Long-Term Severe Mental Disorders Preceding Behavioral Variant Frontotemporal Dementia: Frequency and Clinical Correlates in an Outpatient Sample

BACKGROUND

The behavioral variant frontotemporal dementia (bvFTD) shares some clinical features with severe mental disorders, such as bipolar affective disorder (BAD), schizophrenia (SCZ), and schizoaffective disorder (SZA), and at least for a small subgroup of patients, these conditions may share similar pathological genetic mutations.

OBJECTIVES

To investigate the frequency of a past medical history satisfying diagnostic criteria for BAD, SCZ, and SZA in a bvFTD outpatient sample, and to compare the clinical profile of patients with and without a positive history.

METHODS

Cross-sectional study in which participants were consecutively selected after receiving a diagnosis of probable bvFTD and had a caregiver interviewed with SCID-I. The sample was categorized into two groups: with (bvFTD+) or without (bvFTD-) prior medical history satisfying diagnostic criteria for BAD/SCZ/SZA. Subjects went through cognitive, functional, and neuropsychiatric evaluations.

RESULTS

Overall, 46 bvFTD patients were included; bvFTD+ patients accounted for 36.9% of the sample. The main nosology fulfilling criteria was BAD (76.5%). The groups differed in Neuropsychiatric Inventory scores (p = 0.01), use of antipsychotics (p = 0.01), family history of psychosis (p = 0.01), presence of primitive reflexes (p = 0.04), Frontal Assessment Battery performance (p = 0.01), Ekman's facial emotion recognition test (p = 0.03), frequency of apathy (p = 0.03), and stereotyped behavior (p = 0.01). All these parameters were more frequent/worse in the bvFTD+ group.

CONCLUSIONS

A prior medical history compatible with BAD/SCZ/SZA was found in more than 1/3 of this sample of bvFTD patients and was associated with subtle distinctive clinical features.

Inflammatory and Pro-resolving Mediators in Frontotemporal Dementia and Alzheimer's Disease

Chronic inflammation contributes to neuronal death in Alzheimer's disease (AD) and frontotemporal dementia (FTD). Here we evaluated inflammatory and pro-resolving mediators in AD and behavioural variant of FTD (bvFTD) patients compared with controls, since neuroinflamamtion is a common feature in both diseases. Ninety-eight subjects were included in this study, divided into AD (n = 32), bvFTD (n = 30), and control (n = 36) groups. The levels of hsCRP, IL-1β, IL-6, TNF, and TGF-β1, as well as annexin A1 (AnxA1) and lipoxin A4 (LXA4) were measured in blood and cerebrospinal fluid (CSF). The expression profile of AnxA1 was evaluated in peripheral blood mononuclear cells (PBMCs) as well the distribution of ANXA1 rs2611228 polymorphism. We found reduced peripheral levels of hsCRP and TNF in AD compared with bvFTD patients and controls, and increased levels of TGF-β1 in AD compared to controls. Moreover, reduced plasma levels of AnxA1 were observed in bvFTD compared to AD and controls. There was a significant cleavage of AnxA1 in PBMCs in both dementia groups. The results suggest differential regulation of inflammatory and pro-resolving mediators in bvFTD and AD, while AnxA1 cleavage may impair pro-resolving mechanisms in both groups.

Behavioral variant of frontotemporal dementia or frontal variant of Alzheimer's disease? A case study

Alzheimer's disease (AD) has heterogeneous clinical presentations. Amnestic progressive disorder leading to dementia is the most typical, but non-amnestic presentations are also recognized. Here we report a case of frontal variant of AD. A right-handed woman, aged 68 years, was referred for progressive behavioral disorders and personality changes. She had a corroborated history of dietary changes, hyperorality, impulsivity, affective indifference and apathy, with functional impairment. Cognitive assessment yielded severe executive deficits. Positron emission tomography with fluorodeoxyglucose showed marked hypometabolism in frontotemporal regions, with relative preservation of parietal regions. CSF AD biomarkers showed low Aβ₄₂, high Tau and high P-Tau. The patient fulfilled criteria for probable behavioral variant frontotemporal dementia. However, considering the AD pathophysiological signature on CSF biomarkers, a diagnosis of frontal variant of AD was established. In the perspective of disease-modifying therapies, it is important to identify atypical Alzheimer presentations, as these patients may be candidates for specific treatments.

