Prevalence and clinical correlates of disinhibition in dementia

The neuropsychology of healthy aging: the positive context of the University of the Third Age during the COVID-19 pandemic

Older adults have been reported to have increased susceptibility to the adverse effects of SARS-CoV-2 infection, such as fatal outcomes, cognitive decline, and changes in physical and/or mental health. However, few studies have examined neuropsychological changes by comparing measurements before and during the pandemic in healthy older people. In addition, no longitudinal studies have examined whether older adults may have responded positively to the pandemic. We examined these issues through a 2-year neuropsychological study before and during the pandemic period. Results showed that scores before and during the pandemic were the same in memory and attention, whereas global cognitive, executive, and language functions improved. Participants also showed no longitudinal changes in depression, hypomania, and disinhibition, while apathy and, to a lesser extent, anxiety increased significantly. To examine possible signs of pandemic-related emotional (dys)regulation, subjects were shown images at follow-up that recalled the most dramatic lockdown phase while heart rate variability was recorded. Higher apathy was predicted by poorer global cognitive performance, increased anxiety, and emotional dysregulation as measured by a higher ratio of low-to-high frequency heart rate variability. Thus, preserved global cognition appears to play a protective role against the effects of pandemic-related anxiety and emotional dysregulation on apathy.

A multicentric exploratory study of behavioral and psychological symptom characteristics of dementia

BACKGROUND

Behavioral and psychological symptoms (BPS) are usually the expected consequences of dementia. BPS increases morbidity and burden, affects the quality of life, and impacts care costs. However, the symptom characteristics, clinical correlations, and symptom-specific clusters aiding the diagnosis are less well studied, especially in the Indian population.

MATERIALS AND METHODS

The present study examined the BPS clusters based on various cognitive and neuropsychiatric profiles in patients with dementia under a multicentric study in India. We did a cross-sectional assessment using the Neuropsychiatric Inventory Questionnaire (NPI-Q) and cognitive functions by Montreal Cognitive Assessment (MoCA), and the severity of dementia using the Clinical Dementia Rating (CDR) scale. In addition, all of the participants were evaluated on a structured Clinical Interview for DSM-5 Research Version for past or current psychiatric disorder(s).

RESULTS

We describe the various BPS clusters uniquely associated with the severity of dementia. Further, on linear regression analysis, we predicted three symptom clusters (anxiety, irritability, aberrant motor) in mild, two symptom clusters (disinhibition, agitation/aggression) in moderate and three symptom clusters (delusion, euphoria/elation, disinhibition) in severe dementia.

CONCLUSION

The study provides insights into the various symptom characteristics and inter-relationship of BPS, which may benefit the clinician while assessing patients with dementia.

Apathy and Huntington's Disease: A Literature Review Based on PRISMA

OBJECTIVE

Although apathy is commonly reported among patients with Huntington's disease (HD), this psychiatric symptom has not yet been clearly defined or extensively studied in HD. Most researchers have adopted descriptive approaches, showing that apathy is a multidimensional entity but leaving the processes underlying its different dimensions relatively unexplored.

METHODS

A systematic review of the literature on apathy in HD, focusing on current approaches and measurement tools, was conducted.

RESULTS

Searches in PubMed and PubMed Central yielded 368 articles, 25 of which were included in the present review.

CONCLUSIONS

This systematic review suggests that more comprehensive research is needed to help shed light on apathy in HD, especially regarding its multidimensional aspect and underlying mechanisms.

Apathy and executive functioning among non-demented community-dwelling elderly individuals in an everyday environment: the mediating effect of impulsivity

BACKGROUND

Apathy is common in normal ageing and widely recognized as a predictor of cognitive decline, especially in executive functions. Much less characterized than apathy in the elderly is impulsivity, which increases with ageing. It is also frequently described in comorbidity with apathy in various clinical populations, in whom it is associated with poorer executive functioning. In the present study, by capitalizing on a multidimensional approach, we explore the mediating role of facets of impulsivity on the bidirectional relationships between apathy dimensions and executive functioning in non-demented community-dwelling elderly individuals in daily life.

METHODS

A sample of non-demented community-dwelling older adults (n = 101) completed self-rated questionnaires. Apathy was measured by the Apathy Evaluation Scale; impulsivity was examined through the Urgency, Premeditation, Perseverance, Sensation Seeking, Positive Urgency (UPPS-P) Impulsive Behaviour Scale; and executive functioning in daily life was assessed by the Behaviour Rating Inventory of Executive Function-Adult (BRIEF-A). Two models positing mediation were tested using conditional process modelling.

RESULTS

Hierarchical regressions controlling for depressive symptoms indicated that the cognitive apathy dimension was associated with the UPPS-P facets sensation seeking, lack of perseverance, and premeditation. Among the UPPS-P facets, lack of perseverance and negative urgency were found to contribute significantly to BRIEF-A Metacognitive index variance. Finally, in both models, lack of perseverance was found to totally mediate the relationship between cognitive apathy and the BRIEF-A Metacognitive index.

