Dexamethasone suppression in dementia, depression, and normal aging

Dexamethasone suppression tests (DSTs) were performed for 18 moderately demented elderly patients, 66 depressed elderly outpatients, and 25 age- and sex-matched healthy elderly control subjects. Seventeen percent of the demented patients and 4% of the normal subjects were DST nonsuppressors, compared to 38% of the total depressed group. The postdexamethasone plasma cortisol levels of the dementia group fell between those of the normal and the depressed subjects. In addition, demented patients had postdexamethasone cortisol levels significantly lower than those of depressed patients with high Hamilton depression scores. Older subjects in all diagnostic categories, including normal subjects, had higher postdexamethasone plasma cortisol levels.     

帕金森病认知障碍研究

目的研究帕金森病痴呆患者的认知障碍特点。方法采用语义流畅性、语音流畅性、动作流畅性测验与物品和动作命名测验,评定30例PD无痴呆患者、30例PDD患者与60名正常老年人。结果与正常对照组比较,PD无痴呆患者存在动作流畅性损害(P0.01),PDD患者3项言语流畅性与物品和动作命名均受损(P0.01)。结论 PDD患者存在执行功能障碍与命名损害,PDD是一种伴有皮质功能损害的、以额叶皮质下功能障碍为主要特点的认知损害性疾病。     

Diagnosis of dementia in a heterogeneous population. Development of a neuropsychological paradigm-based diagnosis of dementia and quantified correction for the effects of education.

A brief diagnostic battery of neuropsychological tests was developed for a large-scale epidemiological study of dementia. We operationally defined dementia as defective memory and defective performance in at least two other areas, including orientation, abstract reasoning, construction, and language. Criterion scores for defining defective performance on each test were developed. In a pilot study that used 51 different subjects with a working diagnosis based on physicians' assessment (ie, 32 demented and 29 nondemented subjects), the test-based diagnosis agreed with the working diagnosis in all but two cases. The test battery was then applied to 430 healthy elderly subjects. Eighteen percent of those with 8 or less years of education met criteria for dementia compared with 5% of those with more than 8 years of education. We computed education-corrected scores for each test with the use of residuals from the regression of each test score on education. Based on corrected scores, 12 subjects were reclassified as nondemented and 11 as demented. Subjects who were reclassified as demented were significantly more impaired in activities of daily living than nondemented subjects who were not reclassified. Activities of daily living in subjects who were reclassified as nondemented did not differ from those in demented subjects who were not reclassified. These findings suggest that the neuropsychological battery may have utility in the diagnosis of dementia. However, neuropsychological performance may be influenced by education, and some form of adjustment, such as correction for activities of daily living, may be required in epidemiological studies.     

The role of tests of frontal executive function in the detection of mild dementia

OBJECTIVE: To compare the performance of patients with mild dementia (Mini Mental State Examination (MMSE) >23), depression (Montgomery-Asberg depression rating scale (MADRS) >12) and controls on tests of frontal executive function (FEF), to see if simple tools could be an adjunct to early recognition of dementia in primary care. DESIGN: Subjects were required to score above 23 on the MMSE, and to be non-depressed unless in the depression group. Tests of FEF used were a letter based verbal fluency test, a cognitive estimates test, trail marking parts A and B, and a Stroop colour word test. Subjects were followed up at one year to assess long-term outcomes. SETTING: The Thornhill Unit, an old age psychiatry unit, Moorgreen Hospital, Southampton, UK. PATIENTS: Sixteen patients with a clinical diagnosis of dementia but with normal or borderline MMSE scores, 16 subjects with depression and 19 healthy control subjects. RESULTS: Subjects with mild dementia scored significantly worse than control subjects on all FEF tests used other than verbal fluency. Subjects with mild dementia were only found to score worse than depressed subjects on the cognitive estimates test and Stroop test, with the Stroop test providing better discrimination between these groups. At follow-up, MMSE scores of both dementia and depression groups were worse. CONCLUSIONS: Many simple tests of FEF can distinguish subjects with mild dementia from controls, although caution must be taken in the presence of depression. Of these tests, the cognitive estimates test may provide a simple test which can be used in conjunction with screening tests for dementia, such as the MMSE. The Stroop colour test was the most successful at distinguishing subjects with mild dementia from those with depression, but was more difficult to use. The depression group remained cognitively impaired at follow-up, despite improvements in depressive symptoms.     

