The Human Figure Drawing test as a screen for dementia in the elderly: a community-based study

The Human Figure Drawing (HFD) test is a non-verbal test, mainly based on visuo-spatial and constructional abilities. In screening for dementia, the HFD test can be hypothesised as a good complement to Mini-Mental State Examination (MMSE), which is inherently limited by its verbal nature. In order to test this hypothesis, both MMSE and HFD tests were administered to 461 individuals recruited from a community-based study of the elderly (the Kungsholmen project). According to the Third Revised Diagnostic and Statistical Manual of Mental Disorders, 95 subjects were affected by dementia and 366 were non-demented. We calculated the sensitivity and specificity of MMSE, the HFD test, and the combination of the two. Results showed that MMSE mean scores were significantly reduced between the non-demented group and groups with different severities of dementia. The mean scores of a short version of 29 HFD body details (HFD29) and seven HFD essential body details (HFDess) showed similar, but weaker trends than MMSE. However, the sensitivity increased by 4.2% when HFD29 and HFDess were added to MMSE, compared to the MMSE test alone. This increase partially derived from the portion of questionable and mild demented subjects. Unfortunately, a high drop-out rate was present in the HFD test. We conclude that the use of HFD test has limitations in this well-educated population, due to a high number of refusals and only a small improvement in detecting mild demented cases. The application of this test in lower educated populations requires further investigation.     

Quantitative electroencephalography, with serial subtraction and odour detection in the differentiation of Alzheimer's disease and vascular dementia

The diagnosis of dementia can be difficult, yet diagnostic accuracy has important prognostic and therapeutic implications. Nevertheless, conventional electroencephalography (EEG) has always played a secondary role in dementia investigation. More recently quantitative EEG (qEEG) has allowed more detailed and objective analysis of EEG data, but there is still no clearly defined clinical role for qEEG. We have used relative power qEEG measures made during resting and active brain conditions (serial subtraction and odour detection tasks) to differentiate between demented and non-demented subjects, and between subjects with different forms of dementia. Electroencephalograms were obtained from 15 subjects with clinically diagnosed Alzheimer's disease (AD), 16 with a clinical diagnosis of vascular dementia (VaD), and 16 non-demented control subjects. Discriminate function analyses were used to differentiate groups according to task, electrode site, and frequency bandwidth. Correct classification, as demented or non-demented, was made for 93% of cases using qEEG comparisons of resting states with eyes closed and eyes opened. Almost all subjects with AD and VaD were correctly classified with qEEG recorded during odour detection (95%). qEEG for serial subtraction correctly classified AD and VaD in 91% of the dementia group. These results have important implications for future qEEG research, and may be pertinent to the precision of diagnosis in patients with dementia.     

The demented elderly in the city of Helsinki: functional capacity and placement.

OBJECTIVE: To study prevalence, functional capacity, and placement of demented patients in a randomly selected population. DESIGN: Survey. SETTING: Random sample from population registry of the City of Helsinki. PARTICIPANTS: Nine hundred subjects aged 75 years, 80 years and 85-years, 300 in each group. MEASUREMENTS: For each participant, we completed a questionnaire for the subject and an informant and a functional-capacity scale and Mini-Mental Status Examination by a community nurse, including the Clinical Dementia Rating (CDR) scale. Subjects with CDR of 0.5 or greater were examined by a neurologist who diagnosed the presence or absence of dementia according to DSM-III-R. RESULTS: Ninety-three subjects of the 656 whose CDR was known were found to have dementia. Three-quarters of them lived in institutions, and they comprised 33%, 60%, and 68% of all institutionalized patients in the above-mentioned age groups, respectively. Community residents suffering from dementia often lived with a caring relative and needed many services. A considerable part of the need was not met. CONCLUSIONS: In the older age groups, the need for institutional placement due to dementia is great. According to our study, it seems unlikely that these patients could be cared for in any other way, at least not on a large scale. The need for services for home-dwelling patients is also great, and the relatives carry a heavy load in taking care of demented patients.     

