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A battery of standard neuropsychological tests examining various features of executive function, attention, and visual perception was administered to 27 subjects with questionable to mild dementia and compared to a 4-point caregiver rating scale of driving ability. Based on the results of this study, a computerized maze task, employing 10 mazes, was administered to a second sample of 40 normal elders and questionable to moderately demented drivers. Comparison was made to the same caregiver rating scale as well as to crash frequency. In the first study of neuropsychological tests, errors on Porteus Mazes emerged as the only significant predictor of driving ability in a stepwise regression analysis. In the follow-up study employing the computerized mazes, all 10 mazes were significantly related to driving ability ratings. Computerized tests of maze performance offer promise as a screening tool to identify potential driving impairment among cognitively impaired elderly and demented drivers. ( J Geriatr Psychiatry Neurol 2003; 16:151-155).

The authors surveyed 100 outpatients with dementia during the 2 months following the November 2000 US presidential election. A majority (60%) of respondents voted. Increasing severity of dementia was associated with reduced knowledge about the election as well as reduced voting participation by patients and caregivers. Actively voting persons had general knowledge about the election as evidenced by matching candidate photographs with name and party labels.

The authors assessed and contrasted frontally mediated behavior changes in patients diagnosed with Mild Cognitive Impairment (MCI) and Alzheimer disease (AD). Apathy, executive dysfunction, and disinhibition are common in AD, but these behaviors have not been studied in MCI.Participants were patients diagnosed with AD (n=25) or MCI (n=20). Current behavior and behavior before the onset of cognitive impairment was rated by knowledgeable informants on the Frontal Systems Behavior Scale (FrSBe).Apathy and executive dysfunction exhibited the greatest increase in both MCI and AD, and both increased significantly over baseline scores. No significant differences in behavior change were found between the two groups. Behavior change was moderately correlated with a measure of dementia severity, indicating that greater disease severity was associated with more abnormal behavior.Changes in frontally-mediated behaviors are common in very early and mild stages of cognitive impairment, even before functional decline in daily living is evident. These behaviors deserve more study in MCI because they may have implications for prognosis, treatment adherence, family distress, and patient quality of life.

Background. Clinical and epidemiological research has been done regarding the potential therapeutic benefit of estrogen in outpatients with and without dementia; however, the effects of estrogen therapy on cognition in elderly nursing home patients have not been previously examined. Methods. This retrospective cohort study compared 191 women estrogen users with 663 women nonestrogen users, matched according to age, nursing home facility, year of assessment, and baseline level of cognitive function. The outcome was decline in cognition, measured by the Cognitive Performance Scale, over a minimum follow-up period of 6 months. Results. No significant difference was found in the rate of cognitive decline among estrogen users and nonusers. Conclusions. Estrogen therapy administered to nursing home residents is not associated with a reduction in cognitive decline. This study lends further support to recent controlled clinical trials that found no benefit for estrogen treatment on cognition in outpatients with dementia.

To compare the cognitive and behavioral profiles of Alzheimer's disease (AD) and cognitively impaired patients with Parkinson's disease (PD) and to determine the individual measures that best discriminate the two patient groups.Neuropsychologic studies of patients with AD and PD have generated debate over the distinction between "cortical" and "subcortical" dementias, with some studies showing significant differences and others showing little difference in the cognitive profiles of these groups. Studies evaluating behavioral differences between the patient groups have been somewhat more successful in adequately discriminating these syndromes. To address this issue, we examined cognitive and behavioral profiles of patients with AD and cognitively impaired patients with PD on two frequently used assessment instruments.Patients were diagnosed according to published and accepted criteria for AD and PD. Eighteen patients with AD and 18 patients with PD, matched on age and education, were administered the Mattis Dementia Rating Scale and Frontal Systems Behavior Scale (formally Frontal Lobe Personality Scale).The two groups did not differ on overall Dementia Rating Scale score or total Frontal Systems Behavior Scale score. However, examination of subscale scores revealed that the patients with AD performed significantly worse than the patients with PD on the Memory subscale of the Dementia Rating Scale, and patients with PD were rated as being more apathetic than the patients with AD on the Frontal Systems Behavior Scale. When these two variables were entered into a discriminant function analysis, an overall classification accuracy of 86% was demonstrated, with 89% of the AD group and 83% of the PD group correctly classified.These findings suggest that even though global cognitive dysfunction and behavioral disturbance may appear similar in patients with AD and cognitively impaired patients with PD, specific measures of these functions that are sensitive to the underlying neuropathology of each disease do differ significantly.

