Therapeutic approaches to age-associated neurocognitive disorders

The United Nations projects that the number of individuals with dementia in developed countries alone will be approximately 36,7 million by the year 2050. International recognition of the significant emotional and economic burden of Alzheimer's disease has been matched by a dramatic increase in the development of pharmacological and nonpharmacological approaches to this illness in the past decade. Changing demographics have underscored the necessity to develop similar approaches for the remediation of the cognitive impairment associated with more benign syndromes, such as mild cognitive impairment (MCI) and age-associated cognitive decline (AACD). The present article aims to provide an overview of the most current therapeutic approaches to age-associated neurocognitive disorders. Additionally, it discusses the conceptual and methodological issues that surround the design, implementation, and interpretation of such approaches.

[Perturbations of activities of daily living in Alzheimer's disease. A study of 172 patients with the using a questionnaire completed by caregivers]

Functional decline was studied retrospectively in 172 patients with Alzheimer's disease, AD, using a questionnaire completed by the caregiver. Ninety-nine of these patients had a second assessment after a follow-up of 22.1 +/- 13.8 months. The questionnaire included French versions of the Physical Self-Maintenance Activities, ADL, and of the Instrumental Activities of Daily Living, IADL (Lawton and Brody, 1969). A third part assessing social activities, SADL, was derived from Katz and Lyerly (1963). The earliest and most frequent perturbations in early AD involved SADL, mainly a reduction in social and leisure activities, appearing in subjects with a MMSE score > 26. The earliest decline in IADL involved the ability for handling finances, odd jobs-sewing, and shopping, which were more frequently perturbed than ability to use telephone, traveling or handling medication. The most interesting results of our study were as follows. Functional decline did not allow to distinguish patients with early AD (MMSE score > or = 24) from those with mild dementia (MMSE score 20-23). Mild perturbations of ADL, mainly dressing and walking, were observed in early AD. There was a good correlation, but no parallelism, between functional decline and cognitive decline. Disturbances in ADL and SADL significantly differed only between patients with severe dementia (MMSE < 10) and those of the three other groups. Apathy appeared to be a stronger predictor of functional decline than the score on the MMSE in the early stages of AD. There was a great variability among the patients regarding the type of functional decline as well as the rate of decline. Functional decline is very useful for detecting early AD. However, its specificity seems to be low and the diagnosis should be supported by cognitive assessment.

Apraxic disturbances in patients with mild to moderate Alzheimer's disease

Twenty-two patients meeting the NINCDS-ADRDA diagnostic criteria for probable AD were included in the study, along with 10 matched controls. Praxic disturbances were investigated using eight tasks and the results were interpreted according to the neuropsychological model of Roy and Square modified by Rothi et al. (1988) [Aphasiology 21:381-388] which distinguishes a conceptual system concerned with knowledge of the action and function of gestures and a production system that effects gestures in the environment. Disturbance of the production system was found only in 17 patients. Disturbance of the production system was correlated to disturbance of verbal comprehension. The patients scored lower using the left hand than the right. Disturbance of the conceptual system was found in all patients and was not significantly correlated with other cognitive deficits. No significant difference in results was found according to the type of input to the conceptual system (visual or verbal). Deficits in tasks using real objects were correlated to disturbances of both the production and conceptual systems. Most patients performed poorly both in tasks exploring the conceptual system and in those exploring the production system. However, two patients performed badly in production tasks but had performances in the range of controls for conceptual tasks and one patient had the opposite pattern of dissociation. This provides evidence that the production and the conceptual system are independent. Impairment in the ability to perform everyday activities was correlated to disturbances of the conceptual system whereas poor performances in tasks exploring the production system or in using real objects were not.

[Noncognitive symptoms in Alzheimer's disease. A study of 150 community-dwelling patients using a questionnaire completed by the caregiver]