Studies of body image. IV. Figure drawings in normal and abnormal geriatric and nongeriatric groups.

Figure drawings were obtained from 72 normal adults, 48 adult psychiatric inpatients, 30 senior citizens, and 33 elderly inpatients in a mental hospital. Blind analyses were carried out for "emotional indicators" and other characteristics such as body image disturbance and intellectual impairment. Significant differences were found on almost all measures between the normal elderly and the normal adult. They were also found to discriminate between the normal adult group and the adult psychiatric patients. Very few differences were found between the normal elderly and elderly psychiatric patients, or between normal elderly and adult psychiatric patients. These results imply that norms based upon figure drawings of children or adults may not apply to the elderly and that, therefore, figure drawings may be a less useful diagnostic tool for elderly people than they are for children or adults.     

The progression of mild idiopathic dementia in a community population

Thirty-one subjects aged 75 years and over who were identified as suffering from mild, idiopathic dementia in a large community survey were reviewed at annual intervals for 2 years. Diagnoses and severity ratings were based on defined criteria following a mental state examination, a medical and psychiatric history, detailed cognitive testing, and an interview with relatives or other key informants. Fourteen subjects became more severely demented within 2 years. The initial cognitive test battery failed to reveal any differences between respondents whose dementia advanced and those whose condition remained unchanged, but, in the former group, subjects' symptoms had been present for longer, and a greater proportion had been recognised as demented, or possibly demented, by their general practitioners. We suggest that subjects whose dementia progressed had actually been more severely disabled at the time of identification.     

Comorbidity and dementia

Epidemiological data suggest a strong association between aging, dementia and comorbidity such as cancer, chronic renal failure or undernourishment. These chronic conditions may lead to invasive diagnosis procedures as well as to difficult therapeutic management. When they occur in elderly patients with cognitive disorders or dementia, physicians and caregivers should apply specific care program. For example, if an adjuvant chimiotherapy is discussed for an old demented patient with cancer, informed consent and details about the treatment program should be carefully provide. At the onset of a chronic disease, the assessment of its prognosis as well as its impact on the autonomy or quality of life is particular when the patient is also demented. We discuss the specific characteristics about management of demented elderly patients who require high risk treatment because of severe and lethal diseases.     

Five year follow-up study on dementia in institutions for the elderly]

The purpose of this study was to clarify the prognosis of senile dementia based on a 5-year follow-up study in institutions for the elderly. The subjects consisted of 747 cases over 60 years of age. Of these 316 cases showed clinical dementia but 431 cases had no intellectual disturbance in July, 1987. The mortality rate (56.3%) of the demented group was significantly higher than that (31.8%) of the non-demented group. The mortality rate of patients increased with aging. However, the mortality rate of the demented group did not correlate with the severity of dementia. An autopsy study revealed that the direct causes of death in 51.1% of demented patients were pneumonia and cardiovascular diseases. Among the demented patients followed up for 5 years, 22.5% showed severe worsening of dementia, 25.8% showed slight or moderate degree of worsening and 51.7% showed no change. Factors causing exacerbation of dementia included cerebrovascular disease and bone fracture.     

Copy task performance and urinary incontinence in Alzheimer's disease

The relationship between behavioral symptoms and cognitive impairment in Alzheimer's Disease (AD) is only poorly understood. The aim of the present study was to examine cognitive correlates of urinary incontinence in AD. Although incontinence is generally accepted as an accompaniment of AD, it was our clinical impression that it correlated poorly with global measures of cognitive impairment. A retrospective pilot study of 17 incontinent demented patients and 17 continent patients, matched for age, sex, and total score on the Folstein Mini-Mental Status Exam (MMSE), revealed a striking association between an inability to do a copy task and urinary incontinence. A prospective study confirmed this finding in a sample of 45 patients meeting DSMIII-R diagnostic criteria for dementia, probable Alzheimer's disease. The 17 incontinent patients did not differ from the 28 continent patients in age, sex distribution, or total score on the MMSE. However, the incontinent subjects scored significantly lower on a cube copying task. Qualitative analysis revealed that the drawings by incontinent patients showed features comparable with those observed in the drawings by patients with right-sided parietal lesions, in particular, poor representation of perspective and spatial orientation. Further investigation of the relationship between copying performance and incontinence may have implications for understanding the cortical mechanisms of urinary continence. The present results also underscore the limitations of the MMSE as a measure of dementia severity and suggest there are areas of cognitive ability which are inadequately assessed by MMSE but which may be of major important in understanding the loss of functional skills in the dementing patient.     

