Richard Ronan Murphy

Peripheral (deep) but not periventricular MRI white matter hyperintensities are increased in clinical vascular dementia compared to Alzheimer's disease

Vascular dementia (VAD) is a complex diagnosis at times difficult to distinguish from Alzheimers disease (AD). MRI scans often show white matter hyperintensities (WMH) in both conditions. WMH increase with age, and both VAD and AD are associated with aging, thus presenting an attribution conundrum. In this study, we sought to show whether the amount of WMH in deep white matter (dWMH), versus periventricular white matter (PVH), would aid in the distinction between VAD and AD, independent of age.

The Effectiveness of Small-group Community-based Information Sessions on Clinical Trial Recruitment for Secondary Prevention of Alzheimer’s Disease

Effective and practical recruitment strategies are needed to ensure successful recruitment into the Alzheimer disease clinical trials. To facilitate successful recruitment for the NIH-sponsored A4 (Anti-Amyloid treatment in Asymptomatic Alzheimer’s disease, NCT02008357) trial for the secondary prevention of Alzheimer disease, we developed a small-group community information session to attract and recruit potential research participants. After a successful media campaign, 213 participants were screened through telephone for eligibility, identifying 127 potential participants. Participants were given the option of a traditional one-on-one recruitment session or a small-group session. One-on-one recruitment was performed for 15 participants requesting this procedure, and yielded an overall recruitment rate of 67% (n=10). Substantially more individuals (n=112, 88%) requested small-group sessions to learn about the study. After attending the small-group informational sessions, 98% of potential participants self-reported a greater understanding of the study; and the recruitment rate from these sessions was 90%. Small-group sessions not only improved recruitment success rates, but also contributed to significantly shorter median time for consent processes (20 vs. 60 min) and reduced staff time spent on persons not recruited. Small-group education programs are an effective strategy for enhancing recruitment success and facilitating practical recruitment into clinical trials with high recruitment demands.

Clinical Reasoning: Two see or not two see—Is it really double vision?

A 57-year-old right-handed woman presented to the emergency department with complaints of double vision and intractable nausea that began abruptly 2 days earlier. Her visual symptoms were characterized as seeing overlapping or separate horizontally or diagonally displaced objects. She had no history of headaches or stroke. Her cerebrovascular risk factors included hypertension, type II diabetes, coronary artery disease, and cigarette smoking. Her medications included clopidogrel, lisinopril, paroxetine, and oxycodone. Her family history was notable for late-onset ischemic heart disease in her parents with no first-degree relatives with early vascular disease. On examination, her blood pressure was 158/101 mm Hg, pulse rate was 87 bpm, and she was afebrile. She was alert and fully oriented. Her attention, recall of recent events, and general fund of knowledge were normal. Her speech was fluent and nondysarthric. Cranial nerve examination was notable for no dysconjugacy or nystagmus, but double vision predominately in the horizontal plane, in all directions of gaze. The diplopia persisted with monocular vision in each eye, and did not improve with a pinhole test. The degree of diplopia waxed and waned during the examination, with visual field extinction tests being difficult to perform reliably. Her pupils were equal with bilateral hippus. Visual fields were full to confrontation. Direct funduscopy revealed normal optic discs. She had a mild right hemiparesis with mild right arm and leg drift, but no facial asymmetry. There was mild hypesthesia over her right arm and leg and appendicular ataxia in her right arm that was worse with eyes open. She did not have extinction to double simultaneous sensory stimuli. Gait evaluation was deferred during her initial examination.

DETECTION OF COGNITIVE IMPAIRMENT AFTER ACUTE ISCHEMIC STROKE: VALIDATION OF BRIEF AND MORE COMPREHENSIVE COGNITIVE SCREENING INSTRUMENTS AND IMPLICATIONS FOR BEST PRACTICE

Background: Prior to cognitive decline identifiable via objective testing, older adults often become aware of subtle changes in memory and thinking that impact daily life. This preclinical period, termed subjective cognitive impairment (SCI), may be a key to early detection of dementia-related decline. However, current measurement of SCI is inconsistent across studies and does not consider the multiple ways older adults interpret and answer such questions. Methods:Cognitive interviewing, a structured approach to analyzing sources of response error when individuals respond to questions, was used to systematically appraise older adults’ interpretation of and response to twenty self-report SCI assessment items commonly used in research. The sample (n1⁄455) included independently-living adults age 60 or over with SCI and without dementia; purposive sampling was used to obtain a range of SCI severity. A cognitive interview guide utilized verbal probing techniques to evaluate comprehension, interpretation, difficulty, and potential alternate wording of each item. Interviews were audio-recorded and transcribed, then coded for problem identification using the Question Appraisal System (QAS-99). Results: The most common problem area identified across SCI items was clarity: problems related to communicating the intent or meaning of the question. Specific problems in this area included vague wording that led to multiple ways of interpreting the question (e.g., lack of specificity in identifying important vs. unimportant instances of forgetting) as well as unspecified reference periods (e.g., differences in interpretation of the time frame “happened recently”). Additionally, some questions were inherently affect-laden even when affective language was not included (e.g., comparing one’s memory to peers) and led to respondent resistance when answering. Conclusions:Identifying problems with current assessment items and individual differences in reporting biases across older adult respondents will help to inform future SCI assessment methods. These findings could also aid in the interpretation of current evidence regarding the associations among SCI and a variety of negative outcomes in older adults.