18756_Psicopatologia_13_3:18756_sfk 6/2/09 15:12 P gina 219 Revista de Psicopatología y Psicología Clínica Vol. 13, N.º 3, pp. 219-228, 2008 de Psicología Clínica y Psicopatología NEUROPSYCHOLOGICAL EVALUATION AND COGNITIVE EVOLUTION Facultad de Psicología,Universidad Nacional de Educación a Distancia, Madrid Abstract: We present the case of a university-educated bilingual (Italian-Spanish) Alzheimer patient
aged 61. After a neuropsychological assessment carried out at the Applied Psychology Service of
the Faculty of Psychology at the Universidad Nacional de Educación a Distancia (UNED), an in-
dividualized integral cognitive stimulation program was started that lasted three years. The interest
of this case lies in the fact that the progress of this patient in the two languages was followed through
a series of cognitive tasks (mainly linguistic and categorization). The results show that, as the ill-
ness develops, the patient cannot separate both languages and interferences appear. His first language
remains intact for a longer period of time, as studies of this type have shown.
Keywords: Alzheimer’s disease, neuropsychological assessment, bilingualism, semantic knowledge.
Evaluación neuropsicológica y evolución cognitiva de un enfermo de Alzheimer bilingüe Resumen: Presentamos el caso de un paciente de Alzheimer bilingüe (italiano-español) de 61 años
con estudios universitarios. Tras la evaluación neuropsicológica realizada en el Servicio de Psico-
logía Aplicada (SPA) de la Universidad Nacional de Educación a Distancia (UNED), se inició un
programa de estimulación cognitiva individualizada que duró tres años. El interés de este caso ra-
dica en el hecho de que la evolución del paciente en las dos lenguas fue seguida a través de una se-
rie de tareas cognitivas (principalmente lingüísticas y de categorización). Los resultados muestran
que, según avanza la enfermedad, el paciente no puede separar ambas lenguas y ocurren las inter-
ferencias. Su primera lengua se conserva durante un mayor periodo de tiempo, como los estudios
de este tipo han mostrado.
Palabras clave: Demencia tipo Alzheimer, evaluación neuropsicológica, bilingüismo, conocimiento
namics of neurotransmission when faced withadverse conditions, even in old age. This ca- The scientific basis of non-pharmacological pacity has been demonstrated in cases of de- intervention was summarized, albeit metaphor- mentia, although with lower intensity (Kavira- ically, by Santiago Ramón y Cajal, who said jan and Olazarán, 2005; Orrell, 2003). Therefore, that we are all capable of being the sculptor of it seems logical to think that cognitive stimula- our own brain. This idea is included in the term tion can favour cerebral plasticity and thus main- «neuroplasticity» proposed by Geschwind and tain, if not recover, the cognitive functions which Nottebohm (1985), who referred to the brain’s have been preserved. An intervention programme capacity to adapt, regulate, and remodel the dy- should not only promote greater cognitive func-tion, which allows the patient more autonomy fora longer period of time, but it should also improve Recibido 5 December 2007; accepted 4 July 2008 the patient’s self-esteem and feeling of worth.
Correspondencia: Carmen Díaz, UNED, Facultad de Psico- The study of bilingual individuals with cere- logía, Dpto. Psicología Básica I, Juan del Rosal, 10, 28040 bral lesions and the importance of these lesions in the organization of language have been the Agradecimientos: Este trabajo ha sido posible por la inesti- focus of research during recent years, although mable colaboración de F.P. y su familia. Financiado en partepor los proyectos de invstigación del MEC, SEJ 2004-04233 this area was already being examined during the first half of the 19th century (Lorch, 2007).
18756_Psicopatologia_13_3:18756_sfk 6/2/09 15:12 P gina 220 Few studies examine the linguistic-cognitive er tasks. However, what is not known is exact- function in bilingual Alzheimer’s patients in terms ly why this occurs, although three different the- of disease progression and the intervention to ories exist. One alludes to a greater semantic be adopted. In one of the few studies of this type, overlap (i.e. the shared semantic features of cog- De Vreese, Motta, and Toschi (1988) conclude nate words), another defends the existence of that, in patients suffering from dementia, the only one lexical entry shared by both languages, comprehension and production of the mother and the third attributes it to a phonological over- tongue is preserved longer than the comprehen- sion and production of a second or third lan- The production of speech in bilingual sub- guage, but that cognitive stimulation programmes jects is generally studied through different lan- should be carried out in both languages.