Quality of life (QOL) in patients diagnosed with dementia is of critical importance. Reliable and valid measurement of patient QOL is essential to evaluate the effectiveness of treatment interventions and to gain a better understanding of the detrimental impact of dementia on patients' lives. In this study, the psychometric properties of a new scale developed to measure QOL, the Cornell-Brown Scale for Quality of Life, were examined. Data were collected from 50 dementia clinic outpatients with a range of cognitive impairment. Scale ratings were based on a brief, joint interview with caregivers and patients. Findings indicated that the scale demonstrated adequate interrater reliability (intraclass r = 0.90) and internal consistency reliability (Cronbach alpha = 0.81). Criterion validity was indicated by a positive correlation between QOL scores and visual analogue positive mood ratings (Spearman rho = 0.63) and a negative correlation between QOL and dementia severity as measured by Clinical Dementia Ratings (Spearman rho = -0.35). Reliability and validity were not adversely affected by patient cognitive impairment. Thus, preliminary data indicate that the Cornell-Brown Scale for Quality of Life is a brief, easily administered, reliable, and valid measure of QOL.

OBJECTIVES: To investigate the extent to which treatment with tacrine is associated with a reduction in mortality in nursing home residents with dementia. DESIGN: We performed a retrospective cohort study using the Systematic Assessment and Geriatric drug use via Epidemiology database, which contains data collected with the Minimum Data Set On a cross-section of over 400,000 nursing home residents in five U.S. states. SETTING: Retrospective data analysis of residents in nursing homes. PARTICIPANTS: We identified 1,449 users of tacrine and 6,119 nonusers matched on facility, date of tacrine use, level of cognitive function, and dementia diagnosis. MEASUREMENTS: Comparisons of the two groups were made for sociodemographic variables, dementia severity, number of medications, and major comorbid illness (heart disease, cancer, diabetes mellitus, chronic obstructive pulmonary disease, malnutrition), and survival over the 3-year study period. RESULTS: Based on Cox proportional hazards models, tacrine users showed a significantly lower mortality rate than nonusers. The hazard rate ratio was 0.76 (95% CI = 0.70-0.83). After adjusting for the confounding variables of sociodemographic factors, level of function in activities of daily living, cognitive function, number of drugs, and comorbid illnesses, this survival advantage was still significant at 0.85 (95% CI = 0.77-0.93). CONCLUSION: Treatment of nursing home residents with tacrine is associated with lower mortality, This observation has implications for the socioeconomic impact of cholinesterase inhibitor therapy in those with advanced dementia and for quality of life issues in the nursing home that deserve future investigation.

In the present study, we examined the relationships between ratings on the Global Deterioration Scale (GDS) and activities of daily living and cognitive function in 39 individuals with vascular dementia (VaD). The results of the study revealed significant correlations between GDS rating and performance on cognitive tests, including memory and overall cognitive ability. In addition, the GDS was significantly related to ratings of instrumental activities of daily living. Comparisons between patients with VaD with GDS scores between 4 and 6 (n = 21) and patients with scores between 2 and 3 (n = 18) revealed greater cognitive and functional deficits in the group with higher GDS scores. Further, the GDS score accurately classified 87% of the patients with VaD. These findings provide support for the validity of the GDS in general staging of dementia severity of VaD. ( J Geriatr Psychiatry Neurol 2002; 15:50-54).

BACKGROUND The relationship between subcortical hyperintensity (SH) on magnetic resonance imaging (MRI), cortical perfusion on single photon emission computed tomography (SPECT), and cognitive function is not well understood. The authors examined these relationships in individuals with vascular dementia (VaD), paying particular attention to frontal lobe function to determine whether the presence of SH on MRI was associated with frontal hypoperfusion on SPECT, which in turn would be associated with impairments of executive-attention function. METHODS Patients with vascular dementia (n = 26) were assessed on neurocognitive tests and brain MRI and SPECT. SH volume was quantified from the axial T2-weighted fluid attenuated inversion recovery MRI. Total counts of activation across voxels for 12 cortical regions of interest were determined from SPECT. Perfusion ratios of both total cortical and frontal activation relative to cerebellum activation were derived, and regression analyses were performed to determine the relationships between cognitive, MRI, and SPECT indices. RESULTS SH volume on MRI was significantly associated with frontal lobe perfusion, but not with global cortical perfusion as measured by SPECT. Frontal lobe perfusion did not consistently correlate with performance on measures of executive-attention function, although both total and frontal perfusion ratios were significantly associated with other cognitive functions. CONCLUSIONS These results suggest that a functional "disconnection" between the frontal lobes and subcortical structures does not fully account for the magnitude of global cognitive impairment in VaD. Cortical perfusion as measured by SPECT appears to be associated with cognitive performance, but not specifically executive-attention dysfunction. Additional studies are needed to further examine the relationship between subcortical and cortical function in VaD.

