Behavioral differences between white matter lacunar dementia and Alzheimer's disease: a comparison on the neuropsychiatric inventory

Strengths and Weaknesses of the Vascular Apathy Hypothesis: A Narrative Review

The vascular apathy hypothesis states that cerebral small vessel disease (CSVD) can cause apathy, even when no other symptoms of CSVD are present. In order to examine this hypothesis, the objectives of this narrative review are to evaluate the evidence for a pathophysiological mechanism linking CSVD to apathy and to examine whether CSVD can be a sole cause of apathy. The nature of the CSVD-apathy relationship was evaluated using the Bradford Hill criteria as a method for research on the distinction between association and causation. Pathological, neuroimaging, and behavioral studies show that CSVD can cause lesions in the reward network, which causes an apathy syndrome. Studies in healthy older individuals, stroke patients and cognitively impaired persons consistently show an association between CSVD markers and apathy, although studies in older persons suffering from depression are inconclusive. A biological gradient is confirmed, as well as a temporal relationship, although the evidence for the latter is still weak. The specificity of this causal relationship is low given there often are other contributing factors in CSVD patients with apathy, particularly depression and cognitive deterioration. Differentiating between vascular apathy and other apathy syndromes on the basis of clinical features is not yet possible, while in-depth knowledge about differences in the prognosis and efficacy of treatment options for apathy caused by CSVD and other apathy syndromes is lacking. Since we cannot differentiate between etiologically different apathy syndromes as yet, it is premature to use the term vascular apathy which would suggest a distinct clinical apathy syndrome.

Effect of horticultural therapy on apathy in nursing home residents with dementia: a pilot randomized controlled trial

Objectives: This study aimed to examine (1) the feasibility of the study procedures (i.e. recruitment, retention, attendance, and assessment completion rates), and (2) the effects of horticultural therapy (HT) on apathy, cognitive ability, quality of life, and functional capacity.Methods: This was a parallel-group, match-paired, randomized controlled trial. Thirty-two participants were allocated to either the experimental or the control group. Data were collected at baseline (T0), immediately postintervention (T1), and 3 months postintervention (T2). The Apathy Evaluation Scale-informant version (AES-I); Mini-Mental State Examination (MMSE); Quality of Life in Alzheimer's disease (QoL-AD) scale; Barthel index (BI) were used to measure apathy, cognitive ability, quality of life, and functional capacity, respectively.Results: The recruitment, retention, attendance and assessment completion rates were 22.7%, 87.5%, 100% and 100%, respectively. The between-group differences in AES-I (p = 0.007) and MMSE (p = 0.034) scores were statistically significant at T1. In the experimental group, the AES-I (p = 0.001), MMSE (p = 0.010), and QoL-AD (p = 0.017) scores were significantly different over time. In the post hoc pair-wise analysis, the AES-I scores of the experimental group observed at T1 were significantly lower than that at T0 (p = 0.032). In the control group, the MMSE scores (p = 0.001) were significantly different over time.Conclusion: HT is feasible for residents with dementia and apathy. The HT program effectively reduced apathy and promoted cognitive function, but its effects on quality of life and functional capacity were not observed.

The Diagnostic Challenge of Young-Onset Dementia Syndromes and Primary Psychiatric Diseases: Results From a Retrospective 20-Year Cross-Sectional Study

OBJECTIVE

Distinguishing a dementia syndrome from a primary psychiatric disease in younger patients can be challenging and may lead to diagnostic change over time. The investigators aimed to examine diagnostic stability in a cohort of patients with younger-onset neurocognitive disorders.

METHODS

A retrospective review of records was conducted for patients who were admitted to an inpatient neuropsychiatry service unit between 2000 and 2019, who were followed up for at least 12 months, and who received a diagnosis of young-onset dementia at any time point. Initial diagnosis included Alzheimer's disease-type dementia (N=30), frontotemporal dementia (FTD) syndromes (N=44), vascular dementia (N=7), mild cognitive impairment (N=10), primary psychiatric diseases (N=6), and other conditions, such as Lewy body dementia (N=30).

RESULTS

Among 127 patients, 49 (39%) had a change in their initial diagnoses during the follow-up period. Behavioral variant FTD (bvFTD) was the least stable diagnosis, followed by dementia not otherwise specified and mild cognitive impairment. Compared with patients with a stable diagnosis, those who changed exhibited a higher cognitive score at baseline, a longer follow-up period, greater delay to final diagnosis, and no family history of dementia. Patients whose diagnosis changed from a neurodegenerative to a psychiatric diagnosis were more likely to have a long psychiatric history, while those whose diagnosis changed from a psychiatric to a neurodegenerative one had a recent manifestation of psychiatric symptoms.

CONCLUSIONS

Misdiagnosis of younger patients with neurocognitive disorders is not uncommon, especially in cases of bvFTD. Late-onset psychiatric symptoms may be the harbinger to a neurodegenerative disease. Close follow-up and monitoring of these patients are necessary.

Cognition, mood and behavior in CADASIL

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CADASIL is responsible for cognitive, mood or behavior disturbances.

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Cognitive disturbances range from moderate cognitive slowing to impairment of executive functions and may progress to a global decrease of cognitive efficiency up to severe dementia.

