Management of depression in elderly stroke patients

Poststroke depression (PSD) in elderly patients has been considered the most common neuropsychiatric consequence of stroke up to 6–24 months after stroke onset. When depression appears within days after stroke onset, it is likely to remit, whereas depression at 3 months is likely to be sustained for 1 year. One of the major problems posed by elderly stroke patients is how to identify and optimally manage PSD. This review provides insight to identification and management of depression in elderly stroke patients. Depression following stroke is less likely to include dysphoria and more likely characterized by vegetative signs and symptoms compared with other forms of late-life depression, and clinicians should rely more on nonsomatic symptoms rather than somatic symptoms. Evaluation and diagnosis of depression among elderly stroke patients are more complex due to vague symptoms of depression, overlapping signs and symptoms of stroke and depression, lack of properly trained health care personnel, and insufficient assessment tools for proper diagnosis. Major goals of treatment are to reduce depressive symptoms, improve mood and quality of life, and reduce the risk of medical complications including relapse. Antidepressants (ADs) are generally not indicated in mild forms because the balance of benefit and risk is not satisfactory in elderly stroke patients. Selective serotonin reuptake inhibitors are the first choice of PSD treatment in elderly patients due to their lower potential for drug interaction and side effects, which are more common with tricyclic ADs. Recently, stimulant medications have emerged as promising new therapeutic interventions for PSD and are now the subject of rigorous clinical trials. Cognitive behavioral therapy can also be useful, and electroconvulsive therapy is available for patients with severe refractory PSD

CRISPR/Cas9-mediated deletion of a GA-repeat in human GPM6B leads to disruption of neural cell differentiation from NT2 cells

The human neuron-specific gene, GPM6B (Glycoprotein membrane 6B), is considered a key gene in neural cell functionality. This gene contains an exceptionally long and strictly monomorphic short tandem repeat (STR) of 9-repeats, (GA)9. STRs in regulatory regions, may impact on the expression of nearby genes. We used CRISPR-based tool to delete this GA-repeat in NT2 cells, and analyzed the consequence of this deletion on GPM6B expression. Subsequently, the edited cells were induced to differentiate into neural cells, using retinoic acid (RA) treatment. Deletion of the GA-repeat significantly decreased the expression of GPM6B at the RNA (p < 0.05) and protein (40%) levels. Compared to the control cells, the edited cells showed dramatic decrease of the astrocyte and neural cell markers, including GFAP (0.77-fold), TUBB3 (0.57-fold), and MAP2 (0.2-fold). Subsequent sorting of the edited cells showed an increased number of NES (p < 0.01), but a decreased number of GFAP (p < 0.001), TUBB3 (p < 0.05), and MAP2 (p < 0.01), compared to the control cells. In conclusion, CRISPR/Cas9-mediated deletion of a GA-repeat in human GPM6B, led to decreased expression of this gene, which in turn, disrupted differentiation of NT2 cells into neural cells.Publisher PDFPeer reviewe

How do Iranian older adults define place attachment? a qualitative study

Background: Place attachment is the emotional bond between individuals and environment, which seems to increase wellbeing in old age. The purpose of this study was to explore the concept of place attachment from older adults’ perspective. Methods: In this qualitative study, a total of 14 older adults were purposively included in Aran and Bidgool city, Isfahan, Iran. The data were collected using a semi-structured interview and analyzed applying a directed content analysis approach. Results: As participants reported, place attachment meant intensive love, pride, dependency, and familiarity with the environment. Socio-economic attachment was identified as the most prevalent dimension of place attachment, followed by affective, physical, autobiographical, and religious-cultural attachment. Conclusion: Our findings provided a new understanding of place attachment in the context of Iran. The concept of place attachment was identified with a multidimensional nature from Iranian older adults’ perspective. Such a multidimensionality of place attachment should be considered while planning for age-friendly cities or the operationalization of the subject of aging in place, particularly in the developing societies, like Iran

Epidemiological and recovery facilitating studies of an urban population of stroke patients in Iran

