PubMed Health⌕ Search

Biomedical subjects

D Inzitari

Publications and source records attributed to D Inzitari.

At least 55 records · Page 3Linked to original sources
PubMed2000

Efficacy and safety of nimodipine in subcortical vascular dementia: a subgroup analysis of the Scandinavian Multi-Infarct Dementia Trial.

In Western countries, vascular dementia (VaD) is the most common form of cognitive deterioration after Alzheimer's disease. Therapeutic trials in VaD have so far failed to yield satisfactory results. One explanation of this failure may be the etiological and clinical heterogeneity of the included patients. Patients with subcortical VaD, defined on a clinical and radiological basis, may constitute a more homogeneous group. Thus, we conducted a post-hoc subgroup analysis of the Scandinavian Multi-Infarct Dementia Trial that evaluated the efficacy and safety of oral nimodipine administered for 6 months in 259 patients. The original patients sample was divided on the basis of head CT in those with subcortical VaD (n=92, 45 nimodipine, 47 placebo) and those with multi-infarct dementia (n=167, 83 nimodipine, 84 placebo). While in the total trial population a treatment effect could not be proved, in this subgroup analysis, the subcortical VaD patients treated with nimodipine performed better on the majority of neuropsychological tests and functional scales in comparison with patients on placebo. No trend could be evidenced in the multi-infarct dementia patients. Treatment efficacy was in particular suggested for the Zahlen-Verbindungs-Test, Fuld-Object-Memory Evaluation, Word Fluency, and for the Instrumental Activities of Daily Living scale. The results did not reach statistical significance in this small sample. Our study preliminarily indicates that nimodipine could be effective in patients with small vessel subcortical VaD and supports the rationale for a further controlled and adequately powered trial to test nimodipine in patients with subcortical VaD.

Activities of Daily Living↗
PubMed2000

The Scandinavian Multi-Infarct Dementia Trial: a double-blind, placebo-controlled trial on nimodipine in multi-infarct dementia.

Vascular dementia is a major cause of mental and physical disability in Western countries. Treatment of vascular dementia is currently based on the recognition and control of vascular risk factors, while specific drugs have not been approved yet. The aim of the present multinational, double-blind, placebo-controlled study was to evaluate the safety and efficacy of nimodipine administered for as long as 26 weeks in improving cognition or slowing cognitive deterioration in patients defined as having multi-infarct dementia (DSM-III-R criteria). Two hundred and fifty-nine patients were included (128 nimodipine, 131 placebo), and 251 were available for the intention-to-treat analysis. No significant difference between drug-treated and placebo patients was noted on the Gottfries-Brâne-Steen scale score (primary efficacy criterion), the remaining neuropsychological tests (Zahlen-Verbindungs-Test, Fuld-Object-Memory Evaluation, Word Fluency Test, Digit Span, Mini-Mental State Examination), and the functional scales (index of Activity of Daily Living, Instrumental Activity of Daily Living, Rapid Disability Scale, Clinical Dementia Rating), although the majority of changes were in favor of the active drug group. A lower incidence of cerebrovascular and cardiac events was observed in the nimodipine-treated patients in comparison with the placebo group. This study failed to show a significant effect of nimodipine on cognitive, social or global assessments in patients defined as affected by multi-infarct dementia according to the DSM-III-R criteria. A post-hoc analysis (presented in an accompanying paper) suggests that nimodipine may have a favorable effect in the subgroup of patients defined as affected by subcortical (small vessel) vascular dementia.

Aged↗
PubMed2000

Risk factors and outcome of patients with carotid artery stenosis presenting with lacunar stroke. North American Symptomatic Carotid Endarterectomy Trial Group.

