非痴呆型血管性认知障碍的磁共振波谱成像研究进展

血管性认知障碍（VCI）目前已成为老年人认知障碍的主要病因,其中,非痴呆型血管性认知障碍（VCIND）是VCI的初期阶段,具有可逆性。近年来,磁共振波谱（MRS）以其高分辨率、无创的特点,越来越广泛地应用于临床,成为了研究的热点。目前研究表明,VCIND患者的认知损害包括执行功能、视空间、感知功能、记忆力等几乎所有的主要认知域。MRS与认知量表的联合应用可提高VCIND的临床诊断的准确率。VCIND患者额叶、颞叶NAA/Cr降低较为明确,而丘脑仍需进一步研究。Cho在VCIND患者脑组织中的变化研究结果不甚一致。另外,MRS在M-aMCI与VCIND的鉴别中可起到重要的作用。关于VCIND的研究尚存在诸多问题,且结果差异较大,尚需进一步研究。     

画钟测验联合MMSE在老年认知功能障碍筛查中的应用

目的探讨使用画钟测验（CDT）联合简易智力状况检查（MMSE）筛查老年认知功能障碍的可行性。方法采用多阶段分层整群抽样方法,抽取河北省石家庄市、唐山市、张家口市和邯郸市4个地区共3040名60岁以上老人,对所有被试采集一般人口学资料,同时进行CDT和MMSE评估。结果所有被调查者CDT平均（3．01士1．37）分,低于4分者为43．7％;其中男性老年人cDT〈4分者35．0％,明显低于女性的65．0％,差异有统计学意义（χ2=35．58,P〈0．01）。不同年龄段CDT〈4分者分别为60～64岁（32．2％）,65～69岁（35．8％）,70～74岁（45．6％）,75～79岁（57．5％）,≥80岁（75．1％）。不同文化程度CDT〈4分者分别为文盲82．8％,小学49．3％,初中35．7％,高中30．0％,大专以上24．8％。在2358名MMSE正常老年人中CDT测验低于正常者890名（37．74％）;在1715名CDT测验正常的老年人中检测出MMSE异常者247名（14．40％）。按照CDTO～4分划分为5组进行MMSE评分比较,5组间比较差异有统计学意义（F=402．68,P〈0．01）。CDT得分与MMSE总分、视空间功能、计算力、命名、记忆力、定向力均呈正相关（r分别为0．575,0．423,0．438,0．106,0．249,0．357;P〈0．01）。结论CDT得分在一定程度上反映老年人认知、执行功能损害的状况,CDT联合MMSE可作为筛查老年人认知功能障碍的有效方法。     

脑小血管病患者伴发非痴呆血管性认知功能损害情况及尼莫地平疗效的研究

目的探讨脑小血管病(cerebral small vessel disease,SVD)不同亚型伴发非痴呆血管性认知功能损害的情况,评价尼莫地平对SVD的疗效。方法选择SVD患者118例,包括52例腔隙灶脑梗死(LI)和66例白质疏松(WML)患者。分别将LI组和WML组患者随机分组为治疗组(基础治疗加尼莫地平治疗)和对照组(基础治疗),进行6个月治疗。治疗前后对所有患者采用蒙特利尔认知评估量表(MoCA)、简易智能状态检查表(MMSE)、语义分类流畅测验(动物)、Stroop测验(计算错误数)、画钟试验、积木测验、数字广度顺背测验、数字符号测验、逻辑记忆亚测验和再生亚测验进行认知功能评价,并比较各组患者治疗前后认知功能评分。结果治疗前,LI组患者语义分类流畅测验(动物)、数字符号测验、逻辑记忆亚测验、视觉再生亚测验、MoCA、MMSE评分显著高于WML组患者,Stroop测验得分显著低于WML组患者。经过6个月治疗后,LI组和WML组患者中的对照组治疗前后各项认知功能评分均没有统计学差异(P>0.05)。LI组患者中治疗组MoCA、画钟试验和数字广度顺背测验得分升高,Stroop测验得分下降(均P<0.05);WML组患者中治疗组MoCA、MMSE、画钟试验、数字广度顺背测验和视觉再生亚测验得分升高,Stroop测验得分下降(均P<0.05)。结论 SVD两个亚型伴发非痴呆血管性认知功能损害情况不同,LI患者损害程度比WML患者轻。尼莫地平治疗可较好的改善患者的执行功能、视空间结构能力和注意力。     

