Genuine memory deficits in dementia

Controlled learning with effective cued recall is needed to distinguish between genuine memory deficits due to impairment of specific memory processes and apparent memory deficits due to impairment of other cognitive processes, such as attention, that can limit memory. Effective cued recall is needed for accurate measurement of memory in the elderly because cued recall reveals learning not shown by free recall. When a search procedure was used to control processing for effective encoding and cued recall, nondemented elderly adults recalled all or nearly all 16 items on each trial. Decreased recall by demented patients even after they carried out the same effective processing showed genuine memory impairment that was not due to other cognitive deficits. Cued recall was better than either free recall or recognition in discriminating elderly persons with dementia from those without dementia and by itself accounted for 75 % of the variation in dementia status. Cued recall was especially useful for identifying patients with mild to moderate dementia who were not identified by free recall. It is proposed that elderly persons who have decreased cued recall of a 16‐item list after controlled learning have genuine memory impairment and therefore are likely to be demented because other causes of amnestic syndromes are relatively infrequent in the aged. Controlled learning with effective cued recall should be useful for screening of elderly persons for dementia.     

Application of discriminant analysis to level of performance of alcoholics and nonalcoholics on Wechsler-Bellevue and Halstead-Reitan subtests.

Investigated the utility of subtests from the Wechsler-Bellevue Intelligence Scale and the Halstead-Reitan Neuropsychological Test Battery to differentiate between alcoholics and nonalcoholics (N = 76). Analyses of variance indicated that the alcoholics were more impaired than nonalcoholics. It was found that the Wechsler-Bellevue Performance subtests were more discriminative than were Verbal subtests, with performance on the Halstead-Reitan variables being intermediate. The nine measures that differentiated most significantly between groups were subjected to a stepwise multivariate discriminant analysis. The resulting function correctly classified Ss with an overall accuracy of 74.7%. It was found that the Block Design subtest was the best single discriminator. The findings were discussed in relationship to previous findings and with respect to general issues of clinical neuropsychological assessment.     

Seventy-two hour polygraphic and behavioral recordings of wakefulness and sleep in a hospital geriatric unit: comparison between demented and nondemented patients

Continuous 72-h polygraphic recordings were carried out in 30 hospitalized, mostly severely demented patients and 14 nondemented control patients. Mean age was greater than 80 years in both groups. In the dementia group, the diagnoses were senile dementia Alzheimer type (n = 16), multi-infarct dementia (n = 8), and mixed or undefined dementia (MIX) (n = 6). The nondemented controls suffered from various medical or psychiatric disorders or were recovering from previous accidents. Dementia patients had less stage 2 and REM sleep and thus less total sleep time than did control subjects. No statistically significant differences were noted between dementia subgroups. There were no differences between controls and demented patients in terms of NREM-REM cycle, and there was no association between the severity of the clinical condition and any of the sleep parameters in the demented patients. In contrast to healthy elderly and old persons, women and men patients with dementia showed no differences in their sleep patterns. In both patient groups, most sleep occurred at night, and wakefulness was predominant during the day. Only three of the dementia patients displayed somewhat more daytime than nighttime sleep. The main conclusions were that polygraphic sleep recordings did not contribute to a better differential diagnosis in patients with advanced dementia and that inversion of the sleep/wakefulness rhythm was uncommon in these separately roomed demented patients.     

Neuropsychological similarities and differences among Huntington's disease, multiple sclerosis, and cortical dementia.

A comparison of cognitive function was made among patients with Huntington's disease, multiple sclerosis, and cortical dementia. Utilizing indexes from the Wechsler Adult Intelligence Scale and the Halstead-Reitan Battery, it was found that there was substantially more severe cognitive deficit in the Huntington's disease patients than in the multiple sclerosis patients, and the level of impairment was similar between the Huntington's disease and cortical dementia groups. Qualitative differences, particularly involving amount and type of perseveration, were noted among the three groups. It was concluded that subcortical dementia is not necessarily characterized by mild cognitive impairment, and there appear to be important qualitative differences between cortical and subcortical dementia. Results are discussed in terms of the usefulness of the presently conceptualized distinction between cortical and subcortical dementia.     

Neuropsychological deficits in active licensed professional boxers

Young, active, licensed professional boxers (N = 19) were found to display a pattern of neuropsychological deficits consistent with the more severe punch-drunk syndrome of years past. These deficits resulted in significantly lower test performance than that of control athletes (N = 10) matched for race, age, and level of education. Tests that showed significant differences between groups include subtests of the Quick Neurological Screening Test, subtests of the Halstead-Reitan Neuropsychological Test Battery, and the Randt Memory Test. Fifteen of the 19 boxers scored in the impaired range of the Reitan Impairment Index, as compared to 2 of the 10 controls.     