guage tasks and tasks of linguistic interference In the production of speech, a bilingual sub- between drawings and words. The variables that ject uses at least two types of processes and are usually measured are correct answers/errors mechanisms: attentional and linguistic. The at- tentional mechanism deals with the control that In the present study, which was carried out the bilingual subject needs to have in order to in the context of a non-specific cognitive in- speak in the language required by the commu- tervention programme, we addressed a wide nicative exchange at a given time, without al- series of cognitive processes in the framework lowing the second language to surface or inter- of language interventions, with special em- fere. It is therefore assumed that bilingual subjects phasis on the lexical-semantic level, because have greater cognitive flexibility than monolin- one of the key questions in the linguistic and gual subjects due to the fact that they regularly cognitive area of knowledge of bilingual sub- change the language they express themselves in.
jects is whether their conceptual representa- This has brought about the idea that the process- tions are shared between the two languages. In es involved in the control of execution are more order to answer this question, we designed clas- developed in bilingual subjects than in mono- sification and categorization tasks to verify lingual subjects. Therefore, in old age, when whether the results were the same in both lan- these processes tend to relax and, consequently, guages, regardless of the language in which the have less control of inhibition, the bilingual sub- ject will, to a certain extent, be protected against Given the results of the study by De Vreese a possible impairment in executive control (Byal- et al. (1988), we expected the patient to main- istock, Craik, Klein, and Viswanathan, 2004).
tain linguistic competence in the first language The linguistic processes involved have phono- for longer than the second, which is the one gen- logical, lexical, syntactic, and semantic compo- erally used by the patient, even if more intensive nents. The importance of bilingualism as a fac- stimulation in Spanish (second language) can tor that helps to stabilize cognitive functioning reduce the rate at which it is lost. This study is was recently analysed by Byalistock, Craik, and observational and descriptive, although a large Freedman (2007), who suggest that bilingual- number of semi-experimental tasks and neu- ism could help to delay the symptoms of de- Methodological difficulties arise when mak- The variables involved in bilingual speech ing inferences from the data of only one sub- production include the similarity between the ject. Other authors (Crawford, Garthwaite, Az- languages and the degree of bilingualism that zalini, Howell and Laws, 2006) recently analysed comes from the level of competence in the sec- these difficulties and offered methodological ond language, depending on when it was learnt.
solutions, although always with a significantly In the first case, it appears that cognate (simi- large control group. In our case—a bilingual lar or even identical) rather than non-cognate Alzheimer’s patient—obtaining a control group words e.g. ¨gallina¨ in Spanish and ¨gallina¨ in Italian, facilitate lexical access. This is seen in The aims of this study were to evaluate the de- the minor errors that occur in naming and oth- velopment of the subject’s two languages whilst Revista de Psicopatología y Psicología Clínica 2008, Vol. 13 (3), 219-228 Asociación Española de Psicología Clínica y Psicopatología 18756_Psicopatologia_13_3:18756_sfk 6/2/09 15:12 P gina 221 Neuropsychological evaluation and cognitive evolution of a bilingual alzheimer patient his illness progressed, and to monitor the course mild AD at the Hospital Clínico, Madrid. He of the semantic-conceptual knowledge of the sub- took part in the hospital’s AD immunization ject in relation to the decline in both languages.
project from November 2001 until March 2002,when the project was suspended. During thisperiod, he received no treatment whatsoever.
The main problems reported by the patient andhis wife, from diagnosis until suspension of the immunization project, were difficulties withlearning, recent episodic memory, written and The patient was a right-handed male aged 61 verbal comprehension, arithmetic calculation, years old at baseline. He was diagnosed with probable Alzheimer’s disease (AD) in October The patient is Italian, but, since he was a 2001 at the Neurological Department, Hospital teenager he has lived in Spain, where he obtained a diploma in law and a degree in economics. Hewas the sales manager of an international com-pany and when his condition was diagnosed he was not working. His two children live at home.
He has not experienced behavioural changes and The patient suffered a reactive depression af- has shown himself to be enthusiastic, sociable, ter a conflictive labour situation in 1995 and, and optimistic from as early as his first inter- consequently, stopped work. He visited his doc- view. He uses Spanish in his daily life with fam- tor in 1997 because he had experienced episodes ily, neighbours, and friends, but uses Italian when of forgetfulness. His wife reported that the real he speaks to his mother (who lives in Madrid), cognitive difficulties began in 1999, since from this point he had episodes of forgetfulness on a The patient came to the Applied Psychology daily basis, took little part in conversations, and Service (APS) of the Faculty of Psychology at the repeated himself. In July 2001, he underwent UNED in March 2002 to start a psychological in- complementary neurological tests as a result of tervention programme and he provided the fol- the information obtained during the first inter- lowing information (see Table 1, Figure 1, and view. In October 2001 he was diagnosed with Table 1. Information provided by the patient Year 2000:Neuropsychological Tests:— March: in the Barcelona test (Peña Casanova, 1990), his scores fell within the normal range except for deferred text memory and direct and inverse series.