Decreasing the burden in families caring for a relative with a dementing illness. A controlled study

The purpose of this study was to investigate the efficacy of a specifically designed group support program for relatives of patients with Alzheimer's disease and related disorders. The group program included educational/supportive activities and used basic principles of the cognitive-behavioral approach. Twenty-two subjects participated in an eight-session program. Eighteen control subjects received no treatment. Measures of family burden, levels of depression, and knowledge of dementia were obtained. Experimental subjects showed a significant decrease in total family burden, whereas control subjects actually showed a significant increase, experimental subjects also showed reduction in their levels of depression. Experimental subjects showed a significantly greater improvement than did control subjects on knowledge of dementia. The acquisition of new knowledge was an important ingredient in reducing perception of burden and levels of depression, but other facets of the intervention also accounted for the improvement. Results indicated that a relatively short but intensive support experience can have a positive effect in reducing some of the burden and depression associated with the care of a demented relative.     

Depression as prognostic factor: 6 months follow-up in a geriatric institution

Depression in the elderly and especially in the demented elderly is common, but it is unclear to what extent depression affects the prognosis of dementia. We performed a 6 months follow-up on the elderly to evaluate the effect of depression on the prognosis of dementia. Among the residents in a Korean geriatric institution, a total of 141 elderly residents were included in this study. Those residents who had geriatric depression scale (GDS) scores over 20 were considered as having depression. The subjects were assessed at baseline and at 6 months later with the Korean Mini-Mental State Examination (K-MMSE), Clinical Dementia Rating (CDR) and Barthel index (BI). For all the 141 subjects, the changes of the K-MMSE, CDR and BI scores were first compared between the depressed and non-depressed groups. Then, for the 58 depressed subjects subdivided into three groups (36 subjects in the non-demented group, 14 subjects in the Alzheimer disease (AD) group and 8 subjects in the vascular dementia (VaD) group), the changes of the scores among the three groups were compared. For all subjects, the changes of the K-MMSE and CDR scores were more severe in the depressed group than in the non-depressed group. For the 58 depressed subjects, the changes were significantly different among the three groups (p=0.02 for the K-MMSE, p<0.001 for the CDR), and the changes were the most severe in the VaD group. For the elderly, depression has a significant influence on the cognitive deterioration. Moreover, the effect of depression on the cognitive dysfunction and on the prognosis of dementia is more severe in the demented elderly, and especially for the VaD patients.     

Nonspecific presentation of pneumonia in hospitalized older people: age effect or dementia?

OBJECTIVES: Older adults, when presenting with pneumonia, are often thought to present with nonspecific symptoms instead of more suggestive symptom(s). However, studies designed to determine whether age is associated with nonspecific presentations have yielded contradictory results. Many studies have not distinguished between the effects of preexisting cognitive impairment that results from dementia and the effects of age. The aim of this study is to determine whether there are significant differences in the presentation of pneumonia in demented versus nondemented patients across two age groups. We hypothesized that the nonspecific presentation of pneumonia in older people is due to dementia rather than to chronological age. DESIGN: We compared retrospectively nonspecific (weakness, decreased appetite, urinary incontinence, falls, and delirium) and specific (cough, sputum production, dyspnea, and chest pain) symptoms of pneumonia in 148 hospitalized adult subjects from two urban, general medical teaching hospitals. RESULTS: When the subjects with dementia were included in the analysis, two (falls and delirium) of the five nonspecific symptoms were associated with older age and one other symptom (weakness) showed a trend toward statistical significance. However, when we excluded the demented subjects, nonspecific presenting symptoms were similar in old and young adults with the exception of an increased frequency of delirium on presentation. Similarly, when demented subjects were excluded, we found a stronger association of younger age with the classic specific symptoms than were seen when the demented subjects were included. CONCLUSIONS: We conclude that age differences in the presentation of pneumonia are largely due to the presence of dementia.     

