Comparison of seven sets of criteria used for the diagnosis of vascular dementia

At least seven different sets of criteria are commonly used for the diagnosis of vascular dementia (VaD). These are the ischemic scales (IS) of Hachinski, Rosen and Loeb, the criteria from the DSM-III-R, those outlined by Erkinjuntti et al., the State of California Alzheimer's Disease Diagnostic and Treatment Centers (ADDTC) and the international workgroup of the American National Institute of Neurological Disorders and Stroke (NINDS) and the European "Association Internationale pour la Recherche et l'Enseignement en Neurosciences'. To investigate the differences and similarities of these criteria, we applied them to a sample of 124 demented patients from the Maastricht Memory Clinic. Only 8 patients were diagnosed as having VaD by all criteria. Depending on which criteria were used, the frequencies of VaD and Alzheimer's disease (AD) ranged from 6 to 32%, and from 48 to 56%, respectively. The IS of Hachinski and Rosen resulted in the highest frequencies of VaD, whereas the criteria of Erkinjuntti and those from the ADDTC and the NINDS workgroup yielded the lowest. The number of patients with VaD was reduced substantially when neuroradiological data and the temporal relationship between stroke and dementia were taken into consideration. We conclude that the seven sets of criteria cannot be regarded as interchangeable. Differences in the criteria for VaD and AD may be an overlooked source of interstudy variance

Cognitive impairment in elderly people. Predisposing factors and implications for experimental drug studies

The consequences for cognitive functioning of normal aging, depression and dementia are well known. However, the borderline between normal and pathological cognitive aging is less well understood. Recently, it has been found that it is important to differentiate between 'successful', 'usual' and pathological cognitive aging. This article reviews existing views on this borderline. Recently, it has been found that health-related factors, or biological life events, may determine the rate of cognitive aging. Various different, but similar, diagnostic descriptions of age-related cognitive dysfunction exist simultaneously: benign senescent forgetfulness, malignant senescent forgetfulness, age-associated memory impairment, age-consistent memory impairment, late-life forgetfulness, mild cognitive changes (subthreshold) and cognitive impairment disorders are some examples of different diagnostic categories. There are also various diagnostic tools to obtain these experimental diagnoses; for example, the Global Deterioration Scale, the Clinical Dementia Rating Scale and the Cambridge Mental Disorders of the Elderly Examination. A diagnosis is considered important for the early detection of dementia. Pharmacological treatments are still in the experimental stage. Improvement of cognitive function has particularly been studied in clinical trials with groups of patients with Alzheimer's disease as well as patient groups with age-associated memory impairment. Future strategies may orient more towards treating symptoms of cognitive dysfunction, probably also on the basis of diagnosis of health-related factors, in age-related cognitive decline and depression.

Problems of caregiving spouses of patients with dementia

Twenty-six caregiving spouses of patients with dementia in the Netherlands were interviewed to better understand their problems and needs. Special attention was paid to the information the caregivers received from their general practitioner. Nineteen caregivers indicated that they received little or no information about the disease and its possible consequences. Furthermore, they experienced many problems, because of the disease and the daily care they provided; eleven caregivers indicated a decrease in social contact, which resulted in further problems. Caregivers who sought professional help at an early stage experienced fewer problems in providing daily care. The results of this project suggest that in future health education policy special attention should be paid to the role of the general practitioner and to the importance of a caregiver's social network.

Primitive reflexes in Alzheimer's disease and vascular dementia

Data on the prevalence and clinical value of primitive reflexes (PRs) in dementia are controversial, mainly due to a lack of standardization of the methods by which these signs are elicited and scored. A standardized protocol was used to investigate eight PRs in 20 patients with Alzheimer's disease (AD), 20 patients with vascular dementia (VD), and 20 control subjects for each group. Both patient groups showed considerably more PRs than the control groups. The prevalence of PRs was related to the severity of dementia. No single reflex or combination of PR pathognomonic for dementia could be distinguished. The PR profile of AD and VD patients were similar.