画钟测验对轻度血管性认知障碍和血管性痴呆的诊断作用

目的 探讨画钟测验(clock drawing test, CDT)对识别轻度血管性认知障碍(mild vascular cognitive impairment, mVCI)和轻度血管性痴呆(mild vascular dementia, mVD)患者的敏感度和特异度.方法 mVCI患者80例,mVD患者30例,正常对照80名.由独立的神经心理评估医师盲法检测CDT,采用3分法、阿尔茨海默病协作研究组方法(AD cooperative study)和Rouleau方法进行评分,并进行简易精神状态(mini-mental state examination, MMSE)及其他量表的检测.应用操作者特征性曲线(receiver operating characteristic curve, ROC)确定3种评分方法的CDT对区别mVCI和正常对照以及mVD与正常对照的敏感度和特异度.结果 3组间在年龄、性别和教育程度上匹配.在区别mVCI和正常对照中,3种评分方法CDT的敏感度分别为63.7%、65.0%、68.7%,特异度分别为87.5%、86.2%、78.7%.3种评分方法的CDT对区别mVD和正常对照均有较高的敏感度(90.0%、90.0%、83.3%)和特异度(87.5%、86.2%、95.0%).结论 对识别mVD, CDT是一种有效的筛查手段;但是对识别mVCI, CDT的作用有限.     

Predictors of cognitive impairment in an early stage Parkinson's disease cohort

The impact of Parkinson's disease (PD) dementia is substantial and has major functional and socioeconomic consequences. Early prediction of future cognitive impairment would help target future interventions. The Montreal Cognitive Assessment (MoCA), the Mini‐Mental State Examination (MMSE), and fluency tests were administered to 486 patients with PD within 3.5 years of diagnosis, and the results were compared with those from 141 controls correcting for age, sex, and educational years. Eighteen‐month longitudinal assessments were performed in 155 patients with PD. The proportion of patients classified with normal cognition, mild cognitive impairment (MCI), and dementia varied considerably, depending on the MoCA and MMSE thresholds used. With the MoCA total score at screening threshold, 47.7%, 40.5%, and 11.7% of patients with PD were classified with normal cognition, MCI, and dementia, respectively; by comparison, 78.7% and 21.3% of controls had normal cognition and MCI, respectively. Cognitive impairment was predicted by lower education, increased age, male sex, and quantitative motor and non‐motor (smell, depression, and anxiety) measures. Longitudinal data from 155 patients with PD over 18 months showed significant reductions in MoCA scores, but not in MMSE scores, with 21.3% of patients moving from normal cognition to MCI and 4.5% moving from MCI to dementia, although 13.5% moved from MCI to normal; however, none of the patients with dementia changed their classification. The MoCA may be more sensitive than the MMSE in detecting early baseline and longitudinal cognitive impairment in PD, because it identified 25.8% of those who experienced significant cognitive decline over 18 months. Cognitive decline was associated with worse motor and non‐motor features, suggesting that this reflects a faster progressive phenotype. © 2014 International Parkinson and Movement Disorder Society     