OBJECTIVE: To examine the relationship between carotid artery stenosis, other risk factors, and lacunar stroke. BACKGROUND: Carotid artery stenosis in patients presenting with lacune stroke may be coincidental or causal. The distinction by risk factor profile is uncertain. The risk and cause of subsequent stroke, and benefit of carotid endarterectomy (CE) is unknown. METHODS: Stroke in patients entering the North American Symptomatic Carotid Endarterectomy Trial were classified as nonlacunar, possible lacune (symptoms without CT lacunae), or probable lacune (symptoms with CT lacunae). RESULTS: Of 1,158 patients with hemispheric stroke, 493 had features of lacunar stroke (283 possible and 210 probable). Lacunar stroke presented more commonly in patients with milder (<50%) degrees of internal carotid artery (ICA) stenosis (p = 0.003). History of diabetes and hyperlipidemia, not hypertension, were associated independently even after accounting for the degree of stenosis. Medically treated patients presenting with nonlacunar stroke had a low risk of subsequent lacunar events of 2.9% at 3 years in comparison with 9.2% for probable lacunar presentation (p = 0.03). For patients with 50 to 99% ICA stenosis, the relative risk reductions (RRRs) in stroke from CE were 35% when the presenting stroke was probable lacunar versus 61% when the stroke was nonlacunar. Patients presenting with a possible lacunar stroke had a 53% RRR. CONCLUSIONS: History of diabetes and hyperlipidemia were more important than arterial hypertension as risk factors for patients with lacunar stroke. Patients presenting with lacunar stroke more often had milder ICA stenosis. Although CE reduced the risk of stroke in all patients with 50 to 99% ICA stenosis, lesser benefits were observed in patients presenting with lacunar stroke.

Aged↗
PubMed2000

White matter changes: the clinical consequences in the aging population.

Neuroimaging changes in the cerebral subcortical white matter (WMC) are recognized with the highest frequency in elderly subjects, particularly in those with vascular risk factors. WMC have been consistently reported to be associated with global or selective cognitive deficits, depression, motor and gait impairment. All these deficits are main contributors to disability in the elderly. Moreover, subjects with WMC have an increased risk of cardiovascular events and death from vascular causes. Functional status in subjects with WMC is variable, from normal to severely (physically or cognitively) disable. The association of WMC with age and with some of the clinical manifestations of aging suggests that WMC could be one of the age-related processes involved in the transition to disability in the elderly. Large cohorts of patients with WMC of different severity and detailed follow-up observation may help elucidating this issue. If WMC are shown to have an impact on disability in the aged population, efforts could be made to prevent WMC and WMC-related motor and cognitive deficits, and to identify measures aimed to halt or slow their progression.

Aged↗
PubMed2000

Research criteria for subcortical vascular dementia in clinical trials.

Vascular dementia (VaD) incorporate different vascular mechanisms and changes in the brain, and have different causes and clinical manifestations. Variation in defining the cognitive syndrome, in vascular etiologies, and allowable brain changes in current clinical definitions of VaD have resulted in variable estimates of prevalence, of groups of subjects, and of the types and distribution of putative causal brain lesions. Thus current criteria for VaD select an etiologically and clinically heterogeneous group. This definitional heterogeneity may have been a factor in "negative" clinical trials. An alternative for clinical drug trials is to focus on a more homogeneous group, such as those with subcortical (ischemic) VaD. This designation incorporates two small vessel clinical entities "Binswanger's disease" and "the lacunar state". It comprises small vessel disease as the primary vascular etiology, lacunar infarct(s) and ischaemic white matter lesions as the primary type of brain lesions, and subcortical location as the primary location of lesions. The subcortical clinical syndrome is the primary clinical manifestation, a definition which still requires additional empirical data. We expect that subcortical VaD show a more predictable clinical picture, natural history, outcome, and treatment responses. We propose a modification of the NINDS-AIREN criteria as a new research criteria for subcortical VaD.

Clinical Trials as Topic↗
PubMed2000

Transient global amnesia: a review emphasizing pathogenic aspects.

