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By W. Tangach. Wilmington College, Wilmington Ohio.

Neuropsycholo- gical evaluation can facilitate objective measurement of cognitive generic ivermectin 3mg on-line, neuro- behavioral discount 3mg ivermectin amex, emotional order ivermectin 3mg mastercard, and quality-of-life outcomes associated with treatment as well as aid in determinations regarding treatment (96) discount 3mg ivermectin with mastercard. Pharmacological Treatments Anticholinergics and Cholinesterase Inhibitors Anticholinergic medications used to treat motor symptoms in PD potentially produce adverse effects on memory, executive functions, as well as global cognitive abilities. In placebo-controlled studies, Bedard and colleagues found anticholinergics to induce executive deficits in PD but not in control participants (97,98). Although anticholinergic-induced memory decrements are observable even in patients without preexisting cognitive impairments (99), Saint-Cyr (100) found that confusional states are more likely to be induced by anticholinergics in patients with preexisting cognitive impairment. Thus, anticholinergics should be avoided in elderly patients who are susceptible to developing confusional states (101). Cholinesterase inhibitors were initially used sparingly and rarely in PDD and LBD. There is increasing recognition that cholinesterase inhibitors such as rivastigmine may improve not only cognition, but also neuropsychiatric symptoms in both conditions, and that these agents are well tolerated by patients with PD (102,103). Levodopa and Dopamine Agonists Findings concerning the impact of levodopa on cognitive functions are inconsistent, with studies showing improvement, decrements, and an Copyright 2003 by Marcel Dekker, Inc. Despite these inconsistent findings, evidence is accumulating that levodopa has short-term effects on certain aspects of memory and executive functions, perhaps as mediated by disease stage. For example, Kulisevsky and colleagues (105) reported short-term improve- ments in learning and memory, visuoperception, and certain executive functions associated with dopamine-replacement therapies but stated that these cognitive improvements were not maintained over time. That levodopa affects only certain components of cognitive functions is consistent with the findings of Fournet and colleagues (107), who reported poorer performance only on working memory tasks in patients with PD after withdrawal from levodopa, and of Lange et al. Levodopa’s rather selective effects on working memory and certain executive functions may be related to its mediation of dorsolateral frontal cortex blood flow in response to executive task activation (109). Selegiline Selegiline, a selective monoamine oxidase-B inhibitor, has been hypothe- sized to exert a neuroprotective effect in PD by way of reducing physiological stress associated with MAO-B oxidation of dopamine. Along with improvement in motor functions, several small, uncontrolled studies have found selegiline to be associated with improved global cognitive functioning, P300 latencies, and/or memory in patients with PD (110–113). In contrast, selegiline was reported not to significantly impact cognition in a large sample of untreated patients with early PD (114). Surgical Interventions Ablative Surgeries Ablative surgical interventions for treatment of PD involve stereotactic procedures in which lesions are placed in the globus pallidus, thalamus, or subthalamic nucleus to reduce motor symptoms. Cognitive and emotional outcomes after ablative procedures for PD in the 1950s and 1960s are sparsely documented. Wilkinson and Troster¨ (115) pointed out that outcomes in early and more recent studies are difficult to compare for a Copyright 2003 by Marcel Dekker, Inc. In general, however, modern studies reveal that ablative procedures such as pallidotomy, thalamotomy, and subthalamotomy (especially unilateral) are relatively safe from a cognitive perspective. With regard to unilateral pallidotomy, declines in verbal fluency performance have been reported in approximately 75% of outcome studies that included a measure of verbal fluency (48,116–118). Postoperative decrements on measures of attention, memory, and executive functions (typically mild and transient) have been reported occasionally, and significant cognitive complications even more rarely (for review, see Refs. Preexisting cognitive impairment, advanced age, and dominant hemisphere surgery have been proposed as increasing the risk for postoperative cognitive decline. Few formal neuropsychological studies of bilateral pallidotomy have been undertaken, despite the observation that the most frequent adverse events among such patients are declines in speech and cognition (120). Remarkably, despite their small number, these studies yield inconsistent findings. While some suggest that cognitive declines after bilateral pallidotomy may be limited in scope and severity (121,122) or, indeed, that some gains in memory might be observed (123), others report marked morbidity (124,125). Although early studies examining outcomes after thalamotomy reported decrements in language and memory with regularity (see Ref. Initial reports of the apparent cognitive safety of subthalamotomy (128,129) remain to be confirmed by larger, controlled studies.

How would you monitor his recovery and determine whether he should return to play? As a result 3mg ivermectin, he is taken to the regional neurosurgical centre where a craniotomy for intracranial pressure control is required cheap ivermectin 3 mg on-line. He recovers and the skull defect is closed successfully order ivermectin 3mg with amex. His GCS is 15 and he has no focal neurological signs ivermectin 3 mg low price. How do you approach the problem and what advice would you give? He is worried that repeated heading may cause him to be “punch drunk” in later life. Are there any tests that could assist you in advising him? Concussion: State of the art review Part 1: Experimental science. Apolipoprotein E epsilon 4 associated with chronic traumatic brain injury in boxing. Sparring and cognitive function in professional boxers. Genetic susceptibility to brain injury in sports: A role for genetic testing in athletes? Guidelines for return to contact sports after cerebral concussion. Guidelines for the prevention of catastrophic outcome. Mechanisms and pathophysiology of cerebral concussion. Traumatically induced axonal damage: evidence for enduring changes in axolemmal permeability with associated cytoskeletal change. The neurochemical and metabolic cascade following brain injury: moving from animal models to man. Closed head injury: psychological, social and family consequences. Neurobehavioural Consequences of Closed Head Injury. Clinical and neuropsychological aspects of closed head injury. Delayed recovery of intellectual function following minor head injury. Performance changes during recovery from closed head injury. Paced auditory serial addition task: a measure of recovery from concussion. Duration of post-traumatic amnesia after mild head injury. Memory and information processing capacity after closed head injury. Cumulative and persisting effects of concussion on attention and cognition. Neuropsychological and psychological consequences of minor head injury. Persisting effects of minor head injury observable during hypoxic stress. Neuropsychological deficits in symptomatic minor head injury patients after concussion and mild concussion. Neurobehavioural outcome following minor head injury: a three centre study.

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