Behavioral variant frontotemporal dementia in patients with previous severe mental illness: a systematic and critical review

ABSTRACT Objectives: To explore the relationship between severe/serious mental illness (SMI) and the behavioral variant of frontotemporal dementia (bvFTD), as the patterns of symptoms and cognitive performance that characterize both disorders share similarities. Methods: We performed a systematic review investigating what has already been published regarding the relationship between bvFTD and SMI. Studies were selected from PubMed and LILACS databases, including those published up to February 12, 2018. The search strategy included the following terms: “frontotemporal dementia” plus “bipolar”, OR “frontotemporal dementia” plus “schizophrenia”, OR “frontotemporal dementia” plus “schizoaffective”. Publications without abstracts, case reports with absent genetic or histopathological confirmation, reviews and non-English language papers were excluded across the search process. Results: The search on PubMed retrieved 186 articles, of which 42 met eligibility criteria. On the LILACS database, none met the requirements. Generally, three major research aims were identified: 1) to look for frontotemporal lobar degeneration-associated genetic abnormalities in patients with prior SMI; 2) to compare the cognitive profile between patients affected by neurodegenerative disorders and schizophrenic patients; 3) to highlight the association between bvFTD and preceding psychiatric conditions and/or distinguish them both. The investigated mutations were found infrequently in the studied SMI samples. Cross-sectional studies comparing cognitive performance between bvFTD and psychiatric disorders mostly found no remarkable differences. There were only a few case reports identifying definite frontotemporal lobar degeneration in patients with previous psychiatric diagnoses. Conclusions: The available evidence demonstrates how fragile the current understanding is regarding the association between bvFTD and prior SMI.

Cerebrospinal Fluid Levels of Angiotensin-Converting Enzyme Are Associated with Amyloid-β42 Burden in Alzheimer's Disease

This study was designed to determine whether the levels of renin-angiotensin system (RAS) components are associated with Alzheimer's disease (AD) pathology. Cerebrospinal fluid levels of Angiotensin (Ang) II, Ang-(1-7), angiotensin-converting enzyme (ACE), ACE2, Amyloid-β (Aβ)40, Aβ42, total tau (hTau), and phospho-tau (pTau) were measured in 18 patients with AD and 10 controls. Patients with AD presented decreased levels of ACE when compared with controls. We found a significant positive correlation between ACE and Aβ42 levels among patients. Our results strengthen the hypothesis that ACE is associated with Aβ pathology in AD.

Hemostatic Abnormalities in Dementia: A Systematic Review and Meta-Analysis

Alzheimer's disease (AD) is considered the most frequent cause of dementia. It is known that vascular risk factors play an important role in the development and progression of this condition. Alterations in vascular walls represent documented findings in patients with AD and other dementias affecting elderly people. The authors performed a systematic review and meta-analysis, aiming to synthesize observational studies that evaluated how the hemostatic system may contribute to cognitive decline in the elderly, using papers published until April 2018 and as indexed in Medline (PubMed), Scopus, Web of Science, ScienceDirect, Lilacs, Cinahl, PsycINFO, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. Among 5,278 studies identified, 32 were included in the final synthesis, and these included 485 patients with mild cognitive impairment, 568 with vascular dementia (VD), 1,781 with AD, and 2,855 participants without dementia. AD patients had increased plasma von Willebrand factor (VWF) (standardized mean difference [SMD]: 2.53; 95% confidence interval [CI]: 0.10-4.95), D-dimer (SMD: 0.50; 95% CI: 0.35-0.66), plasminogen activator inhibitor-1 (SMD: 3.34; 95% CI: 1.01-5.67), thrombomodulin (SMD: 1.08; 95% CI: 0.53-1.62), and homocysteine levels (SMD: 0.65; 95% CI: 0.15-1.15). In contrast, the VD group showed increased fibrinogen levels (SMD: 0.77; 95% CI: 0.13-1.41), activated factor VII (SMD: 0.36; 95% CI: 0.05-0.67), factor VIII (SMD: 0.57; 95% CI: 0.22-0.91), VWF (SMD: 2.34; 95% CI: 0.38-4.29), D-dimer (SMD: 1.14; 95% CI: 0.51-1.78), and homocysteine (SMD: 2.17; 95% CI: 1.67-2.68). AD showed an elevation in some markers of endothelial dysfunction, whereas VD presented mostly an involvement of coagulation cascade components.