We studied the noncognitive symptoms in 150 community-dwelling Alzheimer's patients using a questionnaire completed by the caregiver, the Echelle Psychopathologique de la Démence de Type Alzheimer, EPDTA (Psychopathologic Scale of Dementia of Alzheimer Type). EPDTA is a 44-item questionnaire derived from the BEHAVE-AD and the Depressive Mood Scale, covering many aspects of the behavior, affective and psychiatric disturbances. Each item is rated from 0 (never observed) to 6 (most of the time). Frequency (percentage of symptom present) and severity (mean score when the symptom was present) were assessed for each item. The cognitive status and severity of the disease were assessed by the MMSE and two scales completed by the caregiver assessing the Activities of Daily Living scale (ADL) and the Cognitive Difficulties Scale (CDS). Noncognitive symptoms were present in all patients but remained moderate in severity. A principal component analysis of the 33 items exploring the affective disturbances showed seven clinically relevant factors: apathy, anxiety, anosognosia-irritability, euphoria, dysphoria, emotional incontinence and agitation. The most frequent noncognitive symptoms were the affective disturbances, especially apathy, and the sexual behavioural disturbances. No correlation were found between the overall severity of behavioural disturbances and cognitive status, duration of the disease nor demographic variables. However, a slight negative correlation was found between scores on apathy and on the MMSE. A second evaluation was performed in 59 patients after a mean follow-up of 18,2 months. The patients showed a progression of the disease evidenced by the scores on the MMSE, ADL and CDS scales. However, the frequency and severity of the noncognitive symptoms remained identical except for eating disorders, psychotic symptoms and agitation which were more frequent at the second examination and negatively correlated with the MMSE score. Most patients showed affective disturbances and scored high for apathy and anxiety-emotional incontinence dimensions. Like in a previous study, we found a double dissociation between these two dimensions in some patients, suggesting that they depend from different mechanisms. Agressivity, mostly verbal, was found in three quarters of the patients and was correlated to apathy, anosognosia and psychotic symptoms.

CONCLUSION

The relationship between noncognitive manifestations and cognitive deficits in AD is not clear, suggesting that they depend from different biological and psychological mechanisms. Various dimensions may be described in the behavioural disturbances but their relationship with hypothetical biological mechanisms remains difficult. Our study stresses the importance of apathy, which was corelated with various noncognitive psychobehavioral manifestations in AD patients.

[Diagnosis of Alzheimer's disease in the predementia phase: possibilities and benefits]

THE PREDEMENTIA PHASE: Alzheimer's disease is a progressive condition. The state of dementia defined by international criteria only appears after brain lesions have become important. Dementia is defined by the presence of multiple cognitive deficits and restricted independence. Prior to this, the patient experiences isolated memory impairment, either alone or associated with behavior changes which have little effect on his/her independence (predementia phase). The goal of diagnosis at this time is to reduce psychic suffering for the patient and family as well as the social cost of the disease by retarding the onset of dementia. DIAGNOSIS IN THE PREDEMENTIA PHASE: Diagnosis is based on i) evidence of an alteration of the internal temporal regions leading to memory deficit due to impaired memorization processes. There is an elective impairment of recent memory rapidly leading to difficulties perceived by the family and which diminish performance in complex activities of daily living. Recall processes lose their efficacy. ii) Tomoscintigraphic evidence of a perfusion defect or structural imaging evidence of atrophy of the hippocampal regions. iii) Presence of associated psychoaffective changes (apathy). When these three elements are found, the diagnosis of Alzheimer's disease is highly probable and should be made. If all three are not present, it would be advisable to diagnose what is termed "mild cognitive impairment", defined as a group of subjects with a high risk of progressing to dementia in a few years. PATIENT CARE AT THIS PHASE: Neuroprotective drugs may be prescribed in association with psychological and cognitive support within the framework of regular follow-up.

[Memory and affect]

In the last decade, numerous studies have been devoted to the cognitive approach of emotions and their relationship with memory. Cognitive neuropsychologists consider affectivity as a contextual factor which can facilitate the processes of encoding or restitution. It is not clear if emotions are memorized by the same processes as the neutral stimuli. In man, a dissociation was found between loss of memory for affective stimuli in subjects with lesions restricted to amygdala and loss of memory for neutral stimuli in subjects with lesions limited to hippocampus. Experimental studies showed that recall of neutral material was better if subjects were in the same mood at the time of recall as during the time of encoding (mood dependency). Other studies showed that subjects had better memory for material with an affective valence corresponding to their mood than for material with a different affective valence (mood congruency). The discrepancy between the results of various experimental studies on mood and memory are related to methodological difficulties and different theoretical approaches. Studies on autobiographical memory showed that some emotional memories can be specially vivid or persistent (flashbulb memories, Post-Stress Traumatic Disorder) but, in the opposite, that strong emotion can result in lacunar amnesia.