September: Mini Mental State Examination (MEC) (Lobo, Ezquerra, Gómez, Sala, and Seva, 1979) = 29/35.
Year 2001:Neuropsychological Tests:— June: MEC = 26/35, which suggested that the patient was suffering from possible incipient cognitive deterioration (Reis- Brain imaging results:— July: ventricular dilatation in the MRI. SPECT revealed asymmetrical lack of activity in several areas of the cerebral cortex in both hemispheres. Less uptake in nuclei at the base of the right hemisphere than on the contralateral side (seeFig. 1).
September: SPECT revealed hypoperfusion on both temporal-parietal lobes and, albeit with less intensity, on the frontal lobes. More evident on the right hemisphere. According to the report, these data are indicative of AD (see Fig. 2).
Asociación Española de Psicología Clínica y Psicopatología Revista de Psicopatología y Psicología Clínica 2008, Vol. 13 (3), 219-228 18756_Psicopatologia_13_3:18756_sfk 11/2/09 20:51 Página 222 In May 2002, the patient began treatment with Reminyl (4 mg) (galantamine), and his dose wasincreased by the Memory Unit of the GeriatricsService, Hospital Clínico San Carlos, Madrid, to12 mg in September 2002. In February 2004,he continued with the prescribed pharmacolog-ical treatment, Reminyl, at the same dose and be-gan to take Axura (memantine). He also startedtreatment with a vitamin complex, Auxina E mentioned data were collected, a complete neu- 400, an anti-platelet drug to prevent cardiovas- ropsychological assessment was made over four cular diseases, Adiro 100, Ginko Bilova and In the first session, the following areas were evaluated: general cognitive state, state of mind,level of dependence in daily activities, and abil- ity to carry out tasks. In the second session,executive function and attentional capacity, The patient was an irregular attender at group episodic and semantic memory, praxic capac- sessions of the Alzheimer’s Relatives Association ity, and level of dementia were tested (see Ta- (AFAL) in Madrid. Since January 2004, he has bles 2 and 3). The third and fourth sessions been taking fortnightly sessions of psychomotricity were dedicated exclusively to the evaluation exercises with a therapist geared towards reality of the production and comprehension of Span- orientation in his home. Since February 2005, he has been attending twice-weekly physical activi- Throughout the tests, the patient was happy ty group sessions coordinated by a therapist. with his performance and showed neither anx-iety nor frustration. At all times, he was collab-orative, empathetic, and totally willing to carry out the tests. He does not seem to have beenaware of his difficulties. In these sessions, there After the semistructured interview with the was no inter-language interference or contam- patient and his wife, during which the above- ination: he was completely able to keep both Revista de Psicopatología y Psicología Clínica 2008, Vol. 13 (3), 219-228 Asociación Española de Psicología Clínica y Psicopatología 18756_Psicopatologia_13_3:18756_sfk 6/2/09 15:12 P gina 223 Neuropsychological evaluation and cognitive evolution of a bilingual alzheimer patient Table 2. Results of the neuropsychological assessment in the first and second session evaluation — Mini Mental State Examination (MEC) (Lobo, Ezquer- Scores under 26/27 = cognitive deterioration.
— Clock Drawing Test (on order) (Cacho, García-García, Arcaya, Vicente, and Lantada, 1999).
Scores between 0 and 6 = cognitive deterioration.
— Information-Memory-Concentration-Test (Blessed, Tom- — Depression scale (GDS) (shortened version) (Yesavage — Blessed Dementia Rating Scale (Blessed, Tomlinson, Scores above 4 points = probable deterioration.
— Informer Test (shortened version) (Jorm and Korten, 1988) Informant Questionnaire on Cognitive Decline in the Eld-erly (IQCODE), Spanish version (Morales et al. 1992) — Stroop Test (Stroop, 1935) (45 seconds per card). Scores above 57 = probable cognitive deterioration.
1st card, W = 74; 2nd card, C = 34; 3rd card, WC = 12.