CONCLUSIONS

These preliminary findings suggest that, in normal ageing, apathy may share an overlap with impulsivity, contradicting the notion they represent opposite ends of a single behavioural spectrum. Our results argue for bidirectional relationship between a specific apathy dimension (i.e. cognitive apathy) and executive functioning. Moreover, they shed new light on the underlying psychological process implicated (i.e. lack of perseverance) among older adults without dementia and represent an interesting prospect for psychological interventions.

MMP9 modulation improves specific neurobehavioral deficits in a mouse model of Alzheimer's disease

BACKGROUND

Matrix metallopeptidase 9 (MMP9) has been implicated in a variety of neurological disorders, including Alzheimer's disease (AD), where MMP9 levels are elevated in the brain and cerebrovasculature. Previously our group demonstrated apolipoprotein E4 (apoE4) was less efficient in regulating MMP9 activity in the brain than other apoE isoforms, and that MMP9 inhibition facilitated beta-amyloid (Aβ) elimination across the blood-brain barrier (BBB) METHODS: In the current studies, we evaluated the impact of MMP9 modulation on Aβ disposition and neurobehavior in AD using two approaches, (1) pharmacological inhibition of MMP9 with SB-3CT in apoE4 x AD (E4FAD) mice, and (2) gene deletion of MMP9 in AD mice (MMP9KO/5xFAD) RESULTS: Treatment with the MMP9 inhibitor SB-3CT in E4FAD mice led to reduced anxiety compared to placebo using the elevated plus maze. Deletion of the MMP9 gene in 5xFAD mice also reduced anxiety using the open field test, in addition to improving sociability and social recognition memory, particularly in male mice, as assessed through the three-chamber task, indicating certain behavioral alterations in AD may be mediated by MMP9. However, neither pharmacological inhibition of MMP9 or gene deletion of MMP9 affected spatial learning or memory in the AD animals, as determined through the radial arm water maze. Moreover, the effect of MMP9 modulation on AD neurobehavior was not due to changes in Aβ disposition, as both brain and plasma Aβ levels were unchanged in the SB-3CT-treated E4FAD animals and MMP9KO/AD mice compared to their respective controls.

CONCLUSIONS

In total, while MMP9 inhibition did improve specific neurobehavioral deficits associated with AD, such as anxiety and social recognition memory, modulation of MMP9 did not alter spatial learning and memory or Aβ tissue levels in AD animals. While targeting MMP9 may represent a therapeutic strategy to mitigate aspects of neurobehavioral decline in AD, further work is necessary to understand the nature of the relationship between MMP9 activity and neurological dysfunction.

Lockdown Effects on Healthy Cognitive Aging During the COVID-19 Pandemic: A Longitudinal Study

The COVID-19 pandemic is a health issue leading older adults to an increased vulnerability to unfavorable outcomes. Indeed, the presence of physical frailty has recently led to higher mortality due to SARS-CoV-2 infection. However, no longitudinal studies have investigated the role of neuropsychogeriatric factors associated with lockdown fatigue in healthy cognitive aging. Eighty-one healthy older adults were evaluated for their neuropsychological characteristics, including physical frailty, before the pandemic (T0). Subsequently, 50 of them agreed to be interviewed and neuropsychologically re-assessed during the lockdown (T1) and immediately after it (T2). Moreover, during another home confinement, they performed a psychological screening (T3) to evaluate possible mood changes and fatigue. According to Fried's frailty criteria, at T0, 63% of the sample was robust, 34.5% pre-frail, and only 2.5% frail. Significantly, these subjects presented a decrease in handgrip strength and walking speed (29.6 and 6.1%, respectively). Results from Principal Component Analyses and multiple regression models highlighted the contribution of “cognitive” and “psychological” factors (i.e., attentive-executive performance and mood deflections) in explaining handgrip strength and gait speed. At T3, lockdown fatigue was explained by higher scores on the Beck Depression Inventory and lower scores on the Trail Making Test part A. Results from a moderated-mediation model showed that the effect of psychomotor speed on lockdown fatigue was mediated by depression, with a moderating effect of gait speed. Our findings highlight the complex interrelationship between cognitive, psychological, and physical factors in the emergence of pandemic fatigue in a carefully selected older population.