Executive function impairment in community elderly subjects with questionable dementia

BACKGROUND: The neurocognitive profile of community-dwelling Chinese subjects with 'questionable' dementia was studied. METHODS: One hundred and fifty-four ambulatory Chinese subjects were recruited from local social centers for the elderly. Each subject was examined using the Clinical Dementia Rating (CDR), the Cantonese version of the Mini-Mental State Examination (CMMSE), the Chinese version of the Alzheimer's Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), the Category Verbal Fluency Test (CVFT), digit and visual span tests, and the Cambridge Neurological Inventory. The neurocognitive profile of nondemented subjects (CDR 0) was compared with that of subjects with 'questionable' dementia (CDR 0.5). RESULTS: Subjects with 'questionable' dementia were older, and had lower educational levels and global cognitive assessment scores than the controls (CMMSE and ADAS-Cog; t tests, p < 0.001). In addition, they also had significantly lower scores in delayed recall, reverse span, verbal fluency tests and worse performance in complex motor tasks related to executive function (Mann-Whitney tests, p < 0.001). Logistic regression analysis revealed that ADAS-Cog, CVFT, and reverse visual span were significant predictors for the CDR of 'questionable' dementia. CONCLUSION: Aside from memory impairment, executive function deficits were also present in subjects with 'questionable' dementia. To identify groups cognitively at risk for dementia, concomitant assessments of memory and executive function are suggested.     

Confrontation naming deficit in dementia of depression

Unlike patients with irreversible dementia, elderly depressed patients with cognitive impairment are thought to have relatively preserved recognition, memory, and language abilities. To test this hypothesis, the authors compared memory and naming performance in elderly hospitalized patients with major depression alone, reversible dementia of depression, or irreversible dementia. All patient groups performed worse than nondemented, nondepressed control subjects on memory tasks. Patients with dementia of depression performed worse than depressed patients with normal cognition on tests of free recall, delayed recall, and verbal delayed memory but not on tests of delayed visual memory. Patients with dementia of depression and patients with irreversible dementia were severely compromised in both speed and accuracy on the confrontation naming task.     

The neuropsychological profiles of mild Alzheimer's disease and questionable dementia as compared to age-related cognitive decline.

Test scores from a comprehensive neuropsychological battery administered to 1602 subjects consisting of 1347 subjects with probable Alzheimer's disease (AD), 100 subjects with questionable dementia (QD) and 155 non-demented elderly control subjects were cross-sectionally analyzed. Subjects with probable AD were categorized as mild (n = 244), moderate (n = 480), severe (n = 376), and very severe (n = 247) according to modified mini mental status exam (mMMSE) scores. Mean scores on individual neuropsychological tests are provided for each group of subjects. Stratified random sampling was performed to select a sample of mild AD subjects who were matched in age and education to non-demented elderly controls, and analyses focused on the performance of QD subjects and mild AD subjects, whose scores were compared to those of the elderly control subjects. Selected scores were organized by cognitive domain and logistic regressions were used to determine the domains and individual tests within each that were most predictive of group status. Results suggested a profile of scores associated with QD and mild AD including impaired recall of verbal information for both groups. Areas of lower functioning in QD subjects as compared to elderly controls included category fluency and visuospatial ability.     