Errors = 0. Interference: –8.9. The means for the Spanishpopulation are: W = 113; C = 71; WC = 43. Interference = 1.73.
— Trail Making Test (CTMT) (Reitan, 1958). Version A: Time: 1’ 40»Version B: He did not understand the test. The test was sus-pended.
— Barcelona Test (Peña-Casanova, 1990): (subtests were Subtests in which the patient’s performance was below the selected according to the cognitive function to be eval- 30th percentile (probable deterioration) are shown below in — The Global Deterioration Scale (GDS) (Reisberg, Fer- Level 4-(5) Stage = moderate cognitive deterioration (Scale: — Clinical Dementia Rating (CDR) (Hughes et al. 1982).
Level 1 = mild dementia (Scale: 0 to 3).
Table 3. Subtests of the Barcelona Test with points languages separate, made decisions easily, and The results of the neuropsychological tests supported the diagnosis of probable AD ac- cording to the criteria of the National Institute of Neurological and Communicative Disorders and the Alzheimer’s Disease and Related Disorders al. 1984). Similarly, the results of the neuropsy- chological evaluation lead us to believe that the patient was in the early stages of the disease.
Reciprocal coordinationSuperimposed images The most important results were as follows: 1. Memory and learning and executive func- tion. The patient had difficulties with temporal orientation—he responded correctly to 2 of the 5 items in the temporal orientation section of the MEC (Lobo, Ezquerra, Gómez, Sala, and Asociación Española de Psicología Clínica y Psicopatología Revista de Psicopatología y Psicología Clínica 2008, Vol. 13 (3), 219-228 18756_Psicopatologia_13_3:18756_sfk 6/2/09 15:12 P gina 224 Seva, 1979) and to 3 of the 6 items from the In- (ashtray). This was corroborated by the naming formation-Memory-Concentration test (IMC) tests. In the Barcelona test, the subject lies in the (Blessed, Tomlinson, and Roth, 1968). In learn- lowest zone of the profile: he correctly named ing and episodic memory of immediate and de- 92% of the items both in Spanish and in Italian.
ferred facts, the subject responded correctly to In the Semantic Memory Evaluation Battery 1 of the 3 items in the MEC, 0 of 1 item in the (EMSDA) (Peraita, González Labra, Sánchez IMC, and 7 of 23 in immediate recall of texts, Bernardos and Galeote, 2000), he correctly named 5 of 23 in recall of texts with questions, and 6 88% of the items in Spanish and 97% of the items of 23 from the Barcelona Test in deferred mem- in Italian. The results of the tests of reading ory with and without questions (see Table 3).
logatomes, words, and text were normal in both Difficulties in learning and recall were con- languages (all answers correct). The production of firmed by the patient’s wife’s responses to the In- written language as evaluated by dictation tests formant Test (Jorm and Korten, 1988). He made was unaltered (all answers correct). In oral com- mistakes concerning historical events (2 of 4 prehension analysed using the Barcelona sub- correct answers in the IMC). The Ribot phe- tests—pointing out pictures and parts of the body nomenon—memories are lost inversely to when and comprehension of verbal orders—his result they are acquired, that is, the memories that are was within the normal range (all answers correct).
closest in time disappear first, and more remote Alteration of written comprehension was verified memories (such as memories from childhood) using the subtests of the Barcelona test on com- take longer to disappear—was also observed prehension of written orders (he scored 6 out of throughout the evaluation. As far as operative 12 in Spanish and 7 out of 12 in Italian) and com- memory was concerned, the patient’s perform- prehension of phrases and texts (he scored 6 out ance was below normal and his ability to initi- of 8 in Spanish and 7 out of 8 in Italian). ate behaviours, plan and sequence actions, andinhibit inappropriate or interfering behaviour 3. Motor function. The patient found it dif- was altered (see Table 2, points awarded in the ficult to carry out movements (apraxia) both Stroop and Trail Making tests). In the Clock unimanually and bimanually. In the subtest im- Drawing Test, he scored 3 out of 10: this indi- itating right postures, he scored 9 out of 10 (30th cates not only difficulties in executive function, percentile), and in the imitation of bilateral pos- but also difficulties in semantic and episodic tures he scored 6 out of 8 (below the 10th per- memory, attention, and capacity for abstraction. centile). In the subtest arbitrary right sequencesand in reciprocal coordination, he scored 4 out 2. Language.: The production of spontaneous of 8, but his graphic execution was normal in oral language was evaluated in Spanish and Ital- ian using three subtests of the Barcelona test (Peña-Casanova, 1990): conversation-narration, thematic 4. Perception, attention, and capacity for narration, and description. The patient maintained abstraction. The patient experienced perceptive phonological and syntactic components in both discrimination and attention difficulties in sev- languages. At the lexical level, he produced cir- eral areas of the Barcelona test: discrimination cumlocutions, confabulations, and repetitions, of superimposed images (he scored 16 out of which were confirmed mainly by the thematic 20), face matching (he scored 3 out of 6), and al- narration test. The joint evaluation of the above terations in attention capacity and in capacity tests means that the information content was poor for abstraction, as shown by the Clock Drawing both in Spanish and in Italian. In spontaneous lan- Test (he scored 3 out of 10). With regard to solv- guage, his speech was fluent and relevant, but he ing tasks involving logical opinion or capacity for could not always find the right word in Spanish— abstraction, he made mistakes in the Barcelona he said asiento (chair) instead of mesa (table), subtest similarities-abstraction (0 out of 12).