Investigating Neuroimaging Correlates of Early Frailty in Patients With Behavioral Variant Frontotemporal Dementia: A MRI and FDG-PET Study

Frailty is a dynamic clinical condition characterized by the reduction of interconnections among different psychobiological domains, which leads to a homeostatic vulnerability. The association between physical frailty and cognitive dysfunctions is a possible predictor of poor prognosis in patients with neurodegenerative disorders. However, this construct has not been fully analyzed by a multidimensional neuropsychogeriatric assessment matched with multimodal neuroimaging methods in patients with behavioral variant frontotemporal dementia (bvFTD). We have investigated cognitive dysfunctions and frailty status, assessed by both a neuropsychological evaluation and the Multidimensional Prognostic Index (MPI), in a sample of 18 bvFTD patients and compared to matched healthy controls. Gray matter (GM) volume (as assessed by voxel-based morphometry) and metabolism (on 18fluorodeoxyglucose positron emission tomography) were first separately compared between groups, then voxelwise compared and correlated to each other within patients. Linear regression of the MPI was performed on those voxels presenting a significant correlation between altered GM volume and metabolism. The neuropsychological assessment reflected the diagnoses and the functional-anatomical alterations documented by neuroimaging analyses. In particular, the majority of patients presented significant executive dysfunction and mood changes in terms of apathy, depression, and anxiety. In the overall MPI score, the patients fell in the lower range (indicating an early frailty status). On imaging, they exhibited a bilateral decrease of GM density and hypometabolism involving the frontal pole, the anterior opercular region, and the anterior cingulate cortex. Greater atrophy than hypometabolism was observed in the bilateral orbitofrontal cortex, the triangular part of the inferior frontal gyrus, and the ventral striatum, whereas the contrary was detected in the bilateral dorsal anterior cingulate cortex and pre-supplementary motor area. MPI scores significantly correlated only with the co-occurrence of a decrease of GM density and hypometabolism in the right anterior insular cortex, but not with the separate pathological phenomena. Our results show a correlation between a specific pattern of co-occurring GM atrophy and hypometabolism with early frailty in bvFTD patients. These aspects, combined with executive dysfunction and mood changes, may lead to an increased risk of poor prognosis, highlighting a potentially critical and precocious role of the insula in the pathogenesis of frailty.

The Behavioral Effects of Combination Therapy of Memantine and Acetylcholinesterase Inhibitors Compared with Acetylcholinesterase Inhibitors Alone in Patients with Moderate Alzheimer's Dementia: A Double-Blind Randomized Placebo-Controlled Trial

OBJECTIVE

This study aimed to investigate treatment effects of combination therapy of memantine and acetylcholinesterase inhibitors (AchEIs) compared with AchEIs alone on behavioral and psychological symptoms of dementia (BPSD) in patients with moderate Alzheimer's dementia (AD).

METHODS

This was a 12-week, double-blind, randomized, placebo-controlled trial. A total of 148 patients with moderate AD participated in this study. Mini-Mental State Examination, Neuropsychiatric Inventory (NPI), Clinician's Interview-Based Impression of Change plus caregiver input, Gottfries-Bråne-Steen Scale, and Zarit Burden Interview were used as assessment scales.

RESULTS

There were no significant differences in age, sex, or education between AChEIs alone and combination groups. The combination group showed significantly more improvement of NPI-disinhibition score (0.76±2.15) than the AChEIs alone group (-0.14±1.71) after 12 weeks.

CONCLUSION

Our findings suggest that the combination therapy of memantine and AchEIs might be a beneficial option for reducing disinhibition symptoms of patients with moderate AD compared with AchEIs alone. We believe that clinicians need to consider additional memantine treatment when patients with moderate AD complain disinhibition symptom. A larger clinical trial is needed to further determine the efficacy and advantages of such combination therapy of memantine and AchEIs for treating BPSD of patients with moderate AD.

Reduced Self-Awareness Following a Combined Polar and Paramedian Bilateral Thalamic Infarction. A Possible Relationship With SARS-CoV-2 Risk of Contagion?

Reduced self-awareness is a well-known phenomenon investigated in patients with vascular disease; however, its impact on neuropsychological functions remains to be clarified. Importantly, selective vascular lesions provide an opportunity to investigate the key neuropsychological features of reduced self-awareness in neurocognitive disorders. Because of its rarity, we present an unusual case of a woman affected by a combined polar and paramedian bilateral thalamic infarction. The patient underwent an extensive neuropsychological evaluation to assess cognitive, behavioral, and functional domains, with a focus on executive functions. She was assessed clinically in the acute phase and after 6 months from the stroke, both clinically and by magnetic resonance imaging. The patient developed a cognitive impairment, characterised by prevalent executive dysfunction associated with reduced self-awareness and mood changes, in terms of apathy and depression. Such condition persisted after 6 months. In May 2020, the patient underwent the serology test in chemiluminescence to detect IgG antibodies against SARS-CoV-2. The result of the quantitative test highlighted a high probability of previous contact with the virus. We suggest that reduced self-awareness related to executive dysfunction and behavioral changes may be due to combined polar and paramedian bilateral thalamic lesion. Metacognitive–executive dysfunction affecting the instrumental abilities of everyday life might make people less able to take appropriate precautions, facilitating the risk of SARS-CoV-2 contagion.