[Neurology in Paris hospitals, particularly the Salpêtrière before Charcot: Rostan on brain softening]

In the beginning of the 19th century, many studies were devoted to the diseases of the nervous system in France, long before the work of Charcot. The researches of Léon Rostan on the cerebral softening (1819, 1823) were based on the anatomoclinic method developed by the School of Paris whose most famous representatives were Corvisart and Laennec for the study of heart and lung diseases. The researches of Rostan were performed in the Salpêtrière hospital which was, at this time, an hospice for old women. Rostan was appointed Inspector of the Health service in the Salpêtrière hospital in 1812 then Head of a department in 1818. He was 28 year old when he published his book "Researches on the cerebral softening" in 1819. Rostan was the first to describe the spontaneous cerebral softening as a special anatomoclinic entity distinct from encephalitis and apoplexy. He compared this entity to the senile gangrene and stated that it was related to the ossification of cerebral arteries. He described the pathologic features of the brain softening and also its clinical symptomatology in opposition to that of apoplexy. The concept of brain softening according to Rostan was harshly fought by the followers of the Broussais's physiological medicine (from Lallemand, 1830 to Calmeil, 1859) who claimed that all brain softenings were due to the inflammation process and thus should be described as encephalitis. In opposite, the ideas of Rostan were accepted and developed by others such as Carswell in England (1835), Abercrombie in Scotland (1836) and Andral in France (1827, 1840). These authors agreed that some type of cerebral softening was related to a disease of the arterial system. Nevertheless, the modern concept of brain softening was not definitively accepted before the description of the thromboembolic mechanisms by Virchow in Germany (1856) with the help of the microscope, and the anatomoclinic studies of Proust, Laborde and Prevost and Cottard in France (1866). The book of Rostan was dedicated to the "Conseil Général des Hospices" which was created in 1801 to unify the administration of the hospitals in Paris and became the "Administration Générale de l'Assistance Publique à Paris" in 1849. One hundred and fifty years after its publication, the work of Léon Rostan was outstanding by its modernity of the form as well as the substance.

[Memory complaints: epidemiology and diagnostic approach]

IN THE ELDERLY: Complaints of poor memory for everyday activities are common in the young as well as in the elderly. However, in the elderly, memory complaints are especially of interest on account of their frequency and the fear of being related to early Alzheimer's disease. Two types of memory complaints should distinguished. ENCODING/STORAGE DEFECTS: Memory difficulties related to early Alzheimer's disease are mainly related to a deficit in encoding and/or storage. They are restricted to the recent past and rapidly associated with temporal disorientation, limitation in everyday activities and behavioral modifications alerting the family responsible for seeking medical advice in most cases. Short examination of memory performance shows a free recall deficit which is not improved by cued recall. BENIGN DIFFICULTIES: Memory difficulties of benign type are due to a pure recall deficit: they are experienced as well for ancient as for recent past and the difficulty in recall is transient. There are no behavioral modifications or limitation in everyday activities: the disorder is purely subjective. At examination, the deficit in free recall is corrected by cueing. Benign type of memory complaints is mostly related to psychoaffective disturbances and subjects experiencing this type of memory difficulties are not at high risk for developing dementia.

Decreased awareness of cognitive deficits in patients with mild dementia of the Alzheimer type

OBJECTIVE

To study the unawareness of cognitive deficits in patients with mild dementia of Alzheimer type (DAT).

DESIGN

Retrospective study. We surveyed the medical records of outpatients meeting the NINCDS-ADRDA criteria for probable DAT who were able to complete the Cognitive Difficulties Scale (CDS) and had a close informant relative (IR) who could complete the family form of the same questionnaire.

SETTING

A department of neurology in a general teaching hospital.

SUBJECTS

Eighty-eight patients, aged 73.2+/-8.6 years with a mean MMSE score of 22.5+/-3.2. Fifty-two of the 88 patients had a follow-up examination after a mean interval of 21 months.

METHODS

Awareness of cognitive deficits was mainly assessed as the difference between the scores on the CDS completed by the IR and the patient (Index of Unawareness, IU). Two secondary assessments of unawareness were performed: (1) an assessment by the clinician on the basis of the patient's answers to questions probing the awareness of memory deficits; (2) an evaluation by the IR of the frequency of behavioural manifestations of unawareness in everyday life. SPECT was performed in 78 patients to study the relationship between unawareness and the topography of perfusion deficits.

RESULTS

Awareness of the cognitive deficits varied greatly between patients, according to the assessment method used and the stage of progression of the disease. Most patients with mild DAT were cognitively aware of their cognitive deficits but failed to appraise their severity and their consequences in everyday life. Decreased awareness was positively correlated with age and perfusion deficits in the frontal regions and negatively with the anxious symptomatology. However, the main correlate of unawareness was apathy.

CONCLUSION

The nature of unawareness of cognitive deficits appeared to be more dimensional than categorical. In patients with mild dementia, decreased awareness appeared to be more related to affective disturbances, especially to emotional deficit or apathy, than to cognitive deficits.