vaso (glass) instead of florero (vase)—or in Ital-ian—he said pascolo (meadow) instead of bosco In summary, the areas which the patient pre- (forest), piattino (plate) instead of possacenere served within the normal range were reading and Revista de Psicopatología y Psicología Clínica 2008, Vol. 13 (3), 219-228 Asociación Española de Psicología Clínica y Psicopatología 18756_Psicopatologia_13_3:18756_sfk 6/2/09 15:12 P gina 225 Neuropsychological evaluation and cognitive evolution of a bilingual alzheimer patient writing, both when copying and in dictation (all sult that the latter were less frequent. answers correct). Although some mistakes were Because our main objective was to ascertain observed in the semantic memory system, it was whether the conceptual representations of this less deteriorated than the (recent) episodic sys- bilingual patient were shared, we designed some tem. In fact, in two of the Barcelona subtests that identical classification tasks to be applied in evaluate the semantic system—categorical evo- each language in the corresponding sessions cation of animals and completion by denomina- (Díaz and Peraita, 2004; Díaz and Peraita, 2005). tion (in which the subject should complete sen- We designed a classification task (shopping tences where the last word was missing)—the basket) to show one of the main functions of patient had a satisfactory performance for his the semantic memory system, that is, the ca- age and level of education (50th percentile in the pacity of the subject to form groupings, rele- first test and 95th percentile in the second). vant to the logical and/or psychological and/orcontextual points of view. The patient was pre-sented with 48 colour photographs represent- Intervention sessions and follow-up evaluations ing the shopping basket—24 foods and 24 ob-jects—and he was told to make as many groups After obtaining the results of the neuropsy- of objects as he thought necessary, but to make chological evaluation, we decided to draw up an intervention programme to help stimulatethe different preserved cognitive functions andnot only intervene in those where deficits were observed. The final objective was to maintaincognitive skills and/or processes for as long as To illustrate the course of deterioration in this possible. The intervention programme was in- patient, Table 4 shows the results of some of the tegral in that it included activities from each of evaluations over time. Others could not be ap- the cognitive processes: attention, memory, lan- plied due to the cognitive problems experienced guage, executive functions, and praxia. The tech- by the patient, mainly in written and oral com- niques used were reminiscence, cognitive stim- ulation therapy, and reality orientation. A detailed The shopping basket task was applied in five explanation of this intervention programme will sessions over the three years in both languages, and the results are summarised in Table 5. The In order to avoid problems of interference be- patient’s performance in both languages was tween the two languages, sessions were carried very similar in all the sessions, as was the per- out in Spanish or in Italian, but the languages centage of correct answers in the categories of were never mixed in one session. Every attempt was made to ensure that each session in Span- As for control in both languages, at the be- ish was followed by an identical session in Ital- ginning of the cognitive intervention programme, ian. This was not always possible, with the re- no differences were detected in the performance Table 4. Evaluation results of the patient in different tests and at different points in time Note: * Subtest of the Barcelona test Asociación Española de Psicología Clínica y Psicopatología Revista de Psicopatología y Psicología Clínica 2008, Vol. 13 (3), 219-228 18756_Psicopatologia_13_3:18756_sfk 6/2/09 15:12 P gina 226 Table 5. Results in the classification task «Shopping basket» N = 48 items (24 foods and 24 objects) of the activities, regardless of the language used.