The transitory memory disturbance known as transient global amnesia (TGA) remains an enigma from a pathogenic point of view. In spite of its typical benign prognosis, TGA is a frightening experience for patients and their relatives. Moreover, a TGA episode usually leads to extensive investigation of patients in search of organic alterations that might be responsible for the event. Finally, TGA generates queries about therapeutic choices. In this review, we critically re-evaluate the evidence in support of and against the three main pathogenic hypotheses (i.e. ischemia, seizure discharge, and migraine), and we conclude that none of these appears completely convincing. Given the good prognosis and the lack of association with organic and instrumental abnormalities, we advance the hypothesis that TGA may be related to psychological disturbances causing transient alteration in brain metabolism and, consequently, amnesia. Our conclusion has relevant consequences in the evaluation of patients with TGA.

Age Factors↗
PubMed2000

Cognitive impairment without dementia in older people: prevalence, vascular risk factors, impact on disability. The Italian Longitudinal Study on Aging.

OBJECTIVES: To investigate prevalence of "cognitive impairment, no dementia" (CIND) in the Italian older population, evaluating the association with cardiovascular disease and the impact on activities of daily living (ADL). CIND may provide pathogenic clues to dementia and independently affect ADL. DESIGN: Cross-sectional examination in the context of the Italian Longitudinal Study on Aging. SETTING: Random population sample from eight Italian municipalities. PARTICIPANTS: A total of 3,425 individuals aged 65-84 years, residing in the community or institutionalized. MEASUREMENTS: Study participants were screened for cognitive impairment by using the Mini-Mental State Examination. Trained neurologists examined those scoring <24. CIND diagnosis relied on clinical and neuropsychological examination, informant interview, and assessment of functional activities. Age-related cognitive decline (ARCD) was diagnosed in CIND cases without neuropsychiatric disorders responsible for the cognitive impairment. RESULTS: Prevalence was 10.7% for CIND and 7.5% for ARCD, increased with age, and was higher in women. Age (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.06-1.12), stroke (OR, 2.05; 95% CI, 1.26-3.35) and heart failure (OR, 1.73; 95% CI, 1.11-2.68) were significantly and positively associated with CIND at multivariate analysis. Education (OR, 0.61; 95% CI, 0.56-0.65) and smoking (OR, 0.72; 95% CI, 0.54-0.98) showed a negative correlation. Age and myocardial infarction were positively associated with ARCD, whereas a negative correlation was found for education and smoking. The effect of smoking was no more significant either on CIND or ARCD considering current habits or "pack year" exposure. CIND showed an independent impact on ADL (OR, 1.88; 95% CI, 1.41-2.49). CONCLUSIONS: CIND is very frequent in older people. The effect of demographic variables and vascular conditions offers opportunities for prevention. The association with functional impairment is useful to evaluate the burden of disability and healthcare demands.

Activities of Daily Living↗
PubMed2000

Limitations of clinical criteria for the diagnosis of vascular dementia in clinical trials. Is a focus on subcortical vascular dementia a solution?

Vascular dementia (VaD) includes several different vascular mechanisms and changes in the brain, and has different causes and clinical manifestations. Critical to its conceptualization and diagnosis are definitions of the cognitive syndrome, vascular etiologies, and changes in the brain. Variation in these has resulted in different definitions of VaD, estimates of prevalence, and types and distribution of brain lesions. This definitional heterogeneity may have been a factor for negative results in prior clinical trials on VaD. We propose that the division of VaD into subtypes can identify a more homogeneous group of patients for drug trials. A so-called "subcortical" VaD could incorporate two old clinical entities "Binswanger's disease" and "the lacunar state." Small vessel disease is the primary vascular etiology, lacunar infarcts and ischemic white matter lesions are the primary type of brain lesions, the subcortical areas and frontal connections are the primary location of lesions, and a subcortical syndrome as the primary clinical manifestation. The clinical syndromes are likely more variable, and urgently need to be categorized. Selection of these patients for clinical trials could mainly be based on brain imaging features, where the essential changes and the main aspects of the lesions include extensive ischemic white matter lesions and lacunar infarcts in the deep gray and white matter structures. Subcortical VaD is expected to show a more predictable clinical picture, natural history, outcomes, and treatment responses.