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Mood disturbances are extremely variable in intensity, depression is the most frequent symptom.

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Behavioral changes may occur at all stage of the disease, but are often associated with the onset of cognitive alterations. Apathy is the most prominent behavior alteration.

CADASIL is the most common familial cerebral small vessel disease (cSVD). Stereotyped mutations of the NOTCH3 gene are responsible for this archetypal ischemic cSVD that can lead, at the very end stage, to severe dementia. Variable cognitive alterations, mood, or behavior disturbances are frequently observed during the course of the disease. In this review, these clinical manifestations, their occurrence, severity and duration are analyzed in relation to the disease progression. Also, the potential relationships with cerebral lesions and treatment options are discussed.

Sex Differences in Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis

Background: Cerebral small vessel disease (SVD) is a common cause of stroke, mild cognitive impairment, dementia and physical impairments. Differences in SVD incidence or severity between males and females are unknown. We assessed sex differences in SVD by assessing the male-to-female ratio (M:F) of recruited participants and incidence of SVD, risk factor presence, distribution, and severity of SVD features. Methods: We assessed four recent systematic reviews on SVD and performed a supplementary search of MEDLINE to identify studies reporting M:F ratio in covert, stroke, or cognitive SVD presentations (registered protocol: CRD42020193995). We meta-analyzed differences in sex ratios across time, countries, SVD severity and presentations, age and risk factors for SVD. Results: Amongst 123 relevant studies (n = 36,910 participants) including 53 community-based, 67 hospital-based and three mixed studies published between 1989 and 2020, more males were recruited in hospital-based than in community-based studies [M:F = 1.16 (0.70) vs. M:F = 0.79 (0.35), respectively; p < 0.001]. More males had moderate to severe SVD [M:F = 1.08 (0.81) vs. M:F = 0.82 (0.47) in healthy to mild SVD; p < 0.001], and stroke presentations where M:F was 1.67 (0.53). M:F did not differ for recent (2015-2020) vs. pre-2015 publications, by geographical region, or age. There were insufficient sex-stratified data to explore M:F and risk factors for SVD. Conclusions: Our results highlight differences in male-to-female ratios in SVD severity and amongst those presenting with stroke that have important clinical and translational implications. Future SVD research should report participant demographics, risk factors and outcomes separately for males and females. Systematic Review Registration: [PROSPERO], identifier [CRD42020193995].

Neuropsychiatric symptoms associated with cerebral small vessel disease: a systematic review and meta-analysis

BACKGROUND

Cerebral small vessel disease, a common cause of vascular dementia, is often considered clinically silent before dementia or stroke become apparent. However, some individuals have subtle symptoms associated with acute MRI lesions. We aimed to determine whether neuropsychiatric and cognitive symptoms vary according to small vessel disease burden.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, EMBASE, and PsycINFO for articles published in any language from database inception to Jan 24, 2020. We searched for studies assessing anxiety, apathy, delirium, emotional lability, fatigue, personality change, psychosis, dementia-related behavioural symptoms or cognitive symptoms (including subjective memory complaints), and radiological features of cerebral small vessel disease. We extracted reported odds ratios (OR), standardised mean differences (SMD), and correlations, stratified outcomes by disease severity or symptom presence or absence, and pooled data using random-effects meta-analyses, reporting adjusted findings when possible. We assessed the bias on included studies using the Risk of Bias for Non-randomized Studies tool. This study is registered with PROSPERO, CRD42018096673.

FINDINGS

Of 7119 papers identified, 81 studies including 79 cohorts in total were eligible for inclusion (n=21 730 participants, mean age 69·2 years). Of these 81 studies, 45 (8120 participants) reported effect estimates. We found associations between worse white matter hyperintensity (WMH) severity and apathy (OR 1·41, 95% CI 1·05-1·89) and the adjusted SMD in apathy score between WMH severities was 0·38 (95% CI 0·15-0·61). Worse WMH severity was also associated with delirium (adjusted OR 2·9, 95% CI 1·12-7·55) and fatigue (unadjusted OR 1·63, 95% CI 1·20-2·22). WMHs were not consistently associated with subjective memory complaints (OR 1·34, 95% CI 0·61-2·94) and unadjusted SMD for WMH severity between these groups was 0·08 (95% CI -0·31 to 0·47). Anxiety, dementia-related behaviours, emotional lability, and psychosis were too varied or sparse for meta-analysis; these factors were reviewed narratively. Overall heterogeneity varied from 0% to 79%. Only five studies had a low risk of bias across all domains.

INTERPRETATION

Apathy, fatigue, and delirium associated independently with worse WMH, whereas subjective cognitive complaints did not. The association of anxiety, dementia-related behaviours, emotional lability, and psychosis with cerebral small vessel disease require further investigation. These symptoms should be assessed longitudinally to improve early clinical detection of small vessel disease and enable prevention trials to happen early in the disease course, long before cognition declines.

FUNDING

Chief Scientist Office of the Scottish Government, UK Dementia Research Institute, Fondation Leducq, Stroke Association Garfield-Weston Foundation, Alzheimer's Society, and National Health Service Research Scotland.

