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Chen AP, Ismail Z, Mann FD, Bromet EJ, Clouston SAP, Luft BJ. Behavioral Impairments and Increased Risk of Cortical Atrophy Risk Scores Among World Trade Center Responders. J Geriatr Psychiatry Neurol 2024; 37:114-124. [PMID: 37542409 PMCID: PMC10839111 DOI: 10.1177/08919887231195234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
Objective: World Trade Center (WTC) responders are susceptible to both cognitive and neuropsychiatric impairments, particularly chronic posttraumatic stress disorder. The present study examined self-reported behavioral impairments in a sample of 732 WTC responders, 199 of whom were determined to have high risk of WTC-related cortical atrophy by an artificial neural network. Results: We found that responders at increased risk of cortical atrophy showed behavioral impairment across five domains: motivation, mood, disinhibition, empathy, and psychosis (14.6% vs 3.9% in the low-risk group; P = 3.90 × 10-7). Factor analysis models revealed that responders at high risk of cortical atrophy tended to have deficits generalized across all aspects of behavioral impairment with focal dysfunction in sensory psychosis. We additionally describe how relationships are modulated by exposure severity and pharmacological treatments. Discussion: Our findings suggest a potential link between sensory deficits and the development of cortical atrophy in WTC responders and may indicate symptoms consistent with a clinical portrait of parietal dominant Alzheimer's disease or a related dementia (ADRD). Results underscore the importance of investigating neuropsychiatric symptomatology in clinical evaluations of possible ADRD.
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Affiliation(s)
- Allen P.F. Chen
- Department of Neurobiology and Behavior, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Zahinoor Ismail
- Hotchkiss Brain Institute and O’Brien Institute for Public Health, University of Calgary
| | - Frank D. Mann
- Program in Public Health, Renaissance School of Medicine, Stony Brook, NY, USA
- Department of Family, Population, and Preventive Medicine, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Evelyn J. Bromet
- Department of Psychiatry, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Sean A. P. Clouston
- Program in Public Health, Renaissance School of Medicine, Stony Brook, NY, USA
- Department of Family, Population, and Preventive Medicine, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Benjamin J. Luft
- Department of Medicine, Renaissance School of Medicine, Stony Brook, NY, USA
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Singh AK, Malviya R, Prakash A, Verma S. Neuropsychiatric Manifestations in Alzheimer's Disease Patients: Genetics and Treatment Options. CNS Neurol Disord Drug Targets 2024; 23:39-54. [PMID: 36856177 DOI: 10.2174/1871527322666230301111216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 12/03/2022] [Accepted: 12/27/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND Alzheimer's disease (AD) is characterized by neuropsychiatric symptoms (NPS), which cause great misery to those with dementia and those who care for them and may lead to early institutionalization. OBJECTIVE The present systematic review aims to discuss the various aspects of Alzheimer's, including treatment options. METHODS The databases Embase, PubMed, and Web of Science were searched to collect data. RESULTS Incipient cognitive deterioration is commonly accompanied by these early warning signals of neurocognitive diseases. The neurobiology of NPSs in Alzheimer's disease, as well as particular symptoms, including psychosis, agitation, apathy, sadness, and sleep disorders, will be examined in this review. For NPSs in Alzheimer's disease, clinical trial designs, as well as regulatory issues, were also addressed. A fresh wave of research, however, is helping to push the discipline ahead. For medication development and repurposing, we highlight the most recent results in genetics, neuroimaging, and neurobiology. Even though identifying and treating psychosis in adults with dementia is still a challenging endeavor, new options are coming up that give the field fresh focus and hope. Conclsuion: It can be concluded from the complete literature survey that Alzheimer's-related psychosis as well as other symptoms that are not psychotic, have made significant progress in the last decade. These milestones in the development of safer, more effective treatments have been achieved as a consequence of great focus on non-pharmacological interventions like DICE or WHELD; the investigation into ways to improve existing drugs like aripiprazole, risperidone, amisulpride, and Escitalopram for safer precision-based treatment; and the development of a clinical trial program for pimavanserin.
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Affiliation(s)
- Arun Kumar Singh
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University Greater Noida, Uttar Pradesh, India
| | - Rishabha Malviya
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University Greater Noida, Uttar Pradesh, India
| | - Anuj Prakash
- Reference Standard Division, Indian Pharmacopoeia Commission, Sec-23, Raj Nagar, Ghaziabad, Uttar Pradesh, India
| | - Swati Verma
- Department of Pharmacy, School of Medical and Allied Sciences, Galgotias University Greater Noida, Uttar Pradesh, India
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Mudalige D, Guan DX, Ghahremani M, Ismail Z. Longitudinal Associations Between Mild Behavioral Impairment, Sleep Disturbance, and Progression to Dementia. J Alzheimers Dis Rep 2023; 7:1323-1334. [PMID: 38143778 PMCID: PMC10741901 DOI: 10.3233/adr-230086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/07/2023] [Indexed: 12/26/2023] Open
Abstract
Background Clinical guidelines recommend incorporating non-cognitive markers like mild behavioral impairment (MBI) and sleep disturbance (SD) into dementia screening to improve detection. Objective We investigated the longitudinal associations between MBI, SD, and incident dementia. Methods Participant data were from the National Alzheimer's Coordinating Center in the United States. MBI was derived from the Neuropsychiatric Inventory Questionnaire (NPI-Q) using a published algorithm. SD was determined using the NPI-Q nighttime behaviors item. Cox proportional hazard regressions with time-dependant variables for MBI, SD, and cognitive diagnosis were used to model associations between baseline 1) MBI and incident SD (n = 11,277); 2) SD and incident MBI (n = 10,535); 3) MBI with concurrent SD and incident dementia (n = 13,544); and 4) MBI without concurrent SD and incident dementia (n = 11,921). Models were adjusted for first-visit age, sex, education, cognitive diagnosis, race, and for multiple comparisons using the Benjamini-Hochberg method. Results The rate of developing SD was 3.1-fold higher in older adults with MBI at baseline compared to those without MBI (95% CI: 2.8-3.3). The rate of developing MBI was 1.5-fold higher in older adults with baseline SD than those without SD (95% CI: 1.3-1.8). The rate of developing dementia was 2.2-fold greater in older adults with both MBI and SD, as opposed to SD alone (95% CI:1.9-2.6). Conclusions There is a bidirectional relationship between MBI and SD. Older adults with SD develop dementia at higher rates when co-occurring with MBI. Future studies should explore the mechanisms underlying these relationships, and dementia screening may be improved by assessing for both MBI and SD.