Assessment of kendrick cognitive tests for the elderly

The Kendrick cognitive tests for the elderly were administered to 42 elderly patients with SDAT, 32 normal elderly, 10 patients with depression and 20 elderly patients with multi-infract dementia. The scores on KDCT and KOLT revealed significant differences between those who had dementia and those who had non-dementing illness. However, initial test patterns for KOLT and KDCT and test-retest patterns revealed some overlap. For diagnosis of dementia, if one uses the test-retest patterns assigned by Kendrick to the various diagnostic categories, the tests have a specificity of 100% and a sensitivity of only 39% thus suggesting that they are of limited value in predicting the presence or absence of dementia in an individual.     

Characteristics of exploratory eye movements in elderly people: possibility of early diagnosis of dementia

Background: Visual cognitive dysfunction is one of the most important signs indicating the early stage of dementia. Thus, visual testing could be used as an aid to the clinical diagnosis of dementia. In the present study, exploratory eye movement was measured to evaluate visual cognitive function in elderly subjects, including those with dementia. Methods: We analyzed responsive search scores (RSS) from exploratory eye movements of 300 subjects who were examined with an eye mark recorder while viewing S shaped figures. Subjects were divided into three groups (dementia, intermediate, healthy) from the values of the Revised Hasegawa Dementia Scale (HDS‐R), the Mini‐Mental State Examination (MMSE) and the Clinical Dementia Rating. We further divided the intermediate groups into two subgroups, the high score and low score groups, based on RSS. In 202 subjects, Z‐scores of voxel‐based specific regional analysis system for Alzheimer's disease (VSRAD) were obtained from magnetic resonance imaging (MRI). Results: RSS of the dementia group were significantly lower than those in the intermediate and healthy groups, in order: dementia < intermediate < healthy groups. RSS of the low score intermediate group was significantly lower than that of the high score intermediate group. There was no significant difference between the low score intermediate and dementia groups, or between the high score intermediate and healthy groups. No significant differences of either HSD‐R or MMSE were observed between the low score and the high score intermediate groups. The Z‐score of VSRAD using MRI in the low score intermediate group was significantly higher than that in the high score intermediate group. Conclusions: These findings suggest that RSS using an eye mark recorder is a useful psychophysiological marker to evaluate the early stage of dementia as well as at‐risk elderly people.     

Clinical correlates of functional performance in community-dwelling Chinese older persons with mild cognitive impairment

ABSTRACTBackground: Increasing evidence suggests that functional impairment can be detected in older persons with mild cognitive impairment (MCI). This study explores the functional profiles and the clinical correlates of a population-based sample of Chinese older persons with MCI in Hong Kong.Methods: A random sample of 765 Chinese elderly subjects without dementia was recruited, of which 389 were elderly normal controls (Clinical Dementia Rating = 0), and 376 had questionable dementia (CDR = 0.5). The latter were categorized into an MCI group (n = 291) and a very mild dementia (VMD) group (n = 85). Their functional performances were measured and compared with the normal controls (NC). Multiple regression analyses investigated the associations between functional scores (Disability Assessment in Dementia) and clinical correlates (cognitive test scores, neuropsychiatric symptoms and motor signs) in the NC subjects and cognitively impaired subjects.Results: Subjects with MCI had intermediate functional performance between the NC and those with VMD. Regression analyses revealed that lower scores of cognitive tests (delayed recall and categorical verbal fluency tests), apathy, aberrant motor symptoms and parkinsonism features were associated with lower functional scores in clinically non-demented subjects. Functional scores had no correlation with age, education and medical illness burden.Conclusion: Neuropsychiatric symptoms and parkinsonism features were associated with functional impairment in the clinically non-demented elderly in the community. Assessment of these should be incorporated in the evaluation of older persons for early cognitive impairment.     

Cross-cultural studies using a modified mini mental test for healthy subjects and patients with various forms of vascular dementia.