The effects of aging and dementia on concept formation as measured on an object‐sorting task

This study was designed to investigate abstract problem‐solving abilities in elderly normals and in patients with senile dementia of the Alzheimer type (SDAT). A pair of tasks was administered to 17 young normals, 22 aged normals, and 51 patients with SDAT (28 early dementia, 23 advanced dementia). Twenty‐five common household items were simultaneously displayed on a video monitor screen. On both tasks, participants were required to select a subgroup of 8 of the 25 items. On the control task, the selection principle was supplied to the participant. Aged normals were unimpaired on this task, whereas early dementia patients were modestly impaired, and advanced dementia patients were markedly impaired. On the concept‐formation task, the selection principle defining the subgroup of 8 items was deduced by the participant. All participant groups performed significantly more poorly on the concept‐formation version of the task than on the control task. The increase in errors was greatest in the early dementia patients, less in the aged normals, and least in the young normals and advanced dementia patients. The performance of the severely demented participants on the concept‐formation task approached floor levels. Because this test procedure provides a relatively isolated measure of abstract problem‐solving ability and elicits a clear deficit from both aged normals and SDAT patients, it might be useful in the assessment of treatment effects on age‐related cognitive impairment.     

Halstead-Reitan Neuropsychological Test performance of black, Hispanic, and white young adult males from poor academic backgrounds.

Forty-five black, Hispanic, and white young adult males of average range intellectual functioning, from poor academic backgrounds but with average academic achievement scores, were administered the Halstead-Reitan Neuropsychological Test Battery (HRNB). The results indicated that the Impairment Index, based on the traditional cutoffs, did not overly mis-represent this group as impaired. However, using the traditional cutoffs, the percentage in the impaired range on individual subtests ranged from 11% to 71%, suggesting caution when subtests are used apart from the battery (specifically, problems with the Finger Tapping test cutoffs are discussed). The three racial/ethnic groups did not have significantly different Impairment Indexes, and there were few significant differences between them on individual subtests.     

Relative sensitivity of the WAIS-R subtests and selected HRNB measures to the effects of brain damage.

Reitan has argued that Halstead-Reitan Neuropsychological Battery measures are more sensitive to the effects of brain damage than are measures from the Wechsler intelligence scales. This proposal was investigated in groups of 65 brain-damaged subjects and 45 nonbrain-damaged controls equated for age and level of education and subgroups of 34 brain-damaged subjects and 34 nonbrain-damaged controls closely matched on age and WAIS-R full Scale IQ. Differences on Halstead-Reitan measures found in the larger groups were not found in the subgroups matched on age and IQ. Further, discriminant analyses showed that 11 Halstead-Reitan measures were equivalent to the 11 WAIS-R subtests in discriminating brain-damage and nonbrain-damaged subjects. Thus, the proposal for poorer sensitivity of the WAIS-R subtests was not supported.     

Detection of cognitive impairment in the elderly by general internists in Brazil

BACKGROUND:

Cognitive impairment, from mild forms to dementia, is an important social and health concern, principally among older individuals. Elderly patients are usually followed by general internists, who may overlook this condition.

OBJECTIVE:

Our aim was to determine whether cognitive impairment diagnosed by specialists had been previously detected by general internists.

SUBJECTS AND METHODS:

A total of 248 elderly individuals randomly selected from a list of outpatients seen by general internists in a public university hospital in São Paulo, Brazil, were evaluated by a geriatrician. Patients were then classified as having probable cognitive impairment or not, based on their performance on the Mini-Mental State Examination and the Informant Questionnaire on Cognitive Decline in the Elderly. Cases of probable impairment were submitted to routine laboratory investigation, brain computed tomography, and neuropsychological evaluation. The final diagnoses were established by a consensus panel comprising two neurologists and the geriatrician who evaluated the patients using all available data. General internists'' files for all cognitively impaired cases and for a selected sample of individuals without cognitive impairment were checked for any record of cognitive complaints or decline.

RESULTS:

Forty-three patients were classified as demented (n = 21) or as cognitively impaired but not demented (n = 22). The evaluation of the general internists'' files revealed that information on cognitive complaints or decline was recorded for seven (16.3%) of the 43 patients with dementia or cognitive impairment without dementia.