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Affiliation(s)
| | | | - Maryam Ghahremani
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Department of Psychiatry, Department of Community Health Sciences, Department of Clinical Neurosciences, Hotchkiss Brain Institute, O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Department of Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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Cousins O, Schubert JJ, Chandra A, Veronese M, Valkimadi P, Creese B, Khan Z, Arathimos R, Hampshire A, Rosenzweig I, Ballard C, Corbett A, Aasland D, Velayudhan L, O'Neill M, Collier D, Awais R, Sander K, Årstad E, Howes O, Turkheimer F, Hodges A. Microglial activation, tau and amyloid deposition in TREM2 p.R47H carriers and mild cognitive impairment patients: a multi-modal/multi-tracer PET/MRI imaging study with influenza vaccine immune challenge. J Neuroinflammation 2023; 20:272. [PMID: 37990275 PMCID: PMC10664604 DOI: 10.1186/s12974-023-02945-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/31/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Microglia are increasingly understood to play an important role in the pathogenesis of Alzheimer's disease. The rs75932628 (p.R47H) TREM2 variant is a well-established risk factor for Alzheimer's disease. TREM2 is a microglial cell surface receptor. In this multi-modal/multi-tracer PET/MRI study we investigated the effect of TREM2 p.R47H carrier status on microglial activation, tau and amyloid deposition, brain structure and cognitive profile. METHODS We compared TREM2 p.R47H carriers (n = 8; median age = 62.3) and participants with mild cognitive impairment (n = 8; median age = 70.7). Participants underwent two [18F]DPA-714 PET/MRI scans to assess TSPO signal, indicative of microglial activation, before and after receiving the seasonal influenza vaccination, which was used as an immune stimulant. Participants also underwent [18F]florbetapir and [18F]AV1451 PET scans to assess amyloid and tau burden, respectively. Regional tau and TSPO signal were calculated for regions of interest linked to Braak stage. An additional comparison imaging healthy control group (n = 8; median age = 45.5) had a single [18F]DPA-714 PET/MRI. An expanded group of participants underwent neuropsychological testing, to determine if TREM2 status influenced clinical phenotype. RESULTS Compared to participants with mild cognitive impairment, TREM2 carriers had lower TSPO signal in Braak II (P = 0.04) and Braak III (P = 0.046) regions, despite having a similar burden of tau and amyloid. There were trends to suggest reduced microglial activation following influenza vaccine in TREM2 carriers. Tau deposition in the Braak VI region was higher in TREM2 carriers (P = 0.04). Furthermore, compared to healthy controls TREM2 carriers had smaller caudate (P = 0.02), total brain (P = 0.049) and white matter volumes (P = 0.02); and neuropsychological assessment revealed worse ADAS-Cog13 (P = 0.03) and Delayed Matching to Sample (P = 0.007) scores. CONCLUSIONS TREM2 p.R47H carriers had reduced levels of microglial activation in brain regions affected early in the Alzheimer's disease course and differences in brain structure and cognition. Changes in microglial response may underlie the increased Alzheimer's disease risk in TREM2 p.R47H carriers. Future therapeutic agents in Alzheimer's disease should aim to enhance protective microglial actions.
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Affiliation(s)
- Oliver Cousins
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | - Julia J Schubert
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | - Avinash Chandra
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | - Mattia Veronese
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
- Department of Information Engineering, University of Padua, 35131, Padua, Italy
| | - Polena Valkimadi
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | - Byron Creese
- College of Medicine and Health, University of Exeter, Exeter, EX1 2HZ, UK
- Division of Psychology, Department of Life Sciences, Brunel University London, London, UB8 3PH, UK
| | - Zunera Khan
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | - Ryan Arathimos
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | - Adam Hampshire
- Faculty of Medicine, Imperial College London, London, SW7 2AZ, UK
| | - Ivana Rosenzweig
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | - Clive Ballard
- College of Medicine and Health, University of Exeter, Exeter, EX1 2HZ, UK
| | - Anne Corbett
- College of Medicine and Health, University of Exeter, Exeter, EX1 2HZ, UK
| | - Dag Aasland
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | - Latha Velayudhan
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | | | | | - Ramla Awais
- Centre for Radiopharmaceutical Chemistry, University College London, London, WC1E 6BS, UK
| | - Kerstin Sander
- Centre for Radiopharmaceutical Chemistry, University College London, London, WC1E 6BS, UK
| | - Erik Årstad
- Centre for Radiopharmaceutical Chemistry, University College London, London, WC1E 6BS, UK
| | - Oliver Howes
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | - Federico Turkheimer
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK
| | - Angela Hodges
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, SE5 9RT, UK.
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Elefante C, Brancati GE, Pistolesi G, Amadori S, Torrigiani S, Baldacci F, Ceravolo R, Ismail Z, Lattanzi L, Perugi G. The impact of mild behavioral impairment on the prognosis of geriatric depression: preliminary results. Int Clin Psychopharmacol 2023:00004850-990000000-00105. [PMID: 37966156 DOI: 10.1097/yic.0000000000000521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Our study aimed to examine how the presence of Mild Behavioral Impairment (MBI) symptoms influenced the outcome of late-life depression (LLD). Twenty-nine elderly (≥ 60 years) depressive patients, including eleven (37.9%) with MBI, were recruited and followed-up on average for 33.41 ± 8.24 weeks. Psychiatric symptoms severity and global functioning were assessed, respectively, using the Brief Psychiatric Rating Scale (BPRS) and the Global Assessment of Functioning (GAF) scale. BPRS total score significantly decreased from baseline to follow-up (P < 0.001, d = 1.33). The presence of MBI had no significant effect on mood and cognitive symptoms improvement. On the contrary, while a significant increase in GAF score was observed in patients without MBI (P = 0.001, d = 1.01), no significant improvement of global functioning was detected in those with MBI (P = 0.154, d = 0.34) after 6-month follow-up. The presence of MBI in patients with LLD may negatively affect long-term outcome, slowing or preventing functional improvement.
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Affiliation(s)
- Camilla Elefante
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Pisa
| | | | - Gabriele Pistolesi
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Pisa
| | - Salvatore Amadori
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Pisa
| | - Samuele Torrigiani
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Pisa
| | - Filippo Baldacci
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto Ceravolo
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Zahinoor Ismail
- Departments of Psychiatry, Clinical Neurosciences, Community Health Sciences, and Pathology and Laboratory Medicine, Hotchkiss Brain Institute & O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
- College of Health and Medicine, University of Exeter, Exeter, UK
| | | | - Giulio Perugi
- Psychiatry Unit, Department of Clinical and Experimental Medicine, University of Pisa
- G. De Lisio Institute of Behavioral Sciences, Pisa, Italy
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Guan DX, Smith EE, Pike GB, Ismail Z. Persistence of neuropsychiatric symptoms and dementia prognostication: A comparison of three operational case definitions of mild behavioral impairment. Alzheimers Dement (Amst) 2023; 15:e12483. [PMID: 37786862 PMCID: PMC10541800 DOI: 10.1002/dad2.12483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 07/10/2023] [Accepted: 08/30/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION We compared three operational case definitions of mild behavioral impairment (MBI) in the context of MBI prevalence estimates and dementia risk modeling. METHODS Participants were dementia-free older adults (n = 13701) from the National Alzheimer's Coordinating Center. Operational case definitions of MBI were generated based on neuropsychiatric symptoms at one (OV), two-consecutive (TCV), or more than two-thirds (TTV) of dementia-free study visits. Definitions were compared in prevalence and in Cox regressions using MBI to predict incident dementia. RESULTS OV MBI was the most prevalent (54.4%), followed by TCV (32.3%) and TTV (26.7%) MBI. However, OV MBI had the lowest rate of incident dementia (hazard ratio [HR] = 2.54, 95% confidence interval [CI]: 2.33-2.78) and generated poorer model metrics than TCV MBI (HR = 4.06, 95% CI: 3.74-4.40) and TTV MBI (HR = 5.77, 95% CI: 5.32-6.26). DISCUSSION Case ascertainment with longer timeframe MBI operational case definitions may more accurately define groups at risk of dementia in datasets lacking tools designed to detect MBI.Highlights: Mild behavioral impairment (MBI) can identify older adults at risk of dementia.Neuropsychiatric symptom (NPS) assessment tools can be proxy measures for MBI.Hazard for dementia was highest for MBI defined by NPS presence at more than two-thirds of visits.