盐酸多奈哌齐对MCI患者MoCA评分和认知功能的影响

目的 探讨盐酸多奈哌齐对轻度认知障碍(MCI)患者蒙特利尔认知评估量表(MoCA)评分和认知功能的影响. 方法 哈尔滨医科大学附属第一医院神经内科自2010年9月至2011年3月共收治MCI患者50例,其中给予盐酸多奈哌齐治疗30例(盐酸多奈哌齐组),银杏叶片治疗20例(对照组),分析并比较2组患者治疗前、治疗12周、24周后MoCA评分的变化. 结果 盐酸多奈哌齐组患者治疗12、24周时MoCA评分高于治疗前,差异有统计学意义(P＜0.05).治疗12周、24周时盐酸多奈哌齐组MoCA评分均高于对照组,差异有统计学意义(P＜0.05);治疗12周时盐酸多奈哌齐组患者在数字广度、词语流畅性和延迟记忆方面的分项得分高于治疗前,差异有统计学意义(P＜0.05). 结论 MoCA量表能够对MCI患者进行早期诊断,盐酸多奈哌齐对MCI患者进行早期治疗能延缓其进入AD的病程.     

A randomized controlled trial of rivastigmine in patients with cognitive impairment no dementia because of cerebrovascular disease

Narasimhalu K, Effendy S, Sim CH, Lee JM, Chen I, Hia SB, Xue HL, Corrales MP, Chang HM, Wong MC, Chen CP, Tan EK. A randomized controlled trial of rivastigmine in patients with cognitive impairment no dementia because of cerebrovascular disease.
Acta Neurol Scand: 2010: 121: 217–224.
© 2009 The Authors Journal compilation © 2009 Blackwell Munksgaard. Objectives – The safety and efficacy of early acetylcholinesterase inhibitors therapy in patients with cognitive impairment no dementia (CIND) after a cerebrovascular accident have not been examined. In this study, we investigated the safety and efficacy of rivastigmine in cognition, particularly executive function in patients with CIND because of cerebrovascular disease. Methods – This study was a 24‐week, double‐blind, randomized, placebo‐controlled trial of ischemic stroke patients seen at a tertiary hospital who had cognitive impairment no dementia because of cerebrovascular disease. The intervention was either rivastigmine or placebo up to 9 mg/day. The primary outcome of interest was mean change from baseline in the Ten‐Point Clock Drawing and Color Trails 1 and 2. Results – Fifty patients were randomized into rivastigmine (n = 25) and placebo (n = 25) arms. Patients in the rivastigmine group showed statistically significant improvement (1.70 vs 0.13, P = 0.02) on the animal subtask of the verbal fluency measure compared with placebo. There was also a trend (non‐significant) towards improvement in Color Trails II. Conclusions – In this pilot study, we demonstrated that rivastigmine was well tolerated in patients with CIND because of cerebrovascular disease and may potentially improve executive functioning.     

Selective memory impairment on an adapted Mini-Mental State Examination increases risk of future dementia

OBJECTIVE: To determine whether selective memory impairment (SMI) on an adapted Mini-Mental State Examination (aMMSE) test increases risk of future dementia in a population-based survey of central Spain. BACKGROUND: SMI is a strong predictor of dementia in the elderly. However, most approaches have used extensive memory batteries, which are not always suitable for screening purposes. METHODS: The basal cohort consisted of 2982 poorly educated individuals aged 65 or over. Dementia, stroke and parkinsonism cases were previously excluded. At entry, participants received a structured interview including an aMMSE. Two groups were created according to basal cognitive performance, namely: (1) aMMSE > 23 and no word remembered on the aMMSE delayed-recall task (SMI group); and (2) aMMSE > 23 and at least one word remembered on the delayed-recall task (control group). In a three-year follow-up wave, conversion rate to dementia was calculated and logistic regression was performed. RESULTS: Of a total of 2507 subjects who completed the two evaluations, 280 qualified for SMI at entry. In the SMI group, 25 subjects (8.9%) developed dementia vs 26 subjects (1.2%) in the control group. Taking the two groups together, and once demographic and medical variables had been controlled, a low delayed-recall score increased dementia conversion rate (OR 0.47, 95% CI 0.34-0.64). Alzheimer's disease was the main cause of dementia (79.8%). CONCLUSIONS: Memory impairment is a risk factor for future dementia in the neurologically-healthy elderly. This can be observed in a subgroup of subjects with SMI defined on the aMMSE delayed-recall subscore. Some other measurements should be added to the SMI construct to improve its predictive validity.     