[Cerebral lacunae: still under debate]

During the last fifteen years, a new interest has been shown in cerebral lacunes due to the development of brain imagery using Magnetic Resonance Imaging (MRI). The concept of lacunar infarction as defined par Fisher (lacunar hypothesis) can no longer be accepted. Clinical data showed that the so-called lacunar clinical syndromes were far from being specific and could be observed in corticosubcortical infarcts. Epidemiological data pointed out that hypertensive disease was not found in many cases of lacunar infarction. Pathological studies suggest that there are two types of lacunar infarction. Lacunar infarcts resulting in clinical stroke syndromes (type 1 a lacunae) seem to be mainly due to obstruction of the trunk of a perforating artery by atherosclerosis. Silent lacunar infarcts (type 1 b lacunae) result from obstruction of small ramifications of the perforating arteries by a non specific microangiopathy related to age, atherosclerosis, cardiovascular disease as well as to hypertensive disease. Silent lacunar infarcts and dilatation of perivascular spaces (type 3 lacunae) are associated with the white matter hyperintensities shown by MRI in elderly subjects. Lacunar infarcts and diffuse white matter hyperintensities are related to small vessel changes and ischaemic damages resulting from (a) arteriolar occlusion and or (b) loss of autoregulation associated with variations in systemic blood pressure. Both lesions constitute a high risk to develop Vascular Cognitive Impairment (Hachinski) and are frequently associated with Alzheimer's disease. Cases of giant or expanding type 3 lacunae have been reported in the last ten years but the physiopathology of such lacunes and their relationship with clinical symptoms remain a puzzle.

Automatic attentional shifts induced by a noradrenergic drug in Alzheimer's disease: evidence from evoked potentials

Prior research showed that attentional deficits are observed in Alzheimer's disease (AD). These deficits can further impair other cognitive processes. The present experiment was designed to study the shifts in attention induced by a noradrenergic drug (S 12024-2) through their electrophysiological correlates in 12 outpatients with mild AD, using an auditory oddball paradigm. The P3a component, known to be related to automatic attentional processing, was increased by the drug, whereas no changes occurred either in PN or in P3b, which are considered to reflect conscious processing. These results point to an involvement of the noradrenergic system in the modulation of automatic attentional processing, and provide evidence for weakening of the orienting reflex in AD, due to a possible noradrenergic deficit in patients with mild AD.

Memory complaints in young and elderly subjects

OBJECTIVE

To compare the quantitative and qualitative aspects of memory complaints in cognitively normal subjects aged under and above 50 years.

SETTING

A memory clinic located in a general hospital in a suburb of Paris offering direct access to subjects.

DESIGN

Retrospective review of the files of consecutive patients who attended the clinic during one year.

PARTICIPANTS

Subjects were included if (a) they presented with memory complaints, (b) they had normal general cognitive functioning according to age and educational level, (c) they were devoid of present or past history of neurologic or psychiatric disorders.

METHODS

Subjects rated the severity of memory complaints as major or minor and filled in a 8-item questionnaire assessing various memory difficulties in everyday life. Relationship between severity of memory complaints and demographic data, memory performance and affective status was compared in 183 non-depressed, non-cognitively impaired healthy adults aged 50 years and over, and in 77 younger adults.

RESULTS

Semiologic aspects and correlates of memory complaints were similar in younger and older adults. No close relationship was found between severity of memory complaints and memory performance. In both age groups, memory complaints were strongly related to affective status, mainly to the severity of anxious symptomatology. Memory complaints were related to gender in younger subjects, and to subjective assessment of well-being in older.

CONCLUSION

Memory complaints of elderly do not appear basically different from memory complaints of younger subjects. They constitute a complex psychological symptom unlikely to be explained by a few variables and cannot be reduced to the subjective counterpart of memory performance decline associated with age.

[Non-drug management of Alzheimer's disease]

The recent appearance of drugs offering some efficacy has been a major advance in the treatment of Alzheimer's disease. However, non drug therapy of the patients and caring for family members remain the main elements to delay institutionalization. General practitioner has a major role in this approach whose aims are identification and treatment of excess disability, understanding and control of psycho-behavioral manifestations, sustaining and stimulation of cognitive functions and communication, maintaining the patient's autonomy and alleviating of the caregiver's burden. A major point of this approach is to consider the disease manifestations not only as the consequence of brain lesions but also as the impact of the disease on the affective and relational functions of the subject.

Entropy maps characterize drug effects on brain dynamics in Alzheimer's disease

Non-linear quantifiers of brain electrical dynamics (entropy maps computed from the degradation of temporal forecasting of EEG signals) were studied in relation to drug treatment of Alzheimer's disease. A placebo condition was compared to three drug doses (50, 100 and 200 mg). A significant general effect of the drug was found when compared to placebo and specific contrasts between placebo and each of the three drug doses only reveal a significant entropy increase for the highest dose. These effects were localized bilaterally in fronto-temporal areas and support changes in the dynamics of the cerebral structures involved in memory processes.