Introduction Approximately 15 million people have a stroke annually in the world, of whom one third will die within one year and one third will suffer permanent disability. Over 85% of these deaths happen in people living in low- and middle-income countries. Existing evidence indicates motor impairment as the most common disability caused by stroke. Following stroke, mood disorder and cognitive impairment may either directly or indirectly lead to more significant impairments in daily activities, which require more careful services and sometimes institutionalization of the stroke patients. AMPH-like drugs are reported to enhance motor recovery, Activities of Daily Living (ADL), mood, and cognition in stroke rehabilitation, but results from trials with humans are inconclusive. Aims The main objectives of this PhD thesis were to estimate epidemiological aspects of stroke among an urban population in Iran and also to investigate the potential for ―rehabilitation pharmacology‖ of stroke recovery. Our interventional studies are aimed to investigate if levodopa (LD) and /or methylphenidate (MPH) in combination with physiotherapy can improve functional motor recovery, ADL, mood, and cognition in stroke patients. Material and methods The epidemiological studies were multihospital-based, cross-sectional and were performed on patients with stroke admitted to the hospitals in Qom-Iran from January 1st, 2001 through January 1st, 2002 (Study I) and between March 2006 and September 2007 (Study II). In the interventional studies (Study III & IV), a randomized, double-blind, placebocontrolled trial with ischemic stroke patients randomly allocated to one of four treatment groups of either MPH, LD or MPH + LD or placebo combined with physiotherapy was performed. Stroke patients were enrolled within 15 to 180 days after stroke onset. Motor function, ADL, stroke severity, mood, and cognition were assessed by Fugl-Meyer (FM), Barthel Index (BI), National Institute of Health Stroke Scale (NIHSS), Geriatric Depression Scale (GDS), and Mini Mental State Examination (MMSE) at baseline, 15, 90, and 180 days, after start respectively. Results Epidemiological studies: stroke crude rate in Qom city was estimated to be 53/100.000 per year in 2001 and the age-standardized incidence (to the European population) was 384 per 100,000 person-years. In study II the mean age of patients was 68 years. Hypertension was found in 64% of patients, followed by diabetes mellitus in 36%, heart disease in 34%, hypercholesterolemia in 32%, and smoking in 20%. Interventional studies: Motor function and ADL were recovered for all participants during treatment and at 6-month follow-up. There were slight but significant differences in BI and NIHSS compared to placebo at the 6 month follow-up. Mood and cognitive status demonstrated continuously significant improvement in all four groups across baseline and the three follow-ups but the strongest improvement was found between baseline and first follow-up immediately after the intervention. A significant improvement in mood compared to placebo was found with the combined treatment (MPH+LD) at 90 and 180 days. Conclusion Stroke incidence was higher than in Western countries. Hypertension and Diabetes mellitus were more frequent than average global findings. One month case fatality was higher than in European countries but less than in developing countries. We strongly recommend establishing a stroke registry, improved primary and secondary prevention as well as promoting rehabilitation facilities in Iran. A daily dose of LD 100 mg and /or MPH 20 mg combined with physiotherapy for 15 drug therapy sessions were safe and well tolerated and significantly improved mood status in ischemic stroke patients. It showed a slight ADL and stroke severity improvement over time and future studies should determine the optimal therapeutic window for and dosage of psychostimulants, as well as to identify those stroke patients who may benefit from treatment

Clinical aspects of palliative care in advanced Parkinson’s disease

Parkinson's disease (PD) is one of the most common neurodegenerative disorders of the elderly population. Few therapeutic options are available for patients with PD requiring palliative care. Treatment of the early stages of PD is entirely different from later stages. During the later stages, the palliative care model is introduced to provide the patient with comfort and support. Early palliative care in PD requires minimization of dyskinesias and decreasing occurrence of motor and non-motor off times in an effort to maximize independent motor function. In the later stages, the focus of treatment shifts to treating the predominant non-motor symptoms and having a more supportive and palliative nature. The purpose of this review is to provide a summary of the palliative care management issues and palliative care management options of end-stage PD patients