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A 37-year-old man sought medical advice because of an 8-year history of a slowly progressive dementing illness with no clinically apparent discrete strokelike episodes. Cognitive functioning was markedly, globally impaired without lateralizing or localizing features. Widespread livedo reticularis led to a diagnosis of Sneddon's syndrome. Antiphospholipid antibodies and lupus anticoagulant were negative. Magnetic resonance imaging showed widespread cerebral atrophy, cortical and subcortical cerebral infarcts, and extensive periventricular white matter abnormalities. Cerebral angiography revealed diffuse medium- and small-vessel occlusive disease, with numerous collaterals in the mid and distal circulation but no evidence of atherosclerosis or vasculitis. No other cause of a dementing illness was found. We postulate that our patient's dementia was due to the cumulative effects of multiple cerebral infarcts.

Objective: To compare the frequency of use of nonsteroidal anti-inflammatory drugs (NSAIDs) among 302 incident cases of Alzheimer's disease (AD) and age- and sex-matched control subjects., Design: We undertook a retrospective case-control study, using the resources of the Rochester Epidemiology Project., Material and Methods: In ongoing studies of dementia in Rochester, Minnesota, we identified all incident cases of AD with onset between 1980 and 1984. From among all Rochester residents who received care at Mayo Clinic Rochester during those years, we selected one age- (within 3 years) and sex-matched control subject. For this study, exposure to a prescription NSAID was defined as prescribed use for 7 or more days during the 2-year window of time encompassing the year of onset and the year before onset among cases and the corresponding index year and the year prior for control subjects., Results: The odds ratio (OR) for exposure, as described, to a prescription NSAID versus no exposure to any NSAID was 0.79 (95% confidence interval [CI], 0.45 to 1.38); the OR was 1.00 (95% CI, 0.52 to 1.92) for women and 0.40 (95% CI, 0.13 to 1.29) for men. Similarly, the overall OR for aspirin exposure versus no NSAID exposure was 0.90 (95% CI, 0.54 to 1.50)., Conclusion: These data are suggestive but not confirmatory of a protective effect of NSAIDs for AD.

Objective: To examine the psychometric properties, acceptance, and screening efficacy of the Mini-Mental State Examination (MMSE) in an internal medicine practice., Material and Methods: The MMSE was administered more than 4,000 times by 27 internists to 3,513 elderly patients (2,299 women and 1,214 men, 60 to 102 years old) who underwent general medical examinations. The efficacy of the MMSE for screening was measured in a subsample of age- and sex-matched patients with dementia (N = 185) and control subjects (N = 227). MMSE scores were correlated with age and education in the community sample. The attitudes of physicians about the MMSE were assessed with a 12-question survey. Sensitivity, specificity, and predictive values were calculated., Results: Performance on the MMSE among persons older than 59 years was influenced by age and education but not by sex. During an interval of 1 to 4 years, a change of 4 or more points in the total MMSE score is needed to indicate substantial cognitive deterioration. Participating physicians considered the MMSE of little value for routine screening in unselected populations but wanted it available for use as a clinical test. The traditional MMSE cutoff score of 23 or less had a sensitivity of 69% and a specificity of 99%. Use of age- and education-specific cutoff scores improved the sensitivity to 82% with no loss of specificity. With use of typical base rates for dementia in a general medical practice, the positive predictive value was less than 35%., Conclusion: The clinical utility of the MMSE and acceptance by physicians may be improved through awareness of the influences of age and education on the MMSE and by its application in settings with a high base rate of dementia. The MMSE is ineffective when used to screen unselected populations; it should be used for persons at risk of cognitive compromise.

Objective: To present the results of several retrospective epidemiologic studies of dementia in Rochester, Minnesota., Material and Methods: These studies were done by using the medical records-linkage resources of the Rochester Epidemiology Project., Results: The incidence and prevalence of dementia increase sharply with advancing age. No difference is noted in overall age-adjusted incidence rates by gender. Rochester studies provide the only 25-year time trend analyses of the incidence of dementia in the United States. Time trends over three prevalence dates indicate an increase in prevalence in this community. Survival is decreased among patients with dementing illness. Case-control studies of Alzheimer's disease (AD) show that general medical conditions, previous head injury, thyroid disease, exposure to therapeutic radiation, anesthesia, and blood transfusion are generally not risk factors for AD. Patients with depression may have an increased risk for the development of AD. Sociodemographic factors such as education, occupation, marital status, and type of dwelling were not significantly different among patients with AD and their age-and gender-matched control subjects., Conclusion: The Rochester Epidemiology Project has proved to be an excellent resource for the study of the incidence, prevalence, and risk factors for dementia.