Pineal and pituitary-adrenocortical function in physiological aging and in senile dementia

The simultaneous evaluation of the circadian rhythm of plasma melatonin and ACTH and of serum cortisol and DHEAS represents a clinically reliable tool to appreciate the neuroendocrine changes occurring in physiological and pathological brain aging.

A selective impairment of the nocturnal melatonin secretion has been observed in elderly subjects, being significantly related either to the age or to the severity of dementia. A significant increase of serum cortisol levels during evening- and night-times was found in elderly subjects, particularly if demented, when compared to young controls. Besides, both the circadian amplitude of cortisol rhythm and the nocturnal cortisol increase were significantly reduced in relation either to age or to cognitive impairment. By comparison to vascular dementia, patients with Alzheimer's disease exhibited the highest cortisol concentrations throughout the 24 h. The sensitivity of the hypothalamic-pituitary-adrenal axis to the steroid feedback was significantly impaired in old subjects and particularly in the demented ones. The serum DHEAS levels were significantly lower in elderly subjects and even more in demented patients than in young controls. Consequently, a significant increase of the cortisol/DHEAS molar ratio was evident when going from young controls to healthy elderly subjects and to demented patients.

In conclusion, the aging process affects many neuroendocrine functions resulting in subtle but clinically relevant consequences; the occurrence of senile dementia seems to play an additive role.     

Survival and dementia: a 7-year follow-up of an Italian elderly population

The objective of this study was to investigate the association between dementia and mortality in an elderly Italian population. Demented subjects were identified by a previous prevalence study of Alzheimer's disease (AD) and specific dementing disorders. The study sample included all inhabitants of Appignano aged 60 and over (778 subjects), and was followed-up over a period of about 7 years. Periodic records of dates of death were obtained from the Registry Office of Appignano. We found considerably higher mortality ratios for subjects previously diagnosed as having dementia syndrome (12.5% at 1 year and 81.3% at about 7 years) than for those who were non-demented (3.0% at 1 year and 21.5% at about 7 years). In the group of demented subjects (N = 48), we also investigated the influence of sex, age, and specific dementing disorders on mortality ratios. The percentage of demented subjects who died during the whole period of follow-up was higher among men than women (100% vs. 66.7%) and increased considerably with increasing age (50.0% for age class 60-69, 76.5% for age class 70-79, and 86.2% for age class 80+). Mortality of subjects with multi-infarct dementia (MID) and mixed dementia (MD) tended to be slightly higher than in subjects affected by AD. Our results are consistent with those reported in previous population-based studies on survival of dementia patients.     

Autobiographical memory in normal aging and primary degenerative dementia (dementia of Alzheimer type)

Autobiographical memory of old people (71-89 years) was studied by a method of free narratives, with normal subjects as well as patients with primary degenerative dementia (SDAT) at three stages of development. The chronological distribution of memories across the life span in both groups showed a peak in adolescence and early adulthood, decrease in mid-life, and increase in recent years. This distribution is different from the results found with the prompt word method among normal old adults, but is similar to the chronological pattern reported for vivid memories. The distribution in the demented group was more flat, which contradicts theories of selective preservation of early memories. With the progression of dementia, autobiographical memory deficits were first evidenced by inaccessibility or loss of memories, and, at a later stage, by loss of details of the retrieved memories and impairment of temporal structure. Events that marked transitions in the lives of the patients ("landmarks") were less subject to forgetting than nontransitional events. The article argues for an approach to autobiographical memory that takes into account sociocultural and developmental determinants of memorability as well as internal mechanisms of the cognitive system.     