ca, puledro (pony) instead potro, garòfano (car- The patient was competent in both languages nation) instead of clavel, camicia (shirt) instead during the production of spontaneous speech of camisa, piccolo (little) instead of pequeño.
and content was adequate for the conversation- al context. As the illness progressed, he changed ished—it became impossible to get to the cen- from one language to another when he was talk- ter, thus making it necessary to use another type ing to a person, something that did not occur at of intervention—the main caregiver, the patient’s the beginning. Nevertheless, he managed a cer- wife, was extremely positive, in the sense that tain control of the situation as he only changed she was aware that her husband maintained some from one to another whilst talking to a person cognitive and emotional capacities which she who spoke both languages, not only Spanish.
had not expected. At this stage, the patient was His cognitive flexibility was excellent at the be- capable of speaking with an interlocutor, even ginning of the intervention programme as he was if the content of his conversation was very poor, capable of alternating between both languages and he maintained a connection with his im- during oral production. He did this only if the mediate and near environment. The programme other speaker did the same and was able to speak has helped him maintain a high level of effi- Spanish only when the interlocutor spoke in ciency, he felt useful, and the working sessions Spanish; therefore, he was competent in both the were rewarding for him, despite the effort. Fur- bilingual and monolingual mode. This reveals thermore, he had no important behavioural al- complex attentional control, i.e. greater capaci- ty in bilinguals to change linguistic code (Byal-istock et al. 2004; De Vreese, al. 1988).
Seven months later, we detected the intrusion of some Italian words during the tests in Span-ish and vice versa, in particular during the flu- This descriptive study has allowed us to con- ency and classification tasks. During the se- tribute more data to the field of progressive lan- mantic fluency test in Italian, we observed guage deterioration in a bilingual (Span- intrusions of words from the second language in ish/Italian) Alzheimer’s patient, by means of a the first, such as the word gallina (hen) instead follow-up within the framework of a three-year of gallina—these were cognates—corbata (tie) intervention programme. This is particularly in- instead of cravatta, and clavel (carnation) in- teresting, given that there are very few reports stead of garòfano. This had not happened pre- on this type of patient in which an evaluation viously or was extremely sporadic. From Octo- and intervention are made in both languages, a ber 2002, the errors were more obvious in the fundamental aspect if we want to determine the Spanish tasks because he answered in Italian in- real linguistic ability of a person, as pointed out stead of Spanish. Some of these intrusions were lumaca (snail) instead of caracol, formaggio Even though no comparable empirical stud- (cheese) instead of queso, espàndere (spread) ies exist, the most relevant conclusion for our ob- instead of untar, pìzzico (pinch) instead of piz- jectives is that the patient’s competence in both Revista de Psicopatología y Psicología Clínica 2008, Vol. 13 (3), 219-228 Asociación Española de Psicología Clínica y Psicopatología 18756_Psicopatologia_13_3:18756_sfk 6/2/09 15:12 P gina 227 Neuropsychological evaluation and cognitive evolution of a bilingual alzheimer patient Byalistock E., Craik, F.I.M., Klein, R., and Viswanathan, languages survived with almost no interference M. (2004). Bilingualism, aging and cognitive control: during the first three years of the disease. This Evidence from the Simon Task. Psychology and Ag- probably means that the patient sustained at- tentional control of both languages, and that this Byalistock E., Craik, F.I.M., and Freedman, M. (2007).
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Source: http://www.aepcp.net/arc/(6)%202008(3).D%C3%ADaz%20y%20Pera%C3%ADta%20(2008.RPPC).%20Neuropsychological%20evaluation%20and%20cognitive%20of%20Alzheimer.pdf

Lewis wardlaw blackman

B’rosh Hashanah yikatayvoon, uvYom tzome Kippur yaykhtaymoon…mee yekhyeh umee yamoot; mee vehkitzo oomee lo vehkitzo… “On Rosh Hashanah it is written and on Yom Kippur it is sealed … who shall live and who shall die, who will attain a full measure of life and who not.” This is the true story of Lewis Blackman as first reported in The State newspaper of Columbia, South Carolina


Merkblatt für Ärzte und Polizei FTC Haartests zum Nachweis von Betäubungsmitteln und Medikamenten (K.o.-Mitteln) Bei Routineuntersuchungen der Haare werden Opiate, einschließlich Codein und Dihydrocodein, sowie Cocain, THC (Cannabis), Amphetamin und die Designer-Drogen Methamphetamin, MDMA, MDEA und MDA nachgewiesen. Die "Treffsicherheit" ist bei den einzelnen Drogen s

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