Bazhu Decoction, a Traditional Chinese Medical Formula, Ameliorates Cognitive Deficits in the 5xFAD Mouse Model of Alzheimer's Disease

Alzheimer’s disease (AD) is the most common neurodegenerative disorder associated with aging. There are currently no effective treatments for AD. Bazhu decoction (BZD), a traditional Chinese medicine (TCM) formula, has been employed clinically to alleviate AD. However, the underlying molecular mechanisms are still unclear. Here we found that middle- and high-doses of BZD ameliorated the behavioral aspects of 5xFAD transgenic mice in elevated plus maze, Y maze and Morris water maze tests. Moreover, BZD reduced the protein levels of BACE1 and PS1, resulting in a reduction of Aβ plaques. We also identified a beneficial effect of BZD on oxidative stress by attenuating MDA levels and SOD activity in the brains of 5xFAD mice. Together, these results indicate that BZD produces a dose-dependent positive effect on 5xFAD transgenic mouse model by decreasing APP processing and Aβ plaques, and by ameliorating oxidative damage. BZD may play a protective role in the cognitive and anxiety impairments and may be a complementary therapeutic option for AD.

A novel neurocognitive approach for placebo analgesia in neurocognitive disorders

Neural correlates of placebo analgesia (PA) in patients with neurocognitive disorders have not yet been elucidated. The present study aimed to evaluate how and to what extent executive (dys)functions of the medial prefrontal cortex (MPFC) may be related to PA. To this end, twenty-three subjects complaining of different cognitive deficits (from mild cognitive impairment likely due to Alzheimer's disease to mild AD) were recruited. PA was investigated by a well-known experimental venipuncture pain paradigm (open versus hidden [O-H] application of lidocaine). Patients also underwent a comprehensive neuropsychological evaluation and a functional magnetic resonance imaging (fMRI) GO/No-GO task for eliciting selective activation of the MPFC. Selected neuropsychological variables were correlated to the OH-PA paradigm. The association between the fMRI response on the "No-GO" versus "GO" contrast and PA was investigated over the whole-brain by regression analysis. We showed the existence of a relationship between a lower PA and MPFC dysfunctions through the neuropsychological and fMRI assessment. A separate voxel-based morphometry (VBM) analysis controlled for possible influence of grey matter (GM) volume reduction on both fMRI results and PA. fMRI results were not directly affected by, and therefore independent of, disease-specific GM atrophy, which was indeed located more anteriorly within the rostral anterior cingulate and inversely correlated with PA. Our findings shed new light on the underestimated contribution of executive (dys)functions mediated by the MPFC (response-inhibition, self-monitoring and set-shifting abilities) in PA pathogenesis, with a special purely (i.e. independently from brain structural alterations) functional role played by the MCC. Results are discussed in terms of possible clinical relevance in the management of patients with neurocognitive disorders.

Manic behavior and asymmetric right frontotemporal dementia from a novel progranulin mutation

Studies suggest a relationship of manic behavior and bipolar disorder (BD) with behavioral variant frontotemporal dementia (bvFTD). The nature of this relationship is unclear. This report presents a patient with initial manic behavior as the main manifestation of familial bvFTD from a novel progranulin (GRN) mutation. In contrast, there are other reports of a long background of BD preceding a diagnosis of bvFTD. A review of the literature and this patient suggest that manic symptoms result from damage to right frontotemporal neural structures from longstanding BD, as well as from bvFTD and other focal neurological disorders. In addition, there is a subgroup of patients with a probable genetic predisposition to both BD and bvFTD.

Neuropsychological Correlates of Pre-Frailty in Neurocognitive Disorders: A Possible Role for Metacognitive Dysfunction and Mood Changes

Background

Recent studies have suggested that cognitive functions in patients with neurocognitive disorders have a significant role in the pathogenic mechanisms of frailty. Although pre-frailty is considered an intermediate, preclinical state, epidemiological research has begun to dislodge cognition and frailty into their specific subcomponents to understand the relationship among them. We aim to analyse the possible association between pre-frailty and neuropsychological variables to outline which factors can contribute to minor and major neurocognitive disorders.

Methods

60 subjects complaining of different cognitive deficits underwent a deep-in-wide frailty and neuropsychological assessment. We conducted three multiple linear regression analyses adjusted for a combination of demographic measures and involving several neuropsychological–behavioural parameters selected by the literature on physical frailty.

Results

We found a significant association between frailty—as measured by the multidimensional prognostic index (MPI)—and action monitoring and monetary gain (cognitive domain), depression and disinhibition (behavioural domain). Moreover, an association between MPI and impaired awareness for instrumental activities disabilities exists.

