CONTINUUM Lifelong Learning in Neurology最新文献

Objective: This article discusses the prevalence, pathophysiology, assessment, and management of neuropsychiatric symptoms in patients with dementia.

Latest developments: There is a growing body of evidence localizing neuropsychiatric symptoms in dementia to frontal circuits in the brain, as well as relating them to pathologic changes seen in different dementias. Although very few medications have been approved by the US Food and Drug Administration (FDA) for the treatment of neuropsychiatric symptoms in dementia, there are more clinical trials showing the benefit of antidepressants, stimulants, and antipsychotics. In line with that trend, in 2023, the FDA approved the use of brexpiprazole, an atypical antipsychotic, for the treatment of agitation in Alzheimer disease dementia.

Essential points: Neuropsychiatric symptoms are a core feature of all dementias and often emerge before cognitive symptoms manifest. They are highly clinically significant symptoms that disrupt the lives of patients and care partners and greatly influence the decision to place patients in long-term care facilities. The first line of treatment for neuropsychiatric symptoms in dementia is nonpharmacologic behavioral modification, but clinicians often must supplement this intervention with medications using an empiric approach.

Objective: This article familiarizes neurologists with the currently available CSF and plasma biomarkers for the diagnosis of dementia and diagnosis-dependent treatment decisions.

Latest developments: For Alzheimer disease, the recent US Food and Drug Administration (FDA) approval of monoclonal antibody therapy has increased the urgency of confirming the pathologic diagnosis with biomarkers before initiating therapy. The new availability of disease-modifying therapies also highlights the need for biomarkers to monitor efficacy over time. Both of these needs have been partially addressed by the emergence of improved blood-based biomarkers for Alzheimer disease. Regarding other forms of dementia, the latest development is a CSF assay for aggregated α-synuclein, which permits the biomarker confirmation of synuclein pathology in Lewy body dementia.

Essential points: CSF biomarkers for the diagnosis of Alzheimer disease, Lewy body dementia, and Creutzfeldt-Jakob disease are well established. Blood-based biomarkers for dementia diagnosis are emerging and rapidly evolving. Sensitivity and specificity for diagnosis continue to improve, and they are being incorporated into diagnostic decisions. Fluid biomarkers for monitoring the efficacy of therapy are not yet established. Because serial CSF examinations are impractical, the validation of blood-based biomarkers of disease activity will be critical for addressing this unmet need.

Abstract: Care for patients with Alzheimer disease and related neurodegenerative causes of dementia is in the midst of a transformation. Recent advancements in diagnostics and therapeutics reflect a rapidly evolving knowledge base and represent positive steps for patients and clinicians facing these progressive diseases; however, the complexities of emerging biomarkers and treatment options present challenges that will require systematic adaptations to routine care to facilitate effective incorporation of these options. This article reviews ongoing updates in the assessment and management of neurodegenerative causes of dementia, focusing on practical models for innovation that practices and health care systems can use to implement these new tools. In particular, sustainable adaptation in the field will benefit from a comprehensive approach implemented at local levels, including (1) education of clinicians and communities to refine perceptions about dementia care, (2) multifaceted stakeholder engagement to optimize infrastructure and workflows to the new era, and (3) investments in personnel to address existing and exacerbated gaps.

Objective: This article introduces the general principles of assessing, diagnosing, and managing pain relevant to neurologic practice.

Latest developments: Scientific understanding of and clinical practices related to pain and pain management are advancing. The field is remarkable for the diversity of health professions engaged in this effort, including physicians, scientists, psychologists, pharmacists, and many others. Pain classification is transforming with pending changes to the International Classification of Diseases diagnostic coding system, and pain assessment has moved toward consistent application of the biopsychosocial model. The diagnosis of pain has continued to become more sophisticated with the development of additional testing modalities, clearer classification systems, and diagnostic criteria. Pain management requires both pharmacologic and nonpharmacologic elements; systematic review evidence for both of these and interventional and surgical management are increasingly available. The context of treatment remains important given the impact of social determinants of health and limitations of access to diagnostic and treatment resources. Due to global and interprofessional collaborations as well as new research funding, the outlook is positive.

Essential points: Pain is a protean experience for humans; functional MRI (fMRI) and other research modalities show that pain perception is highly multifocal, and modulation occurs at many nervous system levels. Neurologists bring special skills to pain evaluation and management, are well equipped to appreciate both the focal and diffuse nature of pain, and can envision how pain attenuates sleep, cognitive function, mobility, motivation, and social connection. By operationalizing expert knowledge of the nervous system, implementing relevant therapies, and collaborating with diverse health professions to manage pain, neurologists can succeed at and find meaning in optimizing patient outcomes.

Objective: This article explores the multiple etiologies, diagnosis, and management of orofacial pain.

Latest developments: Published in 2019, the International Classification of Orofacial Pain has become the internationally accepted classification system for primary and secondary facial pain. New discoveries in temporomandibular disorders have demonstrated that they are far more complex than the traditional dental mechanistic point of view. A 2020 consensus report released by the National Academies of Sciences, Engineering, and Medicine entitled "Temporomandibular Disorders: Priorities for Research and Care" highlighted this paradigm shift and its importance for patient care, education, and research.

Essential points: Orofacial pain comprises many disorders with different etiologies and pathophysiologies. The subjectivity of the pain experience and the interrelated anatomy and physiology of the craniofacial area add to the complexity of diagnosis when the source and etiology of pain are not clear. As orofacial pain straddles the expertise of multiple disciplines, a multidisciplinary approach combining medication, physical therapy, and procedural and psychological strategies is essential in treating patients with orofacial pain.

Objective: This article synthesizes current knowledge on neuropathic pain, with a brief review of mechanisms, diagnostic approaches, and treatment strategies to help neurologists provide effective and individualized care for patients with this complex condition.

Latest developments: The most promising developments in peripheral neuropathic pain are related to the molecular biology of the peripheral nervous system. Systematic molecular and genetic analyses of peripheral nerve terminals and dorsal root ganglia have advanced our understanding of the genetics of function and disease of peripheral nerves, as well as their physiology and clinical manifestations.

Essential points: Peripheral neuropathic pain, similar to central neuropathic pain, is primarily influenced by the biology and pathophysiology of the underlying structures, peripheral sensory nerves, and their central pathways. The clinical course is widely variable in sensory symptoms and intensities, natural history, and response to treatments.