Existing neuropsychological tests are often complex and time-consuming. We designed a modified Mini Mental Test (MMT) battery for clinical assessment of the global and regional higher cortical functions of the brain. We tested its applicability in healthy subjects with different ethnic, cultural and educational backgrounds. The usefulness of our MMT as a tool for the clinical evaluation of patients with various forms of vascular dementia was determined. The MMT comprises five subtests, including clinical evaluations of: (A) orientation (6 points); (B) attention, right-left discrimination, speech, and calculation (20); (C) immediate recall, and recent and remote memory retrieval (10); (D) praxis (10); and (E) visuospatial orientation, agnosia, hemianopsia, and visual hemineglect (14). The MMT was administered to 100 healthy subjects from two different ethnic backgrounds (Indonesian and Chinese/Taiwanese) and diverse cultural and educational backgrounds, and to 61 patients with various forms of vascular dementia. MMT scores were significantly lower in healthy subjects with a low level of education regardless of their ethnic background (p<0.001). Patients with vascular dementia had much lower MMT scores than did the comparable age-adjusted normal controls (p<0.001). Of the patients with vascular dementia, those with Binswanger's disease had the lowest MMT scores (25.5+/-28.9), followed by those with large cerebral infarcts (48.0+/-7.1), cerebral haemorrhage (49.0+/-8.5), and multiple lacunar infarctions (55.0+/-0.5) (P<0.001). With a cut-off point of 33/55 (partial score/total score), the sensitivity and positive predictive value of the MMT were 0.98 and 0.94, respectively. The MMT is a simple and useful tool for clinical assessment of the cognitive functions of healthy subjects and patients with or without vascular dementia. It can be used for individuals with different ethnic, cultural and educational backgrounds.     

Is caring for elderly relatives with depression as stressful as caring for those with dementia? a pilot study in melbourne

The 30-item General Health questionnaire (GHQ-30) scores of the primary carers of 31 elderly patients with depression were compared with the GHQ-30 scores of 30 primary carers of dementia sufferers. Carers of dementia sufferers who lived with their demented relative had GHQ-30 scores almost four times higher than those carers who lived apart from a dementia sufferer. There was no difference in the GHQ-30 scores of carers of depressed subjects living with or apart from their affected relative. Carers of demented patients tended on average to have higher GHQ-30 scores than carers of depressed patients, but this difference was almost entirely accounted for by the fact that more carers of demented patients lived with their ill relatives. Patient and carer age and sex and severity of patients' depression were not related to the GHQ-30 scores of their carers.     

Fluvoxamine in the treatment of demented elderly patients: a double-blind, placebo-controlled study.

The efficacy of fluvoxamine on cognitive functioning and behavioral changes was evaluated in a double-blind, placebo-controlled study of 46 elderly demented patients. The patients had a DSM-III diagnosis of primary degenerative dementia or multi-infarct dementia and were aged greater than or equal to 65 years. Twenty-two patients were given 150 mg fluvoxamine per day and 24 received placebo tablets; 14 and 15 patients, respectively, completed 6 weeks of treatment. Within treatments, there were no significant changes in median scores on neuropsychological tests (picture recall and recognition, trail making and finger tapping) or the GBS scale scores (degrees of dementia) or GBS subscale score (clinical profiles, including symptoms common in dementia, motor, emotional and intellectual functioning). Between treatments, the median changes in psychometric test scores did not differ significantly. However, within and between treatments, there were trends favoring fluvoxamine on symptoms common in dementia (confusion, irritability, anxiety, fear-panic, mood level and restlessness). In conclusion, the study does not support the hypothesis that fluvoxamine improves cognitive functioning or behavioral changes in elderly dementia patients.     

Positron emission tomography with [18F]fluorodeoxyglucose differentiates normal pressure hydrocephalus from Alzheimer-type dementia.

Because diagnostic criteria for normal pressure hydrocephalus have not been clearly determined, it is often difficult to differentiate patients with this potentially treatable condition from those with Alzheimer-type dementia. We have studied three patients with normal pressure hydrocephalus, 17 patients with Alzheimer-type dementia, and seven healthy elderly controls using positron emission tomography and [18F]Fluorodeoxyglucose (FDG). Both Alzheimer-type dementia and normal pressure hydrocephalus groups showed lower cortical rates of FDG utilisation than controls. However, the patterns of metabolic abnormality were distinctly different in the two dementia groups, with Alzheimer-type dementia subjects demonstrating bilateral temporoparietal hypometabolism while normal pressure hydrocephalus subjects showed globally diminished glucose use.     