Prevalence and Risk Factors of Abusive Behaviors in the Caregivers of People with Dementia in Korea

OBJECTIVE

We investigated the prevalence and risk factors of physically abusive behaviors (PhAB) and psychologically abusive behaviors (PsAB) towards people with dementia (PWD) in family caregivers, and compared their prevalences between East Asian and Western countries.

METHODS

We estimated the prevalence and risk factors of PhAB and PsAB in 467 Korean pairs of community-dwelling PWD and their primary family caregivers. We evaluated abusive behaviors using the Modified Conflict Tactics Scale. In addition, we compared the prevalence of abusive behaviors between Asian and Western countries through a meta-analysis on 12 studies including the current one.

RESULTS

More than a half of the caregivers reported PsAB and about one out of seven caregivers admitted PhAB within past three months. PsAB and PhAB were slightly more prevalent in East Asian countries than in Western countries. Non-Alzheimer type and moderate to severe behavioral and psychological symptoms of dementia were associated with the risk of PhAB but not with the risk of PsAB. Severe care burden and low income were associated with the risk of PhAB and PsAB.

CONCLUSION

PhAB and PsAB were as prevalent in the family caregivers of PWD in Asian countries including Korea as in Western countries. Prevention strategies should be implemented according to the type of abusive behaviors.

Apathy following traumatic brain injury: A review

Apathy is a common problem after traumatic brain injury (TBI) and can have a major impact on cognitive function, psychosocial outcome and engagement in rehabilitation. For scientists and clinicians it remains one of the least understood aspects of brain-behaviour relationships encompassing disturbances of cognition, motivation, emotion and action, and is variously an indication of organic brain disease or psychiatric disorder. Apathy can be both sign and symptom and has been proposed as a diagnosis in its own right as well as a secondary feature of other conditions. This review considers previous approaches to apathy in terms of relevant psychological constructs and those neural counterparts most likely to be implicated after TBI. Neurobehavioural disorders of apathy are characterised chiefly by dysfunction of executive control of goal-oriented behaviour or the neural substrates of reward-based and emotional learning. We argue that it is possible to distinguish a primary disorder of apathy as an organic neurobehavioural state from secondary presentations due to an impoverished environment or psychological disturbance which has implications for treatment.

Comparison of neuropsychiatric symptoms and diffusion tensor imaging correlates among patients with subcortical ischemic vascular disease and Alzheimer's disease

BACKGROUND

The causes of behavioral and psychological symptoms of dementia (BPSD) vary according to the dementia subtype and associated neuropathology. The present study aimed to (i) compare BPSD between patients with subcortical ischemic vascular disease (SIVD) and Alzheimer's disease (AD) across stages, and (ii) explore the associations with diffusion tensor imaging (DTI) in the corpus callosum (CC) and other major fibers.

METHODS

Twenty-four patients with SIVD and 32 with AD were recruited. Four domains of the Neuropsychiatric Inventory (NPI) (hyperactivity, psychosis, affective, and apathy) and two DTI parameters [fractional anisotropy (FA) and mean diffusivity (MD)] within the genu, body (BCC), and splenium (SCC) of the CC and other major fibers were assessed.

RESULTS

Overall, the patients with clinical dementia rating (CDR) 1 ~ 2 had higher scores in apathy domain than those with CDR0.5. Among those with CDR1 ~ 2, SIVD had higher scores in apathy domain than AD. MD values in the BCC/SCC were positively correlated with total NPI score and psychosis, hyperactivity, and apathy domains. FA values in the SCC were inversely correlated with total NPI score and psychosis domain. The correlations were modified by age, the CASI, and CDR scores. Stepwise linear regression models suggested that FA value within the left superior longitudinal fasciculus predicted the hyperactivity domain. MD value within the SCC/left uncinate fasciculus and FA value within the GCC/left forceps major predicted the psychosis domain. MD value within the right superior longitudinal fasciculus and CDR predicted the apathy domain. Further analysis suggested distinct patterns of regression models between SIVD and AD patients.

CONCLUSION

White matter integrity within the BCC/SCC had associations with multi-domains of BPSD. Our study also identified important roles of regions other than the CC to individual domain of BPSD, including the left superior longitudinal fasciculus to the hyperactivity domain, the left uncinate fasciculus/forceps major to the psychosis domain, and the right superior longitudinal fasciculus to the apathy domain. The neuronal substrates in predicting BPSD were different between SIVD and AD patients. Of note, apathy, which was more profound in SIVD, was associated with corresponding fiber disconnection in line with dementia severity and global cognition decline.

Frontal Lobe Dementia and Subcortical Vascular Dementia: A Neuropsychological Comparison

We compared the performance of 40 patients with frontal lobe dementia to that of 40 patients with subcortical vascular dementia (80 patients including, 46 men and 34 women) in a set of tasks assessing attentional, executive, and behavioural tasks. The frontal lobe dementia represents an important cause for degenerative disruption and is increasingly recognised as an important form (up to 25%) of degenerative dementia among individuals of late-middle-age. The main involvement is the frontal-subcortical pathway, which is the final target of impairment even in subcortical vascular dementia. A wider involvement of the cortical (decisional) layers in frontal dementia, in contrast with the prominent and widespread involvement of the subcortical pathways (refinement and corrections programs) creates the different profiles of the two groups. Frontal patients have more difficulties in abstract reasoning, focusing attention, and implementing strategies to solve problems. They exhibit more profound behavioural alterations in personality and social conduct and show only moderate depression, and a total lack of insight concerning their clinical condition. In contrast, the patients with subcortical vascular dementia have poor general cognitive functions, high insight, and important depression and apathy as the principal and most salient characteristic of their behavioral conduct.

