A COMPARISON OF SEMANTIC MEMORY IN VASCULAR DEMENTIA AND DEMENTIA OF ALZHEIMER'S TYPE

Objective. To determine whether semantic memory is impaired in vascular dementia and to assess the utility of semantic memory measures in differentiating vascular dementia from dementia of Alzheimer's type (DAT). Design. Case-control study. Patients. Ten patients with Cambridge Mental Disorders in the Elderly (CAMDEX) diagnosis of ‘definite’ mild or moderate vascular dementia (mean age 77) were individually matched with 10 patients with a CAMDEX diagnosis of ‘definite’ DAT on the basis of age, education, sex, premorbid IQ (as measured by the National Adult Reading Test) and performance on the Cambridge Cognitive Examination (CAMCOG). In addition, 10 age, sex and education matched volunteer or relative controls were assessed. Outcome measures. A detailed semantic memory test battery consisting of five subtests: category fluency, picture naming, picture sorting, word–picture matching and generation of verbal definitions. Results. Compared to normal controls, both patient groups were impaired on all subtests of the semantic battery with the exception of the word–picture matching test. No differences were found between the vascular dementia and DAT groups on any of the measures. Conclusions. Impairment of semantic memory is a feature of both vascular dementia and DAT. Tests of semantic memory appear, therefore, of little value in differentiating between these two major causes of dementia. Further work is required to determine whether the nature of the processing deficit is the same in these conditions. © 1997 John Wiley & Sons, Ltd.     

A COMPARISON OF THE CLOCK DRAWING TEST AND THE PFEIFFER SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE IN A GEROPSYCHIATRY CLINIC

Wolf-Klein and colleagues' clock drawing test (CDT) performance was compared with Pfeiffer's Short Portable Mental Status Questionnaire (Pfeiffer) scores in 145 outpatient geropsychiatry patients. Although normal CDT results were almost always associated with normal Pfeiffer scores, 21% of Pfeiffer normal individuals drew abnormal clocks. Age, but not gender or education, was significantly associated with this finding. Almost all the Pfeiffer normal subjects who drew abnormal clocks were diagnosed with primary psychiatric disorders (85%) or neurologically based organic mood and anxiety disorders (12%); only one (3%) had dementia. We suggest the discrepant performance between the CDT and Pfeiffer may result from psychiatric illness. Contributing to this may be CDT sensitivity to executive skills dysfunction. This dyscontrol can occur in patients with dementia and other neurological disorders, but also presents in some primary mental disorders. Older age may heighten this impairment. In a typical geropsychiatry clinic, the CDT will not have high specificity for Alzheimer's disease as reported by Wolf-Klein and her colleagues. This results from the presence of many patients with primary psychopathology, some of whom will draw abnormal clocks, and a limited number with dementia—particularly Alzheimer's disease. Abnormal CDT results of geropsychiatry outpatients must therefore be interpreted carefully. Additional conclusions regarding the study results are discussed. © 1997 John Wiley & Sons, Ltd.     

CHARACTERISTICS OF LANGUAGE PERFORMANCE IN FOUR GROUPS OF PATIENTS ATTENDING A MEMORY CLINIC

The article compares the performance on language assessment of four matched groups of patients attending a memory clinic. Patients with a clinical diagnosis of Alzheimer's disease and vascular dementia showed deficits on all assessments, but there were differences between the groups relating to reading comprehension, writing to dictation and word fluency. Although the worried well and depressed groups did not present with obvious language deficits, there was wide variation of performance within each group, highlighting the heterogeneity of the groups. Group scores of the worried well and depressed groups compare favourably to available published figures for normal performance. The implications of these findings and the potential role of language assessment in the differential diagnosis of the cause of memory problems are discussed.     

VASCULAR DEMENTIA AND ALZHEIMER'S DISEASE: THE UNSOLVED PROBLEM OF CLINICAL AND NEUROPSYCHOLOGICAL DIFFERENTIAL DIAGNOSIS

The definition of clinical criteria for differential diagnosis of Vascular Dementia (VaD) and Alzheimer's disease (AD) remains controversial. A large group of patients selected was affected by chronic cerebrovascular disease classified as VaD or not (VND), according to DSM IV criteria. Neuropsychological performances of VaD patients were compared with a group of patients affected by probable AD, matched for age, education, and severity of disease. The comparison of performances did not reach statistical significance in single neuropsychological tasks. The results suggest that neuropsychological examination might not clearly differentiate between VaD and AD patients; the similar pattern of cognitive impairment is probably indicative of several common pathogenetic mechanisms.     