In the present study we examined cognitive function, radiographic features, and functional ability in individuals with vascular dementia (VaD). Subjects were subdivided into individuals with only white matter involvement (WM) and individuals with evidence of a cortical infarction in addition to white matter ischemic change (C+WM). Results revealed that both groups of subjects were impaired across cognitive functions. Cognitive performance was more severely impaired among the C+WM group, but the general pattern of deficits did not differ between the two groups. Hachinski scores were significantly higher and instrumental activities of daily living were more severely affected in the C+WM group compared to the WM group. No significant differences were evident between the two groups on overall dementia severity or the extent of white matter involvement. These findings indicate that cognitive function in VaD may be globally impaired, and that cortical infarction in addition to white matter ischemia results in greater impairment, but the differences are largely quantitative rather than qualitative.

To determine gender differences in the prevalence, survival rates, and management of noncognitive behavioral problems of patients with Parkinson's disease (PD) in nursing homes (NH).We performed an observational study on 24,402 residents with PD using the Systematic Assessment and Geriatric drug use via Epidemiology (SAGE) database collected from the Minimum Data Set on a cross-section of over 400,000 NH residents in five US states. Gender differences in behavior were used to predict differences in pharmacologic and nonpharmacologic therapies using logistic regression. Similar analyses were done to evaluate gender differences in 1-year survival rates among patients with PD with and without behavioral problems.36% of men and 33% of women exhibited behavioral problems. Wandering, verbal and physical abusiveness, and inappropriate behavior tended to be more common in men, especially among PD residents with severe cognitive impairment. Hallucinations and delusions were equally prevalent between genders and depressive symptoms were more common in women. Regardless of behavioral manifestation, men were more likely to receive antipsychotic drugs, whereas women were more likely to receive antidepressants. This gender difference in treatment was also widest among the severely demented group. Although women lived longer, no difference in survival curves were noted between PD residents with and without behavioral problems.Gender appears to play an important role in determining the frequency and treatment of behavioral problems of NH residents with PD.

The recent successes of large, multicenter clinical trials of acetylcholinesterase inhibitors for symptomatic treatment of Alzheimer's disease have spawned enthusiasm that this common and fatal neurologic disease is “treatable.” A parallel explosion has occurred in the consumption of alternative medicines by the public seeking more effective, natural, or safer methods for treatment of dementia. Some of these medicines may, in fact, be biologically active in modulating the disease as well as producing side effects and interactions with accepted pharmaceuticals. This review brings to focus the scientific evidence presently available regarding such agents.

We investigated the correlation between cortical perfusion and white matter hyperintensities on magnetic resonance images (MRI) of patients with dementia. The study included 40 subjects, each of whom had undergone both MRI and single-photon emission computed tomography (SPECT) studies as part of their diagnostic evaluation for degenerative dementia. Two neuroradiologists rated the MRI films for severity of periventricular white matter changes on a 0-5 point scale and severity of subcortical white matter changes on a 0-4 point scale. Twelve regions of interest from association cortex were sampled for the semiquantitative analysis of SPECT images. No relationship was found between these global MRI ratings and semiquantitative or qualitative SPECT findings. Dementia severity as measured by the Mini-Mental State Examination and the Clinical Dementia Rating was significantly correlated with SPECT, whereas age was significantly correlated with MRI ratings, particularly in the periventricular regions. These data support the view that cortical SPECT abnormalities are not associated with global MRI abnormalities in the subcortical and periventricular regions of patients with a clinical picture of degenerative dementia.