Depressive symptoms in neurodegenerative diseases

Depressive symptoms are very common in chronic conditions. This is true so for neurodegenerative diseases. A number of patients with cognitive decline and dementia due to Alzheimer’s disease and related conditions like Parkinson’s disease, Lewy body disease, vascular dementia, frontotemporal degeneration amongst other entities, experience depressive symptoms in greater or lesser grade at some point during the course of the illness. Depressive symptoms have a particular significance in neurological disorders, specially in neurodegenerative diseases, because brain, mind, behavior and mood relationship. A number of patients may develop depressive symptoms in early stages of the neurologic disease, occurring without clear presence of cognitive decline with only mild cognitive deterioration. Classically, depression constitutes a reliable diagnostic challenge in this setting. However, actually we can recognize and evaluate depressive, cognitive or motor symptoms of neurodegenerative disease in order to establish their clinical significance and to plan some therapeutic strategies. Depressive symptoms can appear also lately, when the neurodegenerative disease is fully developed. The presence of depression and other neuropsychiatric symptoms have a negative impact on the quality-of-life of patients and caregivers. Besides, patients with depressive symptoms also tend to further decrease function and reduce cognitive abilities and also uses to present more affected clinical status, compared with patients without depression. Depressive symptoms are treatable. Early detection of depressive symptoms is very important in patients with neurodegenerative disorders, in order to initiate the most adequate treatment. We review in this paper the main neurodegenerative diseases, focusing in depressive symptoms of each other entities and current recommendations of management and treatment.

Lacunar stroke, deep white matter disease and depression: a meta-analysis

BACKGROUND

Lacunar stroke is a small (<2 cm) infarction that accounts for approximately 20% of all strokes. While a third of all stroke patients experience depressive symptoms, the prevalence of depression in the lacunar stroke patient population is unclear. This meta-analysis aimed to synthesize the evidence on the effect of lacunar stroke and deep white matter disease on depressive symptoms.

METHODS

A systematic search of electronic databases was conducted, resulting in the inclusion of 12 studies. Analyses were performed on the effects of lacunar stroke, volume and location of lacunes on depression prevalence, and the effect on depression severity. The effects estimates were calculated in random-effects models.

RESULTS

None of the analyses produced statistically significant results. Lacunar stroke patients had a non-significantly higher prevalence of depression compared to patients with non-lacunar cerebrovascular diseases (OR = 1.46, 95% CI: 0.88-2.43, p = 0.15). Neither thalamic (OR = 1.37 (0.85-2.20), p = 0.19), deep white matter (RR = 1.16 (0.85-1.57), p = 0.35), multiple lacunes (OR = 1.34 (0.81-2.22), p = 0.25), or the volume of lacunes (MD = -4.71 (-351.59-342.18), p = 0.98) had an effect on depression prevalence. Lastly, lacunar stroke did not influence depressive symptom severity (MD = 0.96 (-1.57-3.48), p = 0.46).

CONCLUSIONS

The pooled group of patients with lacunar stroke and deep white matter disease appear to have a similar prevalence of depression compared to those with other types of cerebrovascular diseases. However, the small number of studies, heterogeneous comparison groups, and high statistical heterogeneity between studies posed an obstacle to the meta-analysis. To determine appropriate screening and treatment approaches, future research will need to separate lacunar stroke and deep white matter disease patients, and include larger sample sizes and healthy control groups to determine their distinct contributions to depression.

Behavioural and psychological symptoms in poststroke vascular cognitive impairment

Background. Behavioural and psychological symptoms of dementia (BPSD) cause significant patient and caregiver morbidity in vascular cognitive impairment (VCI). Objectives. To study and compare the occurrence and severity of BPSD between multi-infarct dementia (MID), subcortical ischaemic vascular disease (SIVD), and strategic infarct subtypes of poststroke VCI and to evaluate the relationship of these symptoms with the severity of cognitive impairment. Methods. Sixty patients with poststroke VCI were classified into MID, SIVD, and strategic infarct subtypes. BPSD were studied by the neuropsychiatric inventory (NPI). The severity of cognitive impairment was evaluated by the clinical dementia rating scale (CDR). Results. 95% of cases had at least one neuropsychiatric symptom, with depression being the commonest, irrespective of subtype or severity of VCI. Strategic infarct patients had the lowest frequency of all symptoms. SIVD showed a higher frequency and severity of apathy and higher total NPI scores, compared to MID. Apathy and appetite disturbances occurred more commonly with increasing CDR scores. The total NPI score correlated positively with the CDR score. Conclusion. Depression was the commonest neuropsychiatric symptom in VCI. The neuropsychiatric profiles of MID and SIVD were similar. The frequency and severity of apathy and the net burden of BPSD increased with increasing cognitive impairment.