Neuropsychological characteristics of mild vascular cognitive impairment and dementia after stroke

BACKGROUND: Post-stroke cognitive impairment is frequent, with characteristic impairments of attentional and executive performance. OBJECTIVE: The study aims to determine whether the profile and severity of impairment in vascular Cognitive Impairment No Dementia (vascular CIND) is intermediate between that seen in stroke patients without significant cognitive impairment and patients with post-stroke dementia and thus to establish if the potential value of vascular CIND is a useful concept for predicting further cognitive decline and dementia in stroke patients. METHODS: Stroke patients (n=381) > 75 were recruited from representative hospital-based stroke registers in Tyneside and Wearside, UK. Sixty six age matched controls were also recruited. A detailed battery of neuropsychological assessments was completed 3 months post stroke. RESULTS: Deficits of attention (z=5.7; p <0.0001) and executive function (z=5.9; p <0.0001) were seen even in stroke patients without vascular CIND, compared to controls. However, stroke patients with CIND were significantly more impaired again on tests of executive function (z=10.3; p <0.0001) compared to those not meeting CIND criteria; and also had greater impairments of memory (z=10.4; p <0.0001) and language expression (z=10.1; p <0.0001). A similar overall profile of deficits was evident in the CIND and the dementia group, but specific deficits were significantly more pronounced in those with dementia, particularly in orientation (z=7.2; p <0.0001) and memory (z=5.8; p <0.0001). CONCLUSIONS: The current study indicates that attentional and executive impairments are frequent in stroke patients, but deficits of memory, orientation and language are more indicative of CIND and dementia. Further longitudinal studies are required to clarify the relationship between specific lesions and the progression of specific cognitive deficits in post-stroke patients.     

The Montreal Cognitive Assessment: A screening tool for mild cognitive impairment in REM sleep behavior disorder

Mild cognitive impairment (MCI) is a frequent feature in idiopathic REM sleep behavior disorder (RBD), a sleep disturbance that can be a preclinical stage of Parkinson's disease or Lewy body dementia. We evaluated the sensitivity and specificity of two brief screening tools, the Montreal Cognitive Assessment (MoCA) and the Mini‐Mental State Examination (MMSE), in detecting MCI in idiopathic RBD. Thirty‐eight idiopathic RBD patients underwent a comprehensive neuropsychological assessment, including the MoCA and the MMSE. Receiver operating characteristic curves were created for the MoCA and the MMSE to assess their ability to identify MCI in idiopathic RBD patients, with neuropsychological assessment as the gold standard. For the MoCA, a normality cutoff of 26 yielded the best balance between sensitivity (76%) and specificity (85%) with a correct classification of 79%. For the MMSE, the optimal normality cutoff was 30, with a sensitivity of 84% and a specificity of 54% and a correct classification of 74%. The MoCA is superior to the MMSE in detecting MCI in idiopathic RBD patients, showing good sensitivity and very good specificity. © 2010 Movement Disorder Society     

艾地苯醌治疗非痴呆型血管认知功能障碍患者的临床观察

目的:观察艾地苯醌治疗慢性脑供血不足致非痴呆型血管性认知功能障碍患者的临床疗效.方法:将52例病例随机分为两组.两组患者均以银杏叶片作为基础用药常规辅助治疗,治疗组同时加用艾地苯醌治疗,两组用药疗程均为12周.结果:治疗后治疗组简易智能量表(MMSE)评分、蒙特利尔认知评价量表(MoCA)评分均明显提高;事件相关电位P300潜伏期缩短,与治疗前比较,差异有统计学意义,且加用艾地苯醌治疗组优于对照组.结论:艾地苯醌治疗慢性脑供血不足致非痴呆型血管性认知功能障碍疗效优于常规治疗.     