Conclusion

We propose a novel framework for understanding frailty associated with metacognitive–executive dysfunction.

Person-Based Versus Generalized Impulsivity Disinhibition in Frontotemporal Dementia and Alzheimer Disease

BACKGROUND

While much disinhibition in dementia results from generalized impulsivity, in behavioral variant frontotemporal dementia (bvFTD) disinhibition may also result from impaired social cognition.

OBJECTIVE

To deconstruct disinhibition and its neural correlates in bvFTD vs. early-onset Alzheimer's disease (eAD).

METHODS

Caregivers of 16 bvFTD and 21 matched-eAD patients completed the Frontal Systems Behavior Scale disinhibition items. The disinhibition items were further categorized into (1) "person-based" subscale which predominantly associated with violating social propriety and personal boundary and (2) "generalized-impulsivity" subscale which included nonspecific impulsive acts. Subscale scores were correlated with grey matter volumes from tensor-based morphometry on magnetic resonance images.

RESULTS

In comparison to the eAD patients, the bvFTD patients developed greater person-based disinhibition ( P < 0.001) but comparable generalized impulsivity. Severity of person-based disinhibition significantly correlated with the left anterior superior temporal sulcus (STS), and generalized-impulsivity correlated with the right orbitofrontal cortex (OFC) and the left anterior temporal lobe (aTL).

CONCLUSIONS

Person-based disinhibition was predominant in bvFTD and correlated with the left STS. In both dementia, violations of social propriety and personal boundaries involved fronto-parieto-temporal network of Theory of Mind, whereas nonspecific disinhibition involved the OFC and aTL.

Neural correlates of reduced awareness in instrumental activities of daily living in frontotemporal dementia

A decline in instrumental activities of daily living has been described as the earliest functional deficit in patients with neurodegenerative disease. It embraces specific competencies such as: "recalling the date and telephone calls, orienting to new places, remembering the location of objects at home, understanding conversation and the plot of a movie, keeping belongings in order, doing mental calculations and handling money, remembering appointments and shopping lists and performing clerical work". Since changes in instrumental daily living activities are one of the descriptors of behavioural-variant frontotemporal dementia, we decided to investigate the neural correlates of a reduced awareness in this specific domain in twenty-three consecutive behavioural-variant frontotemporal dementia patients. Gray matter volume changes associated with a reduced awareness for the instrumental domain, assessed using a validated caregiver-patient discrepancy questionnaire, were examined. Interestingly, we found disabilities in instrumental daily living activities and a reduced awareness of these to be related to medial prefrontal cortex atrophy, where the mid-cingulate cortices, dorsal anterior insula and cuneous play an important role. Importantly, if the executive system does not function correctly, the comparator mechanism of action self-monitoring does not detect mismatches between the current and previous performance states stored in the personal database, and produces a reduced awareness for the instrumental domain.

Living well with dementia: enhancing dignity and quality of life, using a novel intervention, Dignity Therapy

AIMS AND OBJECTIVES

To assess the feasibility, acceptability and potential effectiveness of Dignity Therapy to improve the quality of life and reduce psychological and spiritual distress in older people with early stage dementia.

BACKGROUND

Dementia is a syndrome with several causes that leads to a progressive decline in multiple areas of functioning. The maintenance of dignity and enhancement of quality of life are key elements of care. Meaningful communication may become more difficult with condition progression. Improvements in communication may have positive effects on the person's quality of life. Dignity Therapy is a short psychotherapeutic intervention that uses a trained therapist to take the person with dementia through a guided interview process, producing a 'generativity' document that creates a lasting, written legacy during a time when they are still able to communicate well.

DESIGN AND METHOD

This was a feasibility mixed method study. Dignity Therapy was undertaken with patients diagnosed as having early stage dementia. Data were gathe-red from pre- and post-Dignity Therapy interviews, a focus group, interviews with key stakeholders, and three outcome measures: The Herth Hope Index; The Patient Dignity Inventory; Perceived Quality of Life/Satisfaction with Quality Life Ratings.

FINDINGS

This study demonstrated that Dignity Therapy is feasible, acceptable and potentially effective for older people with dementia. Three overarching themes emerged: A life in context, A key to connect and Personal legacy.

CONCLUSIONS

We recommend that this feasibility study forms the basis for further study, advocating the prospective benefits to patients with dementia, families and nursing practice.

IMPLICATIONS FOR PRACTICE

Dignity Therapy, as a psychosocial intervention, has the potential to improve the quality of life and enhance person centred care for people with dementia.

