Joukje M. Oosterman

Recent developments in pain in dementia

Epidemiological studies show that, worldwide, the number of people aged over 65 will increase substantially in the next decades and that a considerable proportion of this population will develop dementia.1 Ample evidence shows that ageing is associated with a high rate of painful conditions, irrespective of cognitive status.2 The number of patients with dementia who will experience painful conditions is therefore likely to increase. A key question relates to whether and how patients with dementia perceive pain. Patients with dementia may express their pain in ways that are quite different from those of elderly people without dementia.3 Particularly in the more severe stages of dementia, therefore, the complexity and consequent (frequent) inadequacy of pain assessment leads to the undertreatment of pain. The most commonly used pain assessment instruments seem to be selected primarily according to the communicative capacity of the patient (self report pain rating scales for communicative patients and observation scales for non-communicative patients) instead of according to two main aspects of pain—the sensory-discriminative and motivational-affective aspects. In particular, the motivational-affective aspects of pain are assessed by observation scales, which should therefore be applied to every patient, irrespective of ability to communicate. Distinction between the sensory-discriminative and motivational-affective aspects of pain is of great clinical relevance, as the motivational-affective aspects are particularly likely to reflect pain that needs treatment.4 Moreover, differentiating between these two aspects of pain in relation to the neuropathology of the various subtypes of dementia provides insight into the basis of the alterations in the pain experiences of elderly people with dementia. Future experimental and clinical studies should not only focus on subtypes of dementia but should go a step further and assess pain in disorders in which pain is already present at a stage without cognitive impairment and during the course …

Profile of Cognitive Impairment in Chronic Heart Failure

OBJECTIVES: To determine the frequency and pattern of cognitive dysfunction in outpatients with chronic congestive heart failure (CHF) and to identify the corresponding demographic and clinical correlates.

Fragmentation of the rest-activity rhythm correlates with age-related cognitive deficits

Aging affects both cognitive performance and the sleep‐wake rhythm. The recent surge of studies that support a role of sleep for cognitive performance in healthy young adults suggests that disturbed sleep‐wake rhythms may contribute to ‘age‐related’ cognitive decline. This relationship has however not previously been extensively investigated. The present correlational study integrated a battery of standardized cognitive tests to investigate the association of mental speed, memory, and executive function with actigraphically recorded sleep‐wake rhythms in 144 home‐dwelling elderly participants aged 69.5 ± 8.5 (mean ± SD). Multiple regression analyses showed that the partial correlations of the fragmentation of the sleep‐wake rhythm with each of the three cognitive domains (r = −0.16, −0.19, and −0.16 respectively) were significant. These associations were independent from main effects of age, implying that a unique relationship between the rest‐activity rhythm and cognitive performance is present in elderly people.

Brain lesions on MRI in elderly patients with type 2 diabetes mellitus.

Background and Purpose: Diabetes mellitus (DM) type 2 has been associated with poor cognitive performance and dementia, particularly in elderly patients. The exact mechanisms underlying the cognitive dysfunction in DM remain unclear. Imaging studies of the brain could be helpful to give more insight into possible structural brain lesions underlying these cognitive dysfunctions. Therefore, we performed a study in independently living patients with DM type 2 in order to investigate the association between DM and brain imaging abnormalities. Methods: The study population consisted of 45 patients with DM type 2 without hypertension (mean age 73.4 ± 5.1 years, mean duration 16.5 ± 11.5 years), 45 patients with DM type 2 and hypertension (mean age 73.5 ± 6.1 years, mean duration 11.9 ± 9.2 years) and 44 control subjects (mean age 73.1 ± 5.4 years). All patients and control subjects underwent an MRI of the brain. White matter lesions (WML), cerebral atrophy and medial temporal lobe atrophy were rated by a standardized visual rating scale. Lacunar infarcts were defined as focal hypo-intensities on fluid-attenuated inversion recovery sequences with a hyperintense rim around it. Results: WML occurred more frequently in diabetic patients with hypertension as well as without hypertension. Significantly more deep WML were found in DM patients with and without hypertension when compared to control subjects, whereas no difference was found in the occurrence of periventricular hyperintensities. In all 3 groups, lacunar infarcts occurred sporadically. A trend towards higher atrophy scores was seen in patients with DM compared to control subjects. Conclusions: The data of this cross-sectional study suggest that type 2 DM is an independent risk factor for deep WML in the independently living elderly patients.

Neuroimaging and correlates of cognitive function among patients with heart failure.

Background/Aims: We purposed to investigate the relationship between cerebral abnormalities detected by magnetic resonance imaging (MRI) and cognitive performance in nondemented outpatients with heart failure (HF). Methods: In 58 patients with HF neuropsychological assessment was performed including tests of mental speed, executive functions, memory, language and visuospatial functions. Deep, periventricular and total white matter hyperintensities (WMH), lacunar and cortical infarcts, global and medial temporal lobe atrophy (MTA) were investigated on MRI of the brain. Correlations between MRI findings and the cognitive measures were calculated. Results: MTA correlated with memory (r = –0.353, p < 0.01), with executive functions (r = –0.383, p < 0.01) and the Mini Mental State Examination (r = –0.343, p < 0.05). Total WMH and deep WMH were found to correlate with depression and anxiety scores, but not with cognitive measures. Age, estimated premorbid intelligence and MTA were independent predictors of diminished cognitive performance. Conclusions: In HF patients, MTA was related to cognitive dysfunction, involving memory impairment and executive dysfunction, whereas WMH was related to depression and anxiety.