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Affiliation(s)
| | - Eric E. Smith
- Departments of Clinical Neurosciences and Community Health SciencesHotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | - G. Bruce Pike
- Departments of Radiology and Clinical NeurosciencesHotchkiss Brain InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | - Zahinoor Ismail
- Departments of PsychiatryClinical Neurosciences, and Community Health Sciences, Hotchkiss Brain Institute and O'Brien Institute for Public Health, University of CalgaryCalgaryAlbertaCanada
- Clinical and Biomedical SciencesFaculty of Health and Life Sciences, University of ExeterExeterUK
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Matsuoka T, Narumoto J, Morii-Kitani F, Niwa F, Mizuno T, Abe M, Takano H, Wakasugi N, Shima A, Sawamoto N, Ito H, Toda W, Hanakawa T. Contribution of amyloid and putative Lewy body pathologies in neuropsychiatric symptoms. Int J Geriatr Psychiatry 2023; 38:e5993. [PMID: 37655505 DOI: 10.1002/gps.5993] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/19/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVES Neuropsychiatric symptom could be useful for detecting patients with prodromal dementia. Similarities and differences in the NPSs between preclinical/prodromal Alzheimer's disease (AD) and prodromal Parkinson's disease dementia (PDD)/Dementia with Lewy bodies (DLB) may exist. This study aimed to compare the NPSs between preclinical/prodromal AD and prodromal PDD/DLB. METHODS One hundred and three participants without dementia aged ≥50 years were included in this study. The mild behavioral impairment (MBI) total score and the MBI scores for each domain were calculated using the neuropsychiatric inventory questionnaire score. Participants were divided into five groups based on the clinical diagnosis by neurologists or psychiatrists in each institution based on the results of the amyloid positron emission tomography and dopamine transporter single photon emission computed tomography (DAT-SPECT): Group 1: amyloid-positive and abnormal DAT-SPECT, Group 2: amyloid-negative and abnormal DAT-SPECT, Group 3: amyloid-positive and normal DAT-SPECT, Group 4: mild cognitive impairment unlikely due to AD with normal DAT-SPECT, and Group 5: cognitively normal with amyloid-negative and normal DAT-SPECT. RESULTS The MBI abnormal perception or thought content scores were significantly higher in Group 1 than Group 5 (Bonferroni-corrected p = 0.012). The MBI total score (Bonferroni-corrected p = 0.011) and MBI impulse dyscontrol score (Bonferroni-corrected p = 0.033) in Group 4 were significantly higher than those in Group 5. CONCLUSION The presence of both amyloid and putative Lewy body pathologies may be associated with psychotic symptoms.
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Affiliation(s)
- Teruyuki Matsuoka
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Psychiatry, National Hospital Organization Maizuru Medical Center, Kyoto, Japan
| | - Jin Narumoto
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fukiko Morii-Kitani
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumitoshi Niwa
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiki Mizuno
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mitsunari Abe
- Integrative Brain Imaging Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Harumasa Takano
- Integrative Brain Imaging Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Noritaka Wakasugi
- Integrative Brain Imaging Center, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Atsushi Shima
- Human Brain Research Center, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobukatsu Sawamoto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroshi Ito
- Department of Radiology and Nuclear Medicine, Fukushima Medical University, Fukushima, Japan
| | - Wataru Toda
- Department of Neuropsychiatry, Fukushima Medical University, Fukushima, Japan
| | - Takashi Hanakawa
- Integrative Brain Imaging Center, National Center of Neurology and Psychiatry, Tokyo, Japan
- Department of Integrated Neuroanatomy and Neuroimaging, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Ismail Z, Leon R, Creese B, Ballard C, Robert P, Smith EE. Optimizing detection of Alzheimer's disease in mild cognitive impairment: a 4-year biomarker study of mild behavioral impairment in ADNI and MEMENTO. Mol Neurodegener 2023; 18:50. [PMID: 37516848 PMCID: PMC10386685 DOI: 10.1186/s13024-023-00631-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/05/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND Disease-modifying drug use necessitates better Alzheimer disease (AD) detection. Mild cognitive impairment (MCI) leverages cognitive decline to identify the risk group; similarly, mild behavioral impairment (MBI) leverages behavioral change. Adding MBI to MCI improves dementia prognostication over conventional approaches of incorporating neuropsychiatric symptoms (NPS). Here, to determine if adding MBI would better identify AD, we interrogated associations between MBI in MCI, and cerebrospinal fluid biomarkers [β-amyloid (Aβ), phosphorylated-tau (p-tau), and total-tau (tau)-ATN], cross-sectionally and longitudinally. METHODS Data were from two independent referral-based cohorts, ADNI (mean[SD] follow-up 3.14[1.07] years) and MEMENTO (4.25[1.40] years), collected 2003-2021. Exposure was based on three-group stratification: 1) NPS meeting MBI criteria; 2) conventionally measured NPS (NPSnotMBI); and 3) noNPS. Cohorts were analyzed separately for: 1) cross-sectional associations between NPS status and ATN biomarkers (linear regressions); 2) 4-year longitudinal repeated-measures associations of MBI and NPSnotMBI with ATN biomarkers (hierarchical linear mixed-effects models-LMEs); and 3) rates of incident dementia (Cox proportional hazards regressions). RESULTS Of 510 MCI participants, 352 were from ADNI (43.5% females; mean [SD] age, 71.68 [7.40] years), and 158 from MEMENTO (46.2% females; 68.98 [8.18] years). In ADNI, MBI was associated with lower Aβ42 (standardized β [95%CI], -5.52% [-10.48-(-0.29)%]; p = 0.039), and Aβ42/40 (p = 0.01); higher p-tau (9.67% [3.96-15.70%]; p = 0.001), t-tau (7.71% [2.70-12.97%]; p = 0.002), p-tau/Aβ42 (p < 0.001), and t-tau/Aβ42 (p = 0.001). NPSnotMBI was associated only with lower Aβ42/40 (p = 0.045). LMEs revealed a similar 4-year AD-specific biomarker profile for MBI, with NPSnotMBI associated only with higher t-tau. MBI had a greater rate of incident dementia (HR [95%CI], 3.50 [1.99-6.17; p < 0.001). NPSnotMBI did not differ from noNPS (HR 0.96 [0.49-1.89]; p = 0.916). In MEMENTO, MBI demonstrated a similar magnitude and direction of effect for all biomarkers, but with a greater reduction in Aβ40. HR for incident dementia was 3.93 (p = 0.004) in MBI, and 1.83 (p = 0.266) in NPSnotMBI. Of MBI progressors to dementia, 81% developed AD dementia. CONCLUSIONS These findings support a biological basis for NPS that meet MBI criteria, the continued inclusion of MBI in NIA-AA ATN clinical staging, and the utility of MBI criteria to improve identification of patients for enrollment in disease-modifying drug trials or for clinical care.