Behavioral and psychological symptoms of dementia

Behavioral and psychological symptoms of dementia (BPSD), also known as neuropsychiatric symptoms, represent a heterogeneous group of non-cognitive symptoms and behaviors occurring in subjects with dementia. BPSD constitute a major component of the dementia syndrome irrespective of its subtype. They are as clinically relevant as cognitive symptoms as they strongly correlate with the degree of functional and cognitive impairment. BPSD include agitation, aberrant motor behavior, anxiety, elation, irritability, depression, apathy, disinhibition, delusions, hallucinations, and sleep or appetite changes. It is estimated that BPSD affect up to 90% of all dementia subjects over the course of their illness, and is independently associated with poor outcomes, including distress among patients and caregivers, long-term hospitalization, misuse of medication, and increased health care costs. Although these symptoms can be present individually it is more common that various psychopathological features co-occur simultaneously in the same patient. Thus, categorization of BPSD in clusters taking into account their natural course, prognosis, and treatment response may be useful in the clinical practice. The pathogenesis of BPSD has not been clearly delineated but it is probably the result of a complex interplay of psychological, social, and biological factors. Recent studies have emphasized the role of neurochemical, neuropathological, and genetic factors underlying the clinical manifestations of BPSD. A high degree of clinical expertise is crucial to appropriately recognize and manage the neuropsychiatric symptoms in a patient with dementia. Combination of non-pharmacological and careful use of pharmacological interventions is the recommended therapeutic for managing BPSD. Given the modest efficacy of current strategies, there is an urgent need to identify novel pharmacological targets and develop new non-pharmacological approaches to improve the adverse outcomes associated with BPSD.

Apolipoprotein E genotypes and neuropsychiatric symptoms and syndromes in late-onset Alzheimer's disease

Neuropsychiatric symptoms (NPS) in dementia, previously denominated as behavioural and psychological symptoms of dementia, are often more distressing, impairing, and costly than cognitive symptoms, representing a major health burden for older adults. These symptoms are common features of Alzheimer's disease (AD), and are one of the major risk factors for institutionalization. There is a high prevalence of neuropsychiatric disturbances in patients with AD, including depression, anxiety, apathy, psychosis, aggression, and agitation. At present, the role of the apolipoprotein E (APOE) genotypes in the development of NPS or neuropsychiatric syndromes/endophenotypes in AD patients is unclear. In this article, we summarized the findings of the studies of NPS and neuropsychiatric syndromes in AD in relation to APOE genotypes, with special attention to the possible underlying mechanisms. While some studies failed to find a significant association between the APOE polymorphism and NPS in late-onset AD, other studies reported a significant association between the APOE ɛ4 allele and an increase in agitation/aggression, hallucinations, delusions, and late-life depression or anxiety. However, current cumulative evidence coming from the few existing longitudinal studies shows no association of APOE genotypes with NPS as a whole in AD. Some negative studies that focused on the distribution of APOE genotypes between AD patients with or without NPS further emphasized the importance of sub-grouping NPS in distinct neuropsychiatric syndromes. Explanations for the variable findings in the existing studies included differences in patient populations, differences in the assessment of neuropsychiatric symptomatology, possible lack of statistical power to detect associations in the negative studies, and small sample sizes generating false positives that cannot be consistently replicated. Finally, many reviewed studies were cross-sectional, whereas it would be of paramount importance to evaluate the risk for incident NPS in relation to the APOE genotype in prospectively followed cohorts of AD patients. In fact, identifying predisposing genetic risk factors may allow us to understand the pathophysiological features of neuropsychiatric syndromes or symptoms in AD, so optimizing possible therapeutic options.

Diagnostic criteria for apathy in clinical practice

BACKGROUND

Apathy is an important and distressing behavioural symptom in Alzheimer's disease and in various neuropsychiatric disorders. Recently, diagnostic criteria for apathy have been proposed.

OBJECTIVES

In groups of patients suffering from different neuropsychiatric diseases, (i) to estimate the prevalence of patients meeting the proposed diagnostic criteria; (ii) to estimate the concurrent validity of the criteria with the neuropsychiatric inventory (NPI) apathy item; (iii) to identify the most frequently met criteria or sub-criteria in each specific neuropsychiatric disease and (iv) to estimate the inter-observer reliability of the diagnostic criteria for apathy.

METHODS

This cross-sectional, multicentric, observational study was performed on 306 patients. Each of the participating centres had to check the presence of apathy according to the diagnostic criteria for apathy in consecutive patients belonging to the following diagnoses list: Alzheimer disease (AD), mixed dementia, mild cognitive impairment (MCI), Parkinson's disease (PD), Schizophrenia (DSM-IV) and major depressive episode. In addition to the clinical interview, the assessment included the Mini Mental Score Examination (MMSE) and the NPI. At the end of the visit, clinicians were required to check the diagnostic criteria for apathy.

RESULTS

Using the diagnostic criteria for apathy, the frequency of apathy was of 53% in the whole population, 55% in AD, 70% in mixed dementia, 43% in MCI, 27% in PD, 53% in schizophrenia and 94% in major depressive episode. In AD, mixed dementia, MCI and PD, the NPI apathy score was significantly higher for patient fulfilling the apathy criteria. Goal-directed cognitive activity (criteria B2-Cognition) was the most frequently observed domain followed by goal-directed behaviour (criteria B1-Behaviour) and emotion (criteria B3), respectively. Inter-rater reliability was high for the overall diagnostic (κ coefficient = 0.93; p = 0.0001) and for each criteria.