Assessing mental flexibility: neuroanatomical and neuropsychological correlates of the trail making test in elderly people

The Trail Making Test part B (TMT-B) is highly sensitive to age-related changes in the brain and cognitive function. However, the precise contribution of periventricular hyperintensities (PVH), deep white matter hyperintensities (DWMH), and medial temporal lobe atrophy (MTA) to task performance remains unspecified. Similarly, diminished performance may be due to deficient flexibility functions, but also to other age-related cognitive decline (e.g., mental slowing). The aim of the present study was to determine neuroanatomical (PVH, DWMH, MTA) and neuropsychological (working memory, executive function, speed and attention, episodic memory) predictors of TMT-B performance in elderly people. Results showed that MTA was the strongest predictor of TMT-B performance. The predictive value of the neuropsychological scores differed among the various TMT-B variables. For example, all neuropsychological domains predicted the TMT-B total completion time, whereas only executive function predicted the ratio score (TMT-B/A). We conclude that MTA is a very important predictor of TMT-B performance in elderly people. Furthermore, multiple cognitive functions are involved in TMT-B performance and a mild decline in any of these functions may result in diminished TMT-B performance. Therefore it is crucial to use the ratio score when one wishes to examine executive function ability.

Memory functions in chronic pain: examining contributions of attention and age to test performance

ObjectivesPrevious studies have revealed that memory performance is diminished in chronic pain patients. Few studies, however, have assessed multiple components of memory in a single sample. It is currently also unknown whether attentional problems, which are commonly observed in chronic pain, mediate the decline in memory. Finally, previous studies have focused on middle-aged adults, and a possible detrimental effect of aging on memory performance in chronic pain patients has been commonly disregarded. This study, therefore, aimed at describing the pattern of semantic, working, and visual and verbal episodic memory performance in participants with chronic pain, while testing for possible contributions of attention and age to task performance. MethodsThirty-four participants with chronic pain and 32 pain-free participants completed tests of episodic, semantic, and working memory to assess memory performance and a test of attention. ResultsParticipants with chronic pain performed worse on tests of working memory and verbal episodic memory. A decline in attention explained some, but not all, group differences in memory performance. Finally, no additional effect of age on the diminished task performance in participants with chronic pain was observed. DiscussionTaken together, the results indicate that chronic pain significantly affects memory performance. Part of this effect may be caused by underlying attentional dysfunction, although this could not fully explain the observed memory decline. An increase in age in combination with the presence of chronic pain did not additionally affect memory performance.

A unique association between cognitive inhibition and pain sensitivity in healthy participants.

The experience of pain constitutes a complex phenomenon that is determined by and reflects the interplay of many factors, including cognitive functions. Little is known, however, about the precise role of executive functions in pain sensitivity. Importantly, these functions may be directly related to the ability to control pain. The present study evaluated the relationship between pain sensitivity and executive functions in a sample of healthy volunteers. Pain sensitivity was assessed with the cold pressor test. The immersion time, here defined as the time until substantial pain was reported, was measured. Additional pain intensity and pain unpleasantness ratings were obtained as an indication of pain experience. The results revealed a unique association between cognitive inhibition (i.e. the Stroop interference score), but not other executive functions, and immersion time, pain intensity, and pain unpleasantness. Specifically, better cognitive inhibition was related to a reduction in pain sensitivity as evident by an increased immersion time and decreased pain intensity and pain unpleasantness ratings. As such, cognitive inhibition may be an important determinant of pain sensitivity.

Relationship between chronic pain and cognition in cognitively intact older persons and in patients with Alzheimer's disease

Background: Brain areas that are involved in cognition and mood also play a role in pain processing. Objective: The goal of the present study was to examine the relationship between chronic pain and cognition [executive functions (EF) and memory], while controlling for mood, in cognitively intact older persons and in patients with Alzheimer’s disease (AD). Methods: Two groups of subjects participated: 20 older persons without dementia and 19 patients in an early stage of probable AD who suffered from arthrosis/arthritis. Pain intensity and pain affect were assessed by the Colored Analogue Scale for Pain Intensity and for Pain Affect, the Faces Pain Scale (FPS) and the Number of Words Chosen-Affective (NWC-A). Level of depression and anxiety were evaluated by questionnaires. EF and memory were assessed by neuropsychological tests. Results: The results show that significant correlations between specific cognitive functions, pain intensity and pain affect were lacking in the cognitively intact older persons. Cognition, in particular memory, appeared to be related to depressive symptoms. In contrast, a significant positive correlation was observed between EF, pain intensity and pain affect measured by the FPS in the AD group. Conclusions: Although older persons with depression were excluded, in studies on pain and cognition one should control for the presence of depressive symptoms in older persons with and without dementia.

The role of white matter hyperintensities and medial temporal lobe atrophy in age-related executive dysfunctioning.

Various studies support an association between white matter hyperintensities (WMH) and deficits in executive function in nondemented ageing. Studies examining executive functions and WMH have generally adopted executive function as a phrase including various functions such as flexibility, inhibition, and working memory. However, these functions include distinctive cognitive processes and not all may be affected as a result of WMH. Furthermore, atrophy of the medial temporal lobe (MTA) is frequently observed in ageing. Nevertheless, in previous studies of nondemented ageing MTA was not considered when examining a relationship between white matter and executive function. The goal of the present study was to examine how WMH and MTA relate to a variety of executive functions, including flexibility, fluency, inhibition, planning, set shifting, and working memory. Strong correlations were observed between WMH and MTA and most of the executive functions. However, only MTA was related to flexibility and set shifting performance. Regression analysis furthermore showed that MTA was the strongest predictor of working memory, after which no further significant association with WMH was noted. Alternatively, both MTA and periventricular hyperintensities independently predicted inhibition performance. These findings emphasize the importance of MTA when examining age-related decline in executive functioning.