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Affiliation(s)
- Zahinoor Ismail
- Department of Psychiatry, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
- Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada.
- O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada.
- Department of Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, B3183, Exeter, EX1 2HZ, UK.
| | - Rebeca Leon
- Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
| | - Byron Creese
- Department of Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, B3183, Exeter, EX1 2HZ, UK
| | - Clive Ballard
- Department of Clinical and Biomedical Sciences, Faculty of Health and Life Sciences, University of Exeter, B3183, Exeter, EX1 2HZ, UK
| | | | - Eric E Smith
- Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB, T2N 4N1, Canada
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Jin P, Xu J, Liao Z, Zhang Y, Wang Y, Sun W, Yu E. A review of current evidence for mild behavioral impairment as an early potential novel marker of Alzheimer's disease. Front Psychiatry 2023; 14:1099333. [PMID: 37293396 PMCID: PMC10246741 DOI: 10.3389/fpsyt.2023.1099333] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/31/2023] [Indexed: 06/10/2023] Open
Abstract
Mild behavioral impairment (MBI) is a neurobehavioral syndrome that occurs in the absence of cognitive impairment later in life (≥50 years of age). MBI is widespread in the pre-dementia stage and is closely associated with the progression of cognitive impairment, reflecting the neurobehavioral axis of pre-dementia risk states and complementing the traditional neurocognitive axis. Despite being the most common type of dementia, Alzheimer's disease (AD) does not yet have an effective treatment; therefore, early recognition and intervention are crucial. The Mild Behavioral Impairment Checklist is an effective tool for identifying MBI cases and helps identify people at risk of developing dementia. However, because the concept of MBI is still quite new, the overall understanding of it is relatively insufficient, especially in AD. Therefore, this review examines the current evidence from cognitive function, neuroimaging, and neuropathology that suggests the potential use of MBI as a risk indicator in preclinical AD.
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Affiliation(s)
- Piaopiao Jin
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jiaxi Xu
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Zhengluan Liao
- Department of Geriatric VIP No. 3 (Department of Clinical Psychology), Rehabilitation Medicine Center, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, China
| | - Yuhan Zhang
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ye Wang
- The Second School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Wangdi Sun
- Department of Psychiatry, Zhejiang Hospital, Hangzhou, China
| | - Enyan Yu
- Department of Psychiatry, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
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Creese B, Arathimos R, Aarsland D, Ballard C, Brooker H, Hampshire A, Corbett A, Ismail Z. Late-life onset psychotic symptoms and incident cognitive impairment in people without dementia: Modification by genetic risk for Alzheimer's disease. Alzheimers Dement (N Y) 2023; 9:e12386. [PMID: 37139261 PMCID: PMC10150165 DOI: 10.1002/trc2.12386] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/01/2023] [Indexed: 05/05/2023]
Abstract
Introduction Late-life onset psychosis is associated with faster progression to dementia in cognitively normal people, but little is known about its relationship with cognitive impairment in advance of dementia. Methods Clinical and genetic data from 2750 people ≥50 years of age without dementia were analyzed. Incident cognitive impairment was operationalized using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) and psychosis was rated using the Mild Behavioral Impairment Checklist (henceforth MBI-psychosis). The whole sample was analyzed before stratification on apolipoprotein E (APOE) ε4 status. Results In Cox proportional hazards models, MBI-psychosis had a higher hazard for cognitive impairment relative to the No Psychosis group (hazard ratio [HR]: 3.6, 95% confidence interval [CI]: 2.2-6, p < 0.0001). The hazard for MBI-psychosis was higher in APOE ε4 carriers and there was an interaction between the two (HR for interaction: 3.4, 95% CI: 1.2-9.8, p = 0.02). Discussion Psychosis assessment in the MBI framework is associated with incident cognitive impairment in advance of dementia. These symptoms may be particularly important in the context of APOE genotype.
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Affiliation(s)
- Byron Creese
- Department of Clinical and Biomedical SciencesFaculty of Health and Life SciencesUniversity of ExeterExeterUK
| | - Ryan Arathimos
- Social Genetic and Developmental Psychiatry CentreInstitute of Psychiatry, Psychology and NeuroscienceKing's College LondonLondonUK
| | - Dag Aarsland
- Department of Old Age PsychiatryInstitute of PsychiatryPsychology and NeuroscienceKing's College LondonLondonUK
- Centre for Age‐Related MedicineStavanger University HospitalStavangerNorway
| | - Clive Ballard
- Department of Clinical and Biomedical SciencesFaculty of Health and Life SciencesUniversity of ExeterExeterUK
| | - Helen Brooker
- Department of Health and Community SciencesFaculty of Health and Life SciencesUniversity of ExeterExeterUK
| | - Adam Hampshire
- Department of Brain SciencesFaculty of MedicineImperial College LondonLondonUK
| | - Anne Corbett
- Department of Health and Community SciencesFaculty of Health and Life SciencesUniversity of ExeterUK
| | - Zahinoor Ismail
- Departments of PsychiatryClinical Neurosciences, and Community Health SciencesHotchkiss Brain Institute and O'Brien Institute for Public HealthUniversity of CalgaryCalgaryAlbertaCanada
- Department of Health and Community Sciences, Faculty of Health and Life SciencesUniversity of ExeterExeterUK
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Rodríguez-Hidalgo E, García-Alba J, Novell R, Esteba-Castillo S. The Global Deterioration Scale for Down Syndrome Population (GDS-DS): A Rating Scale to Assess the Progression of Alzheimer's Disease. Int J Environ Res Public Health 2023; 20:5096. [PMID: 36982004 PMCID: PMC10049652 DOI: 10.3390/ijerph20065096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 06/18/2023]
Abstract
The aim of this study is to adapt and validate the global deterioration scale (GDS) for the systematic tracking of Alzheimer's disease (AD) progression in a population with Down syndrome (DS). A retrospective dual-center cohort study was conducted with 83 participants with DS (46.65 ± 5.08 years) who formed the primary diagnosis (PD) group: cognitive stability (n = 48), mild cognitive impairment (n = 24), and Alzheimer's disease (n = 11). The proposed scale for adults with DS (GDS-DS) comprises six stages, from cognitive and/or behavioral stability to advanced AD. Two neuropsychologists placed the participants of the PD group in each stage of the GDS-DS according to cognitive, behavioral and daily living skills data. Inter-rater reliability in staging with the GDS-DS was excellent (ICC = 0.86; CI: 0.80-0.93), and the agreement with the diagnosis categories of the PD group ranged from substantial to excellent with κ values of 0.82 (95% CI: 0.73-0.92) and 0.85 (95% CI: 0.72, 0.99). Performance with regard to the CAMCOG-DS total score and orientation subtest of the Barcelona test for intellectual disability showed a slight progressive decline across all the GDS-DS stages. The GDS-DS scale is a sensitive tool for staging the progression of AD in the DS population, with special relevance in daily clinical practice.