[Electrophysiologic study in a patient presenting with expanding cerebral lacunae]

A 42-year-old man was affected with multiple cerebral lesions suggesting expanding lacunae. He had suffered for about 15 years of headaches and blurred vision. Neurological examination showed a Parinaud syndrome and a skew deviation. Magnetic resonance imaging showed an enlargement of the third and lateral ventricles and multiple intraparenchymatous lesions with a signal similar to that of the cerebrospinal fluid. These lesions were located in the mesencephalon and right thalamic region. Important discrepancies between the topography of the lesion and the clinical data were observed. Neurological examination, ocular movements during wake and neuropsychological testing suggested sub-cortical dysfunction. These results suggest functional rather than lesional repercussion of expansive lacunae.

[Which memory clinic and for whom?]

The burgeoning of interest in Alzheimer's disease since the early 1980s has resulted in the development of memory clinics to improve the diagnosis and management of patients with the disease. Some memory clinics, however, have a broader interest in memory disorders, especially in those associated with normal ageing. Some questions should be considered with regard to the activity of memory clinics: (1) should the patients be systematically subjected to a multidisciplinary team and standardized examinations or to a single specialist in charge of adjusting examinations and management to particular situations? (2) Who should be responsible for the financial cost of memory clinics: the patients, the National Health Service or research grants? Evaluation procedures should be set up as soon as possible to answer these questions.

Utilization of the Draw a Person Test in the elderly

The purpose of this study was to assess quantitative and qualitative changes that occurred in the drawing of the human figure during depression and dementia in the elderly. A modified scale version of the Draw a Person Test (DAP) is presented. The first study (80 subjects) enabled the reduction of the number of items from 73 to 20 according to interrater reliability and diagnostic sensitivity to differentiate patients with dementia from control subjects. The second study (160 subjects: 51 with dementia, 70 with major depression, 39 elderly controls) used this 20-item DAP for cognitive assessment. The second study also featured an additional qualitative assessment (DAP 50) considering five components based upon a projective examination of the drawings. Combination of the 20-item DAP and the DAP 50 provides a complete approach to patients in accordance with the affective dimension. Results showed the ability of the 20-item DAP to discriminate dementia from depression with a better cutoff score of 7 and the usefulness of the DAP 50 in the investigation of impaired components during depression and dementia in the elderly, with the goal of specifying key aspects of psychopathology in dementia.

Affective disturbances in Alzheimer's disease

OBJECTIVE

To evaluate the emotional disturbances in patients with Alzheimer's disease (AD) using both a categorical and a dimensional approach.

DESIGN

Prospective study.

SETTING

Outpatient clinic in a neurological department from a general University Teaching Hospital.

MEASURES

A semi-structured interview was used to fill in the Hamilton Depression Rating Scale, the Retardation Rating Scale for depression, the Tyrer and Covi scales for anxiety, and the Depressive Mood Scale for emotional disturbances. The cognitive status was assessed by the Mini-Mental State Examination and the Mattis Dementia Rating Scale.

PATIENTS

One hundred eighteen consecutive AD outpatients fitting the criteria for probable or possible AD, according to the National Institute of Neurological and Communication Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association, were compared with 34 community-dwelling healthy older controls and with 20 inpatients meeting the diagnostic criteria for depression according to the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition-Revised.

RESULTS

No AD patient met the criteria for Major Depressive Episode or Generalized Anxiety Disorder, but 10 (8%) met the criteria for Dysthymic Disorder. AD patients scored significantly higher than the control group but lower than the depressed group for depressive and anxious symptomatology. Depressive symptomatology was correlated negatively to the cognitive status and positively to anxious symptomatology. Two main dimensions in emotional disturbances were described using the Depressive Mood Scale: Emotional Deficit (anhedonia, hypoexpressiveness) and Loss of Control (felt irritability, hyperexpressiveness). Emotional Deficit was correlated positively to the depressive symptomatology and correlated negatively to the cognitive status and the Loss of Control dimension. Loss of Control was correlated positively to the severity of the depressive and anxious symptomatology and weakly to cognitive performance.

CONCLUSION

Affective changes were found frequently in AD patients, but no major affective disorder was found. The dimensional approach seems to be more appropriate than the categorical approach to describe the emotional disturbances in these patients.