Cognitive test scores in community-based older adults with and without dementia

In an epidemiological survey of a rural, largely blue-collar, community, 1,363 randomly selected adults, aged 65 years, were administered a cognitive screening battery (including in part the CERAD neuropsychological tests): Mini-Mental State Examination; Word List Learning, Recall, and Recognition; Story, Immediate and Delayed Recall; Boston Naming Test; Verbal Fluency; Temporal Orientation; Constructional Praxis; Draw a Clock; and Trailmaking. Cognitively impaired subjects and cognitively intact controls underwent independent standardized diagnostic assessments and were rated on Clinical Dementia Rating (CDR) scale. Overall, subjects at higher CDR levels (more severe dementia) had worse scores on all tests; showing that standard neuropsychological tests are valid for characterizing the cognitive impairments seen in dementia, even in community settings. However, non-demented scores on the CERAD tests in this community-based sample were lower than reported from CERAD's pooled healthy controls from Alzheimer's Disease Centers (ADCs) nationwide. Thus, 'normal' scores from specialty dementia clinics, where there may be a selection bias, may differ from normative scores from rural and/or less-educated populations. Patients from such populations may be functionally intact despite low test scores. Community-based studies are required to complement specialty clinic-based studies of dementia and cognitive functioning.     

Neuropsychological profile of patients with Parkinson's disease without dementia

Cognitive deficits are often associated with Parkinson's disease (PD), although their prevalence in PD patients without dementia is still unknown. In order to describe the neuropsychological profile of PD patients without dementia, a sample of 103 PD patients was compared with a control group consisting of 38 healthy elderly subjects. Psychometric assessment consisted of the Mini Mental State Examination, the Dementia Rating Scale and a battery of neuropsychological tests. The Beck Depression Inventory was used to assess depression in PD patients. Dementia was diagnosed in 27 patients. Among non-demented subjects, 34 (45%) had no cognitive impairment and 42 (55%) had a mild cognitive impairment. Subjects with mild cognitive impairment were older, had a later onset of the disease, and more severe motor symptoms than cognitively intact subjects. Identification of mild cognitive impairment is important, since these symptoms are important for patient management and may also facilitate to determine prognosis.     

Alcohol, dementia, and Alzheimer's disease: comparison of neuropsychological profiles

Thirty-nine detoxified elderly alcoholics (mean age = 65.85) completed a comprehensive assessment designed to identify individuals meeting DSM-IV criteria for alcohol-related dementia. Ten subjects meeting criteria (mean age = 69.8; mean Mini-Mental State Examination [MMSE] = 25.1) were compared to the 29 nondemented alcoholics (mean age = 64.5; mean MMSE = 27.8), 9 patients with Alzheimer's disease (mean age = 73.4; mean MMSE = 22.3), and 15 control subjects (mean age = 70.8; mean MMSE = 28). Comparison of neuropsychological test scores revealed several statistically significant differences. Furthermore, the overall pattern of test performance between the two demented groups was different. Alzheimer's patients were more impaired on confrontation naming, recognition memory, animal fluency, and orientation. Alcohol dementia subjects were more impaired than controls on initial letter fluency, fine motor control, and free recall. However, alcohol dementia subjects did not differ from controls on tests of verbal recognition memory. This study suggests that it is possible to clinically differentiate the cognitive deficits of alcohol-related dementia from typical Alzheimer's disease. However, the results are preliminary and are based on small sample sizes so should be interpreted with caution.     