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Affiliation(s)
- Emili Rodríguez-Hidalgo
- Specialized Service in Mental Health and Intellectual Disability, Institute of Health Assistance (IAS), Parc Hospitalari Martí i Julià, 17190 Girona, Spain
- Neurodevelopmental Group [Girona Biomedical Research Institute]-IDIBGI, Institute of Health Assistance (IAS), Parc Hospitalari Martí i Julià, 17190 Girona, Spain
| | - Javier García-Alba
- Research and Psychology in Education Department, Complutense University of Madrid, 28040 Madrid, Spain
| | - Ramon Novell
- Specialized Service in Mental Health and Intellectual Disability, Institute of Health Assistance (IAS), Parc Hospitalari Martí i Julià, 17190 Girona, Spain
- Neurodevelopmental Group [Girona Biomedical Research Institute]-IDIBGI, Institute of Health Assistance (IAS), Parc Hospitalari Martí i Julià, 17190 Girona, Spain
| | - Susanna Esteba-Castillo
- Specialized Service in Mental Health and Intellectual Disability, Institute of Health Assistance (IAS), Parc Hospitalari Martí i Julià, 17190 Girona, Spain
- Neurodevelopmental Group [Girona Biomedical Research Institute]-IDIBGI, Institute of Health Assistance (IAS), Parc Hospitalari Martí i Julià, 17190 Girona, Spain
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Hu S, Patten S, Charlton A, Fischer K, Fick G, Smith EE, Ismail Z. Validating the Mild Behavioral Impairment Checklist in a Cognitive Clinic: Comparisons With the Neuropsychiatric Inventory Questionnaire. J Geriatr Psychiatry Neurol 2023; 36:107-120. [PMID: 35430902 PMCID: PMC9941652 DOI: 10.1177/08919887221093353] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare the utility of the Mild Behavioral Impairment-Checklist (MBI-C) and Neuropsychiatric Inventory Questionnaire (NPI-Q) to capture NPS in subjective cognitive decline (SCD), mild cognitive impairment (MCI), and dementia. METHODS In this cross-sectional memory clinic study, linear regression models compared MBI-C (n = 474) and NPI-Q (n = 1040) scores in relation to Montreal Cognitive Assessment (MoCA) score. RESULTS MBI prevalence was 37% in subjective cognitive decline, 54% in mild cognitive impairment, and 62% in dementia. Worse diagnostic status was associated with higher MBI-C and NPI-Q score (P < .001), lower MoCA (P < .001), and greater age (P < .001). Higher MBI-C (β -.09; 95% CI -.13, -.05) and NPI-Q (β -.17; 95% CI -.23, -.10) scores were associated with lower MoCA scores, with psychosis most strongly associated (β -1.11; 95% CI -1.56, -.65 vs β -1.14; 95% CI -1.55, -.73). CONCLUSIONS The MBI-C captures global and domain-specific NPS across cognitive stages. Both the MBI-C and NPI-Q have utility in characterizing NPS.
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Affiliation(s)
- Sophie Hu
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Scott Patten
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Anna Charlton
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Karyn Fischer
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Gordon Fick
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Eric E. Smith
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Zahinoor Ismail
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Department of Psychiatry, University of Calgary, Calgary, AB, Canada
- O’Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
- Zahinoor Ismail, MD, Hotchkiss Brain Institute, University of Calgary, 3280 Hospital Drive NW, TRW Building 1st Floor Calgary, AB T2N 4Z6, Canada.
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Lin RS, Yu DS, Chau PH, Li PW, Ismail Z. Reliability and Validity of the Traditional Chinese Version of the Mild Behavioral Impairment - Checklist Among Persons With Mild Cognitive Impairment - A Validation Study. J Geriatr Psychiatry Neurol 2023; 36:26-38. [PMID: 35430911 DOI: 10.1177/08919887221093363] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To evaluate the reliability and validity of the traditional Chinese version of the Mild Behavioral Impairment Checklist (MBI-C) among Hong Kong Chinese with mild cognitive impairment (MCI). METHODS A total of 172 participants were recruited from 2 community facilities. Cronbach's alpha (α) was calculated to evaluate internal consistency. Intra-class correlation coefficient (ICC) was used to measure 2-week test-retest reliability. Construct validity was evaluated by conducting exploratory factor analysis to identify the internal structure of MBI-C, and assessing the correlation between theoretically related constructs, including objective and subjective cognitive impairment, neurotic personality, social supports, and maladaptive coping. Concurrent validity was assessed by its correlation with Neuropsychiatric Inventory Questionnaire (NPI-Q). RESULTS The results revealed good internal consistency and test-retest reliability of the MBI-C. Item analysis identified 4 items with low item-to-total correlations. The EFA identified a seven-factor structure. Hypothesis testing identified its significant correlations with subjective cognitive impairment, neurotic personality, social supports, and maladaptive coping. Concurrent validity was supported by its significant correlation with the NPI-Q. CONCLUSIONS The traditional Chinese version of MBI-C is a valid and reliable outcome measure to assess the severity of neuropsychiatric symptoms of the MCI population.