Depression, insight, and personality changes in Alzheimer's disease and vascular dementia

Although it is generally believed that depression, retained insight, and preserved personality occur more frequently in vascular dementia than in Alzheimer's disease, there is little empiric evidence for this presumption. Most studies on this subject have been carried out with severely demented inpatients, and confounding factors such as age, sex, and severity of dementia have not been sufficiently taken into account. We compared 48 patients with relatively mild vascular dementia with 48 patients with Alzheimer's disease, matched for age, sex, and stage of dementia, to investigate if depression, lack of insight, and personality changes were related to the cause of dementia. The two groups did not differ regarding the incidence of major depression, the mean depression score, the awareness score, or the sum of scores on the items of the Blessed Dementia Scale concerning personality changes. We conclude that depression, lack of insight, and personality changes do not favor an etiology of vascular dementia over that of Alzheimer's disease. The present findings underscore the notion that the severity of the dementia should be considered in studies on the differences between vascular dementia and Alzheimer's disease.

Treatment of depression in Parkinson's disease: a meta-analysis

Despite a 40% prevalence of depression in idiopathic Parkinson's disease (PD), an extensive literature search found only 12 controlled studies of treatment efficacy. A meta-analysis of these was performed in pursuit of guidelines for pharmacological treatment. Articles were scored on a scale from 0 to 100 on a specially adapted list of methodological criteria. Only 4 articles scored more than 50 points, and these generally did not use depression rating scales. Thus, there are virtually no empirical data on the treatment of depression in PD. Further studies are urgently needed, both for the sake of patient care and to gain a better understanding of the pathophysiological mechanisms underlying depression in PD and the interrelation between depression and cognitive decline.

Public education about normal forgetfulness and dementia: importance and effects

In the Netherlands considerable attention has been given to dementia, but hardly any is paid to normal forgetfulness. Two information meetings about the differences between normal forgetfulness and dementia were organized in order to meet current information needs. Evaluation of those meetings gave more insight into the characteristics of people who are worried about their diminishing memory and provided the opportunity of measuring changes in knowledge and anxiety. Almost 50% of the 450 participants indicated that they were worried about their memory; 66% of these people reported being more or less reassured afterwards. Although the level of knowledge increased, no correlation was found between increased knowledge and decreased anxiety. Because of people's anxiety about possible dementia, it is important to provide the general public with more information about this subject. More research, with a control group, is necessary to draw conclusions about the effectiveness of health education in this area.

Primitive reflexes in Parkinson's disease

A standardised protocol for the examination of 15 primitive reflexes in which the amplitude and the persistence were scored separately, was applied to 25 patients with Parkinson's disease and an equal number of healthy matched control subjects. Most reflexes were found considerably more often in the patients than in the control subjects, especially the snout, the glabellar tap, and its variant, the nasopalpebral reflex. Only the mouth open finger spread reflex was present more often in the control subjects. For all reflexes except this last, the scores for amplitude and persistence of the reflexes for the control group never exceeded the scores for the patient group. Reflexes persisted more often in the patients than in the control subjects. Parkinsonism alone can explain a large number of primitive reflexes, irrespective of the severity or duration of the disease. In contrast, the number of reflexes was related more closely to cognitive scales. It is concluded that such reflexes may be helpful in diagnosing Parkinson's disease. In addition, a standardised protocol for eliciting and scoring is essential for the study of these reflexes in parkinsonism and other neuropsychiatric conditions.

[Public information on normal forgetfulness and dementia: effectiveness of a systematically developed information pamphlet]

Previous research revealed that many elderly people are worried about their memory and are afraid of falling victim to dementia. An information brochure was developed in 1991 for this target group. After reading the brochure, 63% of all respondents who were worried about dementia beforehand (n = 307), said that their anxiety had decreased or disappeared. Approximately 3% of the total group of 400 respondents became more worried. A cognitive test battery was used to determine whether people's increased or decreased anxiety was justifiable. This test battery gave an indication of the severity of cognitive problems. A sample of 104 people was tested. Thirty subjects achieved a low test score and sixteen of them were inappropriately reassured by the brochure. Approximately 64% of fifty-four subjects who performed well on cognitive test and were worried about dementia beforehand, were rightly reassured, but the other 36% were (still) unnecessarily worried. The occurrence of dementia in a close relative covaried with worries about possible dementia in people with good test results. In conclusion, it appeared that an information brochure about normal forgetfulness and dementia may reduce the anxiety for dementia.

Primitive reflexes in healthy, adult volunteers and neurological patients: methodological issues

A study was made to determine whether two experienced clinicians elicited and scored primitive reflexes (PR) differently and whether reliability could be improved by standardization. Three studies were carried out, using a protocol for the examination of 14 PR. In the first study with 31 healthy young subjects, two investigators found virtually no difference in the routine neurological examination. However, the interobserver agreement was very poor, indicating the need for a further improvement of the PR protocol. In the second study, 30 neurological patients were examined with an improved, more explicit and standardized protocol, in which the amplitude and the persistence of the reflex were scored separately. Interobserver agreement improved considerably, and was high for amplitude as well as persistence. In the third study, 36 neurological patients were examined twice by one investigator within 2 weeks. Good to excellent intraobserver agreement was found. No pathognomonic or strictly localizing reflex could be distinguished.