CONCLUSION

This study is the first one to test the diagnostic criteria for apathy in clinical practice. Results make the diagnostic criteria useful for clinical practice and research.

Neurobiology of apathy in Alzheimer's disease

Apathy is considered the most frequent neuropsychiatric disturbance in dementia and its outcome is generally deleterious. Apathy can be related to a dysfunction of the anatomical-system that supports the generation of voluntary actions, namely the prefrontal cortex and/or the prefrontal-subcortical circuits. In Alzheimer's disease, pathological and neuroimaging data indicate that apathy is likely due to a dysfunction of the medial prefrontal cortex. Accordingly, in this review article, we propose a pathophysiological model to explain apathetic behavior in Alzheimer's disease, combining data from neuroimaging, neuropathology and experimental research on the role of orbito-frontal cortex, anterior cingulate cortex, basal ganglia and dopamine in decision-making neurobiology.

Clinical characteristics in subcortical ischemic white matter disease

BACKGROUND: Vascular white matter lesions (WML) represent one of the main neuroimage findings in individuals older than 65 years and its clinical significance is still partially understood. OBJECTIVE: To describe and analyze the clinical profile of a high severity sample with WML focusing on the frontal executive control. METHOD: Outpatients (n=20) with high severity WML evaluated with magnetic resonance imaging were selected using the Fazekas scale. RESULTS: Most patients (n=17; 85%) presented an altered Trail Making Test ratio (section B/section A); on verbal fluency, 15 individuals (75%) performed below the cutoff score. Apathy (5.9 ± 4.65) and depression (3.05±3.67) were frequent as assessed by the Neuropsychiatric Inventory. The impairment in functional activities strongly correlated with apathy (r=0.814, p<0.001) and verbal fluency (r=0.744, p<0.001). CONCLUSION: Executive dysfunction, apathy, and ratio depression were the main characteristics found. Extension of WML may have distinct impact on the clinical picture, but further studies with methodological adjustments are necessary to provide more definitive conclusions.

Neuropsychiatric symptoms in 921 elderly subjects with dementia: a comparison between vascular and neurodegenerative types

OBJECTIVE

i) to describe the neuropsychiatric profile of elderly subjects with dementia by comparing vascular (VaD) and degenerative dementias, i.e. dementia with Lewy bodies (DLB) and Alzheimer's disease (AD); ii) to assess whether the severity and type of dementia are associated with clinically relevant neuropsychiatric symptoms (CR-NPS).

METHOD

One hundred and thirty-one out-patients with VaD, 100 with DLB and 690 with AD were studied. NPS were evaluated by the neuropsychiatric inventory (NPI).

RESULTS

Vascular dementia had lower total and domain-specific NPI scores and a lower frequency of CR-NPS than AD and DLB, for which frequency of CR-NPS increased significantly with disease severity, particularly in AD. Logistic regression analysis showed that a higher CDR score and a diagnosis of degenerative dementia were independently associated with CR-NPS.

CONCLUSION

Vascular dementia is associated less with CR-NPS than AD and DLB. Frequency of CR-NPS increases with disease severity in AD and, to a lesser extent, in DLB.

Rivastigmine in Chinese patients with subcortical vascular dementia

BACKGROUND

We explored the efficacy and tolerability of rivastigmine among Chinese patients with subcortical vascular dementia.

METHODS

Forty subjects were randomized to either placebo (n = 20) or rivastigmine (n = 20) in a double-blind 26-week trial. Outcome measures were cognition (mini-mental state examination, frontal assessment battery), neuropsychiatric inventory (NPI), instrumental activities of daily living, clinical dementia rating scale, and adverse events.

RESULTS

No statistical significant benefit could be observed in the active group in any of the efficacy measures. A trend favoring active group was observed only in the NPI subscore of irritability (p = 0.066) and aberrant motor behavior (p = 0.068). Withdrawal rate was 30% and 15% in the active and placebo group, respectively.

CONCLUSION

Among Chinese subcortical vascular dementia patients, there was no apparent cognitive benefit associated with use of rivastigmine over the 6 months period. A trend favoring rivastigmine was observed in certain behavioral measures. Rivastigmine was associated with more withdrawals relative to placebo.

Syndromes démentiels du sujet âgé: démarches diagnostiques

Dementia is a deterioration in several cognitive functions that affects daily living and is observed in the absence of impaired vigilance. Dementia may be revealed by symptoms of memory loss but also by a loss of functional autonomy, onset of depression or by behavioral problems; it may also be recognized during a screening examination. Evaluation of cognitive functions is an essential stage of this diagnosis. Simple tests that any physician can perform provide a first approach. A more detailed cognitive evaluation by a specialist or neuropsychologist is then necessary (except in advanced cases). Once dementia is diagnosed, a causal investigation is required to assess its severity and extent, in order to organize management. Lack of recognition of dementia in the elderly and delay in its diagnosis raise the question of screening to detect it at an earlier stage.