无痴呆型血管性认知功能障碍的诊断和治疗进展

血管因素是独立于年龄的导致痴呆的第二大危险因素.在血管性认知损害(VCI)早期即无痴呆型血管性认知功能障碍(VCIND)甚至认知损害发生之前,血管性因素以及脑血管病是唯一可治疗的,并且能够延缓甚至逆转痴呆进展的干预靶点.因此早期诊断出VCIND的病例,治疗血管性因素及脑血管病,有利于VCI的一级预防和二级预防.现对VCIND的诊断、预防和治疗的进展作一综述.     

Towards community diagnosis of dementia: testing cognitive impairment in older persons in Argentina,Chile and Cuba

Extensive research into the risk factors associated with dementia, how best to diagnose this syndrome and how to help families care for dementia patients has not been undertaken in Latin American countries, where the family and government support systems differ from developed nations. In an attempt to identify the risk factors associated with dementia in the cultural context of Latin America and to assist health planners and researchers in preparing for future needs of families in an ageing society, the Pan American Health Organization undertook the first-ever study of the prevalence of dementia in Latin America. The study consisted of a cross-sectional examination of non-institutionalized individuals 60 years of age and older in Buenos Aires (Argentina), Santiago (Chile) and Havana (Cuba). The study had a two-phase research design: a screening phase for the identification of persons with cognitive impairment and a confirmation phase for diagnosis of the presence of dementia. This article reports the results of the first phase of the collaborative multicountry study.     

Conceptualization of mild cognitive impairment: a review

BACKGROUND: Several factors have prompted renewed interest in the concept of declines in cognitive function that occur in association with aging, in particular the area between normal cognition and dementia. We review the changing conceptualization of what has come to be known as mild cognitive impairment (MCI) in an effort to identify recent developments and highlight areas of controversy. METHODS: Standard MEDLINE search for relevant English-language publications on mild cognitive impairment and its associated terms, supplemented by hand searches of pertinent reference lists. RESULTS: Many conditions cause cognitive impairment which does not meet current criteria for dementia. Within this heterogenous group, termed 'Cognitive Impairment, No Dementia' (CIND), there are disorders associated with an increased risk of progression to dementia. Still, the conceptualization of these latter disorders remains in flux, with variability around assumptions about aging, the relationship between impairment and disease, and how concomitant functional impairment is classified. Amongst patients with MCI, especially its amnestic form, many will progress to Alzheimer's disease (AD). In contrast with clinic-based studies, where progression is more uniform, population-based studies suggest that the MCI classification is unstable in that context. In addition to Amnestic Mild Cognitive Impairment (AMCI), other syndromes exist and can progress to dementia. For example, an identifiable group with vascular cognitive impairment without dementia shows a higher risk of progression to vascular dementia, Alzheimer's disease and mixed dementia. CONCLUSIONS: Recent attempts to profile patients at an increased risk of dementia suggest that this can be done in skilled hands, especially in people whose symptoms prompt them to seek medical attention. Whether these people actually have early AD remains to be determined. The more narrowly defined MCI profiles need to be understood in a population context of CIND.     

Motor intentional disorders in vascular mild cognitive impairment and vascular dementia of subcortical type

Subcortical vascular mild cognitive impairment (svMCI), a prodromal stage of subcortical vascular dementia (SVaD), is primarily associated with frontal injuries, whereas amnestic MCI (aMCI) is associated with temporoparietal injuries. Twenty-seven patients with svMCI, 20 with aMCI, 14 with SVaD, and 10 normal controls underwent motor intentional tasks (force initiation, development, maintenance, and termination) using a force dynamometer. Of the four motor intentional tasks, the maintenance task proved sensitive in differentiating svMCI from aMCI. In most motor intentional tasks, performances of svMCI patients were intermediate between those of controls and SVaD patients (initiation and termination: NC=aMCI=svMCI>SVaD; development: NC>aMCI=svMCI>SVaD; maintenance: NC=aMCI>svMCI=SVaD).