A special form of cerebral lacunae: expanding lacunae

The case of a 42 year old man with headache, blurred vision, and diplopia allowed the description of a particular form of cerebral lacunae-that is, expanding lacunae. Brain MRI showed hydrocephalus and multiple lesions in the thalamomesencephalic region. The radiological features of these lesions were similar to the histological brain coronal section of a case reported in 1983 in which expanding lacunae were related to a dilatation of the perivascular spaces and a focal segmental necrotising angiitis. The role of the lymphatic drainage of the brain is discussed to explain the dilatation of the perivascular spaces. The hypothesis of a hydrodynamic factor being responsible for the expanding character of the lacunae was suggested by the location of the lesions and the influence of various clinical events on the symptomatology.

[Study methods of drugs in Alzheimer disease]

The availability of new drugs for Alzheimer's disease, with different pharmacological profiles, leads to a redefinition the relevant methodology for developing drugs in this indication, including the inclusion/exclusion criteria, the duration of the studies, and therefore, the relevant guidelines. This was the purpose of the Giens Round-table devoted to the new methodology for drug development in Alzheimer disease.

Sexual behavioral changes in Alzheimer disease

The frequency and correlates of sexual behavioral changes in Alzheimer disease (AD) were assessed in two studies. In the first study, we reviewed the medical records of 135 consecutive community-living patients who fit the criteria of the National Institute of Neurological and Communicative Disorders and Stroke/Alzheimer Disease and Related Disorders Association for probable or possible AD, and we asked spouses to complete a questionnaire that included two questions about sexual activity. Indifference to sexual activity was reported by 70% of the spouses, and sexual behavioral modifications were reported by 50%. No correlation was found between sexual changes and the general characteristics of the patients, the severity of the disease, or depressive symptomatology. Sexual changes were correlated to the severity of behavioral and mood disorders, mainly to a reduction of activity and emotional deficit. Seventy-seven of the patients had a second examination after an interval of 18.9 +/- 9.9 months. The links between sexual changes and the other variables were similar to those found by the first examination. In the second study, a questionnaire was sent by mail to the spouses of 100 patients. No relationship was found between sexual changes and the severity of cognitive deficits, previous sexual agreement, age, or gender. Sexual changes were considered a factor of maladjustment for the couple by 46% of the spouses.

[Conversion hysteria]

Conversion disorder is characterized by symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological condition. The symptoms or deficits are related to psychological factors but not intentionally produced or feigned. They could be associated with true neurological disorders and their diagnosis is difficult. Neurologically they do not conform to known neurological mechanisms but instead follow the individual conceptualization of a condition and vary according to attention and emotions. Psychologically they are related to a psychic conflict or a stressful event. They could be associated to other manifestations of the hysterical neurosis or various mental conditions.

Economic analysis of Alzheimer's disease in outpatients: impact of symptom severity

To assess the economic burden of Alzheimer's disease (AD), we carried out a cross-sectional prevalence cost-of-illness study in France. Fifty-one probable AD patients (NINCDS-ADRDA) actually treated in ambulatory care were recruited in two university outpatient centers. Demographic, clinical (including actual Mini-Mental State Examination scores), and economic data were collected by clinical investigators and trained interviewers. Total costs included actual expenditures such as direct medical costs and direct nonmedical costs, as well as indirect costs (loss of earnings due to loss of productivity). Cost valuation was based on the societal perspective using an opportunity costing approach. We found that indirect costs represented a significant portion of total costs (36%-40%). In terms of expenditures, patients and caregivers were found to bear the major part of AD total costs. We found a positive and significant correlation between disease severity and costs. Our findings support the hypothesis of a relationship between disease evolution and healthcare costs.

The phenotype of "pure" autosomal dominant spastic paraplegia

We studied 23 families with "pure" autosomal dominant spastic paraplegia. Examination of 142 at-risk individuals allowed identification of 70 patients, including 12 who were clinically affected but unaware of symptoms. The frequency of lower limb muscle weakness, decreased vibration sense, hyperreflexia in the upper limbs, and sphincter disturbances increased with the disease duration. The distribution of age at onset was unimodal, with a mean onset of 29 years (range, 1 to 68). The clinical manifestations of "early-onset" (< 29 years) and "late-onset" (> 29 years) patients were not significantly different. Age at onset varied as much within families as among families; anticipation and imprinting did not occur. No clinical criteria allowed differentiation among the families studied. Only linkage studies can provide accurate classification of this disease.