NEUROPSYCHOLOGICAL MEASURES AND SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY IN THE DIFFERENTIATION AND CLASSIFICATION OF CEREBRAL PERFUSION DEFICITS IN ALZHEIMER'S DEMENTIA

The accurate diagnosis of Dementia of the Alzheimer's Type (DAT) continues to be an area of difficulty for the fields of neuropsychology and neurology. The introduction of new medications that appear to mediate the insidious progression of the disorder increases the need for timely differentiation of DAT from other dementia-related disorders. The present study examined the relationship between hemispheric differences in regional cerebral blood flow with corresponding lateral neuropsychological processing deficits in patients with DAT. Eighty patients with a diagnosis of DAT were administered Single Photon Emission Computerized Tomography (SPECT) scans and a battery of left and right hemisphere neuropsychological-based tasks. The results of ANOVA indicated that patients with DAT who were not suffering from perfusion deficits exhibited significantly fewer neuropsychological deficits than did patients with DAT who had perfusion deficits. The neuropsychological tests that measured verbal ability, logical memory, word-pair learning, reading, arithmetic, and visual-perceptual organization were all significantly lower in the group with perfusion deficits. Further analysis indicated that patients with left hemisphere perfusion deficits tended to have poorer neuropsychological skills than did individuals with right hemisphere perfusion deficits, diffuse perfusion deficits, and no perfusion deficits. A Stepwise Discriminant Analysis was unable to use the neuropsychological variables to classify patients accurately into perfusion deficit groups.     

ALZHEIMER'S DISEASE IN POLAND

I am not a specialist—I am simply a carer who not long ago did not even know that there was such an affliction as Alzheimer’s disease. I have been looking after my mother, who has dementia, for eight years and working part-time whenever a nurse was available. In this paper I want to share my experiences of caring in Poland and describe the growth of our local support organisations. © 1997 John Wiley & Sons, Ltd.     

DIFFERENTIAL PERFORMANCE OF ALZHEIMER'S AND VASCULAR DEMENTIA PATIENTS ON A BRIEF BATTERY OF NEUROPSYCHOLOGICAL TESTS

The purpose of this article was to examine the differences in neuropsychological test performance between groups with Alzheimer's and vascular dementia. Patients included in this study were those diagnosed with Alzheimer's Disease (AD) or Vascular Dementia (VAD) through a series of neuroradiological tests that included at a minimum a CT or MRI scan and a SPECT scan. Of the 113 AD patients, the average age was 80.08 (SD = 5.91) years and average education was 12.85 (SD = 2.88). Of the 109 VAD patients, average age was 78.67 (SD = 5.35) and average education was 13.10 (SD = 2.65). Tests included selected subtests of the WAIS-R, Word Fluency, Rey Figure, Boston Naming Test, Math, Reading, and subtests from the WMS-R. Five tests showed significant differences in favor of the VAD group: Information, Similarities, Picture Completion, WRAT Mathematics, and the Boston Naming Test. Both groups did well on Reading, while both did poorly on the Rey and Word Fluency. Although both groups did poorly on memory measures, the VAD patients showed better performance. Overall, the two groups did not differ significantly on the more complex tests, but did differ on more basic tests and all the memory tests. This pattern of similar score on complex tests and different scores on basic tests demonstrates the theory that both types of dementia affected higher, more complex skills. Differences between the groups were only apparent when basic skills were compared and were not reflected in more complex and neuropsychologically “sensitive” tests.     

IMPROVEMENT OF PICTURE RECALL BY REPETITION IN PATIENTS WITH DEMENTIA OF ALZHEIMER TYPE

The evidence for positive effects of repetition on recall performance in patients with dementia of Alzheimer type is equivocal. This may be due to the difference repetition conditions used. The aim of this study was therefore to evaluate the effects of different repetition modes on the improvement of recall performance in demented subjects. Twenty-four patients with Alzheimer type dementia and 24 control subjects with remitted depression were included in the study. Pictures were presented repeatedly using different presentation modes at a constant total presentation time. Free recall was tested repeatedly after different periods of delay (0–8 hours). Immediate and delayed list repetition significantly improved recall performance in both groups. Within-list repetition did not improve total recall in demented subjects. The repeated measurement design sensitively detected minor changes in recall performance. These were not observed using other measures of recall and recognition (hits, false alarms, indices of signal discrimination). © 1997 by John Wiley & Sons, Ltd.     