At least half of the patients who present with progressive decline in their memory, cognitive, and intellectual abilities will eventually be diagnosed as having Alzheimer's disease. The diagnosis is reached by clinical and ancillary evaluation and exclusion of all other causes of dementia. Recently, considerable advances have been made in our understanding of the neurobiologic features of Alzheimer's disease. Cortical neurons contain paired helical filaments with a very specific electron microscopic appearance. These filaments contain proteins with unusual properties. A severe decline in cholinergic activity in the cortex is related to a marked loss of cholinergic neurons in deep cerebral structures, such as the nucleus basalis of Meynert in the substantia innominata. No specific treatment is available for Alzheimer's disease. Patients and the relatives who take care of them require substantial help and assistance in coping with the disease.

A short test of mental status (encompassing about 5 minutes) was administered to 93 consecutive neurologic outpatients without dementia, 67 outpatients with Alzheimer-type dementia, and 20 outpatients with dementia of miscellaneous causes. The mean scores for patients with Alzheimer-type dementia were lower than those for the nondemented patients in the total scoring and on all subtests (P less than 0.001). When a total score of 29 or less (maximal attainable score, 38) was used as a screen for dementia, a sensitivity of 92% and a specificity of 91% were reached. For patients older than 60 years of age, a score of 29 or less resulted in a sensitivity of 95% and a specificity of 88%. Thus, in general, this easily administered test distinguishes demented from nondemented patients, but it should not be used as the sole means of diagnosing dementia.

Maintenance of high autopsy rates is associated with specific benefits, especially for clinical practice and for clinical and epidemiologic research. We have compiled and evaluated (on the basis of related costs and benefits) a comprehensive list of recommendations to resurrect the autopsy and reestablish it as a central contributor to medical practice, teaching, and research.

Osteogenic sarcoma frequently disseminates by hematogenous routes. A 32-year-old patient underwent evaluation for an acute cerebral infarction. Cardiac auscultation disclosed an abnormal diastolic sound. Echocardiographic examination revealed a large left atrial mass, which was found at thoracotomy to be metastatic osteogenic sarcoma. Cerebral computed tomographic scans at the time of initial examination and 3 months later demonstrated new cerebral lesions consistent with metastatic growths. The abrupt cerebral infarction, other clinical findings, and results of diagnostic studies strongly suggested that the acute cerebrovascular event was the result of metastatic cerebral embolization from the tumor material found in the thorax. Cerebral infarction is an unusual and catastrophic complication of thoracic metastatic lesions of osteogenic sarcoma.

In multiple sclerosis, behavioral changes, including alterations in cognitive functions and psychiatric abnormalities, have been recognized with increasing frequency in recent years. Multiple sclerosis formerly was thought to be primarily a disorder of the brain stem and spinal cord; however, functional changes that can be attributed, at least in part, to cerebral dysfunction are being recognized. Certain cognitive functions such as memory and conceptual processes seem to be preferentially impaired. The degrees of impairment of other functions such as attention and visuospatial skills are now being evaluated. Psychiatrically, affective disorders seem to be the most common diagnoses, and debate exists about whether these abnormalities are a function of the demyelinating process itself or are a reaction to the disability produced by the disorder.

In this study, we examined in detail the patterns of autopsy rates for a half century (1935 through 1985) among residents of Olmsted County, Minnesota. The time trend of the autopsy in this community represents, in many respects, a microcosm of national trends. In the process of this analysis, we identified several medical and socioeconomic variables that may influence the rate of autopsy, including the age at death, physical location of death, gender, surgical procedures preceding death, immediate cause of death, and direct and indirect costs of the autopsy. In particular, the advancing mean age at death and the increase of the nursing home as a social phenomenon seem to have had a profound effect on autopsy rates both in Olmsted County and throughout the United States.