SP - Neurology & Neuroscience

Pneumococcal pneumonia in a confused older person – is it enough for diagnosis of delirium?

Objective: To discuss the high suspicion of meningitis in an immunocompromised patient presenting with pneumococcal bacteraemia as Streptococcus pneumoniae (SP) exhibits a notable tropism for the meninges. With the recent rise in non-PCV13 serotypes, it is important to remain vigilant about the possibility of pneumococcal meningitis in susceptible individuals despite the widespread use of pneumococcal vaccines. Health promotion through vaccination should be encouraged to prevent an increase in invasive pneumococcal disease (IPD) incidence.

Case Presentation: The patient is an 82-year-old gentleman with low-grade lymphoproliferative disorder who presented with confusion. CXR reported diffuse bilateral shadow suggestive of possible acute infection. Intravenous antibiotics were commenced for delirium related to community-acquired pneumonia. Blood culture confirmed the presence of SP. Given this organism’s predilection for meninges, he was re-assessed clinically, which identified neck stiffness and positive Kernig and Brudzinski’s sign. CSF sample showed raised protein, LDH and white cells with low glucose. CSF PCR confirmed the presence of SP. Intravenous antibiotics were adjusted, and the patient recovered fully. After discharge, conjugated pneumococcal vaccine and monthly immunoglobulin replacement were recommended due to the high risks and life-threatening nature of IPD.

Discussion: Despite vaccination efforts, Streptococcus pneumoniae remains the leading cause of bacterial meningitis. It is associated with long-term neurological complications and high mortality rates, even with antibiotic treatment. Despite only a brief neurological presentation, a high index of suspicion for meningitis is warranted, especially where SP appears in blood culture as it denotes invasiveness.

Conclusion: This case report emphasises the significance of early diagnosis and treatment of pneumococcal meningitis in the older to reduce morbidity/mortality, and the need for vaccination to safeguard against serious infections caused by SP. It also highlights diagnostical problems of meningitis in the older who frequently present with delirium in the context of less sinister infections such as chest infection.

Introduction

Small vessel disease (SVD) lesions may cause symptoms apart from stroke. We aimed to determine whether white matter hyperintensity (WMH) progression and incident infarcts associate with gait, mood, and cognitive symptoms.

Method

We recruited patients with non-disabling stroke (modified Rankin Scale <3), performed diagnostic MRI, and questioned participants/informants about gait, mood, cognitive, Center Epidemiologic Studies-Depression Scale (CES-D), Neuropsychiatric Inventory-Questionnaire (NPI-Q) symptoms and Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE).

The baseline visit occurred < 3months post-stroke. We repeated MRI and symptoms assessments every 3-6 months for 12 months, assessing WMH change and incident infarcts (i.e. new since previous scan) on DWI or FLAIR. We analysed WMH using cubed root normalised for intracranial volume. We used linear mixed-effects models, adjusting for age, gait speed, modified Rankin Scale, and time for gait symptoms; age, anxiety, MoCA, stroke subtype, and time for cognitive/neuropsychiatric symptoms. 

Results

We recruited 230 participants (mean age=65.8 [SD=11.2] years; 34% female; 56.5% lacunar); median baseline WMH volumes = 8.26mL (IQR 3.65-19.0); one-year = 8.24mL (IQR = 4.15-20.1). Incident infarcts (n=110, 82/110 (74.5%) small subcortical subtype) occurred in 53/230 (23%) of patients.

WMH progression over one year was associated with falls (OR=4.13 [95% CI=1.6-10.1]); self-reported brain fog (OR=3.13 [95% CI=1.11-8.82]); and increasing NPI-Q scores (est=2.12 [95% CI=0.46-3.77] p=0.012). Baseline and one-year WMH volumes were cross-sectionally associated with apathy (baseline OR=8.78 [95% CI=2.56-31.88]; one-year OR=4.83 [95% CI=1.43-17.26]).

Higher CES-D depression scores were associated with incident infarcts (mean 15.2 [12.9] with vs 11.9 [SD10.6] without; est=2.26 (95% CI=0.12-4.4), p=0.038). WMH progression and infarcts were not associated with fatigue, anxiety, subjective memory complaints, confusion, dizziness, or IQCODE scores.

Conclusions

SVD progression following minor stroke co-associates with specific gait/cognitive/mood symptoms. WMH progression and incident infarcts may cause non-focal, non-stroke symptoms which characterise a potential ‘SVD syndrome’.