OBJECTIVE: To examine the relationship between gender and specific types of behavior problems that occur in patients with Alzheimer's disease. DESIGN: This was an observational study using the Dementia Behavior Disturbance Scale to quantify and define behavioral problems encountered by caregivers. Multiple regressions were used to control for the possible influence of dementia severity as measured by the Mini-Mental State Examination and the duration of dementia. SETTING: Patients were sampled from the outpatient dementia clinics of Roger Williams Hospital and Miriam Hospital in Providence, Rhode Island. PARTICIPANTS: A total of 125 patients with probable Alzheimer's disease, defined by NINCDS-ADRDA diagnostic criteria, were included in the study. There were 75 women and 50 men. MAIN OUTCOME MEASURES: Caregivers rated the presence and frequency of 28 different behavior problems from the Dementia Behavior Disturbance Scale. Domains of behavior disturbance were then defined by a factor analysis of the data. RESULTS: Male and female groups were comparable for the demographic variables of age, education, and duration of dementia, as well as severity of depression, degree of cognitive impairment and overall severity of behavior disturbance. Among the six behavior factors that were defined, two were significantly related to gender. One factor, which included apathy and vegetative signs, was related to male gender; a second factor, which included reclusiveness and emotional lability, was related to female gender. CONCLUSIONS: Although overall severity of behavior disturbance in Alzheimer's disease may be related primarily to severity of dementia, significant differences in the types of behaviors manifested exist between males and females with the disease.

This study examined the relation between awareness of memory and functional decline and cognitive function in patients with Alzheimer disease (AD). Twenty-six patients with early AD and 16 nondemented elderly controls were studied. Awareness of deficits was determined by using (a) a discrepancy score between subject's and caregiver's ratings on a memory questionnaire, (b) a discrepancy score between subject's and caregiver's ratings on an activities-of-daily-living scale, and (c) a clinical rating of dementia awareness for patients. Whereas self-ratings of memory and activities of daily living were not significantly different between AD patients and controls, these two measures differed significantly when AD patients' ratings were compared with those of their caregivers. Measures of awareness of deficits correlated with one another and were primarily associated with performance on tests of executive and visuospatial functions but not with depression. Early AD is characterized by a failure of self-monitoring. Deficits in self-monitoring have been proposed to occur after damage to the frontal lobes and other cerebral areas. Impaired awareness of memory and functional deficits in AD is related to cognitive impairments, which may involve frontal and right hemisphere connections.

A patient with Alzheimer's disease and mild features of parkinsonism was treated with tacrine. Tremor and gait dysfunction worsened but responded to the addition of levodopa without adversely affecting cognitive function. The implications for experimental treatment strategies of patients with combined Alzheimer's and Parkinson's disease are discussed.

Over the past 10 years, several instruments developed specifically for the assessment of Quality of Life (QOL) in dementia have been introduced. The goal of the current review is to present, compare, and critique existing QOL measures for dementia populations to assist investigators and clinicians in selecting the optimal inventory for their specific needs. Nine measures are reviewed with a focus on conceptualizations of QOL, psychometric data, targeted patient population, and administration and scoring procedures. Critical discussion and comparison of the instruments is presented after the scales are described individually. Differences in definitions of QOL, assessment procedures, and methods that were used to establish the validity of instruments are highlighted. An important direction for future research on QOL scales for dementia is to establish their responsiveness to change over time. It will also be important to identify factors that affect reports of QOL, determine the how perceived QOL affects decisions regarding the care of dementia patients, and evaluate interventions to increase patient QOL.

Objective: To define gender differences in noncognitive behavioral problems of patients with AD and differences in the associated treatment of those problems. Design/Methods: We performed an observational study using the Systematic Assessment and Geriatric drug use via Epidemiology (SAGE) database, which contains data collected with the Minimum Data Set on a cross-section of nursing home residents in five US states. Behavior problems were documented at the first assessment of 28,367 residents with AD. We evaluated the role of gender differences in behavior as predictors of differences in nonpharmacologic versus specific pharmacologic therapies with psychoactive medications using logistic regression. Results: Men were more likely than women to exhibit behavior problems such as wandering, abusiveness, and social impropriety (59% versus 50% for any behavior problem). Hallucinations and delusions as well as depression were equally prevalent in men and women. Nevertheless, men were more likely to receive psychoactive medications. Among the specific drug categories examined, and controlling for age and degree of cognitive impairment, men were more likely to receive antipsychotic drugs and less likely to be receiving antidepressants. Conclusion: Gender appears to play an important role in determining the frequency of behavioral problems in nursing home residents with AD, which may influence choice of treatments as well as the decision whether to treat. The use of more potent tranquilizers in men with problem behaviors has potential implications for morbidity, deserving further investigation.

