Original Paper Dermatology 2014;228:78–85 DOI: 10.1159/000357220
Received: May 2, 2013 Accepted after revision: November 9, 2013 Published online: January 11, 2014
Mild Cognitive Impairment in Patients with Moderate to Severe Chronic Plaque Psoriasis Paolo Gisondi a Francesca Sala b Franco Alessandrini c Virginia Avesani b Giada Zoccatelli c Alberto Beltramello c Giuseppe Moretto b Giuseppe Gambina c Giampiero Girolomoni a a
Section of Dermatology and Venereology, Department of Medicine, University of Verona, and b Center for Alzheimer and Cognitive Diseases, Unit of Neurology, and c Neuroradiology Service, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
Abstract Background: Psoriasis is frequently associated with cardiometabolic comorbidities and depression that are risk factors for cognitive impairment. Objective: To investigate cognitive performance in psoriatic patients. Method: Cognitive performances were assessed by neuropsychological tests in 41 patients with psoriasis and 37 controls. Diagnostic criteria for mild cognitive impairment (MCI) were (1) subjective complaint of a memory deficit, confirmed by a relative or caregiver, (2) pathological performance on neuropsychological tests investigating cognitive domains, (3) normal performance of daily living activities and (4) no dementia. Neuroimaging was studied by high-field magnetic resonance imaging and cortical thickness analysis. Results: MCI was found in 18 out of 41 (44%) patients with psoriasis compared to 4 out of 37 (11%) controls (p = 0.002). In particular, patients with psoriasis had lower scores in the delayed recall of the Rey Auditory Verbal Learning Test (p = 0.04), Backwards Digit Span Test (p = 0.002), Weigl’s Sorting Test (p = 0.01) and
© 2014 S. Karger AG, Basel 1018–8665/14/2281–0078$39.50/0 E-Mail [email protected] www.karger.com/drm
Trail Making Test B (p = 0.008). In the 7 patients submitted to cortical thickness analysis, a reduction in brain thickness in parahippocampal, superior temporal and frontal gyri of the left hemisphere was observed. Conclusions: Patients with psoriasis may have a precocious impairment of long-term verbal memory, executive functions and attention. © 2014 S. Karger AG, Basel
Introduction
Psoriasis is a chronic inflammatory disease which is often associated with features of the metabolic syndrome, including obesity, diabetes and dyslipidemia [1–3]. Patients with psoriasis commonly present unhealthy life behaviors such as heavy smoking and drinking which are generally correlated with psoriasis severity and/or exacerbation [4, 5]. Psoriasis is also frequently associated with psychological distress and depression [6]. All of the aforementioned conditions likely confer to patients with psoriasis a high risk of developing major cardiovascular events including stroke and also cognitive impairment [7, 8].
Dr. Paolo Gisondi Department of Medicine, Section of Dermatology and Venereology University of Verona Piazzale A. Stefani 1, IT–37126 Verona (Italy) E-Mail paolo.gisondi @ univr.it
Downloaded by: University of Wollongong 130.130.37.84 - 5/18/2016 4:00:47 PM
Key Words Psoriasis · Mild cognitive impairment · Brain imaging · Diffusion tensor imaging · Dementia screening
Methods Psoriasis and Comorbidity Evaluation Subjects were visited by a dermatologist who registered demographic data, psoriasis severity and comorbid conditions. Hypertension was diagnosed if the participants were taking antihypertensive medications, if a physician had ever told them that they had hypertension, or if the average of 3 blood pressure readings was superior to 140/90 mm Hg. Noninvasive brachial blood pressure was measured 3 times within a 15-min time frame using a traditional sphygmomanometer on the left arm of the subject who was in the supine position. Symptoms of depression were investigated using the Beck Depression Inventory [18]. Subjects were defined as having diabetes mellitus if they were taking hypoglycemic medications, had a fasting plasma glucose concentration >5.9 mmol/l or if a physician had ever told them that they had diabetes. The hypertriglyceridemia and hypercholesterolemia diagnoses were confirmed if serum triglycerides were ≥1.7 mmol/l and total cholesterol was ≥4.9 mmol/l and/or if patients were prescribed fibrates or statins. Venous blood was drawn in the morning after an overnight fast. Serum lipids and glucose were determined by standard laboratory procedures (DAX 96, Bayer Diagnostics, Milan, Italy). Circulating levels of CRP were measured by a nephelometric assay on a Behring Nephelometer II. The CRP serum level was expressed as milligrams per liter with levels >5 considered above the normal
Psoriasis and Cognitive Functions
range. Plasma levels of total homocysteine (including free and protein-bound homocysteine) were measured by an HPLC method, and plasma levels of folic acid were measured by an immune-enzyme assay (microparticle enzyme immunoassay method). Homocysteine serum levels were expressed as micromoles per liter with levels >15 considered above the normal range. The folic acid serum level was expressed as nanomoles per liter with a normal range of 5–25. Body weight was measured to the nearest 0.1 kg (Salus, Milan, Italy) and height to the nearest 0.5 cm with a stadiometer (Salus) while the subjects were wearing light indoor clothing and no shoes. The body mass index was calculated as body weight divided by stature squared. The level of education of subjects was measured reporting years of formal education received while attending primary and/or secondary school and/or university. Current smokers were defined as participants who smoked cigarettes daily or who had stopped smoking