Subjective cognitive decline (SCD) is defined by cognitive complaints expressed by the individual, without evidence of cognitive impairment on objective neuropsychological tests. Studies have analyzed SCD among patients with specific groups of diseases. An increased understanding of the association between disease patterns and subjective cognitive decline is essential to develop targeted interventions for these groups. Using data from the baseline of the Brazilian Longitudinal Study of Aging (ELSI-Brazil), this cross-sectional study included 2,508 participants. Subjective Cognitive Decline (SCD) was assessed using the Subjective Cognitive Decline Initiative Working Group's criteria. Multimorbidity (MM) was defined as the presence of two or more of 14 self-reported health conditions. Clusters of MM were identified based on the most prevalent dyads and triads of diseases within the sample. Robust Poisson regression models were used to estimate adjusted prevalence ratios (PR) for the association between MM clusters and SCD, accounting for potential confounders. The following dyads of chronic conditions were associated with higher prevalence of SCD: ophthalmological problems/osteoporosis (RR: 1.497 p=0.042), heart problems/stroke (RR: 2.33, p<.001), and hypertension />asthma (RR: 3.309, p=0.013). No triads had positive association with SCD, although the triads of ophthalmological problem/hypertension/osteoporosis (RR: 0.367, p<.001) and hypertension />cardiac problems/dyslipidemia (RR: 0.545, p=0.012) were negatively associated with the prevalence of SCD. Our study demonstrated an association between SCD and MM clusters, which is important for developing and managing care for individuals with cognitive decline and/or those multimorbidity patterns. The results could also provide a foundation for future research exploring the causality between these variables.

Introduction. Social support for physical activity is important for engaging older adults in physically active lifestyles. Few studies examined the impact of individual exercise trainers (IETs) in the context of dementia prevention interventions with physical activity. We aimed to assess the contributions of IETs in the remote delivery of a home-based dementia prevention program combining physical exercise and cognitive training targeting older adults at risk for dementia.
Methods. Convergent mixed-method analysis was conducted using data from SYNERGIC@Home, a feasibility study of a 16-week intervention that included one-on-one supervised physical exercise (3 sessions/week) fully delivered through Zoom. Quantitative data consisted of descriptive statistics, measures of adherence, participants’ preference and satisfaction. Qualitative interviews centred on participants’ experience and motivation were conducted post-intervention.
Results. Of the 60 participants randomized to one of four intervention arms (mean age 68.9, 76.7% female), 52 completed the interventions with high overall adherence (87.5%). Pre-intervention, participants expressed a clear preference for cognitive interventions, but post-intervention preference shifted to exercise. IETs (n=21) were part-time research assistants, each assigned to one participant after completing CSEP Certified Personal Trainer® or Clinical Exercise Physiologist™ certification as part of their training. One full-time Lead IET coordinated and supervised the other trainers. IETs worked the closest with study participants, also working closely with study coordinator and with study physician for adverse event monitoring. Interviewed participants (n=15) often described the positive relationships that developed with their IET. Trainers were instrumental in participants’ motivation and enjoyment, personalizing the sessions and addressing technological issues. Satisfaction rates with IETs (n=54 exit survey respondents) were high.
Conclusions. Exercise trainers played crucial roles that extended beyond the supervision of exercise sessions and contributed to participant engagement in the interventions. Access to these allied health professionals should be featured more prominently in strategies/programs promoting active lifestyles among older adults.
 

An 80 year old man living independently with his wife presented with progressive unsteadiness, generalised weakness and muscle aches over 2 months, following a short episode of flu-like symptoms. Systems review revealed shortness of breath, a hoarse voice, 2kg weight loss and occasional non-drenching night sweats. Bloods showed elevated WCC, CRP and ESR. He was started on 20mg of prednisolone for a working diagnosis of polymyalgia rheumatica. These symptoms did not improve, even after this increased to 30mg. He was admitted to hospital after he developed left leg weakness evolving over the course of 1 day. On examination, he had generalised muscle wasting, no fasciculations, preserved reflexes, left sided foot drop and right sided ulnar nerve palsy. MRI head and spine did not reveal a structural cause. CT thorax-abdomen-pelvis showed no evidence of malignancy, lymphadenopathy or hepatosplenomegaly. An autoimmune screen revealed a strongly positive rheumatoid factor, but negative ANA, ANCA, anti-DSDNA antibodies. A myositis panel and anti-neuronal antibodies were negative. CSF biochemistry showed normal cell count and protein level, with negative oligoclonal bands. Nerve conduction studies suggested a chronic axonal length-dependent peripheral neuropathy and a degree of myopathy. He then developed symmetrical bilateral foot drop and median nerve palsies. FDG-PET-CT showed increased activity within various visualised skeletal muscles- due to either myositis, denervation or physiological changes. Muscle & sural nerve biopsy showed no myositis, but intense inflammation and arterial wall destruction with moderate axonal degeneration suggestive of vasculitic neuropathy. A diagnosis of mononeuritis multiplex caused by tissue-specific vasculitis was made. He received pulsed IV methylprednisolone before starting rituximab. He was discharged when his mobility improved. This case demonstrates that vasculitis can present without rash and mimic polymyalgia rheumatica, which is more common in older patients. Thorough examination and revisiting the diagnosis if steroids do not show improvement is advised.

