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Hindle J.V.,Bangor University | Hindle J.V.,Betsi Cadwaladr University Health Board | Petrelli A.,University of Vechta | Petrelli A.,University of Cologne | And 3 more authors.
Movement Disorders | Year: 2013

Cognitive decline and dementia are frequent in patients with Parkinson's disease (PD). The evidence for nonpharmacological therapies in Alzheimer's disease and other dementias has been studied systematically, but the evidence is unclear for their efficacy in cognition and dementia in PD. An international collaboration produced a comprehensive, systematic review of the effectiveness and of nonpharmacological and noninvasive therapies in cognitively intact, cognitively impaired, and PD dementia groups. The interventions included cognitive rehabilitation, physical rehabilitation, exercise, and brain stimulation techniques but excluded invasive treatments, such as surgery and deep brain stimulation. The potential biases and evidence levels for controlled trials (CTs) were analyzed based on Cochrane and National Institute for Health and Clinical Excellence criteria. After exclusions, 18 studies were reviewed, including 5 studies of cognitive training, 4 of exercise and physical therapies, 4 of combined cognitive and physical interventions, and 5 of brain stimulation techniques. The methodology, study populations, interventions, outcomes, control groups, analyses, results, limitations, biases, and evidence levels of all reviewed studies were described. There were 9 CTs, including 6 randomized CTs (RCTs). Although 5 trials showed positive results, only 1 study of cognitive training achieved evidence grading of 1+ with a low risk of bias. There were no studies on PD dementia. Current research on nonpharmacological therapies for cognitive dysfunction and dementia in PD is very limited in quantity and quality. There is an urgent need for rigorous RCTs of nonpharmacological treatments for cognitive impairment and dementia in PD. © 2013 Movement Disorder Society. Source

Stutchfield P.R.,Betsi Cadwaladr University Health Board
Archives of disease in childhood. Fetal and neonatal edition | Year: 2013

To determine whether antenatal betamethasone prior to elective term caesarean section (CS) affects long term behavioural, cognitive or developmental outcome, and whether the risk of asthma or atopic disease is reduced. A questionnaire based follow-up of a multicentre randomised controlled trial (Antenatal Steroids for Term Elective Caesarean Section, BMJ 2005). Four UK study centres from the original trial. 862 participants from the four largest recruiting centres, 92% of the original study. 824 (96%) were traced and 799 (93%) were successfully contacted. Fifty-one percent (407/799) completed and returned the questionnaire. The children were aged 8-15 years (median 12.2 years, 52% girls). 386 gave consent to contact schools with 352 (91%) reports received. Questionnaires including a strengths and difficulties questionnaire, International Study of Asthma and Allergies in Childhood, general health and school performance. There were no significant differences between children whose mothers received betamethasone and controls for the mean total strengths and difficulties questionnaire scores and subscores for hyperactivity, emotional symptoms, prosocial behaviour, conduct or peer problems. 25 (12%) children whose mothers received betamethasone had reported learning difficulties compared with 27 (14%) control children. The proportion of children who achieved standard assessment tests KS2 exams level 4 or above for mathematics, English or science was similar as were the rates of ever reported wheeze (30% vs 30%), asthma (24% vs 21%), eczema (34% vs 37%) and hay fever (25% vs 27%). Antenatal betamethasone did not result in any adverse outcomes or reduction in asthma or atopy. It should be considered for elective CS at 37-38 weeks of gestation. : Original trial was preregistration, the trial publication is BMJ. 2005 Sep 24;331(7518):662. Source

Hindle J.V.,Bangor University | Hindle J.V.,Betsi Cadwaladr University Health Board
Journal of Neural Transmission | Year: 2013

Parkinson's disease (PD) has been described as an age-related disease. Ageing significantly increases the risk of psychosis and dementia. Older patients often have a complex mixture of delirium, psychosis, dementia, gait and balance problems and other comorbidities which can cause significant management problems. There are concerns about the safety and tolerability of the treatments for psychosis and dementia. Delirium is common in older Parkinson's patients and must be assessed and managed carefully. The aetiology of psychosis in Parkinson's is complex and often associated with the development of cognitive impairment. Initial adjustments of Parkinson's drugs should be considered if symptoms are intrusive. Where drug therapy is required, evidence suggests that quetiapine may be a safe initial option. There is no contraindication to the use of clozapine in older patients, with the required blood monitoring. Dementia is almost inevitable with very advanced disease and increasing age, and is associated with a marked cholinergic deficit in the brain. Cholinesterase inhibitors may be more effective in PD than in Alzheimer's disease and appear relatively safe with appropriate monitoring of the pulse. There is much less evidence for the use of memantine. There is no current evidence for the use of specific non-pharmacological therapies in the management of psychosis or dementia in PD. Due to the associated gait and balance problems, older Parkinson's patients benefit from comprehensive multi-disciplinary assessment. © 2013 Springer-Verlag Wien. Source

Crossley D.R.,Betsi Cadwaladr University Health Board
Psychiatrist | Year: 2012

This article considers why whole-person care is often aspired to but remains problematic for psychiatry. One reason is that psychiatry wants to use ideas about the self in restricted senses rather than examine the idea as a whole. In particular, this includes wider issues that interconnect values to identity, which then ambiguously get raised in clinical practice, such as questions about who it is good to be. This issue is the context behind unresolved boundary disputes in mental health around well-being, spirituality, self-esteem and recovery, and reflects broader cultural tensions about the making of modern identity best understood in a historical context. It has impacts on service design, therapeutics and training. Suggestions are made about how the self can be approached in psychiatric practice. Source

Kudlicka A.,Bangor University | Clare L.,Bangor University | Hindle J.V.,Bangor University | Hindle J.V.,Betsi Cadwaladr University Health Board
Movement Disorders | Year: 2011

Impairment of executive function (EF) is commonly reported as a feature of PD. However, the exact pattern of executive impairment remains unclear. Also, there is an ongoing discussion surrounding the definition and conceptualization of EF, which might affect the clarity of research evidence on cognition in PD. The aim of this systematic review was to describe the pattern of executive impairment in early-stage PD emerging from the research literature and to identify critical issues for improving consistency in this field. The PsychInfo, MEDLINE, Science Direct, CINAHL, and Cochrane Library databases were searched using the term "Parkinson's disease" combined with each of 14 cognitive abilities defined as representing aspects of EF. The review was limited to studies that investigated EF as the central variable in early-stage, nondemented PD patients. The review identified 33 studies of EF that were operationalized in terms of 30 abilities tested by 60 measures and variously interpreted. Many measures were used only once, so only a small part of the available research evidence could be synthesized in the meta-analysis. The meta-analysis was undertaken using data from five commonly used tests of EF drawn from 18 studies. This revealed consistent evidence for cognitive difficulties across all five EF tests. Research on EF in PD is characterized by a considerable lack of clarity with regard to measure selection and interpretation. The findings support the view that EF impairments are evident in PD. However, the clinical significance of the cognitive abnormalities reported has yet to be clarified. © 2011 Movement Disorder Society. Source

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