Cognitive Correlates of Impaired Testamentary Capacity in Alzheimer's Dementia

BACKGROUND

Testamentary capacity (TC) is a legal construct about the ability to make or change a will. Although studies of financial and medical capacities have noted a strong association between capacity and cognition, no study has examined the cognitive correlates of TC in Alzheimer's disease (ad).

METHODS

Study participants were 22 cognitively healthy controls and 20 persons with mild to moderate ad who were administered a neuropsychological battery and the Testamentary Capacity Instrument (TCI), a new performance-based measure of TC. Both TCI Element and TCI Total scores were calculated. TCI Total scores were calculated for the purposes of expanding correlational analyses (i.e., Pearson's product-moment) and are not intended for forensic TC evaluations. Final predictors were identified using linear and logistic regression modeling.

RESULTS

All ad participants but one obtained TCI Totals that fell >2.5 standard deviations below the control group mean. Initial cognitive correlates of TCI performance were measures of general cognition, language, verbal memory, executive function, and processing speed. The four cognitive variables showing the highest t values and correlating with TCI Total score > 0.7 were entered into logistic and linear regression models. Final predictor models consisted of measures of verbal memory, executive function, and semantic knowledge and demonstrated shared variance of 0.71 (linear) and 0.82 (logistic).

CONCLUSIONS

A diagnosis of ad dementia is associated with clinical impairment in TC and associated cognitive abilities and indicates that a legal assessment of TC is warranted. Second, the results offer insight into the cognitive basis of TC in persons with Alzheimer's dementia.

Assessment of Testamentary Capacity in Older Adults: Description and Initial Validation of a Standardized Interview Instrument

OBJECTIVE

Testamentary capacity (TC) is a legal construct, which concerns a person's mental capacity to make or amend a will. Although expert clinicians are frequently asked to assess TC in forensic settings, there are few instruments and little empirical research to inform and guide their assessments. The present study describes the development and psychometric properties of a standardized assessment measure of TC (Testamentary Capacity Instrument-TCI), and investigates its reliability and validity.

METHODS

The TCI is an interview-based, psychometric measure, which assesses a testator's knowledge of four conceptual elements, which together comprise the legal basis for TC in the Anglo-American legal system: (1) what a will is, (2) nature and extent of assets/property, (3) possible heirs/claimants to property, and (4) plan to distribute assets to heirs after death. Cronbach's alpha and percentage exact agreement were used to examine TCI element reliabilities. Using independent samples t-tests, MANOVA and MANCOVA, we investigated validity by comparing TCI element performance of cognitively intact older adults (n = 22) and older adults with ad dementia (n = 20).

RESULTS

The TCI elements showed good internal consistency and good inter-rater reliability. The ad group performed significantly below the control group on all four TCI elements, with effect sizes exceeding 1.2, suggesting that the TCI has content and construct validity.

CONCLUSIONS

Relative to cognitively intact older adults, older adults with ad dementia showed significant impairment on all four TCI conceptual elements. The TCI has promise as a standardized quantitative measure of TC to support clinical assessment of TC in forensic settings.

Abnormal von Willebrand factor secretion, factor VIII stabilization and thrombus dynamics in type 2N von Willebrand disease mice

Essentials Type 2N von Willebrand disease involves impaired von Willebrand factor to factor VIII binding. Type 2N von Willebrand disease mutations exhibit qualitative and mild quantitative deficiencies. Type 2N von Willebrand disease mice exhibit unstable venous hemostatic thrombi. The factor VIII-binding ability of von Willebrand factor regulates arteriole thrombosis dynamics.