Introduction

Physical and cognitive decline at an older age is preceded by changes that accumulate over time until they become clinically evident difficulties. These changes, frequently overlooked by patients and health professionals, may respond better than fully established conditions to strategies designed to prevent disabilities and dependence in later life. The objective of this study was twofold: to provide further support for the need to screen for early functional changes in older adults and to look for an early association between decline in mobility and cognition.

Methods

A cross-sectional cohort study was conducted on 95 active functionally independent community-dwelling older adults in Havana, Cuba. We measured their gait speed at the usual pace and their cognitive status using the MMSE. A value of 0.8 m/s was used as the cut-off point to decide whether they presented a decline in gait speed. A quantitative analysis of their EEG at rest was also performed to look for an associated subclinical decline in brain function.

Results

Results show that 70% of the sample had a gait speed deterioration (i.e., lower than 0.8 m/s), of which 80% also had an abnormal EEG frequency composition for their age. While there was no statistically significant difference in the MMSE score between participants with a gait speed above and below the selected cut-off, individuals with MMSE scores below 25 also had a gait speed < 0.8 m/s and an abnormal EEG frequency composition.

Conclusions

Our results provide further evidence of early decline in older adults – even if still independent and active - and point to the need for clinical pathways that incorporate screening and early intervention targeted at early deterioration to prolong the years of functional life in older age.

Introduction Medication-related harm (MRH) is defined as any negative outcome, harm or injury caused by taking a medication (Falconer et al. Eur J Clin Pharmacol, 2018;75(2):137-145). People living with dementia (PLWD) take more medications than those without dementia, increasing their risk of MRH (Mueller et al. Exp Gerontol 2018;106:240-245). There is urgent need to explore the scale of MRH affecting PLWD. This systematic review aimed to determine the prevalence of MRH in PLWD and evaluate various outcomes to assess its impact.

Methods Twelve databases were systematically searched for articles published in English from date of inception to April 2023. Papers of any study design reporting on the prevalence and/or outcomes of MRH in PLWD were eligible for inclusion. Quality was assessed using the Cochrane Risk Of Bias tool for randomised trials (ROB-2) or the Risk Of Bias In Non-randomised Studies of Exposures (ROBINS-E). Due to lack of consensus on the definition of MRH and the heterogeneity of included studies, a narrative synthesis will be undertaken.

Results In total, 5,951 articles were identified, and 4,946 remained following removal of duplicates. After title/abstract screening, 419 full-text articles were assessed for eligibility. Ninety-eight studies were included in the review. Quality assessment is ongoing. Overall, 29 studies investigated adverse drug events, affecting 5-83% of participants, and 22 studies assessed mortality associated with drug use, with most reporting an increase in mortality. Antipsychotics were the most commonly implicated medication class, studied in 24 papers.

Conclusion This systematic review is the first to report on the prevalence of MRH in PLWD. However, it will not be possible to conduct a meta-analysis to fully analyse the scale of this issue. This review will identify gaps in the current evidence base and inform future research aiming to explore factors contributing to, and ways to reduce, PLWD experiencing MRH.