The assessment of fitness to drive in people with dementia

OBJECTIVE: To determine whether cognitive tests predict fitness to drive in patients with dementia. DESIGN: Two group comparison of patients with dementia and healthy elderly volunteers, and comparison of patients with dementia who were found safe to drive and those found unsafe, followed by a validation study. PARTICIPANTS: Forty-two people with dementia and 33 healthy elderly volunteers with no known memory problems who were driving. Of the 42 people with dementia 37 were assessed on the road. A second sample of 17 people with dementia was also assessed on the road. MAIN MEASURES: Stroke Drivers Screening Assessment, Mini Mental State Examination, Salford Objective Recognition Test, Stroop Test, Test of Everyday Attention, Visual Object and Space Perception Battery, Behavioural Assessment of the Dysexecutive Syndrome, Adult Memory and Information Processing Battery. RESULTS: All healthy elderly volunteers were safe to drive but 10 of the 27 patients with dementia were unsafe. Discriminant function analysis identified a combination of tests, which correctly classified 92% of drivers with dementia as safe or unsafe. Validation of this prediction on an independent sample had 59% accuracy using a cut-off of 0 but 88% accuracy using a cut-off of 5. CONCLUSIONS: Safety to drive in people with dementia could be predicted from a combination of six cognitive tests. These correctly identified 67% of safe drivers in a validation sample. This assessment could be used to identify those who need evaluation of their safety on the road.     

Development and validation of a test for early diagnosis of dementia with differentiation from depression (TFDD)

Psychometric tests used for the early detection of dementia often are seen as too difficult or too complex. Classical neuropsychologic tests were not developed for this purpose. Sensitivity and specificity to discriminate "healthy" vs. "ill" are low. For measuring both dementive and depressive symptoms, so far no test has been published. The objective of this study was to develop a sensitive and specific test for dementia that is easy to administer and to evaluate. Moreover, it should discriminate dementia from depressive pseudodementia. With respect to former studies, items were selected that recognized patients in the beginning of the disease. Additionally, depressive symptoms were rated. With the items for dementia, 88 patients with dementia of the Alzheimer type, 52 patients with depressive disorder and 37 healthy elderly controls were investigated. In this group of already diagnosed patients, the test reached a sensitivity and specificity of 100 percent (healthy elderly controls vs. patients with Alzheimer's disease: n = 125, U = 0, p < 0.001; patients with depressive disorder vs. patients with Alzheimer's disease: n = 140, U = 0, p < 0.001; healthy elderly controls vs. patients with depressive disorder: n = 89, U = 485.5, p < 0.001). For the dementia items, the inter-rater-reliability was rs = 0.996 (p < 0.001, n = 18), for the depression items it was rs = 0.753 (n = 18, p < 0.001). The test-retest-reliability was rs = 0.868 (p < 0.001, n = 35) for the dementia items and rs = 0.7 (n = 8, p < 0.05) for the depression items. These validation data will make the test useful for practitioners. Its ability to discriminate patients suffering from dementia of the Alzheimer type from healthy controls is comparable to tests consuming more time.     

Assessing memory deterioration with the Wechsler Memory Scale, the National Adult Reading Test, and the Schonell Graded Word Reading Test

The National Adult Reading Test (NART), the Schonell Graded Word Reading Test (SGWRT), and the Wechsler Memory Scale, Form I (WMS) were administered to 65 healthy subjects aged 65 to 89 years. Regression equations were derived which allowed total raw score on the WMS to be predicted from the subject's age and from the number of errors on the NART alone or on the NART and SGWRT combined. The distribution of discrepancies between obtained and predicted WMS scores for each equation did not depart significantly from normality and the percentage of subjects at each discrepancy score is provided. The standard error of prediction for each equation is slightly less than that for predicting WAIS IQ from the NART. Sixteen patients with clinical diagnoses of senile dementia of the Alzheimer type obtained discrepancies as large or larger than the most discrepant 2% of normal subjects. These results suggest that this procedure may provide a brief but effective assessment of cognitive deterioration in the elderly and may be capable of assessing dementia earlier than the NART/WAIS combination.