SUMMARY

Background von Willebrand factor (VWF) and factor VIII (FVIII) circulate as a non-covalent complex, with VWF serving as the carrier for FVIII. VWF indirectly influences secondary hemostasis by stabilizing FVIII and transporting it to the site of primary hemostasis. Type 2N von Willebrand disease involves impaired binding of VWF to FVIII, resulting in decreased plasma levels of FVIII. Objectives In these studies, we characterize the impact of three type 2N VWD variants (R763A, R854Q, R816W) on VWF secretion, FVIII stabilization and thrombus formation in a murine model. Methods Type 2N VWD mice were generated by hydrodynamic injections of mutant murine VWF cDNAs and the influence of these variants on VWF secretion and FVIII binding was evaluated. In vivo hemostasis and the dynamics of thrombus formation and embolization were assessed using a murine tail vein transection hemostasis model and an intravital thrombosis model in the cremaster arterioles. Results Type 2N VWD variants were associated with decreased VWF secretion using cell and animal-based models. FVIII-binding to type 2N variants was impaired in vitro and was variably stabilized in vivo by expressed or infused 2N variant VWF protein. Both transgenic type 2N VWD and FVIII knockout (KO) mice demonstrated impaired thrombus formation associated with decreased thrombus stability. Conclusions The type 2N VWD phenotype can be recapitulated in a murine model and is associated with both quantitative and qualitative VWF deficiencies and impaired thrombus formation. Patients with type 2N VWD may have normal primary hemostasis formation but decreased thrombus stability related to ineffective secondary hemostasis.

Effect of dietary folic acid supplementation on egg folate content and the performance and folate status of two strains of laying hens

Enrichment of eggs with folate is possible when dietary folic acid levels are increased. However, development of optimal strategies for the production of folate-enriched eggs requires knowledge as to differences due to strain of bird and a greater understanding of the factors limiting egg folate deposition. To this end, a study was designed to determine the response of two leghorn strains that differ in production performance. Hyline W36 and W98 hens (n = 6 per diet) received a barley-based ration containing 0, 2, 4, 8, 16, 32, 64, or 128 mg/kg of crystalline folic acid for 21 d. Response criteria included production parameters, measures of blood folate status, and egg folate content. Significant (P < 0.05) main effects of folate supplementation were observed for egg folate content and plasma folate, which increased, and homocysteine concentrations, which decreased with supplementation; performance, however, was not affected. The Hyline W98 strain had significantly (P < 0.05) higher total egg and yolk weights and feed consumption when compared with the W36. Significant (P < 0.05) ration x strain interactions were observed for egg and yolk weight, egg folate content, and plasma homocysteine. The higher egg mass producing strain, Hyline W98, benefited from increased folic acid through a reduction in plasma homocysteine concentrations, suggesting that this strain has a higher requirement for folate than the W36 strain. Overall, egg folate content is maximized when crystalline folic acid is supplemented to the diet at 2 mg/kg or higher. Higher levels of egg folate are not achieved due to the saturation of the precursor pool for egg folate deposition.

Banteng (Bos javanicus) embryos and pregnancies produced by interspecies nuclear transfer

The banteng (Bos javanicus), a member of the bovidae family, is currently listed as threatened by the IUCN Red List and it is estimated the total world population is <10,000 animals. In exotic or endangered species, the lack of oocytes and recipients precludes the use of traditional somatic cell nuclear transfer (NT), and an approach such as interspecies NT may be the only alternative to produce embryos and offspring. A total of 348 enucleated domestic bovine oocytes were reconstructed with either male (Treatment A) or female (Treatment B) adult banteng fibroblasts and a total of 103 bovine oocytes were parthenogenically activated as a control (Treatment C). There was no significant difference in fusion rate (68 versus 77%) between Treatments A and B. Of fused couplets, those in Treatment A had greater (P < 0.05) cleavage (67 versus 51%) and blastocyst (28 versus 15%) rate than Treatment B. Of a total of 24 blastocysts transferred into 12 domestic cattle recipients from Treatment A, two pregnancies (17%) were established with heart beats detectable at 30 day by rectal ultrasonography. No pregnancies resulted from the transfer of 14 blastocysts from Treatment B. Both pregnancies were subsequently lost, one between 30 and 60 days and the second between 60 and 90 days of gestation. The bovine cytoplast supported mitotic cleavage of banteng karyoplasts, and was capable of reprogramming the nucleus to achieve blastocyst stage embryos and pregnancies in exotic bovids.