[Complaints of memory loss in the elderly]

Frequency of memory complaints increases with age. Such complaints can be the presenting symptom of Alzheimer's disease. Most cases, however, are not related to Alzheimer's disease. They are included in the constructs of benign senescent forgetfulness or age-associated memory impairment. In the later, memory complaints are considered as the subjective counterpart of the age-associated decline in memory test performance. Actually, memory complaints are associated with various factors: perceptual disorders, general health, functional disability, affective disturbances, psychosocial changes... The first step in the management of memory complaints is to rule out Alzheimer's disease and affective disturbances which could require specific therapeutic measures. Most often, memory complaints are the only presenting symptom: the signification of complaints should be analysed in each individual considering all the possibly causal factors in order to elaborate the appropriate management.

Factors associated with low cognitive performance in general practice

In the preparatory phase of a randomised controlled trial data were collected to assess the magnitude of changes on cognitive functions in 1628 volunteers (age range 45-75 years) that were recruited from general practitioners' patient population. Subjects were administered a short neuropsychological battery of tests including three paper-and-pencil tests, which assessed immediate recall, delayed memory, and attention. Being on antihypertensive medication was associated with low results for all three tests in every age group, and in all strata according to blood pressure levels. Psychotropic drug use was correlated with low results for all three tests. Differences between psychotropic drug users and nonusers increased with age. Antihypertensive treatment and psychotropic drug use seem to be important to consider in longitudinal studies of cognitive decline in aging.

Age and cerebral infarction: a postmortem study of 77 cases of cerebral infarcts in the middle cerebral artery territory

Adverse effect of age on ischemic stroke short-term mortality was reported in some studies and attributed either to more frequent extracerebral causes of death or to an increased severity of ischemia in the aged brain. Relationship between age, size of infarcts, and causes of death were studied in 77 consecutive patients who died from infarction in the middle cerebral artery territory. Area of infarcts was assessed by planimetry, and results were expressed as an index of infarcted area. No significant relationship was found between age and the size of infarcts, the cause of death, or the interval from stroke to death. These results do not support the hypothesis of an increased severity of ischemia in the aged brain.

Infarcts in the middle cerebral artery territory. Pathological study of the mechanisms of death

Correlates of the size of infarcts, the time from stroke to death, and the mechanisms of death were studied in 77 consecutive patients who died from infarction in the middle cerebral artery territory. The area of infarcts was assessed by planimetry on schemas of representative brain levels and the results were expressed as a ratio of infarcted area on the whole MCA territory. No clear relationship was found between the size of infarcts in the MCA territory, and any of the characteristics of the patients, but extensive infarcts were more frequent when the internal carotid artery was occluded. No evidence was found of an adverse effect of age, diabetes or initial hyperglycemia on the size of infarcts. The mechanisms of death were not linked to sex, age, high blood pressure, diabetes, blood glucose level at admission, presence and location of an arterial occlusion, or etiology of the infarct. On the contrary, they varied as a function of interval from stroke to death. Transtentorial herniation, the main cerebral cause of death, occurred mainly in the first week and was related to the large size of infarcts. Rare recurrences of stroke and frequent extracerebral mechanisms of death (mainly pneumonia, pulmonary embolism and cardiopathy) occurred later on.

[Dementia. Diagnostic problems]

NINCDS-ADRDA criteria are currently used to include patients into therapeutic trials in Alzheimer's disease (AD). However, specificity of these criteria is not very high (from 64 to 87% of diagnosis accuracy). The main causes of errors are the other degenerative dementias such as Frontal Lobe Dementias and Diffuse Lewy Body Disease. On the other hand, clinical heterogeneity of the patients fitting the criteria is large. To increase the power of therapeutic trials it is suggested: 1) to use specific criteria to rule out the other degenerative dementias when the efficacy of the tested drug is presumed to be specific for AD (cholinomimetics, inhibitors of beta-amyloid deposits...); 2) a better definition and assessment of the target symptoms when symptomatic improvement is the goal of the trial.

[Topographical analysis of endogenous evoked potentials in depressed old people and in patients with Alzheimer's type dementia]

Latencies, amplitudes and localization of the maximum of the peaks of late onset evoked responses have been studied in 3 groups of elderly people: normal, depressed and demented (probable dementia of Alzheimer type DAT) at the early stage of the disease. Evoked responses with an auditory oddball paradigm have been recorded with 16 electrodes in 2 situations: counting the target sounds, and motor response with measurement of the reaction time. No difference in amplitude was observed between the 3 groups. Only a significant difference for P3 latency was observed between the DAT and the depressed groups and only in the counting situation. The maximum P3 response was most often found on the anterior areas in the DAT group and in the posterior areas in the normal and depressed groups. The topographic localization of the P3 peak could therefore be of some help in the characterize of subjects with probable DAT at the early stage of the disease.