[Forgetful or demented? Who worries and why?]

Many elderly people complain about their memory or are afraid to become demented. Research shows that in most cases this worry is unsubstantiated. Anxiety and uncertainty are primarily caused by a lack of proper information about the differences between normal forgetfulness and dementia. In order to be able to effectively inform the general public, more insight and a better understanding are needed about level of knowledge, needs and characteristics of the target group. For this reason, a survey was carried out among 500 elderly people who ordered an information brochure on memory and dementia. Approximately 32% of the respondents worry very much about their forgetfulness and 57% worry somewhat. Among other things, respondents ascribe their memory complaints to bad concentration (61%), stress and tension (45%) and the medication they use (30%). Almost 22% indicate that they worry a lot about possible dementia and 47% worry somewhat about dementia. The main predictors for respondents' concern about dementia are the extent to which people are hindered by their forgetfulness in daily life and the fact that someone in the near family has or has had dementia. Of all respondents who worry about their memory, 26% consulted their general practitioner to discuss their complaints. Important reasons for not seeking help despite being worried, are that many subjects do not want to bother their general practitioner (48%) and feel that they are not taken seriously by their social environment (27%).

[Psychiatric disorders in patients of a memory outpatient clinic]

OBJECTIVE

To determine whether psychiatric conditions other than depression are relevant in elder patients with memory disturbances.

METHODS

430 consecutive outpatients (242 males, 188 females; mean age 61.7 years) who visited the Maastricht Memory Clinic were examined, according to a standardised diagnostic procedure, including somatic, neurological, psychiatric and neuropsychological examination. Psychiatric disorders were diagnosed according to DSM-III(-R) criteria.

RESULTS

Of 152 patients with dementia, 34 had a secondary depressive syndrome, 19 another secondary psychiatric disorder. Of the 37 patients with a psycho-organic disorder other than dementia, 16 had an organic mood disorder. Of the other 241 patients, 152 had 159 primary psychiatric diagnoses: mood disorders in 100 cases and other psychiatric disorders in 59 cases, especially adjustment disorders, anxiety disorders and personality disorders. Together, only 60% percent of all primary or secondary psychiatric disorders were mood disorders. Various ways in which organic substrate, cognitive problems and psychopathology can be interrelated are discussed.

CONCLUSION

Although affective disorders were the most frequent psychiatric disorders, several other psychiatric conditions were related to memory disturbances as well. Psychiatric assessment in patients with memory complaints should not be restricted to the diagnosis of depressive symptoms.

Diagnosing dementia: a comparison between a monodisciplinary and a multidisciplinary approach

Discrepancies were examined in diagnostic outcome between a monodisciplinary approach and a multidisciplinary, criteria-based approach in patients referred to a university memory clinic. Of 278 patients not fulfilling dementia criteria, 19 had been previously diagnosed as demented (specificity: 0.93). In 60 of 152 demented patients, dementia had not been diagnosed before (sensitivity: 0.61). Underreporting was frequent for mildly demented patients and for patients with coexisting depressive symptoms. In patients referred by psychiatrists, sensitivity rates for dementia and Alzheimer's disease were low; in patients referred by neurologists, depression often went unreported. Results underscore the need for more frequent use of integrated multidisciplinary services for cognitively disturbed patients.

[Screening for dementia: validity of the Cognitive Screening Test (CST) and the Mini-Mental State Examination]

The Cognitive Screening Test (CST--short version), a Dutch orientation questionnaire, and the Mini-Mental State Examination (MMSE) were compared with respect to their ability to discriminate between mildly demented, moderately demented and non-demented patients. The difference between mildly and moderately demented patients was based on the Global Deterioration Scale score. The CST and the MMSE were administered to patients who had been referred to the Memory Clinic of the University Hospital of Maastricht. Both instruments were successful in discriminating moderately and severely demented from non-demented patients. The CST and the MMSE were also successful with respect to the classification of depressive, non-demented elderly patients. The CST did not succeed in the correct classification of mildly demented patients (50% false-negative). The results of the MMSE in this group of mildly demented patients were moderate (25% false-negative). It is concluded that the value of both screening instruments, and especially the short version of the CST is limited for clinical practice.