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Affiliation(s)
- Rose Sy Lin
- School of Nursing, Li Ka Shing Faculty of Medicine, 71020University of Hong Kong, Hong Kong
| | - Doris Sf Yu
- School of Nursing, Li Ka Shing Faculty of Medicine, 71020University of Hong Kong, Hong Kong
| | - Pui H Chau
- School of Nursing, Li Ka Shing Faculty of Medicine, 71020University of Hong Kong, Hong Kong
| | - Polly Wc Li
- School of Nursing, Li Ka Shing Faculty of Medicine, 71020University of Hong Kong, Hong Kong
| | - Zahinoor Ismail
- Hotchkiss Brain Institute and O'Brien Institute for Public Health, 2129University of Calgary, Calgary, AB, Canada
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Farvadi F, Hashemi F, Amini A, Alsadat Vakilinezhad M, Raee MJ. Early Diagnosis of Alzheimer's Disease with Blood Test; Tempting but Challenging. Int J Mol Cell Med 2023; 12:172-210. [PMID: 38313372 PMCID: PMC10837916 DOI: 10.22088/ijmcm.bums.12.2.172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 11/25/2023] [Accepted: 12/13/2023] [Indexed: 02/06/2024]
Abstract
The increasing prevalence of Alzheimer's disease (AD) has led to a health crisis. According to official statistics, more than 55 million people globally have AD or other types of dementia, making it the sixth leading cause of death. It is still difficult to diagnose AD and there is no definitive diagnosis yet; post-mortem autopsy is still the only definite method. Moreover, clinical manifestations occur very late in the course of disease progression; therefore, profound irreversible changes have already occurred when the disease manifests. Studies have shown that in the preclinical stage of AD, changes in some biomarkers are measurable prior to any neurological damage or other symptoms. Hence, creating a reliable, fast, and affordable method capable of detecting AD in early stage has attracted the most attention. Seeking clinically applicable, inexpensive, less invasive, and much more easily accessible biomarkers for early diagnosis of AD, blood-based biomarkers (BBBs) seem to be an ideal option. This review is an inclusive report of BBBs that have been shown to be altered in the course of AD progression. The aim of this report is to provide comprehensive insight into the research status of early detection of AD based on BBBs.
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Affiliation(s)
- Fakhrossadat Farvadi
- Center for Nanotechnology in Drug Delivery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Hashemi
- School of Biomedical Sciences and Pharmacy, College of Health, Medicine and Wellbeing, the University of Newcastle, Newcastle, Australia
| | - Azadeh Amini
- Department of Pharmaceutical Biomaterials and Medical Biomaterials Research Center, Faculty of Pharmacy, Tehran University of Medical sciences, Tehran, Iran
| | | | - Mohammad Javad Raee
- Center for Nanotechnology in Drug Delivery, Shiraz University of Medical Sciences, Shiraz, Iran
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Vellone D, Ghahremani M, Goodarzi Z, Forkert ND, Smith EE, Ismail Z. Apathy and APOE in mild behavioral impairment, and risk for incident dementia. Alzheimers Dement (N Y) 2022; 8:e12370. [PMID: 36544988 PMCID: PMC9763783 DOI: 10.1002/trc2.12370] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/17/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
Abstract
Introduction Mild behavioral impairment (MBI) is a high-risk state for incident dementia and comprises five core domains including affective dysregulation, impulse dyscontrol, social inappropriateness, psychotic symptoms, and apathy. Apathy is among the most common neuropsychiatric symptoms (NPS) in dementia but can also develop in persons with normal cognition (NC) or mild cognitive impairment (MCI). The later-life emergence and persistence of apathy as part of the MBI syndrome may be a driving factor for dementia risk. Therefore, we investigated MBI-apathy-associated progression to dementia, and effect modification by sex, race, cognitive diagnosis, and apolipoprotein E (APOE) genotype. Methods Dementia-free National Alzheimer's Coordinating Center participants were stratified by persistent apathy status, based on Neuropsychiatric Inventory (NPI)-Questionnaire scores at two consecutive visits. Hazard ratios (HRs) for incident dementia for MBI-apathy and NPI-apathy relative to no NPS, and MBI-apathy relative to no apathy, were determined using Cox proportional hazards regressions, adjusted for baseline age, sex, years of education, race, cognitive diagnosis, and APOE genotype. Interactions with relevant model covariates were explored. Results Of the 3932 participants (3247 with NC), 354 had MBI-apathy. Of all analytic groups, MBI-apathy had the greatest dementia incidence (HR = 2.69, 95% confidence interval [CI]: 2.15-3.36, P < 0.001). Interaction effects were observed between cognitive diagnosis and APOE genotype with the NPS group. The contribution of apathy to dementia risk was greater in NC (HR = 5.91, 95% CI: 3.91-8.93) than in MCI (HR = 2.16, 95% CI: 1.69-2.77, interaction P < 0.001) and in all APOE genotypes, was greatest in APOE ɛ3 (HR = 4.25, 95% CI: 3.1-5.82, interaction P < 0.001). Discussion Individuals with MBI-apathy have a markedly elevated risk for future dementia, especially when symptoms emerge in those with NC. Both cognitive status and APOE genotype are important moderators in the relationship between MBI-apathy and incident dementia. MBI-apathy may represent a group in whom apathy is a preclinical or prodromal manifestation of dementia and identify a precision medicine target for preventative interventions.
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Affiliation(s)
- Daniella Vellone
- Hotchkiss Brain InstituteCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Maryam Ghahremani
- Hotchkiss Brain InstituteCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Department of PsychiatryCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Zahra Goodarzi
- Hotchkiss Brain InstituteCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Mathison Centre for Mental Health Research and EducationCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Department of MedicineCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,O'Brien Institute for Public HealthCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Nils D. Forkert
- Hotchkiss Brain InstituteCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Department of RadiologyCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Department of Clinical NeurosciencesCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Alberta Children's Hospital Research InstituteUniversity of CalgaryCalgaryAlbertaCanada
| | - Eric E. Smith
- Hotchkiss Brain InstituteCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Department of Clinical NeurosciencesCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Zahinoor Ismail
- Hotchkiss Brain InstituteCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Department of PsychiatryCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Mathison Centre for Mental Health Research and EducationCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Department of Community Health SciencesCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Department of MedicineCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,O'Brien Institute for Public HealthCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,Department of Clinical NeurosciencesCumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada,College of Medicine and HealthUniversity of ExeterExeterUK
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Creese B, Ismail Z. Mild behavioral impairment: measurement and clinical correlates of a novel marker of preclinical Alzheimer's disease. Alzheimers Res Ther 2022; 14:2. [PMID: 34986891 PMCID: PMC8734161 DOI: 10.1186/s13195-021-00949-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 12/14/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Late-life onset neuropsychiatric symptoms are established risk factors for dementia. The mild behavioral impairment (MBI) diagnostic framework was designed to standardize assessment to determine dementia risk better. In this Mini Review, we summarize the emerging clinical and biomarker evidence, which suggests that for some, MBI is a marker of preclinical Alzheimer's disease. MAIN: MBI is generally more common in those with greater cognitive impairment. In community and clinical samples, frequency is around 10-15%. Mounting evidence in cognitively normal samples links MBI symptoms with known AD biomarkers for amyloid, tau, and neurodegeneration, as well as AD risk genes. Clinical studies have found detectable differences in cognition associated with MBI in cognitively unimpaired people. CONCLUSION The emerging evidence from biomarker and clinical studies suggests MBI can be an early manifestation of underlying neurodegenerative disease. Future research must now further validate MBI to improve identification of those at the very earliest stages of disease.