134 EVALUATION OF APOPTOSIS IN BOVINE EMBRYOS BY FLUORESCENT LABELING OF CASPASES-3 AND -7

Reports indicate that apoptosis is more prevalent in in vitro-produced (IVP) embryos than in in vivo-derived (IVD) embryos. These studies most often utilize the TUNEL procedure to label fragmented DNA. DNA fragmentation, however, is not unique to apoptosis as cells undergoing necrosis also exhibit substantial DNA fragmentation. Also, improper tissue handling has been reported to induce enough DNA fragmentation for TUNEL-positive staining of nuclei. Thus, the objective of this study was to evaluate the presence of caspases-3 and -7 as indicators of apoptosis in bovine fresh IVD embryos (F-IVD; n = 32), frozen-thawed IVD embryos (FT-IVD; n = 32) and IVP embryos cultured in CR1aa (n = 64). Embryos (quality grades, QG = 1 to 4) were evaluated for apoptotic cells by using a fluorescence-based assay for the detection of active caspaces (Caspatag®, Caspase 3,7 In Situ Assay Kit, Chemicon International, Inc., Temecula, CA, USA). To validate this assay, positive controls (PC) were prepared by incubating IVP-embryos in cyclohexamide for 3 to 4 h prior to staining. After staining, embryos were placed on slides and the number of apoptotic cells/embryo were counted. Embryos in which individual fluorescent points were not apparent were categorized as having profuse staining patterns (PSP) and were assigned an arbitrary apoptotic cell value of 20. Data were analyzed using PROC GLM of SAS with a post hoc LSD test. More than 65% of all embryos displayed at least 1 fluorescent cell, regardless of treatment. PC embryos consistently exhibited PSP. Overall, culture conditions did not markedly affect the incidence of apoptosis. FT-IVD embryos had significantly more (P < 0.05) apoptotic cells (8.2 ± 2.9) than F-IVD (0.9 ± 0.3). However, when embryos exhibiting PSP were excluded, the statistical difference was no longer present (1.5 ± 0.9 vs. 0.9 ± 0.3, respectively). It is unclear why some embryos exhibit specific staining patterns while others exhibit PSP, but we hypothesize that PSP embryos are likely degenerate. Interestingly, different degrees of fluorescence were often present within an embryo. Often, small pinpoint areas of fluorescence were detected while other times the fluorescence appeared to consume the entire cytoplasm of the cell. The capase protein has been localized in the cytoplasm of the cell, so the different degrees of fluorescence may represent different degrees of apoptosis. There was no major effect of culture environment on apoptosis when embryos were categorized by QG. Furthermore, within a treatment, there was no significant difference in apoptosis across embryo QG. To our knowledge, this is the first report of apoptosis evaluated in relation to embryo QG. Based on these findings, apoptosis does not appear to be heavily involved in the reduced developmental potential of IVP bovine embryos. The authors would like to sincerely thank Dr. Neil Schrick for his generous donation of frozen in vivo-derived bovine embryos.

Prevalence and severity of Doppler-detected valvular regurgitation and estimation of right-sided cardiac pressures in patients with normal two-dimensional echocardiograms

To assess the prevalence and severity of Doppler-detected valvular regurgitation, as assessed by multiple Doppler modalities, in patients with structurally normal hearts, we analyzed Doppler echocardiograms in a consecutive sample of 206 referred patients who were found to have completely normal M-mode and two-dimensional echocardiograms. Valvular regurgitation was detected by Doppler in 94 percent, and 56 percent had regurgitation in at least two valves (mitral, tricuspid, and/or aortic). Mitral, tricuspid, and aortic regurgitation was detected in 73 percent, 68 percent, and 12 percent, respectively, with moderate regurgitation occurring in 6 percent, 5 percent, and 2 percent, respectively. The presence of mitral and tricuspid regurgitation was not related to age, although the prevalence of moderate regurgitation was three times more prevalent (p < 0.05) in those > 50 years old compared with those < or = 50 years. Aortic regurgitation was two to three times more prevalent (p < 0.01) in patients > 50 years compared with younger subjects, and moderate aortic regurgitation was three times more prevalent in older patients. Of those with measurable right-sided cardiac pressures, estimated right atrial pressure was < 10 mm Hg in 93 percent of patients, and estimated pulmonary artery systolic pressure was < or = 30 mm Hg in 57 percent of patients. Estimated right atrial pressure was > 10 mm Hg in only 7 percent, and only 13 percent had estimated pulmonary artery systolic pressure > or = 40 mm Hg. These data indicate a very high prevalence of trivial and mild mitral and tricuspid regurgitation in patients with otherwise "normal" hearts, suggesting that these findings are physiologically normal. These data should be considered when addressing management in patients with Doppler-detected valvular regurgitation in order to prevent "iatrogenic heart disease."