[Different disciplines, different diagnoses?--A survey among participants of a consensus conference on dementia]

It is hardly known to what extent consensus criteria for dementia are adhered to in clinical practice. An inquiry was held among the participants of the Dutch consensus meeting on dementia to investigate this point. 85 clinicians diagnosed the case descriptions of 10 patients with cognitive dysfunctions. The inquiry was split into two parts, i.e. before and after the meeting. There was no difference between the two parts in the level of consensus. There was not difference between the disciplines in syndrome diagnoses. However, with regard to etiology, significant differences existed between the specialties. Furthermore, the agreement increased with the severity of the cognitive disturbances. In cases where depressive symptoms coexisted, the diagnosis was more often in error. The nature of the diagnoses appeared to be dependent on the discipline of the diagnostician. This study underlines the necessity of a multidisciplinary diagnostic approach based on well accepted criteria.

[Slowly progressive aphasia without dementia]

Slowly progressive aphasia without dementia is a rare disease, first described in 1982. Since then the existence of a nosological entity bearing that name is disputed. Case histories of two patients are described, with emphasis on clinical presentation and the importance of early diagnosis and neuropsychological evaluation. It is concluded that slowly progressive aphasia is a sign caused by a neurodegenerative cerebral disorder starting in the dominant hemisphere, ultimately accompanied by symptoms of generalised dementia.

Differential diagnosis of dementia: intra- and interdiscipline agreement

Ninety clinicians from six disciplines diagnosed ten case descriptions of patients, judged by a multidisciplinary expert committee to suffer from dementia. Five cases were diagnosed before and five after a consensus meeting on the diagnosis of dementia. A significant change in the level of agreement between the disciplines could not be established. The analysis did show a significant difference between the disciplines in the use of etiologic diagnoses. The results indicated that, in order to avoid possible bias caused by medical specialization, a multidisciplinary approach for this type of patient is recommended.

Differential diagnosis of dementia: a comparison between the expert system EVINCE and clinicians

The diagnostic performance of the expert system EVINCE was compared with that of 85 clinicians in diagnosing 10 patients suspected of suffering from dementia. A multidisciplinary expert committee provided a standard diagnosis as reference for comparison. The results showed that the syndrome and etiologic diagnoses made by EVINCE were in very close agreement with those of the expert committee and that the diagnostic performance of EVINCE was better than that of the average clinician. The present findings indicate that expert systems, especially those within the realm of complex multidimensional medical problems, could be a valuable aid in medical practice.

A desktop expert system for the differential diagnosis of dementia. An evaluation study

EVINCE-I is a desktop expert system for the differential diagnosis of dementia, implemented on a personal computer. It is intended to assess the effectiveness of this new technology in modeling a psychiatrist who uses international guidelines for diagnosing dementia. EVINCE-I was tested in diagnosing 19 patients with varying stages of dementia and 10 patients showing other disorders except dementia. EVINCE-I and the human expert were in perfect agreement on the diagnosis of dementia and correlated highly on the diagnosis of dementia of the Alzheimer type and multiple infarct dementia. EVINCE-I thus offers important possibilities as a tool in investigating the data and procedures used by the human expert.

[An experimental expert system for the differential diagnosis of the dementia syndrome. Initial evaluation]

EVINCE-I is an expert system for neuropsychiatric diagnostics implemented on a personal computer. It is developed to assess the possibilities of an expert system which models the procedures used for medical decision taking and data analysis by a neuro-psychiatrist when making a differential diagnosis in the domain of dementia syndromes. The knowledge of the system centers around detection of Alzheimer's disease, multi-infarct dementia and depression-induced dementia. EVINCE-I and the human expert were compared in their ability to diagnose 29 patients, i.e. 19 patients with early stages of dementia and 10 patients showing varying disorders except dementia. It is shown that EVINCE-I is able to detect dementia and its main causes, and produce diagnoses that agree with those of the human expert.

[The confusion relating to the concept of dementia and Alzheimer's disease]

Much confusion exists about the definition of the term dementia and about diagnostic criteria of dementing diseases. This confusion not only forms an impediment in the progress of scientific research, but is also potentially harmful for patient care. Recently, considerable improvements are made by consensus conferences in designing operational diagnostic criteria. However, application of these in daily practice is still not optimal. In this publication, differences in meaning of the concept of dementia and Alzheimer's Disease are discussed. A proposal is made how to overcome misunderstandings in daily practice.