[Comparison of SPECT and quantified EEG features in Alzheimer's type dementia]

Forty-one patients with probable dementia of the Alzheimer type (DAT) have been studied by computerized EEg (C-EEG) and single photon emission tomography (SPECT) using 123-IMP. Four groups have been distinguished according to SPECT hypoperfusion topography: frontal, temporo-parietal, fronto-parietal and fronto-temporo-parietal. C-EEG parameters were much more disturbed in the 2 latter than in the 2 former groups. Thus a normal C-EEG could indicate a dominant frontal or temporo-parietal form of DAT. Therefore some bias due to duration or rate of disease progression cannot be excluded. So far the important finding is that EEG changes are diffuse and do not reflect the topography of SPECT hypoperfusion questioning the value of EEG topographical analysis in DTA.

[EEG value for the prediction of the evolution of Alzheimer's type dementia]

Twenty patients selected as probable dementia of the Alzheimer type (DAT) have been examined two times during a mean follow-up period of 14.5 months. Two groups have been distinguished at the end of this period: a cognitively impaired one and a stable one. EEG features at T1, at T2 or the difference T1-T2 does not allow an accurate and predictive discrimination between the two groups. But we cannot conclude that EEG is useless for prediction of the rate of progression of the disease in DAT because most of the cognitively stable patients are also stable for mean frequency. So mean frequency could be an interesting marker of evolutivity but this to be tested with more patients including more subjects reaching the severe stage of dementia.

[Quantified EEG in the diagnosis of Alzheimer's type dementia]

79 subjects (mean age 70.2 ans, 31 males, 48 females) selected as probable dementia of the Alzheimer type, at the early stage of the disease and 17 normal aged people (mean age: 72.2, 5 males, 12 females) were recorded with a 16 channel computerized-EEG (C-EEG) with topographical analysis of the observed changes and with classical visual analysis of the EEG. Quite simple C-EEG parameters as mean dominant frequency (MF) and alpha to theta ratio are able to discriminate patients from normal with a greater accuracy than visual analysis. The values of 8.6 for the MF and 1.3 for the alpha/theta ratio are proposed as cut off values between normal and DAT patients. The topographical analysis appear to be of no additional usefulness in the discrimination of the two groups.

[Intellect and mood disorders in multiple sclerosis]

Recent studies showed that mild or moderate cognitive deficits and affective disturbances are frequent in patients with multiple sclerosis and can be found early in the course of the disease. Cognitive deficits are related to brain lesions but not clearly to functional disability. Affective disturbances are partly determined by the presence of brain involvement, but also by an emotional reaction to the disorder. Psychological disorders must be taken in account for a better management of the patients and their family.

[Memory, aging and Alzheimer's disease]

Memory disorders in elderly can be related to various conditions. The concept of "Age-Associated Memory Impairement" is grounded on a age-related memory deficit in memory testing associated with a memory complaint which is considered as the subjective manifestation of the memory deficit. Actually, memory deficit in objective testing and memory complaints do not appear correlated. Impairment in memory performance is mostly related to neurobiologic brain changes associated with aging or Alzheimer's disease. Conversely, memory complaints are more related to psychosocial factors. However, clinical data and qualitative analysis of the memory disturbances are requested to understand the precise significance of memory deficits in objective testing.

[Early diagnosis of Alzheimer's disease]

An early diagnosis of Alzheimer's disease is nowadays required for a better assistance of the patient and his family, and also to carry out therapeutic trials at that stage. This early diagnosis rests on a systematic study of disorders of memory and behaviour in an elderly subject, on the demonstration of a deficient cognition and on the use of accurate diagnostic criteria.

[Klüver-Bucy syndrome in man: study of behavioral eating disorders]

Patients with Klüver-Bucy syndrome have severe behavioral disturbances of food intake associated with complex neuropsychological features. The complex mechanisms of these troubles are discussed on the basis of pathological and psychological data, and the supposed models of regulation of food intake.

'Expanding cerebral lacunae' in a hypertensive patient with normal pressure hydrocephalus

A hypertensive patient who had been treated successfully for normal pressure hydrocephalus (NPH), died from a left thalamic haemorrhage. Neuropathological examination showed recent and old thalamic haematomas and numerous parenchymal cavities or 'cerebral lacunae'. Two lacunae bulged into the lateral ventricles, and had all the characteristics of so called 'expanding lacunae'. They were surrounded by a single layer of epithelial-like cells, contained a normal, patent, arteriole, and presented as space occupying lesions. Only two similar cases have been reported previously. The complexity of the neuropathological features of 'cerebral lacunae' is emphasized and the relationships between cerebral hypertensive disease, NPH, and expanding lacunae are discussed.