CONCLUSIONS:

General internists seldom detected cognitive decline in elderly patients in Brazil. Further studies should be conducted to elucidate the reasons for this low rate of detection.     

Dietary intake and clinical, anthropometric and biochemical indices of malnutrition in elderly demented patients and non-demented subjects

Anthropometric and biochemical indices of nutritional status and weighed dietary intake have been studied in hospitalized patients with senile dementia, demented patients living in the community and age-matched control subjects who were not cognitively impaired. Demented patients were lighter than control subjects, and had a lower body mass index, skinfold thickness, mid-arm circumference and arm muscle bulk. The hospitalized patients were more seriously affected than those living in the community, and body weight was significantly negatively correlated with duration of hospitalization. Over a 6-month period the hospitalized patients showed a further weight loss, while those living in the community did not. Both groups of demented patients had higher intakes of energy, protein, vitamins and minerals than the control subjects. The diet of the hospitalized patients was slightly, but not significantly, superior to that of the patients living in the community. Biochemical evidence of specific vitamin inadequacy was equally prevalent in all three groups of subjects, and there were no significant correlations between the degree of cognitive impairment or behavioural disorder and any of the indices of nutritional state. Clinical signs suggestive of malnutrition were not correlated with either biochemical evidence of deficiency or cognitive impairment and behavioural disturbance.     

Magnesium and potassium status in elderly subjects with and without dementia of the Alzheimer type

Magnesium status was evaluated in healthy elderly people, and in patients affected from dementia of the Alzheimer type. Magnesium levels were determined in plasma, erythrocytes (RBC), lymphocytes (MNC), and granulocytes (PMN), and were compared with measurements in young healthy adults. Significantly lower plasma Mg concentrations were found in elderly people compared to controls, with no difference between cognitively normal and demented subjects. Mg levels in healthy elderly people were higher in MNC and lower in PMN, compared to the younger group. No difference was observed between demented patients and young controls in Mg content of white blood cells, but the patients had higher Mg/K ratios. In addition, significant correlations were found between cognitive impairment and the Mg/K ratio in MNC. When we assessed the philothermal response of granulocytes, a significant correlation was observed in demented subjects between the migration rate of PMNs and the PMN Mg/K ratio.     

Analyzing the subcortical dementia syndrome of Parkinson's disease using the RBANS.

On mental status examinations, groups of equally impaired patients with subcortical (Huntington's disease, HD; Parkinson's disease, PD) or cortical (Alzheimer's disease, AD) dementias exhibit different patterns of neuropsychological deficits. Using the Repeatable Battery for Assessment of Neuropsychological Status (RBANS), classification accuracies of 90% or greater have been reported for individual patients with AD or HD. To test the generality of the RBANS classification algorithm, we studied patients with dementia (AD and PDD) and without dementia (PDND). Classification accuracies were AD: 87%, PDD: 78%, and PDND: 39%. Comparisons of performance on subtests of the RBANS showed that all groups performed more poorly on tests that require motor skill or rapid information processing and that memory performance by the PD groups was not improved by procedures that enhance encoding and facilitate retrieval. The RBANS is useful for discriminating patterns of cognitive impairment in PD and AD, but only if the diagnosis of dementia is established independent of the RBANS test results. Cognitive slowing is not specific to subcortical dementia and current concepts of memory dysfunction in PD may require re-examination.     

Intellectual loss in Alzheimer's dementia and WAIS-R intrasubtest scatter

Patterns of intrasubtest scatter in the WAIS-R protocols of patients (n = 32) with Alzheimer's disease were compared to those of normal elderly controls (n = 32). The Alzheimer's patients showed more randomly dispersed item failures on some subtests, but normal controls showed more intrasubtest variability on other measures. Rates of correct diagnostic classification based on scatter measures were only slightly better than chance despite the presence of prominent anomia, memory impairment, construction apraxia, and significant decline from premorbid intellectual level in demented patients. In contrast, demographically based estimates of intellectual loss produced accurate diagnostic classification in 81% of the cases. The incremental validity of qualitative scatter analysis in the evaluation of suspected Alzheimer's disease appears to be minimal.     