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Affiliation(s)
- Byron Creese
- Medical School, College of Medicine and Health, University of Exeter, Exeter, UK.
| | - Zahinoor Ismail
- Departments of Psychiatry, Clinical Neurosciences, Community Health Sciences, and Pathology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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Pan Y, Shea YF, Ismail Z, Mak HKF, Chiu PKC, Chu LW, Song YQ. Prevalence of mild behavioural impairment domains: a meta-analysis. Psychogeriatrics 2022; 22:84-98. [PMID: 34729865 DOI: 10.1111/psyg.12782] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/10/2021] [Accepted: 10/18/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Mild behavioural impairment (MBI) is a neurobehavioural syndrome characterised by later life emergence of persistent neuropsychiatric symptoms. Our previous meta-analysis showed that MBI is prevalent among cognitively normal (CN), subjective cognitive impairment (SCI) and mild cognitive impairment (MCI) subjects. This study is to calculate the pooled prevalence of MBI domains among CN, SCI, and MCI subjects. METHODS A search of relevant literature published between 1 January 2003 and 6 August 2021 was conducted. Meta-analysis using a random effects model and meta-regression was performed. RESULTS Ten studies conducted among 12 067 subjects (9758 CN, 1057 SCI and 1252 MCI) with retrievable MBI domains data underwent meta-analysis, revealing pooled prevalence of affective dysregulation (AFD), impulse dyscontrol (IDS), decreased motivation (DMT), social inappropriateness (SIP) and abnormal perception/thought (APT) of 32.84% (95% CI 24.44-42.5%), 26.67% (95% CI 18.24-37.23%), 12.58% (95% CI 6.93-21.75%), 6.05% (95% CI 3.44-10.42%), and 2.81% (95% CI 1.67-4.69%) respectively. AFD and APT domains demonstrated ordinal increase in pooled prevalence from CN, SCI and MCI subgroups, but meta-regression demonstrated no significant difference in MBI domains prevalence among cognitive subgroups (in contrast to the significant increase in MBI prevalence from CN to SCI to MCI). The pooled prevalence of AFD and IDS are greater than that of DMT, SIP and APT among all cognitive subgroups. Several variables were found to explain the high heterogeneity. CONCLUSIONS AFD and IDS are the two most prevalent MBI domains and remain the same with cognitive deterioration. This finding is potentially relevant to clinical practice.
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Affiliation(s)
- Yining Pan
- School of Biomedical Sciences, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Yat-Fung Shea
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Zahinoor Ismail
- Departments of Psychiatry and Clinical Neurosciences, Hotchkiss Brain Institute and O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Henry Ka-Fung Mak
- Department of Diagnostic Radiology, The University of Hong Kong, Hong Kong SAR, China
| | - Patrick Ka-Chun Chiu
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - Leung-Wing Chu
- Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - You-Qiang Song
- School of Biomedical Sciences, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Matsuoka T, Ueno D, Ismail Z, Rubinstein E, Uchida H, Mimura M, Narumoto J. Neural Correlates of Mild Behavioral Impairment: A Functional Brain Connectivity Study Using Resting-State Functional Magnetic Resonance Imaging. J Alzheimers Dis 2021; 83:1221-1231. [PMID: 34420972 PMCID: PMC8543254 DOI: 10.3233/jad-210628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: Mild behavioral impairment (MBI) is associated with accelerated cognitive decline and greater risk of dementia. However, the neural correlates of MBI have not been completely elucidated. Objective: The study aimed to investigate the correlation between cognitively normal participants and participants with amnestic mild cognitive impairment (aMCI) using resting-state functional magnetic resonance imaging. Methods: The study included 30 cognitively normal participants and 13 participants with aMCI (20 men and 23 women; mean age, 76.9 years). The MBI was assessed using the MBI checklist (MBI-C). Region of interest (ROI)-to-ROI analysis was performed to examine the correlation between MBI-C scores and functional connectivity (FC) of the default mode network, salience network, and frontoparietal control network (FPCN). Age, Mini-Mental State Examination score, sex, and education were used as covariates. A p-value of 0.05, with false discovery rate correction, was considered significant. Results: A negative correlation was observed between the MBI-C total score and FC of the left posterior parietal cortex with the right middle frontal gyrus. A similar result was obtained for the MBI-C affective dysregulation domain score. Conclusion: FPCN dysfunction was detected as a neural correlate of MBI, especially in the affective dysregulation domain. This dysfunction may be associated with cognitive impairment in MBI and conversion of MBI to dementia; however, further longitudinal data are needed to examine this relationship.
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Affiliation(s)
- Teruyuki Matsuoka
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - Daisuke Ueno
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
| | - Zahinoor Ismail
- Departments of Psychiatry, Clinical Neurosciences, and Community Health Sciences, Hotchkiss Brain Institute and O'Brien Institute for Public Health, University of Calgary, Calgary, Canada
| | - Ellen Rubinstein
- Department of Sociology and Anthropology, North Dakota State University, Fargo, ND, USA
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Jin Narumoto
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Kyoto, Japan
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Matuskova V, Ismail Z, Nikolai T, Markova H, Cechova K, Nedelska Z, Laczo J, Wang M, Hort J, Vyhnalek M. Mild Behavioral Impairment Is Associated With Atrophy of Entorhinal Cortex and Hippocampus in a Memory Clinic Cohort. Front Aging Neurosci 2021; 13:643271. [PMID: 34108874 PMCID: PMC8180573 DOI: 10.3389/fnagi.2021.643271] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/16/2021] [Indexed: 12/22/2022] Open
Abstract
Objectives Mild behavioral impairment (MBI) is a syndrome describing late-onset persistent neuropsychiatric symptoms (NPS) in non-demented older adults. Few studies to date have investigated the associations of MBI with structural brain changes. Our aim was to explore structural correlates of NPS in a non-demented memory clinic sample using the Mild Behavioral Impairment Checklist (MBI-C) that has been developed to measure MBI. Methods One hundred sixteen non-demented older adults from the Czech Brain Aging Study with subjective cognitive concerns were classified as subjective cognitive decline (n = 37) or mild cognitive impairment (n = 79). Participants underwent neurological and neuropsychological examinations and brain magnetic resonance imaging (MRI) (1.5 T). The Czech version of the MBI-C was administered to participants’ informants. Five a priori selected brain regions were measured, namely, thicknesses of the orbitofrontal cortex (OFC), anterior cingulate cortex (ACC), posterior cingulate cortex (PCC), and entorhinal cortex (ERC) and volume of the hippocampus (HV), and correlated with MBI-C total and domain scores. Results Entorhinal cortex was associated with MBI-C total score (rS = −0.368, p < 0.001) and with impulse dyscontrol score (rS = −0.284, p = 0.002). HV was associated with decreased motivation (rS = −0.248, p = 0.008) and impulse dyscontrol score (rS = −0.240, p = 0.011). Conclusion Neuropsychiatric symptoms, particularly in the MBI impulse dyscontrol and motivation domains, are associated with medial temporal lobe atrophy in a clinical cohort of non-demented older adults. This study supports earlier involvement of temporal rather than frontal regions in NPS manifestation. Since these regions are typically affected early in the course of Alzheimer’s disease (AD), the MBI-C may potentially help further identify individuals at-risk of developing AD dementia.
