6:e nationella konferensen i Kognitiv Medicin, Göteborg, 29 nov 2018 Tema: Exekutiv funktionsnedsättning Vaskulär kognitiv sjukdom subtyper och exekutiv dysfunktion Anders Wallin, professor, överläkare, specialist i neurologi och psykiatri, Sahlgrenska universitetssjukhuset, Göteborg; anders.wallin@gu.se ordf Svensk Förening för Kognitiv Medicin; www.kognitivmedicin.se
Vaskulär kognitiv sjukdom ovanlig utveckling 1900-1970 Vanlig sjukdom 1970-1995 Undanskymd roll 1995- Renässans kunskapsutveckling
Vaskulär kognitiv sjukdom (vascular cognitive impairment; VCI) Definition
Kärlskador vid VCI Martin Dichgans, and Didier Leys Circ Res. 2017;120:573-591
Vävnadsskador vid VCI Martin Dichgans, and Didier Leys Circ Res. 2017;120:573-591
Neurovaskulära enheten
Vaskulär kognitiv sjukdom klassifikation VCI Vascular cognitive impairment, VCI Post stroke dementia, PSD Subcortical ischemic vascular dementia [=Subcortical small vessel dementia], SIVD Multi-infarct (cortical) dementia, MID Mixed dementias, Mix Alzheimer s disease, AD Dementia of Lewy body type, DLB Mild Major PSD SIVD MID Mix PSD-AD VCI-AD PSD-DLB VCI-DLB PSD-# VCI-# Skrobot el al., 2018
Kognitiva funktioner som påverkas till följd av kärl- och vävnadsskador o Snabbhet och uppmärksamhet o Minne och inlärning o Spatial funktion o Språk o Exekutiv funktion o Social kognition
Criteria for Behavioral and Cognitive dysexecutive syndrome Behavioral disorders Highly suggestive Global hypoactivity with apathy and/or abulia Global hyperactivity with distractability and/or psychomotor insability Stereotypes and perseverative behavior Environmental dependency (imitation and utilization behavior) Supportive deficits and developing areas Disorders of emotional control (apathy, euphoria, moria, emotional lability) Disorders of social behavior Disorders of sexual, eationg, and urinary behavior Sponataneous confabulation, reduplicative paramnesia Cognitive disorders Highly suggestive Response inhibition Rules deduction and generation Maintenance and shifting of sets Information generation (fluency tasks) Supportive deficits and developing areas Planning Response initiation and sustained alertness Coordination of dual tasks Episodic memory strategic processes (retrieval and memory selection) Theory of mind and metacogntive processes Godefroy et al. Ann Neurol. 2010 Dec;68(6):855-64. doi: 10.1002/ana.22117.
Poststrokedemens Resttillstånd eller progressiv sjukdom?
Post-stroke cognitive impairment: Comparison of MMSE and MoCA on executive subtests Fu et al. Geriatr Gerontol Int 2017; 17: 2329 2335.
Post-stroke cognitive impairment: Comparison of MMSE and MoCA on executive subtests Fu et al. Geriatr Gerontol Int 2017; 17: 2329 2335.
Post-stroke cognitive impairment: Comparison of MMSE and MoCA on executive subtests Conclusions The MoCA executive tasks are more sensitive in detecting executive dysfunction compared with the MMSE executive tasks. Fu et al. Geriatr Gerontol Int 2017; 17: 2329 2335.
Subcortikal småkärlssjukdom(svd) Det finns stöd för uppfattningen att subkortikal småkärlssjukdom är den vanligaste formen av vaskulär kognitiv sjukdom Penetrerande arterioler ( ekrarna i bilden) är skadade vid sjukdomen Dichgans & Leys, 2017
Research criteria for major subcortical ischemic vascular disease in clinical trials This designation incorporates two small vessel clinical entities "Binswanger's disease" and "the lacunar state". It comprises small vessel disease as the primary vascular etiology, lacunar infarct(s) and ischaemic white matter lesions as the primary type of brain lesions, and subcortical location as the primary location of lesions. The subcortical clinical syndrome is the primary clinical manifestation, a definition which still requires additional empirical data Erkinjuntti T, Inzitari D, Pantoni L, Wallin A, Scheltens P, Rockwood K, Roman GC, Chui H, Desmond DW. J Neural Transm Suppl. 2000;59:23-30.
Neuroimaging standards for research into small vessel disease and its contribution to ageing and neurodegeneration Wardlaw et al., 2013
Meta-analys VCIND
The neuropsychological profile of vascular cognitive impairment not demented: A meta analysis The neuropsychological profile of vascular cognitive impairment not demented: A meta analysis, Volume: 9, Issue: 1, Pages: 109-136, First published: 25 February 2014, DOI: (10.1111/jnp.12039)
The neuropsychological profile of vascular cognitive impairment not demented: A meta analysis The neuropsychological profile of vascular cognitive impairment not demented: A meta analysis, Volume: 9, Issue: 1, Pages: 109-136, First published: 25 February 2014, DOI: (10.1111/jnp.12039)
The neuropsychological profile of vascular cognitive impairment not demented: A meta analysis The neuropsychological profile of vascular cognitive impairment not demented: A meta analysis, Volume: 9, Issue: 1, Pages: 109-136, First published: 25 February 2014, DOI: (10.1111/jnp.12039)
Slutsatser Exekutiv dysfunktion är karaktäristisk för VCI/SSVD men inte på egen hand sjukdomsdiagnostiskt Screeninginstrument för kliniskt bruk behöver standardiseras Studier av exekutiva komponenter behöver fördjupas och relateras till kärl- och vävnadsskador, neurovaskulära störningar och nätverksavvikelser
Tack för uppmärksamheten!