Effects of aging and dementia upon recent visuospatial memory

In two experiments, a total of 20 young normals, 29 elderly normals, and 76 elderly demented subjects were administered a computerized delayed visuospatial recall task. Subjects were instructed to remember which room of a 25-room house had a light on in the window. A choice reaction time task was interposed during the delay interval (0–120 seconds) between stimulus presentation and recall. The test was designed to be (1) face valid-relevant to the subjects' everyday lives, (2) sensitive and specific to the cognitive decline associated with senile dementia of the Alzheimer's type (SDAT), and (3) comparable to animal memory tests. Immediate recall of the spatial location of a single stimulus was found to be deficient in severely demented subjects only, and all groups exhibited a decline in recall accuracy with increasing delay intervals. This decline in recall accuracy was greatest in severely demented subjects, smaller in less demented subjects, still smaller in aged normals, and smallest in young normals. No significant forgetting of spatial location occurred between 30 and 120 seconds after stimulus presentation. Increasing stimulus number decreased recall accuracy in all groups and the elderly and elderly demented subjects were more sensitive to the increase in stimulus load than the young normals. Choice reaction time also proved sensitive to age and severity of dementia. Correlation analyses demonstrated that delayed spatial recall (as well as choice reaction time) is highly correltated with clinically evaluated global cognitive status, as well as with tests of verbal recall. These results confirm previous reports that spatial recall is impaired by both age and SDAT. It is concluded that this test procedure and others applying similar approaches should be useful in the assessment of age-related cognitive dysfunction and in the evaluation of potential pharmacological treatments for these disorders.     

Application of Choynowski's Memory Scale in assessment of patients with dementia

Introduction

Neuropsychological assessment of patients with dementia necessitates the use of varied memory tasks designed to measure different memory processes, including information memorization, retention and retrieval. A valid memory battery should be demonstrated to discriminate between demented and non-demented subjects and its scores should be related to the degree of intellectual impairment. The objective of this study was to evaluate the potential usefulness of Choynowski''s Memory Scale in assessment of patients with dementia.

Material and methods

Thirty-two patients with dementia and 64 age- and gender- matched healthy controls took part in the study. All participants were examined by means of Choynowski''s Memory Scale, and the patients were additionally assessed by the Mini Mental State Examination and Clock Drawing Test (CDT).

Results

All subtests of Choynowski''s Memory Scale were found to highly significantly (p ≤ 0.001) discriminate between patients with dementia and healthy controls. Except for Digit Span, all other subtests of Choynowski''s battery were highly correlated with the global mental status as assessed by MMSE with correlation coefficients ranging from 0.59 to 0.81. Most subtests of Choynowski''s Memory Scale were also moderately or highly correlated with performance on the CDT, and the correlations coefficients between the total score on Memory Scale and the CDT were r = 0.66 and r = 0.61 (p ≤ 0.001) for the free recall drawing and copying, respectively.

Conclusions

Choynowski''s Memory Scale showed high discriminative properties and strong associations with the degree of intellectual impairment in dementia. The results encourage the use of this battery in clinical settings.     

Effects of aging and dementia upon recent visuospatial memory

In two experiments, a total of 20 young normals, 29 elderly normals, and 76 elderly demented subjects were administered a computerized delayed visuospatial recall task. Subjects were instructed to remember which room of a 25-room house had a light on in the window. A choice reaction time task was interposed during the delay interval (0–120 seconds) between stimulus presentation and recall. The test was designed to be (1) face valid-relevant to the subjects' everyday lives, (2) sensitive and specific to the cognitive decline associated with senile dementia of the Alzheimer's type (SDAT), and (3) comparable to animal memory tests. Immediate recall of the spatial location of a single stimulus was found to be deficient in severely demented subjects only, and all groups exhibited a decline in recall accuracy with increasing delay intervals. This decline in recall accuracy was greatest in severely demented subjects, smaller in less demented subjects, still smaller in aged normals, and smallest in young normals. No significant forgetting of spatial location occurred between 30 and 120 seconds after stimulus presentation. Increasing stimulus number decreased recall accuracy in all groups and the elderly and elderly demented subjects were more sensitive to the increase in stimulus load than the young normals. Choice reaction time also proved sensitive to age and severity of dementia. Correlation analyses demonstrated that delayed spatial recall (as well as choice reaction time) is highly correltated with clinically evaluated global cognitive status, as well as with tests of verbal recall. These results confirm previous reports that spatial recall is impaired by both age and SDAT. It is concluded that this test procedure and others applying similar approaches should be useful in the assessment of age-related cognitive dysfunction and in the evaluation of potential pharmacological treatments for these disorders.     