How common is dementia in Parkinson's disease?

Current estimates suggest that about one in three patients with Parkinson's disease will become demented. Critical review of the studies on which this conclusion is based indicate that this figure is inflated. Errors in separating idiopathic Parkinson's disease from other causes of the akinetic-rigid syndrome, in differentiating dementia from confusional states, depression, and even normal ageing, and in defining and assessing dementia itself may have led to overestimation of the prevalence. A more conservative estimate is that one in five patients with Parkinson's disease is demented, but this assertion needs to be put to rigorous examination.     

A visual recognition memory test for the assessment of cognitive function in aging and dementia

Young, non-demented elderly, and elderly demented subjects were administered a computerized visual recognition memory task. In the task, subjects were instructed to point out the new object from a group of objects whose number was progressively incremented. The test was subject-paced and made use of face-valid stimulus materials; it is closely comparable to tests developed for memory assessment in non-human primates that are sensitive to the effects of hippocampal ablation. The present task was found to elicit significant differences in performance between young and non-demented aged subjects, between the non-demented and demented elderly, and between demented subjects in the early and more advanced stages of senile dementia of the Alzheimer type (SDAT). In a discriminant analysis, the visual recognition memory test scores correctly classified 72.6% of the aged subjects and early SDAT patients. No significant difference in task performance was found between SDAT patients and demented patients with a significant cerebrovascular etiological component. Thus, although the task does not appear to be suitable for diagnostic purposes it would be useful for the assessment of treatment effects upon age-related cognitive dysfunction.     

Examining the reliability and validity of the Hebrew version of the Mini Mental State Examination

The Mini Mental State Examination is used worldwide for the screening and diagnosis of dementia. The aim of the present study was to examine the reliability and validity of the Hebrew version of the Mini Mental State Examination. The Hebrew version of the Mini Mental State Examination was administered to 36 demented and 19 non-demented elderly persons. Test-retest reliability scores were calculated as exact agreement rates, and ranged from good to excellent for all the items. Strong convergent validity, as measured by the correlation between the MMSE and the CAM-COG (r = 0.94), was found. Good predictive value was observed as over three-quarters of the participants were correctly classified as demented or non-demented. The Hebrew version of the MMSE was found to be a useful and valid instrument for the determination of dementia in the elderly population.     

Sexuality and dementia

Sexuality, love, companionship and intimacy remain important parts of life in older people and demented patients. The most frequent sexual disorder reported by spouses of patients with dementia is sexual indifference related to apathy and blunted affect. Increase of sexual demands is rare and many behaviors considered as inappropriate or expressing hypersexuality actually express affective needs or result from cognitive disturbances. Permanence of sexual activity is most often a factor of adjustment for married dementia sufferers and their caregivers. However, some sexual behaviors are stressing for the spouses, mainly women spouses. In nursing homes or long term care facilities, expressing sexuality by demented subjects and dealing with inappropriate sexual expression are source of concerns for the nursing staff, other residents, and families. Information about sex and dementia and a psychobehavioral approach can decrease the strain of families and caregivers.     

Dementia among medical inpatients. Evaluation of 2000 consecutive admissions

Two thousand consecutive patients aged 55 years and older admitted to a department of medicine in a large university hospital were examined for the presence of dementia. The occurrence of moderate and severe dementia was 9.1% for all age groups. It increased from 0.8% in the age group from 55 to 64 years to 31.2% in patients aged 85 years and older. Of the demented patients, 41.4% were delirious at admission, and 24.9% of all delirious patients were demented. Patients with vascular dementia constituted 72.4%, those with primary degenerative dementia 23.0%, and those with specific causes 4.6% of all demented patients. The mean hospitalization time for demented patients was significantly longer, and they needed significantly more daily nursing care, when compared with nondemented patients.