Brain↗
PubMed2000

Subcortical vascular dementia as a specific target for clinical trials.

Vascular cognitive impairment is considered the second most common form of mental deterioration in the elderly after degenerative dementias. Therapeutic approaches to vascular dementia mainly rely on the identification and treatment of risk factors. A number of drugs have also been tested with the aim of improving or slowing cognitive decline in patients affected by various forms of cerebrovascular disease. Most of these trials have yielded unsatisfactory results. We hypothesize that some of these failures depend on the inclusion of patients with pathophysiologically heterogeneous types of vascular cognitive decline. In this paper, we review some of the most important trials that tested drugs with a preventive or therapeutic aim in vascular dementia patients. Preliminary results suggest that some beneficial effects can be detected only when the trial population is homogeneous on a clinical and pathogenic basis. In particular, subcortical vascular dementia, a form with a rather univocal clinical, radiological, and pathological picture, seems a particularly apt choice as a target for future clinical studies. At present, only one therapeutic trial is being conducted in patients affected by this specific form of vascular dementia.

Aged↗
PubMed2000

Prognosis with Parkinson's disease in europe: A collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group.

Data are lacking on the prognosis (institutionalization and death) of PD cases identified in population-based studies. Data from five population-based European studies were compared and pooled. Each study used comparable two-step screening methods to identify cases and performed one or more follow-up examinations of their respective participants after defined periods of time. PD was classified on the basis of questionnaire and clinical data. The studies include 16,143 participants (252 with PD). The relative risk (RR) (95% CI) of death associated with PD was 2.3 (1.8 to 3.0). The risk for death in men with PD (RR 3.1 [2.1 to 4.4]) was higher than in women with PD (RR 1. 8 [1.2 to 5.1]). The rate of institutionalization varied across studies, increased with age, and was considerably higher in PD cases compared to noncases. Women with PD had a fivefold higher risk to live in a care facility than did men with PD. These data on mortality and rate of institutionalization reflect the high burden of PD in the population.

Age Factors↗
PubMed2000

Prognosis with stroke in Europe: A collaborative study of population-based cohorts. Neurologic Diseases in the Elderly Research Group.

The authors pooled four population-based European studies to determine the risk for institutionalization and death after stroke. Risk for institutionalization was assessed in 13,095 subjects. Survival was calculated for prevalent stroke in 7929 individuals and incident stroke in 8550 individuals. The adjusted risk of long-term care for cases compared to noncases was 2.8 (95% CI 2.6 to 4.5). At 5 years, the excess risk of death in prevalent cases was 1.6 (1.2 to 2.0), and the age- and sex-adjusted survival rate was 0.87 compared to 0.91 in noncases. The 5-year survival rate for incident cases was 0.84.

Age Factors↗
PubMed1999

Dementia is a major predictor of death among the Italian elderly. ILSA Working Group. Italian Longitudinal Study on Aging.