α-Melanocyte stimulating hormone prevents GABAergic neuronal loss and improves cognitive function in Alzheimer's disease

In Alzheimer's disease (AD), appropriate excitatory-inhibitory balance required for memory formation is impaired. Our objective was to elucidate deficits in the inhibitory GABAergic system in the TgCRND8 mouse model of AD to establish a link between GABAergic dysfunction and cognitive function. We sought to determine whether the neuroprotective peptide α-melanocyte stimulating hormone (α-MSH) attenuates GABAergic loss and thus improves cognition. TgCRND8 mice with established β-amyloid peptide pathology and nontransgenic littermates were treated with either α-MSH or vehicle via daily intraperitoneal injections for 28 d. TgCRND8 mice exhibited spatial memory deficits and altered anxiety that were rescued after α-MSH treatment. The expression of GABAergic marker glutamic acid decarboxylase 67 (GAD67) and the number of GABAergic GAD67+ interneurons expressing neuropeptide Y and somatostatin are reduced in the hippocampus in vehicle-treated TgCRND8 mice. In the septohippocampal pathway, GABAergic deficits are observed before cholinergic deficits, suggesting that GABAergic loss may underlie behavior deficits in vehicle-treated TgCRND8 mice. α-MSH preserves GAD67 expression and prevents loss of the somatostatin-expressing subtype of GABAergic GAD67+ inhibitory interneurons. Without decreasing β-amyloid peptide load in the brain, α-MSH improves spatial memory in TgCRND8 mice and prevents alterations in anxiety. α-MSH modulated the excitatory-inhibitory balance in the brain by restoring GABAergic inhibition and, as a result, improved cognition in TgCRND8 mice.

Unawareness of deficits in ischemic injury: role of the cingulate cortex

Reduced awareness of illness is a well-known phenomenon that has been studied in patients with vascular disease, but the precise nature of their executive dysfunction is an intriguing question that still has to be resolved. It would be particularly interesting to study patients with reduced awareness of disease possibly related to vascular lesions of the prefrontal cortex. Due to the clinical importance of the case, here we present a patient with a selective right anterior cingulate ischemic injury and impaired awareness of deficits. We suggest that the cingulo-frontal area dysfunction may represent one of the corresponding neurobiological substrates of his persistent unawareness, which has not yet been evaluated in the literature on patients with acquired brain injury (ABI).

Inhibitory dysfunction in frontotemporal dementia: a review

Failure of inhibitory control is an early and consistent feature in patients suffering from frontotemporal dementia (FTD). This appears because of their pervasive ventromedial prefrontal atrophy-particularly in the orbitofrontal cortex-which has been linked to inhibitory dysfunction in studies on human and monkey lesions. However, the range of measures currently available to assess inhibitory processes in FTD is limited, and, as such, inhibitory dysfunction in FTD remains relatively underexplored. Subjective caregiver questionnaires are useful for defining disinhibition as it manifests behaviorally; however, endorsement of symptoms can vary largely across patients as it is contingent on the perceptiveness of the caregiver. The few objective neuropsychological tasks that tap directly into inhibitory functioning have potential, although they mostly rely on intact language and semantics, which can confound performance in FTD patients. An emergent possibility is to explore inhibitory functioning in FTD through nonverbal experimental tasks. Adaptation of such experimental tasks into clinical tools is a promising avenue for exploring one of the earliest behavioral features in FTD patients and concomitantly tap into their prevalent orbitofrontal cortex dysfunction. We suggest that improved characterization of early inhibitory dysfunction may facilitate more accurate diagnosis of FTD.

Impaired awareness of deficits in Alzheimer's disease: the role of everyday executive dysfunction

The present study analyzed the awareness of deficits in 117 mild Alzheimer's disease participants. Since few studies have examined the cognitive and behavioral domains of reduced awareness in detail, we performed a domain-specific assessment using the Awareness of deficit Questionnaire - Dementia scale with the novel aim of describing the relationship with everyday executive dysfunction. Through the use of the subtests of the Behavioral Assessment of the Dysexecutive Syndrome, we hypothesized that executive cognitive functions may play an important role in the reduced awareness of deficits. We also considered other variables of interest to provide a novel comprehensive explanation of this phenomenon. Our first approach to the study was a factor analysis considering the role of these variables in the awareness of deficits; subsequently, regression analysis models were used to define which variables were associated with a reduction of awareness in cognitive and behavioral domains. In particular, the factors retained from the factor analysis, in terms of inhibition, self-monitoring, set-shifting, and mood orientation changes, appear to be important skills for awareness of instrumental activities of daily living (R(2) = .32). We also found hypo manic mood orientation and a tendency through apathy to be prominent indications of reduced behavioral awareness (R(2) = .13).

Apathy following stroke

OBJECTIVE

We will review the available evidence on the frequency, clinical correlates, mechanism, and treatment of apathy following stroke.

METHODS

We have explored relevant databases (that is, PubMed, MEDLINE, and PsycINFO) using the following key words and their combinations: apathy, motivation, abulia, stroke, cerebrovascular disease, basal ganglia, prefrontal cortex, anterior cerebral infarction, and thalamus.