Cognitive impairment in the lateralized phenotype of corticobasal degeneration

Corticobasal degeneration (CBD) is a rare disorder, which normally includes a combination of neurobehavioural features, movement disorders and other manifestations. It is now recognized that CBD patients usually present with two phenotypes: the lateralized phenotype and the dementia phenotype. The aim of our work was to determine the nature and the progression of cognitive and behavioural impairment in 10 lateralized CBD patients. In our patients, the most salient aspects of cognitive impairment were: an evident alteration of rapid alternating operative strategies, associated with the evident impairment of set shifting, of executive operations, of operative and sequential procedure and of implementation of judgement and abstract reasoning. The self-activation of retrieval processes is partly preserved in CBD. As all the other types of subcortical impairments, even CBD encompasses both cognitive impairment as well as a wide range of behaviour disturbances, such as progressive alterations of sleep, depression, and of anxiety (with a remarkable incidence of somatic pain). This suggests that in addition to neuropsychological assessment, quantification of the personality behaviour disorder is important for standardizing the diagnosis of subcortical vascular dementia and distinguishing it from any other dementias.

Prevalence, resource utilization and costs of vascular dementia compared to Alzheimer's dementia in a population setting

OBJECTIVES

To determine the prevalence of dementia and to measure the monetary impact and health resources utilization of vascular dementia (VD) compared to Alzheimer's dementia (AD) in persons aged over 64 years in a population setting.

METHODS

Retrospective, cross-sectional study. In the initial phase, information was obtained on specific clinical characteristics from the subjects with an active diagnosis of dementia. The second phase consisted of a clinical evaluation and validation of the cases. Mini-Mental State Examination was used to assess cognitive impairment. Dementia and its subtypes were determined using established diagnostic criteria. Information was obtained on the use of health care resources (direct costs) and the number of hours devoted by the primary caregiver (indirect costs) for patients with a documented diagnosis of AD or VD within the last 6 months prior to the interview. A multiple logistic regression analysis was performed to correct the model.

RESULTS

A total of 6,004 subjects were analyzed, 258 with diagnosis of dementia (overall prevalence: 4.3%). An evaluation was made of 224 patients, and gross prevalence of AD and VD was 2.4 and 1.0%, respectively. Cost per patient per semester was EUR 8,086 for AD and EUR 11,039 for VD (p = 0.016). 85.5% of the cost was attributable to primary caregiver time in AD and 84.4% in VD.

CONCLUSIONS

The prevalence of AD and VD increases with age. No sociodemographic differences were seen between AD and VD. Costs associated with health care resource and primary caregiver utilization were high, being higher in VD than in AD.

Démarche diagnostique devant un syndrome démentiel

PURPOSE

The high prevalence of dementia, particularly of Alzheimer's disease, the increase of their incidence with age, and the population aging make this group of diseases a major problem for public health. Nevertheless, diagnosis is difficult because it depends on evolution of disturbances that patients often cannot precisely relate, on complex neuropsychological explorations, and on pathological examination difficult to obtain. Today in France, geriatricians are fully implicated in the diagnosis of dementia and all the physicians who give care to elderly, should lead easily a diagnosis of dementia.

CURRENT KNOWLEDGE AND KEY POINTS

In February 2000 ANAES (French governmental agency for accreditation and evaluation of health system) published recommendations called "practical recommendations for the diagnosis of Alzheimer's disease". These recommendations allow physicians to standardize their practices and consist of a rigorous clinical history and examination, a neuropsychological analysis, standard investigations and application of diagnostic criteria already widely diffused and used.

FUTURE PROSPECTS AND PROJECTS

Deepening of knowledge, in particular in the domains of neuropsychology and functional cerebral imagery, should allow physicians to diagnose early dementia. These early diagnosis should allow to initiate a multidisciplinary, preventive and effective care for patients. Specific drugs, that will be available, will be intended mostly for patients with early diagnosis, ideally at a pre-dementia state.

Progression of dementia associated with lacunar infarctions

BACKGROUND

Lacunar stroke (L) is the most common stroke subtype associated with vascular dementia (VaD-L).

OBJECTIVE

To evaluate the cognitive and behavioral course in patients with probable VaD-L.

METHODS

We longitudinally measured rates of change on MMSE, digit span, logical memory, Controlled Oral Word Association, CERAD battery and neuropsychiatric inventory (NPI) in 77 patients (age at entry 69 +/- 8.1 years) with probable VaD-L for 25.75 +/- 11 months.

RESULTS

The mean number of follow-up visits was 2.6 +/- 0.67 (range 2-4). Time interval between any two consecutive visits was at least 5 months (range 5-41). MMSE deteriorated by 1.44+/- 1.8 points annually and NPI increased by 6.01 +/- 13.7 points annually (p < 0.0001). The rates of cognitive and behavioral decline were predominantly influenced by the cognitive state at entry into the study and the occurrence of new vascular episodes during follow-up [(-0.95 +/- 1.7) MMSE and (+2.02 +/- 14.1) NPI points annually without vascular episodes vs. (-2.09 +/- 1.6) and (+11.3 +/- 11.4) points following vascular episodes (p < 0.0001)]. Impaired cognition was associated with impaired behavior (p < 0.001). VaD-L patients without additional vascular episodes at follow-up have a progressively deteriorating course as well (p < 0.0001).