PROTON MAGNETIC RESONANCE SPECTROSCOPY IN DEMENTIA OF ALZHEIMER TYPE

Reduced N-acetyl aspartate (NAA) and increased myo-inositol (MI) levels have been reported in patients with dementia of Alzheimer type (DAT) in comparison with controls. We wished to assess the validity of these findings and to evaluate possible correlations of metabolite proportions with cognitive dysfunction in DAT. Twelve patients with DAT and 10 healthy age-matched controls were included. The severity of dementia was assessed using different scales including the Mini-Mental State Examination. MRS was performed with a conventional 1.5 Tesla scanner in a single voxel in the centrum semi-ovale (TE=30 ms or TE=136 ms TR=1500 ms). The evaluation of MRS results was limited by low interrater, intermeasurement (different echo times) and test–retest reliabilities, by a high interindividual variance and by the failure to measure absolute metabolite concentrations. These problems in mind, it was remarkable that previously reported reductions of NAA levels in patients with DAT could be reproduced in the present sample. The proportion of NAA was diminished in demented subjects in comparison with controls (37% vs 44.90%; short TE). A non-significant trend towards minor reductions of creatine, choline and MI proportions in these subjects might indicate that proportions of other metabolites necessarily increase when NAA is reduced. Cognitive dysfunction of demented subjects was significantly correlated with reductions of NAA, but not with increases of MI. Due to the present technical and methodological problems and to the non-specificity of findings, proton MRS cannot be applied to support the diagnosis of DAT in a clinical setting. © 1997 by John Wiley & Sons, Ltd.     

APOLIPOPROTEIN E GENOTYPES AND SERUM LIPID LEVELS IN ALZHEIMER'S DISEASE AND MULTI-INFARCT DEMENTIA

Objective. Assessment of apolipoprotein E genotype, serum cholesterol, triglycerides, high density lipoprotein-cholesterol and low density lipoprotein-cholesterol levels in different types of dementia. Subjects. 102 consecutive referrals to an old age psychiatry service based at Manchester were classified according to clinical criteria based on ICD 10. Results. Thirty-seven were considered to have Alzheimer's disease, 16 multi-infarct dementia and 33 to be free from dementia. Sixteen patients, in whom a definitive diagnosis could not be reached or sufficient information was not available, were excluded from the study. There was an increase in the prevalence of the Apo E4 allele in both Alzheimer's disease (χ²=3.82, p<0.05) and multi-infarct dementia (χ²=1.93, p<0.16) by Wald tests compared to individuals without dementia. The increased prevalence of the E4 Allele in multi-infarct dementia was not related to serum lipid levels. Conclusion. The hypothesis that the onset of multi-infarct dementia may be precipitated by E4's mediation of higher serum cholesterol levels is not supported by the present study. © 1997 by John Wiley & Sons, Ltd.     

THE EFFECTS OF POVERTY AND EDUCATION ON TEMPOROPARIETAL PERFUSION IN ALZHEIMER'S DISEASE: A RECONSIDERATION OF THE CEREBRAL RESERVE HYPOTHESIS

The cerebral reserve hypothesis proposes that education may provide extra brain reserve that allows an individual to cope longer before Alzheimer's disease (AD) is expressed clinically. Studies of temporoparietal (TP) blood perfusion have been used to support this hypothesis. We reconsider the reserve hypothesis by examining various models of the effects of poverty and its relationship to education on TP perfusion. Of 41 patients with ‘probable’ AD, 63% evidenced TP hypoperfusion with SPECT. When each variable was examined separately, persons with lower education (OR=4.40, 95% CI 1.09–17.73,p=0.04) and poverty (OR=5.43, 95% CI 1.37–21.62,p=0.02) were significantly less likely to have TP hypoperfusion. However, neither variable had independent effects when tested simultaneously. Neither additive (poverty+education) nor interactive (poverty×education) explanatory models of TP hypoperfusion had any additional significant explanatory power. The findings suggest that the conclusion that higher education provides a protective effect in AD may be premature, and that there is equally compelling evidence that lower education and/or poverty may diminish cerebral reserve.     

PREVALENCE AND CORRELATES OF AGGRESSIVE BEHAVIOURS OCCURRING IN PATIENTS WITH ALZHEIMER'S DISEASE

Objectives. To determine the prevalence and clinical correlates of verbal and physical aggression occurring in Alzheimer's disease sufferers. Design. A retrospective note review was performed to classify the subjects according to whether they were verbally or physically aggressive (assaultive) or non-aggressive. The characteristics of the three groups were compared. Subjects. The subjects were 262 patients who were living in non-institutional settings and had been diagnosed as suffering from dementia of Alzheimer's type. Results. Fifty-two per cent exhibited some aggressive behaviour. Ninety-one (35%) patients were reported to be verbally aggressive and a further 46 (18%) were assaultive to their carers. Male gender (relative risk 2.17, 95% confidence interval 1.11–4.17) and the presence of dyspraxia (relative risk 2.89, 95% confidence interval 1.43–5.88) both increased the likelihood of assaultive behaviour. Verbal aggression was not associated with any of the clinical features measured. Conclusion. Aggressive behaviour is a common phenomenon in AD and approximately one in five sufferers is assaultive. Assaultive behaviour is associated with male gender and dyspraxia. © 1997 by John Wiley & Sons, Ltd.     