Elevated urinary free cortisol in patients with dementia

Urinary free cortisol (UFC), 17-hydroxycorticosteroids (17-OHCS) in urine and dexamethasone suppression test (DST) were examined in patients with dementia of Alzheimer type (DAT) and multi-infarct dementia (MID), and nondemented elderly. Eight of 19 patients (42.1%) were DST nonsuppressor. UFC was significantly elevated in patients with dementia, compared with that in nondemented elderly. There was no difference in UFC levels between DAT and MID. The UFC level correlated with post-DST plasma cortisol level at 1600 in demented patients. The mean level of 17-OHCS in demented patients was increased, although the difference was not significant statistically. In demented patients, UFC levels, not 17-OHCS levels in urine were correlated with Mini-Mental State Examination scores. These results suggest that a hypothalamo-pituitary-adrenal axis function is activated in demented patients and that this activation relates generally to dementation itself, not to an etiology of dementia. Measurement of UFC might be a biological marker of dementia and may have a value in diagnosis of dementia.     

Telomere length is not predictive of dementia or MCI conversion in the oldest old

The contribution of telomere shortening to the onset of certain age-related diseases, such as dementia, and its role as a predictor of cognitive impairment remain unclear. We tested these hypotheses by analyzing telomere length in 449 inpatients in a large cohort of the oldest old (mean age 85 years) followed up yearly. No significant difference in telomere length was observed between cognitively normal patients (205), demented patients (195; 82 mixed dementia, 77 Alzheimer's disease and 21 vascular dementia) and patients (49) with mild cognitive impairment (MCI). Similarly, no significant differences in telomere length were found between patients with different etiologies or severities of dementia. Telomere length and change in cognitive status (from normal to MCI or dementia, or from MCI to dementia) were not associated after two years of follow-up. This longitudinal study in very old patients provided no evidence to suggest that telomere length could be used to distinguish between demented and non demented patients, regardless of the type of dementia, or to predict dementia or MCI conversion.     

Gender differences in the cognitive impairment in Alzheimer's disease

Summary Introduction: There is evidence for gender differences in cognitive functioning. Men and women with Alzheimer's disease (AD) might also differ in the pattern of cognitive deficits. We hypothesised that gender differences in the cognitive deficits of Alzheimer's disease may be related to pre-existing gender differences in cognitive functioning. Method: The performances of 84 subjects with AD and 438 non-demented elderly, using the structured interview for the diagnosis of dementia of the Alzheimer type, multi-infarct dementia and dementias of other aetiology according to ICD-10 and DSM-III-R (SIDAM), were investigated. Subscores for different cognitive functions were compared between men and women. Confounding variables, i.e. age, degree of cognitive impairment, level of education, presence of lifetime diagnosis of major depression and of recent depressive symptoms, were accounted for by multiple regression analyses. Results: Non-demented elderly women had inferior visuoconstructive skills than men. In agreement, women with Alzheimer's disease also had inferior visuoconstructive skills, but in addition they tended to perform worse in items for intellectual abilities than men. Conclusion: Women seem to have minor weaknesses in spatial thinking compared to men. This may explain the inferior test results of non-demented and demented women in visuoconstructive tasks. However, our data also give some evidence for additional domain specific gender differences of cognitive impairment of AD that could not be observed in non-demented elderly, i.e. inferior test results in items for intellectual abilities in demented women compared with demented men. Gender differences in the neurodegenerative process of AD may add to gender differences in domain specific cognitive impairment. Further research on this topic is needed.     

Neuropsychological profiles associated with subcortical white matter alterations and Parkinson's disease: implications for the diagnosis of dementia.

Despite the emergence of a number of new classification systems, the diagnosis of cerebrovascular dementia remains controversial. Also controversial is the significance of periventricular and deep white matter alterations (WMA) as seen on magnetic resonance imaging (MRI). To further clarify this issue, MRI scans were used to regroup patients clinically diagnosed with Alzheimer's disease (AD) or subcortical ischemic vascular dementia (IVD) into cohorts presenting with either little versus significant WMA on MRI. These two groups were then compared to demented patients diagnosed with idiopathic Parkinson's disease (PD) using a comprehensive neuropsychological protocol. Neuropsychological assessment failed to distinguish between patients with PD and significant WMA. By contrast, both of these patient groups exhibited disproportionate impairment on tests of executive systems functioning, whereas patients with little WMA showed greater impairment on tests of declarative memory and semantic knowledge. These findings constitute further evidence that the pattern of cognitive impairment associated with significant WMA is distinctly different when compared to AD. These results are discussed within the context of a growing body of literature suggesting that elements of the underlying neuropathologies in AD and IVD are linked. Implications for the diagnosis of dementia are also discussed.