CONCLUSION

VaD-L is characterized by cognitive and behavioral decline. The rate of decline is determined mainly by the severity of the cognitive and behavioral impairment at baseline and by the occurrence of new vascular episodes.

Non-cognitive benefits of galantamine (Reminyl) treatment in vascular dementia

Vascular dementia (VaD) is a condition that involves deterioration in cognitive and non-cognitive areas. Although cognitive impairment is the defining symptom evaluated during clinical trials, changes in non-cognitive areas such as behavior, global functioning and activities of daily living are assessed because they assist in determining quality of life and overall well-being. Therapy has focused traditionally on preventing and controlling risk factors, as no approved treatments are currently available for these patients. Acetylcholinesterase inhibitors (AChEIs), the treatment of choice in patients with Alzheimer's disease (AD), are a potential treatment option for patients with VaD. Galantamine, an AChEI with nicotinic receptor modulation, has demonstrated clinically relevant benefits (cognition, global functioning, functional ability, behavior) in patients with either AD with cerebrovascular disease (AD with CVD) or probable VaD in a 6-month, randomized, double-blind, placebo-controlled study.

Differences in the behavioral and psychological symptoms between Alzheimer's disease and vascular dementia: are the different pharmacologic treatment strategies justifiable?

BACKGROUND

This study aimed (1) to compare the behavioral and psychological symptoms of dementia (BPSD) between patients with Alzheimer's disease (AD) and vascular dementia (VaD); (2) to investigate the differences in the correlates of BPSD between them; and (3) to suggest potential different pharmacological strategies in treating BPSD of either etiology.

METHODS

In a study group of 135 patients with dementia (99 AD, 36 VaD), information on age, gender, education, age at onset and duration of dementia was collected. The severity of dementia was measured by the following assessment scales: Korean version of Mini-Mental State Examination (MMSE-K) for cognitive function; Blessed Dementia Scale (BDS) for functional activities of daily living (ADL); Barthel Index (BI) for physical ADL; and Brief Psychiatric Rating Scale (BPRS), Hamilton Depression Scale (HAM-D) and Hamilton Anxiety Scale (HAM-A) for BPSD. The independent variables between the patients with AD and VaD were compared, and then the correlations of BPSD with other variables were estimated.

RESULTS

HAM-D and HAM-A scores were higher in patients with VaD than in those with AD, while other variables demonstrated no statistical differences. BPRS score correlated with scores on MMSE-K, BDS and BI in AD, but only with BDS in VaD. The HAM-D score correlated with scores on BDS and BI in AD, but only with BDS in VaD. The HAM-A score was correlated with score on BDS in AD not in VaD.

CONCLUSIONS

BPSD were more severe in the patients with VaD. However, BPSD correlated more prominently with cognitive or ADL impairments in patients with AD. Different treatment approaches to BPSD may be required according to the clinical differentiation of dementia type.

Relevant clinical outcomes in probable vascular dementia and Alzheimer's disease with cerebrovascular disease

Two important prerequisites for assessing therapeutic benefits in patients with vascular dementia (VaD), or Alzheimer's disease (AD) with cerebrovascular disease (CVD), are the inclusion of appropriate patients and the use of relevant outcome measures. There is substantial overlap in the clinical symptomatology, risk factors, imaging changes, pathophysiology and neurochemical mechanisms between VaD, AD and AD with CVD. While validated and acceptable clinical criteria suitable for clinical trials have been developed for VaD, there is still debate as to how mixed cases (i.e. AD with CVD) are best conceptualized. As with AD, there is consensus that outcome measures in studies of patients with VaD, or AD with CVD, should include assessments of cognitive and global function, of ability to perform activities of daily living (ADL) and of behavioral symptoms. Other measures, e.g., caregiver burden, would be desirable. Care must be taken in extrapolating AD-specific evaluations to VaD, however, because different specific domains are affected and the disease course is different. In clinical trials, cognitive performance and global function decline steadily in patients with untreated AD compared with smaller changes in patients with untreated VaD, while behavior and ADL deteriorate over 6 months in patients with either untreated AD or untreated VaD. Such differences in untreated outcome need to be considered when interpreting trial results using outcome measures that were largely designed for studies of patients with AD.

Neuropsychological deficit in early subcortical vascular dementia: comparison to Alzheimer's disease

To further clarify the cognitive syndrome in subcortical vascular dementia (VaD), we investigated 20 patients with early-stage VaD as compared with 30 patients with Alzheimer's disease (AD) and 22 normal controls using episodic memory, attention/executive function and language tests. The patient groups were closely matched in terms of age, education and severity of dementia. The VaD patients had a significantly better free recall, cued recall and recognition memory than AD patients, the recognition being within normal limits in VaD. In addition, VaD patients had a greater number of perseverative errors during the Modified Card Sorting test, while AD patients exhibited more perseverations of semantic fluency. The results of retrieval deficit syndrome and increased number of perseverations during tasks sensitive to frontal lobe function are in agreement with the studies emphasizing the importance of frontal dysfunction in subcortical VaD. These findings are relevant for the early diagnosis of VaD and might be useful in the differential diagnosis with AD.