SELEGILINE IN THE TREATMENT OF BEHAVIOURAL DISTURBANCE IN ALZHEIMER'S DISEASE

Objective. The purpose of this study was to examine the behavioural and cognitive effects of selegiline in a group of moderately behaviourally disturbed AD patients. Design. This was a 14-week randomized double-blind placebo-controlled study of selegiline (10 mg) and placebo. Setting. An outpatient clinic in an urban-based tertiary referral centre in the USA. Patients. Twenty-five outpatients meeting NINCDS criteria for probable Alzheimer's disease with associated behavioural disturbance. Measures. The Brief Psychiatric Rating Scale (BPRS), the Dementia Mood Assessment Scale (DMAS) and the Alzheimer Disease Assessment Scale (Cognitive) (ADAS-COG). Results. In the primary analysis, improvement on the BPRS and DMAS scores with selegeline treatment did not reach statistical significance. A secondary analysis using a parallel design showed a significant benefit of drug treatment on BPRS scores with a trend towards improvement on the DMAS. Among the 10 subjects who could be tested, there was a significant improvement in cognitive function on the ADAS-COG with selegiline compared to placebo. Conclusions. Short-term selegiline treatment produced an improvement in behaviour and had a significant effect on cognition in a subset of testable patients. © 1997 by John Wiley & Sons, Ltd.     

EXECUTIVE DYSFUNCTION SCREENING TEST FOR NEUROPSYCHIATRIC DISORDERS

The Analogies Understanding Test (AUT) was developed as a brief cognitive screening task of executive problem solving. A few of the test items at the beginning are “facilitated” as a means of engaging patients. Individuals with schizophrenia and mild Alzheimer's Disease (AD) made significantly less correct responses than their control groups. The schizophrenia patients, but not AD patients, made significantly more perseverations than controls on the AUT. As expected, AUT performance in schizophrenia patients correlated with the Wisconsin Card Sorting test measures. Preliminary findings suggest that the AUT test may be useful as a measure of executive dysfunction in neuropsychiatric patients.     

THE MICROSTRUCTURE OF EATING IN PEOPLE WITH DEMENTIA WHO ARE HYPERPHAGIC

Objectives. To describe (a) the nature of eating abnormalities and (b) mechanisms of hunger and satiation in hyperphagic subjects with dementia. Design. Case-control study. Three groups of subjects were compared: people with dementia, reported by their carers to be hyperphagic and who overate under experimental conditions; people with dementia who ate normally; normal elderly. Subjects were individually matched across groups. Setting. Subjects with dementia: living either in the community or in long-stay, psychogeriatric wards; the normal elderly controls lived at home. All lived in the UK. Participants. Participants with dementia fulfilled criteria for Alzheimer's disease. Hyperphagic group (n=18): aged 54–91, MMSE scores 0–20. Normal elderly controls (n=14) were individually matched for age and sex. Non-hyperphagic demented controls (n=14) were also matched for cognitive impairment. Measures. Two standardised test meals were given: a single food meal and a mixed food meal. Eating microstructure (latency period before eating; loading rate; chewing rate; rate of energy consumption and behaviour patterns during meal), were measured from videorecordings. Present Behavioural Examination was used to assess eating behaviour and MMSE to test cognitive impairment. Results. The hyperphagic group started to eat much more rapidly than non-hyperphagic demented controls, (W=59.0;p=0.006) and had a significantly higher initial eating rate (t=2.28,p<0.0005). Unlike the normal elderly, neither group with dementia showed a significant deceleration during the meal. Conclusions. People with dementia have impaired satiation mechanisms. Hyperphagic subjects with dementia have more marked impairment of satiation and increased hunger compared with non-hyperphagic demented subjects.     