RESULTS

The frequency of apathy following stroke has been consistently estimated between 20% and 25%. It appears to be associated with the presence of cognitive impairment, a chronic course characterized by progressive functional decline, and with disruption of neural networks connecting the anterior cingulate gyrus, the dorsomedial frontal cortex, and the frontal pole with the ventral aspects of the caudate nucleus, the anterior and ventral globus pallidus, and the dorsomedian and intralaminar thalamic nuclei. Published treatment studies have been mostly limited to anecdotal case reports, generally using dopamine agonists or stimulant medications. Cholinesterase inhibitors and nefiracetam may significantly reduce apathetic symptoms. However, their efficacy was examined in relatively small clinical trials that require replication.

CONCLUSION

Apathy is a frequent neuropsychiatric complication of stroke that, although often associated with depression and cognitive impairment, may occur independently of both. Its presence has been consistently associated with greater functional decline. However, there is no conclusive evidence about which is the best treatment for this condition.

Disinhibition: Clinical Challenges in the Long-Term Care Facility

Clinicians use the word disinhibition and its derivatives to describe a resident's behavior. Up to 30% of people with dementia may manifest behavioral disinhibition; sexual disinhibition is also a problem, but less frequently. Several causal relationships have been hypothesized, with frontal lobe deterioration among the best documented. Lobar lesions or trauma, seizure activity, cerebellar dysfunction, and drugs have been implicated as well. Behavioral disinhibition creates clinical challenges in the long-term care facility, and to date, no drug treatment has been approved for this indication. Behavioral interventions are the strategies of first choice. Reports of drug treatment are limited to case reports and very small studies.

Generalized and symptom-specific insight in behavioral variant frontotemporal dementia and primary progressive aphasia

Behavioral variant frontotemporal dementia (FTD) and primary progressive aphasia (PPA) are related dementias with different presenting symptoms but with increasing symptom overlap as they progress. Loss of insight is associated with early behavioral variant FTD, but not PPA. This study used the Frontal Behavioral Inventory to compare patient and caregiver concepts of symptom presence and severity. Patients with behavioral variant FTD were found to have worse insight overall than PPA patients. However, the PPA group showed reduced insight into behavioral symptoms, and the behavioral variant FTD groups had intact insight into some language symptoms. Theoretical and clinical implications are discussed.

Patterns and correlates of sexual activity and condom use behavior in persons 50-plus years of age living with HIV/AIDS

This study characterized rates of sexual activity and identified psychosocial and behavioral correlates of sexual activity and condom use in a metropolitan sample of 290 HIV-infected adults 50-plus years of age. Thirty-eight percent of participants were sexually active in the past three months, 33% of whom had at least one occasion of anal or vaginal intercourse that was not condom protected. Rates and correlates of sexual activity and condom use differed between gay/bisexual men, heterosexual men, and heterosexual women. In the past three months, 72% of heterosexual men were sexually active compared to only 36% of gay/bisexual men and 21% of heterosexual women. However, among sexually active persons, only 27% of heterosexual men reported inconsistent condom use compared to 37% of gay/bisexual men and 35% of heterosexual women. As the number of older adults living with HIV/AIDS in the U.S. continues to increase, age-appropriate secondary risk-reduction interventions are urgently needed.

Public awareness of dementia: A study in Botucatu, a medium-sized city in the State of São Paulo, Brazil

Dementia is a progressive and debilitating disease affecting an increasing number of people worldwide. Despite its importance, only a few studies have examined public awareness of dementia. We present a study of the public awareness of dementia in Botucatu, São Paulo, Brazil.

Self-awareness and self-monitoring of cognitive and behavioral deficits in behavioral variant frontotemporal dementia, primary progressive aphasia and probable Alzheimer's disease

Lack of insight is a core diagnostic criterion for behavioral variant frontotemporal dementia (bvFTD), and is believed to be intact in the early stages of primary progressive aphasia (PPA). In other neurological conditions, symptom-specific insight has been noted, with behavioral symptoms appearing especially vulnerable to reduced insight. Different components of insight, self-awareness and self-monitoring, are also often considered separate phenomena. The current study compared insight in patients with PPA, bvFTD, and probable Alzheimer's disease (PrAD) and a group of cognitively intact control subjects. Additionally, differences in insight for the domains primarily affected by the three types of dementia, namely, Behavior, Naming, and Memory, were assessed, and self-awareness and self-monitoring were compared. A total of 55 participants were enrolled. Participants were asked to complete self-estimate scales demonstrating their perceived ability immediately prior to, and immediately following a test in each domain of interest. Results indicated that PPA and normal control groups performed very similarly on control (Weight and Eyesight) and cognitive domains, whereas bvFTD and PrAD patients were unable to accurately assess Memory. All three diagnostic groups failed to accurately assess their behavioral symptoms, suggesting that this domain is vulnerable to loss of insight across diagnoses. Naming ability, in contrast, was either accurately assessed or underestimated in all groups. Finally, there were no notable differences between self-awareness and self-monitoring, potential explanations for this are examined.

