-syndromalen Zuordnung der Symptome. So können unnötige und belastende Untersuchungen vermieden werden.

An update on the diagnosis and management of dementing conditions.

Worsening memory is a common complaint in the elderly and predictably causes affected individuals and their families to wonder whether the underlying cause is Alzheimer disease, the most common form of dementia. Alzheimer disease is a devastating illness that unavoidably leads to a complete loss of independence and, as a result, substantial emotional, physical, and financial distress for patients and their families. The causes and severity of memory impairment in the elderly are diverse, however, so any given case might not necessarily be secondary to a neurodegenerative disorder such as Alzheimer disease. Consequently, it is critical to rule out potentially reversible causes of dementia and to initiate treatment while cognitive and functional deficits are still mild and more likely to respond to treatment. Furthermore, identifying the etiology and defining a suitable treatment plan early in the course of dementia allows patients to be more actively involved in the management of their disease and is more likely to improve quality of life for both patients and caregivers. This review presents the etiology of dementia in the elderly, describes the diagnostic process, and discusses current therapeutic strategies, including pharmacological agents, nonpharmacological interventions, safety assessments, legal issues, and caregiver needs.

Nutritional deficiency as a complex cause of reversible dementia and cutaneous manifestations in elderly: case report and review

Vitamin deficiency can be an important cause of cognitive impairment and cutaneous manifestations in elderly with a history of malnutrition. However, to understand the different etiologies and to choose the right one to proper disease management might not be an easy task, especially in individuals from this population with these findings, sometimes non-specific. Hypothesis of reversible dementia associated with pellagra and B12 vitamin are important. In the case of electrolytes deficiency, less likely, there is the hypothesis extrapontine osmotic demyelination syndrome. The following case discuss these findings together. Objective: to present a case of reversible dementia and cutaneous manifestations associated with vitamin deficiency in a context of neurological complication after untimely correction of sodium; to discuss pathophysiological processes relevant to the case. Case report: A 62-year-old woman in meat restriction for 1 year, with post-radioiodine hypothyroidism. Admitted to investigate well delimited erosions with scaling, hyperchromia and blisters in both hands and glabella. The major hypothesis at the time was pellagra. However, in few weeks she developed other clinical findings: food intolerance, pain and abdominal distension and some sort of cognitive impairment. Computed tomography (CT) of the abdomen showed fluid distention with air level throughout the colonic frame and distal segment of the ileum, without obstructive factors. There is loss of the usual haemorrhages of the sigmoid and descending colon, suggesting chronic alterations. Rectosigmoidoscopy was performed and parental feeding was introduced. There was evolution with improvement of cutaneous lesions and development of hyponatremia, followed by anemia, reduction of level of consciousness and hemodynamic instability. Magnetic resonance imaging presented changes suggestive of extra-pontine myelinolysis associated with hyponatremia. Laboratory tests revealed anti-parietal cell antibody with a 1/160 reagent result, upper digestive endoscopies compatible with atrophic gastritis and gastric polyps with absence of active or previous bleeding. Following the infirmary, the patient achieved a progressive improvement in the level of consciousness and dementia, resuming most of the cognitive functions. The hypothesis of extrapontine myelinolysis associated with the correction of hypernatremia and pellagra, secondary to the vegan diet was suggested by radiologists. Discussion: the case discussed is a probable reversible dementia associated with vitamin deficiency. Factors suggestive of this context were: dermatological lesion, restricted diet to meat, atrophic gastritis in upper digestive endoscopy and progressive dementia during hospitalization. As a confounding factor, there was an untimely correction of hyponatremia with findings suggestive of extrapontine myelinolysis according to the radiology team, which could have contributed to the dementia symptoms, though less likely. Conclusion: Pellagra and other nutritional deficiencies should be considered in the diagnosis of patients with restrictive diets, especially those with gastrointestinal tract disorders. The correction of hypernatremia, when present, should be adjusted with caution, aiming at the protection of the central nervous system.

Pick’s disease and subdural haematoma: A diagnostic red herring

Frontotemporal dementia (FTD), otherwise known as Pick’s disease, is a clinically heterogeneous group of sporadic and familial neurodegenerative diseases. These conditions are characterized by dementia, behavioural and language dysfunction and loss of executive skills resulting from the degeneration of the frontal and temporal lobes. Although reversible causes of dementia are always sought during the evaluation of patients with progressive cognitive decline, the occurrence of a reversible aetiology may distract from evaluating for neurodegenerative causes of dementia. This report is about a 66-year old man with features of FTD and superimposed chronic subdural haematoma.

Neuroimaging in Dementias.

Dementia is a global health issue, the burden of which will worsen with an increasingly aging population. Alzheimer's disease (AD) is the most common dementia, with 50 to 60% of all dementias attributable to AD alone, while the rest are mostly due to frontotemporal lobar dementia, dementia with Lewy bodies, Parkinson's disease dementia, and vascular dementia. Diagnosis of dementias is made clinically with the aid of other testing modalities including neuroimaging. While the role of imaging has traditionally been to exclude reversible causes of dementia, positron emission tomography (PET) with 18-fluorine fluorodeoxyglucose and magnetic resonance imaging now are increasingly used more for definitive diagnosis of dementia in the prodromal stages and to aid with formulating the differential diagnoses. Introduction of molecular imaging modalities such as amyloid PET and tau PET have improved diagnostic certainty in the clinical trial setting and promise to find their way into the clinic in the near future. In this review, we will focus on the multimodality imaging of dementias especially AD and its differential diagnoses.

Tendências atuais no diagnóstico e terapêutica da hidrocefalia de pressão normal

A hidrocefalia de pressão normal, também chamada de síndrome de Adams e Hakim, é uma patologia relativamente infreqüente, mas que adquire relevância nos dias atuais, uma vez que consiste em importante causa reversível de demência. A tríade clínica clássica inclui distúrbios da marcha, demência e incontinência urinária. A cirurgia de derivação ventricular ainda é o procedimento de escolha na maioria dos casos, apesar de não estar isenta de complicações, as quais levam à necessidade de revisão do sistema em até 20% dos casos. Apesar do conhecimento que emergiu nos últimos 40 anos, os resultados pós-cirúrgicos de implantação de shunts em pacientes diagnosticados com hidrocefalia de pressão normal, não melhoraram signifi cativamente na última década. Por essa razão, fatores preditivos de bom prognóstico com o tratamento de derivação, como ausência de atrofi a cerebral e sintomatologia recente (menor que um ano) devem ser identifi cados no pré-operatório, para que ocorra a seleção criteriosa dos pacientes que serão submetidos à cirurgia. Ao contrário da cirurgia de derivação ventricular, o uso da ventriculostomia endoscópica ainda é controverso. Procura-se indicá-la para pacientes nos quais haja suspeita de estenose interventricular funcional e naqueles em que o teste de infusão ventricular demonstre aumento da resistência ao fluxo liquórico.