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Affiliation(s)
- Veronika Matuskova
- Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Zahinoor Ismail
- Department of Psychiatry, Cumming School of Medicine, Calgary, AB, Canada.,Department of Clinical Neurosciences, Cumming School of Medicine, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, Calgary, AB, Canada.,Hotchkiss Brain Institute and O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Tomas Nikolai
- Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Hana Markova
- Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Katerina Cechova
- Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Zuzana Nedelska
- Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Jan Laczo
- Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Meng Wang
- Department of Clinical Neurosciences, Cumming School of Medicine, Calgary, AB, Canada.,Department of Community Health Sciences, Cumming School of Medicine, Calgary, AB, Canada
| | - Jakub Hort
- Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
| | - Martin Vyhnalek
- Memory Clinic, Department of Neurology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czechia
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Ismail Z, McGirr A, Gill S, Hu S, Forkert ND, Smith EE. Mild Behavioral Impairment and Subjective Cognitive Decline Predict Cognitive and Functional Decline. J Alzheimers Dis 2021; 80:459-469. [PMID: 33554909 PMCID: PMC8075401 DOI: 10.3233/jad-201184] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mild behavioral impairment (MBI) and subjective cognitive decline (SCD) are dementia risk states, and potentially represent neurobehavioral and neurocognitive manifestations, respectively, of early stage neurodegeneration. Both MBI and SCD predict incident cognitive decline and dementia, are associated with known dementia biomarkers, and are both represented in the NIA-AA research framework for AD in Stage 2 (preclinical disease). OBJECTIVE To assess the associations of MBI and SCD, alone and in combination, with incident cognitive and functional decline in a population of older adults. We tested the hypothesis that MBI and SCD confer additive risk for decline. METHODS Cognitively normal participants were followed up annually at Alzheimer's Disease Centers. Logistic regression assessed the relationship between baseline classification (MBI-SCD-, MBI-SCD+, MBI+SCD-, or MBI+SCD+) and 3-year outcome. RESULTS Of 2,769 participants (mean age=76), 1,536 were MBI-SCD-, 254 MBI-SCD+, 743 MBI+SCD-, and 236 MBI+SCD+. At 3 years, 349 (12.6%) declined to CDR >0, including 23.1% of the MBI+group, 23.5% of the SCD+group, and 30.9% of the intersection group of both MBI+and SCD+participants. Compared to SCD-MBI-, we observed an ordinal progression in risk (ORs [95% CI]): 3.61 [2.42-5.38] for MBI-SCD+ (16.5% progression), 4.76 [3.57-6.34] for MBI+SCD- (20.7%), and 8.15 [5.71-11.64] for MBI+SCD+(30.9%). CONCLUSION MBI and SCD together were associated with the greatest risk of decline. These complementary dementia risk syndromes can be used as simple and scalable methods to identify high-risk patients for workup or for clinical trial enrichment.
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Affiliation(s)
- Zahinoor Ismail
- Department of Psychiatry, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, Canada
- O’Brien Institute for Public Health, Cumming School of Medicine, Calgary, Canada
| | - Alexander McGirr
- Department of Psychiatry, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, Canada
| | - Sascha Gill
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, Canada
| | - Sophie Hu
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, Canada
| | - Nils D. Forkert
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Eric E. Smith
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
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Shu J, Qiang Q, Yan Y, Wen Y, Ren Y, Wei W, Zhang L. Distinct Patterns of Brain Atrophy associated with Mild Behavioral Impairment in Cognitively Normal Elderly Adults. Int J Med Sci 2021; 18:2950-2956. [PMID: 34220322 PMCID: PMC8241773 DOI: 10.7150/ijms.60810] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/30/2021] [Indexed: 01/25/2023] Open
Abstract
A cross-sectional study was conducted to evaluate patterns of gray matter changes in cognitively normal elderly adults with mild behavioral impairment (MBI). Sixteen MBI patients and 18 healthy controls were selected. All the participants underwent a neuropsychological assessment battery, including the Mini-mental State Examination (MMSE), Geriatric Depression Scale (GDS), Self-rating Anxiety Scale (SAS), and Chinese version of the mild behavioral impairment-checklist scale (MBI-C), and magnetic resonance imaging (MRI) scans. Imaging data was analyzed based on voxel-based morphometry (VBM). There was no significant difference in age, gender, MMSE score, total intracranial volume, white matter hyperdensity, gray matter volume, white matter volume between the two groups (p > 0.05). MBI group had shorter education years and higher MBI-C score, GDS and SAS scores than the normal control group (p < 0.05). For neuroimaging analysis, compared to the normal control group, the MBI group showed decreased volume in the left brainstem, right temporal transverse gyrus, left superior temporal gyrus, left inferior temporal gyrus, left middle temporal gyrus, right occipital pole, right thalamus, left precentral gyrus and left middle frontal gyrus(uncorrected p < 0.001). The grey matter regions correlated with the MBI-C score included the left postcentral gyrus, right exterior cerebellum, and left superior frontal gyrus. This suggests a link between MBI and decreased grey matter volume in cognitively normal elderly adults. Atrophy in the left frontal cortex and right thalamus in MBI patients is in line with frontal-subcortical circuit deficits, which have been linked to neuropsychiatric symptoms (NPS) in dementia. These initial results imply that MBI might be an early harbinger for subsequent cognitive decline and dementia.
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Affiliation(s)
- Jun Shu
- Department of Neurology, Huadong Hospital affiliated to Fudan University, No. 221, West Yan An Road, Shanghai, China
| | - Qiang Qiang
- Department of Neurology, Huadong Hospital affiliated to Fudan University, No. 221, West Yan An Road, Shanghai, China
| | - Yuning Yan
- Department of Neurology, Huadong Hospital affiliated to Fudan University, No. 221, West Yan An Road, Shanghai, China
| | - Yang Wen
- Department of Neurology, The Third People's Hospital of Chengdu, China
| | - Yiqing Ren
- Department of Neurology, Huadong Hospital affiliated to Fudan University, No. 221, West Yan An Road, Shanghai, China
| | - Wenshi Wei
- Department of Neurology, Huadong Hospital affiliated to Fudan University, No. 221, West Yan An Road, Shanghai, China
| | - Li Zhang
- Department of Neurology, Huadong Hospital affiliated to Fudan University, No. 221, West Yan An Road, Shanghai, China
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