TYPES AND PHENOMENOLOGIC SUBTYPES OF DEMENTIA IN TAIWAN: A PSYCHIATRIC INPATIENT STUDY

An investigation of 91 consecutive psychiatric inpatients with suspected dementia was designed to evaluate the relative frequency of different types and phenomenologic subtypes of dementia in Taiwan. The type of dementia was reviewed to determine different aetiologies. Phenomenologic subtypes of dementia were investigated according to the classifications of theDiagnostic and Statistical Manual of Mental Disorders. In contrast to previous studies in Taiwan, dementia of the Alzheimer's type (59.3%) was more frequent than vascular dementia (26.4%). The relative frequencies of phenomenologic subtypes were as follows; uncomplicated, 43%; with delusion, 38%; with delirium, 14%; with depression, 5%. This is the first report regarding the clinical subtypes of psychiatric demented inpatients in Taiwan. In spite of correct aetiological diagnosis of dementia, this report highlights the non-cognitive problems of dementia.     

A PROSPECTIVE POPULATION STUDY OF PSYCHOSOCIAL RISK FACTORS FOR LATE ONSET DEMENTIA

The role of psychosocial risk factors in the development of late onset, severe dementia was examined in a longitudinal prospective study of a representative sample followed from 70 to 79 years of age. Subjects with any signs of dementia at the age of 70 were excluded. Eighteen risk factors occurring before the age of 70 were studied, five from childhood and youth, five from adult age and eight from the age of 65–70. Thirty-eight subjects developed dementia, and they were compared to the other 326 subjects. Death of a parent before the age of 16, previous arduous manual work, physical illness in the spouse after the age of 65 and serious illness in a child after the age of 65 made independent contributions to the prediction of dementia. There was a dose--response relationship: in subjects without exposure 3% developed dementia, in subjects with exposure to one or two risk factors 8% developed dementia, and in subjects with exposure to three or more risk factors 20% developed dementia. The association with psychosocial risk factors was similar in the aetiological subgroups Alzheimer's disease and vascular dementia. There was no association with education or alcohol abuse. We suggest that the associations between psychosocial risk factors and dementia are due to the effects of stress, but other interpretations are also possible. The results should be regarded as preliminary until confirmed by others.     

THE COMBINATION OF SILVER TECHNIQUES FOR STUDYING THE PATHOLOGY OF ALZHEIMER'S DISEASE

Alzheimer's diseaseis a progressive neurodegenerative disorder, which implicates the whole central nervous system. The hallmarks of the disease are the development of neuritic plaques and neurofibrillary tangles, the accumulation of β-amyloid in the cytoplasm of the neurons (soluble β-amyloid oligomers) and the neuropile space (insoluble amyloidal fibrils), the neuronal loss, and the devastating synaptic alterations. Despite the fact that for the identification of the plaques and tangles and for the detection of the amyloid deposits and the neuronal loss, there are specific techniques even in light microscopy, synaptic pathology can be studied only with electron microscopy or indirectly with immunohistochemistry, because several alterations in the density of proteins located in synaptic junction (drebrin, synapsin, synaptophisin) may be occurring. Thus, this article presents original Nauta method impregnating degenerating axons as well as axonic terminals in post-mortem material derived from patients suffering from Alzheimer's disease. Furthermore, the article proposes its application in combination with Golgi method and Gallyas technique for a spheroid view of the neuronal degeneration and synaptic pathology in the study of any brain region in Alzheimer's disease.     

THE BEHAVIOR PATHOLOGY IN ALZHEIMER'S DISEASE RATING SCALE (BEHAVE-AD): RELIABILITY AND ANALYSIS OF SYMPTOM CATEGORY SCORES

The interrater reliability of the Behavior Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), a psychiatric rating scale especially designed for the evaluation of behavioral disturbances in dementia patients, was studied in both English-speaking US patients and a French-speaking elderly patient population from France. Additionally, the quantitative relationship between severity of Alzheimer's disease (AD) and mean scores on each of the BEHAVE-AD categories and mean total BEHAVE-AD score was determined in a separate study of 140 patients diagnosed as having probable AD. In both reliability studies significant correlations were obtained for all BEHAVE-AD symptom category scores and for mean total BEHAVE-AD scores. Analysis of BEHAVE-AD scores as a function of disease severity demonstrated a non-linear relationship between severity of behavioral symptoms and the global and cognitive advance of AD. Moreover, score analysis of the BEHAVE-AD indicates that these behavioral disturbances become most severe in the moderate and moderately severe stages of the illness. The results of these studies provide support for the reliability of the BEHAVE-AD. Additionally, the BEHAVE-AD provides basic knowledge about the nature and severity of the behavioral symptoms in AD. The latter information may be useful for the development of appropriate and effective psychopharmacologic intervention strategies for these difficult to manage behaviors. Furthermore, these results have implications for the methodology of pharmacologic trials of putative cognitive-enhancer compounds in AD.