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10TH CONTINUING MEDICAL

EDUCATION ON NEUROLOGY
POST STROKE
COGNITIVE &
BEHAVIOR
IMPAIRMENT
STROKE Death

40.6 per 100.000

Physical RISKESDAS 2013

30% population
in the world Disability

Fungsi
Behavior Cognition
Eksekutif
Subtype 1: large vessel Subtype II:. Subtype III
occlusion •Arteriolosclerosis, lipohyalinosis, • ‘strategic’ infarction
• Atherothromboembolism hypertensive, arteriosclerotic, (thalamus and hippocampus)
• Artery-to-artery, embolism or amyloid or collagen angiopathy • Cardioembolism and
cardioembolism. •40-50% intracranial small vessel
• 20-40% •Hypertension, DM, hyperlipidaemia, disease
• Hypertension, carotid artery hyperhomocysteinaemia, CKD, • 10-15%
disease or atherosclerosis, AF infection and OSA, obesity, smoking,
and CAD •Most of stroke survival
Kalaria, Biochimica et Biophysica Acta 1862 (2016)
AD and Stroke Sharing Common Risk Factors
• Hypertension, diabetes, smoking,
hypercholesterolemia, heavy alcohol
consumption and APOE4 isoforms.
• CVD increases the risk of developing AD
dementia or vascular dementia by 3x
• Hypertension is a consistent CVD risk
factor for developing stroke and dementia.

Kapasi. Biochimica et Biophysica Acta xxx (2016)


Erkinjunti et al. J Neural Trasam 2000
Kapasi A et al. Vascular contributions to cognitive impairment, clinical Alzheimer's
disease, and dementia in older persons. Biochim Biophys Acta. 1862;2016:878–86.
FRONTAL SUBCORTICAL CIRCUIT
Dysexecutive Function APATHY DISINHIBITION

Dorsolateral Medial prefrontal Orbital prefrontal


prefrontal
Dopamin, Noradrenergik

Dopamin, Serotonin,&
Dopamin & Asetilkolin

Noradrenergik
Nukleus kaudatus Nukleus akumbens Nukleus kaudatus

Globus palidus Globus palidus Globus palidus

Talamus Talamus Talamus

FAB ; TMT A&B AES FAB


Pathogenic Factors Causing Vascular Cognitive
Impairment / Vascular dementia.

Kurt A Jellinger Front. Aging Neurosci., 10 April 2013


Prevalence of Post-stroke Behavior Symptoms
Prevalence of Post-stroke Cognitive Impairment
 Three months cross sectional study, started June 2016
Target: Preliminary clinical epidemiological data
 Sites involved: city of Bandung & Kupang (4 hospitals)
155 stroke subjects (2-36 months post-stroke)
(ICH: 11, Embolic stroke 10; aterotrombotic /lacuner stroke: 134)
Assessment: NPI & MOCA-Ina
Cognitive Function Frequency Percent

PSCI (MoCA-INA <24) 123


79.4
Non PSCI (MoCA-INA
32 20.6
>=24)
Total 155 100.0

PSC=Post stroke cognitive impairment= Post stroke neurocognitive disorders


Prevalence: 20% to 80%

•Sun. Annual of Translational Medicine Vol 2, No 8 (August 2014)


Pattern & Severity of PSCI
Paulus Anam Ong MD,
International Symposium on Neurocognitive Disorders
Singapore 2015
7. Apathy/Indifference
8. Disinhibition
9. Irritability/Lability
10. Aberrant motor behavior
11. Sleep/Nighttime Behavio
Disorders
12. Appetite and Eating
Disorders
Neuropsychiatric Inventory. Comprehensive Assessment of Psychopathology in Patients with Dementia. UCLA 2009
NUMBER OF SYMPTOMS PERCENTAGE (%)
0 23,53
1 17,65
2 7,84
3 13,73 76.47%
4 3,92
5 7,84
6 9,80
7 1,96
8 3,92
9 7,84
10 0,00
11 1,96
Percentage

45.2

38.1 38.06
35.5
32.9
31
27.7
23.9

14.8 15.5
13.5
9
First ever stroke
Recurrent stroke
Abe’s BPSD Score-Ina
(Diadaptasi dan disesuaikan oleh Anam, 2017)

Nama Pasien : Tgl Pemeriksaan : / /


Tanggal lahir : / / N ama Informan :
No. Med.Rec : Hubungan dgn pasien:

Pertanyaan Jarang Sesekali Kadang- Sering


No. Contreng satu dari keempat pilihan disamping (Kurang (Sebulan kadang (Sekali
dari sekali sekali atau (Sekali sehari
sesuai kejadian gangguan perilaku di bawah ini dalam lebih) atau
seminggu
setahun) atau lebih) lebih)
1 Mondar-mandir di dalam/diluar rumah 0 3 6 9
Apakah pasien bolak-balik tanpa tujuan yang jelas?
2 Masalah makan dan toilet 0 3 6 9
Apakah dia mengalami perubahan nafsu makan, berat
badan, atau kebiasaan makan (Tidak usah dijawab bila
pasien tidak bisa makan sendiri/harus disuapi).
Apakah ada perubahan dalam jenis makanan yang disukai
atau perubahan dalam buang air besar/kecil?
3 Delusi dan halusinasi 0 2 4 6
Apakah dia memiliki keyakinan yang menurut saudara
tidak benar (misalnya ada orang berniat
mencelakai/mencuri miliknya? Berkata bahwa anggota
keluarga bukan mereka lagi atau rumah bukan rumah
mereka? Kelihatan seperti sedang melihat/mendengar,
atau mengalami sesuatu yang sebenarnya tidak ada?
4 Berbicara kasar/menyinggung perasaan 0 2 4 6
Apakah dia berteriak, mengutuk, atau berbicara kasar?
5 Terbalik siang dan malam 0 2 4 6
Apakah dia kesulitan memulai tidur, mondar-mandir/
melakukan aktivitas yang tidak sesuai pada malam hari
atau tidur berlebihan pada siang hari?
6 Eksitasi dan agitasi 0 1 2 3
Apakah dia mudah marah kepada orang yang coba
mengurusnya/menolak mandi, ganti pakaian? Keras
kepala dan bertindak semaunya sendiri?
7 Apati dan acuh tak acuh 0 0 1 2
Apakah dia telah kehilangan minat terhadap lingkungan
sekitarnya/mengerjakan sesuatu? Kurang motivasi
memulai aktivitas baru? Sulit terlibat dalam percakapan,
pekerjaan rumah tangga, atau apatis dan acuh tak acuh?
8 Depresi dan murung 0 0 0 1
Apakah dia berkata atau berperilaku seoalah-olah dia
sedang sedih atau depresi?
9 Tindakan kekerasan 0 0 0 1
Apakah dia mencoba menyakiti/memukul orang lain?
10 Mudah tersinggung 0 0 0 1
Apakah dia mudah tersinggung/sakit hati? Suasana hati
cepat berubah? Tidak sabar berlebihan?
Skor Total /44
Cognitively Impaired Cognitively Normal

APPETITE
NIGHTTIME BEHAVIOR
ABERRANT MOTOR BEHAVIOR
IRRITABILITY
DISINHIBITION
APATHY
ELATION
ANXIETY
DEPRESSION
AGITATION
HALLUCINATION
DELUSION
Anam, 2017
0 10 20 30 40 50
Medication Level of Comments Recommendation
Evidence
Donepezil Class IIa, level Modest benefit for cognitive scores, less Donepezil can be used to
A, for pure^ strong evidence for functional improve cognition in VaD
improvement. Doses studied: 5 and 10
VaD mg/day.
Galantamine Class IIa, level Modest benefit in cognitive measures in Galantamine can be used
A For mixed pure VaD. Benefit in both cognition and to improve cognition and
function in mixed dementia. Doses functional abilities in
dementia; studied; titration up to 24 mg/day. mixed dementia
class IIb for (AD+VaD)
Pure VaD
Rivastigmine Class IIa, level Modest benefit on cognitive measures in Rivastigmine can be used
Memantine Afor "pure" VaD pure VaD. Doses studied: 1–4 and 6– to improve cognition in
12mg/day. Modest cognitive benefits VaD. Role of Memantine
only. Doses studied; titration up to 20 in VaD yet to be clarified
mg/day
ARTEMIDA Trial
(A Randomized Trial of Efficacy, 12 Months International Double-Blind Actovegin)
Alla Guekht; Ingmar Skoog; Sally Edmundson; Vladimir Zakharov; Amos D. Korczyn,
Stroke. 2017;48:1262-1270

• Aim to assess benefit of Actovegin in The primary end point: change from
patients who have had an ischemic baseline in ADAS-Cog score
stroke 5-7 days before.
•Patients ≥ 60 years of age with a MOCA
score of ≤ 25 points

Actovegin group:
248 patients (2000mg/day) i.v. infusion
for 7days followed by 1200-mg tablets to
12 months)
3 6 12
Placebo group:
255 patients with standard treatment for
12 months)
ARTEMIDA Trial
Stroke. 2017;48:1262-1270

• Actovegin had a beneficial


effect on cognitive outcomes in
patients with PSCI
• Actovegin is safe and tolerable
Compare to treated group, treatment naïve group has a significant lower Global and all
domain of cognition; with more confluent White Matter Hyperintensity Lesion (Fazekas
score) and higher Global Cortical Atrophy score (Chrismanity, Anam, Ganiem 2015)
• Five studies (3RCTs + 2 Case-control)
• Encompassing 54.678 subjects
ALA
treatment
on BDNF ALA treatment
protein on neurogenesis
levels.
1. von Gunten A, Schlaefke S, Uberla K. World J Biol Psychiatry. 2015;27:1–12.
2. Chen N, Yang M, Guo J, Zhou M, Zhu C, He L. Cochrane Database Syst Rev.
2013;1, CD008900.
3. Guekht AB. J Stroke Cerebrovasc Dis. 2011;20:310–8.
Xu at al, Efficacy and feasibility of antidepressant treatment in patients with post-stroke depression
Medicine (Baltimore). 2016 Nov; 95(45): e5349.
• A total of N = 658 participants were
involved in the included 12 studies
• Alzheimer’s disease, vascular dementia,
mixed type dementia, Lewy body
dementia, and frontotemporal dementia

Other effect of music intervention:


Depression (Ueda, 2013; Raglio et al, 2015)
Anxiety (Sung et al 2012)
Cognitive function & QoL (Raglio, 2015)
Pedersen (2017)., Frontier in Psychology(8); Ueda, T.,(2013) Ageing Res. Rev. 12, 628–641; Sung, H. C (2012). Int. J. Geriatr.
Psychol. 27, 621–627; Raglio, A., (2015). J. Am. Geriatr. Soc. 63,
Low-frequency rTMS in VaD model
rats improve learning & memory,
protect pyramidal cells from apoptosis,
and promote hippocampal synaptic
plasticity [YangHY 2015].
Behavioural Brain Research, vol. 281, pp.
149–155, 2015.Neuron, vol. 66, no. 2,
pp. 198–204, 2010.
Author(s): Deng Min, Wang Xu-Feng, Curr Neurovasc Res. 2016;13:230–8.
Alzheimer’s & Dementia 9 (2013) 657–665
Conclusion:
Multidomain intervention could
improve or maintain cognitive
functioning in at-risk elderly people
from the general population

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