 Introduction: The COVID-19 pandemic has raised concerns about its long-term effects, leading to conditions such as "Long COVID." Neurological manifestations, including "Brain Fog" with impaired cognitive function, have been reported, but their relationship with age and memory decline remains unclear. Method: This study aimed to investigate the effects of COVID-19 infection on memory function and explore the relationship between age and memory scores. The research utilized data from the 'COVID-19 Online Rapid Objective Neuro-memory Assessment' (CORONA) study, employing an online survey with a memory task. Ethical approval was obtained, and participants aged 18 and older were recruited globally, with 5,308 participants included in the analysis. Memory scores were obtained through a task featuring four categories. Statistical analysis, including T-tests and linear regression, was employed to evaluate the data. Results: Participants testing positive for COVID-19 (n = 678) exhibited lower mean total memory scores than those testing negative (n = 4,630), with a statistically significant difference (P < 0.05). Hospitalized COVID-19 patients (n = 37) had significantly lower memory scores compared to non-hospitalized patients (n = 641), suggesting a greater impact of hospitalization on memory function. Age was associated with declining memory scores, with an overall trend of decreasing scores as age increased. Three age groups exhibited significant differences in memory scores between COVID-19 positive and negative participants. Conclusion This study provides evidence that COVID-19 infection may be associated with worsened memory outcomes and cognitive function. Hospitalization due to COVID-19 appears to have a more substantial impact on memory than the infection alone. A steeper decline in memory scores with age was observed among COVID-19-positive participants, suggesting potential age-related vulnerability to memory decline associated with COVID-19. However, discrepancies in results may be attributed to sample size limitations, emphasizing the need for larger cohorts in future research.

Introduction:

The presence of ischemic cerebrovascular accident in COVID 19 patients is a complication that has stood out due to its complications, the predisposing factors are the procoagulant state derived from the infection as well as cardiovascular arrhythmic causes. Patients: Describe the frequency of cerebral ischemia and cardiac rhythm disturbances in patients admitted to the emergency room from July 2020 to January 2021 and its impact on prognosis and mortality.

Methods:

Retrospective study of 306 adults infected by SARS COV2 by antigenic or molecular test. The presence of these events was examined in a follow-up and the associated complications were described.

Results:

There was a higher frequency of COVID 19 in the Male gender 78% in relation to the Female 22%, the ROX values were higher in the survivors at 2 h 5.7 (4.6 - 6.8), in relation to the deceased 3 ,2 (2.9 - 4.2), The presence of ischemic cerebrovascular events occurred in 9 patients (2.9%), occurring in 8 of the male gender and 1 of the female gender, the average age of those who presented said complication was 72, 3 years with standard deviations of 62.9 and 81.7 respectively, 3 of them presented cardiorespiratory arrest. Arrhythmic causes were found in only 1 of the patients, the rest were cryptogenic events. None of the cerebral panangiography studies showed aneurysms or vascular malformations. The mortality of patients with cerebral ischemia was 33% (3/9). It was not possible to perform thrombolysis in any patient. Only 1 patient was a candidate for mechanical thrombectomy.

Conclusions:

The present study showed that the presence of cerebral ischemia is not so uncommon, approaching what has been published in other series and reported works. Studies with larger groups of patients are required to validate the results found here.

Introduction

In 2017 NHS England introduced proactive identification of frailty into the General Practitioners (GPs) Contract. There is currently little information as to how this policy has been operationalised by front-line clinicians, their working understanding of frailty, or perceptions of impact on patient care. Evidence from international settings suggests primary care clinicians may have mixed interpretations of frailty, with important implications for their willingness to support different frailty interventions. We aimed to explore the conceptualisation of frailty, and how community-dwelling frail older adults are identified in primary care.

Methods

Semi-structured interviews were conducted with primary care staff across England, including GPs, physician associates, nurse practitioners, paramedics and pharmacists. Thematic analysis was facilitated through NVivo (Version 12).

Results 31 practitioners participated (12 GPs, 19 non-GPs). Frailty was seen as difficult to define, with uncertainty in its value as a medical diagnosis. The most common working model was the frailty phenotype, associated with deterioration at end of life. There were a mixture of formal and informal processes for identifying frailty. A few practices had embedded population screening and structured reviews. Informal processes included use of ‘housebound’ as a proxy for frailty, identification through chronic disease and medication reviews, and holistic assessment through good continuity of care. Many clinicians described poor accuracy of the electronic Frailty Index, yet it was commonly used to grade frailty during protocolised chronic disease reviews. The Clinical Frailty Score, in contrast, was felt to be easy to use and interpret, but inconsistently recorded within electronic health records. Most clinicians favoured better tools for identifying frailty, alongside resources to support these individuals.

Conclusions

Concepts of frailty in primary care differ. Identification is predominantly ad-hoc, opportunistic and associated with terminal illness. A more cohesive approach to frailty, relevant to primary care, together with better diagnostic tools, may encourage wider recognition.