The hospital records and head CT scans of 44 patients with hemorrhagic infarction were retrospectively analyzed. The majority of cases (73%) were embolic or possibly embolic in etiology, and 55% were not associated with anticoagulant therapy. Adverse prognosis was most clearly related to infarct size, underlying systemic illness, and symptomatic hemorrhage. Of the nineteen patients in whom serial CT scans documented conversion from bland to hemorrhagic infarction, 12 exhibited no clinical worsening at the time that hemorrhagic infarction was observed; the remaining seven, all of whom worsened, were receiving anticoagulant therapy at the time of documented conversion. Fourteen patients in whom anticoagulant therapy was used despite the findings of hemorrhagic infarction remained stable or improved during hospitalization.

Introduction This survey characterizes viewpoints of cognitively intact at-risk participants in an Alzheimer Prevention Registry if given the opportunity to learn their genetic and amyloid positron emission tomography (PET) status. Methods A total of 207 participants were offered a 25-item survey. They were asked if they wished to know their apolipoprotein E ( APOE ) and amyloid PET status and if so, reasons for wanting to know, or not, and the effects of such information on life plans. Results One hundred sixty-four (79.2%) of the registrants completed the survey. Among those who were unaware of their APOE or amyloid PET results, 80% desired to know this information. The most common reasons for wanting disclosure were to participate in research, arrange personal affairs, prepare family for illness, and move life plans closer into the future. When asked if disclosure would help with making plans to end one's life when starting to lose their memory, 12.7% versus 11.5% responded yes for APOE and amyloid PET disclosures, respectively. Disclosure of these test results, if required for participation in a clinical trial, would make 15% of the people less likely to participate. Likelihood of participation in prevention research and the desire to know test results were not related to scores on brief tests of knowledge about the tests. Discussion These results suggest that stakeholders in AD prevention research generally wish to know biological test information about their risk for developing AD to assist in making life plans.

The objective of this study was to validate a Spanish version of the Cornell-Brown Scale (CBS) for quality of life (QoL) in dementia. One hundred persons with mild-to-moderate dementia (Diagnostic and Statistical Manual of the American Psychiatric Association, 4th edition) were recruited and interviewed at 5 Spanish centers to obtain sociodemographic information, health perceptions, depressive symptoms (Geriatric Depression Scale 15-item version), functional ability (Barthel Index), dementia severity (Mini-Mental State Examination), specific QoL (CBS), and generic QoL (World Health Organization Quality of Life-BREF version). Analysis was carried out using classical psychometric methods. Internal consistency reliability for the CBS was good (0.87). A priori hypotheses about the relationship between CBS and the World Health Organization Quality of Life-BREF version psychological domain and Geriatric Depression Scale 15-item version were confirmed, indicating good construct validity. Regarding contrasting groups' differences, CBS scores significantly differentiated between healthy and unhealthy and depressed and nondepressed participants but not between those with mild and moderate dementia. The exploratory factor analysis showed a 5-factor solution, which accounted for 63.9% of the total variance of CBS. This study is the first to report the factor structure of the CBS. These results indicate that CBS is a useful tool in assessing persons with dementia. Replication of these results with larger samples is advised. The Spanish version of the CBS is reliable and valid in persons with mild/moderate dementia who are living at home and with a known caregiver.

Better tools for assessing cognitive impairment in the early stages of Alzheimer's disease (AD) are required to enable diagnosis of the disease before substantial neurodegeneration has taken place and to allow detection of subtle changes in the early stages of progression of the disease. The National Institute on Aging and the Alzheimer's Association convened a meeting to discuss state of the art methods for cognitive assessment, including computerized batteries, as well as new approaches in the pipeline. Speakers described research using novel tests of object recognition, spatial navigation, attentional control, semantic memory, semantic interference, prospective memory, false memory and executive function as among the tools that could provide earlier identification of individuals with AD. In addition to early detection, there is a need for assessments that reflect real-world situations in order to better assess functional disability. It is especially important to develop assessment tools that are useful in ethnically, culturally and linguistically diverse populations as well as in individuals with neurodegenerative disease other than AD.

• A patient with membranoproliferative glomerulonephritis and renal dysfunction caused bySchistosoma mansoniwas treated with oxamniquine. High levels of circulating immunocomplexes returned to normal following treatment, although renal function for the long term was unchanged. Specific antischistosomal therapy may be of partial benefit to patients with this disease. (Arch Intern Med1983;143:1477-1479)