BACKGROUND: Neurologic diseases are rarely listed on death certificates because death is more often attributed to cardiovascular and pneumonic events occurring during terminal stages. OBJECTIVE: To evaluate the effect of major age-associated neurologic and non-neurologic diseases on survival in a cohort of Italian elderly. METHODS: A population-based multicenter survey, carried out in eight Italian municipalities, with a sample of 5,632 individuals aged 65 to 84 years. The entire sample was screened for all the diseases under study, and all individuals were interviewed about risk factors. Those who screened positive underwent clinical assessments by specialists. Two years after the baseline survey, the study population was followed up to determine the vital status either directly from the individuals or from proxy respondents. A copy of the death certificate was obtained for each individual who had died. The risk of dying (mortality risk ratio [MRR]) was calculated using the Cox proportional hazards model in which we included all the diseases under study, age, gender, and years of education. RESULTS: At follow-up (mean duration 26.7 +/- 5.4 months) 444 individuals had died. The Cox proportional hazards model selected the following as significant predictors of death: age (for year of age MRR = 1.12; 95% confidence interval [CI], 1.08 to 1.15), male gender (MRR = 1.72; 95% CI, 1.27 to 2.34), institutionalization (MRR = 4.17; 95% CI, 2.20 to 7.94), dementia (MRR = 3.61; 95% CI, 2.55 to 5.11), neoplasm (MRR = 2.01; 95% CI, 1.20 to 3.38), heart failure (MRR = 1.87; 95% CI, 1.27 to 2.76), and diabetes (MRR = 1.62; 95% CI, 1.12 to 2.34). CONCLUSIONS: These data provide further evidence on the malignancy of dementia, which proved the major predictor of death in the elderly, with an MRR higher than neoplastic diseases and other severe age-associated conditions.

Age Distribution↗
PubMed1999

White matter changes in stroke patients. Relationship with stroke subtype and outcome.

White matter changes (WMC), detected by imaging techniques, are frequent in stroke patients. The aim of the study was to determine how WMC relate to stroke subtypes and to stroke outcome. We made a systematic Medline search for articles appearing with two of the following key words: either 'WMC or white matter lesions or leukoencephalopathy or leukoaraiosis' and 'stroke or cerebral infarct or cerebral hemorrhage or cerebrovascular disease or transient ischemic attack (TIA)'. WMC, as defined radiologically, are present in up to 44% of patients with stroke or TIA and in 50% of patients with vascular dementia. WMC are more frequent in patients with lacunar infarcts, deep intracerebral hemorrhages, cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy and cerebral amyloid angiopathy. After an acute ischemic stroke, WMC are associated with a higher risk of death or dependency, recurrent stroke of any type, cerebral bleeding under anticoagulation, myocardial infarction, and poststroke dementia. WMC in stroke patients are often associated with small-vessel disease and lead to a higher risk of death, and poor cardiac and neurological outcome. However, several questions remain open and need further investigations.

Age Factors↗
PubMed1999

Stroke in the very old : clinical presentation and determinants of 3-month functional outcome: A European perspective. European BIOMED Study of Stroke Care Group.

BACKGROUND AND PURPOSE: The oldest old represent the fastest-growing segment of the elderly population in developed countries. Knowledge of age-specific aspects of stroke is essential to establish diagnostic and therapeutic pathways and to set up prevention and rehabilitation programs. We sought to evaluate stroke features and functional outcome in patients aged >/=80 years compared with the younger age groups. METHODS: In a European Union Concerted Action involving 7 countries, 4499 patients hospitalized for first-in-a-lifetime stroke were evaluated for demographics, risk factors, clinical presentation, resource use, and 3-month disability (Barthel Index) and handicap (Rankin Scale). RESULTS: Overall, 3141 patients (69.8%) were aged <80 years, and 1358 (30.2%) were aged >/=80 years. At baseline, female sex, prestroke institutionalization, and a worse prestroke Rankin score were significantly more frequent in the older patients, as were coma, paralysis, swallowing problems, and urinary incontinence in the acute phase (all P values <0.001). Brain imaging and other diagnostic tools were significantly less used in the older patients. Paralysis, swallowing problems, and incontinence during hospitalization independently predicted 3-month disability or handicap in both groups. For the older patients, prestroke institutionalization proved a further strong and independent determinant of 3-month disability (odds ratio, 2.33; 95% CI, 1.22 to 4.45) and handicap (odds ratio, 7.04; 95% CI, 1.62 to 30. 69). CONCLUSIONS: In the very old, both medical and sociodemographic factors may significantly influence stroke outcome, showing peculiar characteristics. Knowledge of these determinants may reduce the burden on health systems, improving quality of care.

Adolescent↗