Insight and danger in Alzheimer's disease

To determine the frequency, and demographic and clinical correlates of dangerous behaviours in Alzheimer's disease (AD). We assessed a consecutive series of 278 patients with AD and 45 age-comparable healthy controls with a comprehensive psychiatric and neuropsychological evaluation. Caregivers rated the frequency of patients' exposure to dangerous situations or commission of dangerous behaviours. The frequency of dangerous behaviours was 16% in the AD group and 2% in the healthy control group. The presence of anosognosia was associated with a threefold increase in the risk of dangerous behaviours, but there was no significant association between dangerous behaviours and patients' age, years of education, diagnosis of major or minor depression and presence of suicide ideation. Sixteen per cent of a consecutive series of patients with AD had dangerous behaviours during the month preceding the clinical evaluation. Anosognosia was the main clinical correlate of dangerous behaviours in this population.

Epidemiology and Management of Apathy in Patients with Alzheimer??s Disease

Although apathy is a diagnostic term used with increasing frequency in both neurology and psychiatry, confusion still exists as to its proper definition and assessment, and whether apathy should be considered a symptom of major psychiatric diseases or an independent syndrome in its own right. Moreover, critical questions regarding the phenomenology and clinical correlates of apathy and the syndromic validity of this construct still exist. Despite these nosological concerns, there is strong evidence that apathy is a common finding in Alzheimer's disease (AD). However, the treatment of apathy is still elusive. Current data are obtained from randomised controlled trials that did not investigate apathy per se, but rather a number of other behavioural and psychological variables. In this context, acetylcholinesterase inhibitors and psychosocial interventions are the only available modalities for treating apathy in AD with some efficacy.

Phenomenology and clinical correlates of delusions in Alzheimer disease

OBJECTIVES

The objectives of this study were to determine whether anosognosia, depression, and elevated mood are associated with delusions in Alzheimer disease (AD), and to examine the validity of standardized diagnostic criteria for psychosis of dementia.

METHOD

The authors assessed a consecutive series of 771 patients with AD attending a dementia clinic with a comprehensive neuropsychologic and psychiatric evaluation that included specific measures of delusions, hallucinations, anosognosia, depression, and elevated mood.

RESULTS

Delusions were found in one-third of the patients and hallucinations in 7%. Most patients with hallucinations also had delusions. A principal component analysis of the Psychosis Dementia Scale, which rates the presence and severity of delusions, produced the factors of paranoid misidentification and expansive delusions. Paranoid, but not expansive, delusions increased across the stages of the illness. Anosognosia and depression were significantly and independently associated with the presence of delusions, whereas elevated mood was significantly associated with expansive, but not paranoid, delusions. A multiple logistic regression analysis demonstrated that delusions in AD were significantly associated with depression, anosognosia, overt aggression, and agitation.

CONCLUSIONS

Anosognosia, depression, global cognitive deficits, and elevated mood are the main psychiatric correlates of paranoid misidentification and expansive delusions in AD, whereas overt aggression and agitation are the most frequent behavioral concomitants of psychosis in AD.

A diagnostic formulation for anosognosia in Alzheimer's disease

OBJECTIVE

To determine the earliest symptoms of anosognosia in people with Alzheimer's disease and to validate a criteria-guided strategy to diagnose anosognosia in dementia.

METHODS

A consecutive series of 750 patients with very mild or probable Alzheimer's disease attending a memory clinic, as well as their respective care givers, was assessed using a comprehensive psychiatric evaluation.

RESULTS

The factors of anosognosia for (1) basic activities of daily living (bADL), (2) instrumental activities of daily living (iADL), (3) depression and (4) disinhibition were produced by a principal component analysis on the differential scores (ie, caregiver score minus patient score) on the anosognosia questionnaire for dementia. A discrepancy of two or more points in the anosognosia-iADL factor was found to have a high sensitivity and specificity to identify clinically diagnosed anosognosia in people with Alzheimer's disease. By logistic regression analysis, the severity of dementia and apathy were both shown to be noticeably associated with anosognosia in people with Alzheimer's disease.

CONCLUSION

Anosognosia in those with Alzheimer's disease is manifested as poor awareness of deficits in iADL and bADL, depressive changes and behavioural disinhibition. The frequency of anosognosia is found to increase considerably with the severity of dementia. The validity of a specific set of criteria to diagnose anosognosia in people with Alzheimer's disease was shown, which may contribute to the early identification of this condition.