Received: May 2, 2013 Accepted after revision: November 9, 2013 Published online: January 11, 2014
Mild Cognitive Impairment in Patients with Moderate to Severe Chronic Plaque Psoriasis Paolo Gisondi a Francesca Sala b Franco Alessandrini c Virginia Avesani b Giada Zoccatelli c Alberto Beltramello c Giuseppe Moretto b Giuseppe Gambina c Giampiero Girolomoni a a
Section of Dermatology and Venereology, Department of Medicine, University of Verona, and b Center for Alzheimer and Cognitive Diseases, Unit of Neurology, and c Neuroradiology Service, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
Abstract Background: Psoriasis is frequently associated with cardiometabolic comorbidities and depression that are risk factors for cognitive impairment. Objective: To investigate cognitive performance in psoriatic patients. Method: Cognitive performances were assessed by neuropsychological tests in 41 patients with psoriasis and 37 controls. Diagnostic criteria for mild cognitive impairment (MCI) were (1) subjective complaint of a memory deficit, confirmed by a relative or caregiver, (2) pathological performance on neuropsychological tests investigating cognitive domains, (3) normal performance of daily living activities and (4) no dementia. Neuroimaging was studied by high-field magnetic resonance imaging and cortical thickness analysis. Results: MCI was found in 18 out of 41 (44%) patients with psoriasis compared to 4 out of 37 (11%) controls (p = 0.002). In particular, patients with psoriasis had lower scores in the delayed recall of the Rey Auditory Verbal Learning Test (p = 0.04), Backwards Digit Span Test (p = 0.002), Weigl’s Sorting Test (p = 0.01) and
© 2014 S. Karger AG, Basel 1018–8665/14/2281–0078$39.50/0 E-Mail [email protected] www.karger.com/drm
Trail Making Test B (p = 0.008). In the 7 patients submitted to cortical thickness analysis, a reduction in brain thickness in parahippocampal, superior temporal and frontal gyri of the left hemisphere was observed. Conclusions: Patients with psoriasis may have a precocious impairment of long-term verbal memory, executive functions and attention. © 2014 S. Karger AG, Basel
Introduction
Psoriasis is a chronic inflammatory disease which is often associated with features of the metabolic syndrome, including obesity, diabetes and dyslipidemia [1–3]. Patients with psoriasis commonly present unhealthy life behaviors such as heavy smoking and drinking which are generally correlated with psoriasis severity and/or exacerbation [4, 5]. Psoriasis is also frequently associated with psychological distress and depression [6]. All of the aforementioned conditions likely confer to patients with psoriasis a high risk of developing major cardiovascular events including stroke and also cognitive impairment [7, 8].
Dr. Paolo Gisondi Department of Medicine, Section of Dermatology and Venereology University of Verona Piazzale A. Stefani 1, IT–37126 Verona (Italy) E-Mail paolo.gisondi @ univr.it
Downloaded by: University of Wollongong 130.130.37.84 - 5/18/2016 4:00:47 PM
Key Words Psoriasis · Mild cognitive impairment · Brain imaging · Diffusion tensor imaging · Dementia screening
Methods Psoriasis and Comorbidity Evaluation Subjects were visited by a dermatologist who registered demographic data, psoriasis severity and comorbid conditions. Hypertension was diagnosed if the participants were taking antihypertensive medications, if a physician had ever told them that they had hypertension, or if the average of 3 blood pressure readings was superior to 140/90 mm Hg. Noninvasive brachial blood pressure was measured 3 times within a 15-min time frame using a traditional sphygmomanometer on the left arm of the subject who was in the supine position. Symptoms of depression were investigated using the Beck Depression Inventory [18]. Subjects were defined as having diabetes mellitus if they were taking hypoglycemic medications, had a fasting plasma glucose concentration >5.9 mmol/l or if a physician had ever told them that they had diabetes. The hypertriglyceridemia and hypercholesterolemia diagnoses were confirmed if serum triglycerides were ≥1.7 mmol/l and total cholesterol was ≥4.9 mmol/l and/or if patients were prescribed fibrates or statins. Venous blood was drawn in the morning after an overnight fast. Serum lipids and glucose were determined by standard laboratory procedures (DAX 96, Bayer Diagnostics, Milan, Italy). Circulating levels of CRP were measured by a nephelometric assay on a Behring Nephelometer II. The CRP serum level was expressed as milligrams per liter with levels >5 considered above the normal
Psoriasis and Cognitive Functions
range. Plasma levels of total homocysteine (including free and protein-bound homocysteine) were measured by an HPLC method, and plasma levels of folic acid were measured by an immune-enzyme assay (microparticle enzyme immunoassay method). Homocysteine serum levels were expressed as micromoles per liter with levels >15 considered above the normal range. The folic acid serum level was expressed as nanomoles per liter with a normal range of 5–25. Body weight was measured to the nearest 0.1 kg (Salus, Milan, Italy) and height to the nearest 0.5 cm with a stadiometer (Salus) while the subjects were wearing light indoor clothing and no shoes. The body mass index was calculated as body weight divided by stature squared. The level of education of subjects was measured reporting years of formal education received while attending primary and/or secondary school and/or university. Current smokers were defined as participants who smoked cigarettes daily or who had stopped smoking