Cognitive impairment in HTLV-1-associated myelopathy, proviral load and inflammatory markers

OBJECTIVES

Myelopathy is a well-established long-term clinical manifestation of HTLV-1 infection. Besides motor dysfunction, cognitive impairment may be another consequence of HTLV-1 infection. Moreover, inflammatory markers may be associated with cognitive impairment in these patients. The present study compared the cognitive performance of HAM/TSP patients with healthy controls and investigated the associations between cognitive performance, proviral load and blood inflammatory markers.

METHODS

Eighty-three patients fulfilling diagnostic criteria for HAM/TSP were submitted to a comprehensive clinical, cognitive and functional evaluation, brain magnetic resonance imaging and determination of levels of IL-1β, IL-6, TNF-α, immunoglobulins and HTLV-1 proviral load in blood and cerebrospinal fluid. The control group was composed of 88 cognitively healthy subjects, matched for age, sex and educational level.

RESULTS

Compared to healthy subjects, HAM/TSP patients displayed significant global cognitive impairment and executive function deficits. HAM/TSP cognitive impairment was significantly associated with altered levels of IgM, IgG, IL-6 and TNF-α in blood. There was no association between HAM/TSP cognitive impairment and HTLV-1 proviral load.

CONCLUSIONS

This study suggests cognitive impairment may be a long-term clinical manifestation of HTLV-1 infection, which seems to be linked to the persistent inflammatory activity that is found in the disease.

Phenocopy syndrome of behavioral variant frontotemporal dementia: a systematic review

Background

The phenocopy syndrome of behavioral variant of frontotemporal dementia (phFTD) refers to patients presenting with neuropsychiatric symptoms mimicking the behavioral variant frontotemporal dementia (bvFTD), but lacking frontotemporal atrophy/hypometabolism on neuroimaging and not evolving to dementia during the follow-up. It is important to recognize phFTD for clinical and research purposes.

Objective

The aim of this study was to perform a systematic review of the available literature on phFTD taking into account its clinical, cognitive, imaging, genetic, and pathological features.

Methods and results

We searched for the following terms in two electronic databases (PubMed and Scopus): “frontotemporal dementia and slowly progressive,” “frontotemporal dementia and phenocopy,” “frontotemporal dementia and non-progressive,” “frontotemporal dementia and benign progression,” and “frontotemporal dementia and benign.” We did not include review articles. Papers had to be written in English, French, Portuguese, or Spanish. Overall, 235 studies were retrieved in the initial search. A total of 31 studies composed the final selection, comprising 292 patients. Patients with phFTD are predominantly male and have no major cognitive deficits, with globally preserved executive functions and episodic memory. Some cases (n = 7) of slowly progressive FTD have been associated with C9orf72 genetic expansion. There are only four reports of phFTD neuropathological data, with two patients with no neurodegenerative findings and two with frontotemporal lobar degeneration with ubiquitin-positive inclusions.

Conclusion

The neurobiological underpinnings of phFTD remain unknown. It is controversial whether phFTD belongs to the FTD spectrum. Studies with biomarkers and pathological data are needed to solve the phFTD conundrum.

No Evidence of Association Between Soccer Heading and Cognitive Performance in Professional Soccer Players: Cross-Sectional Results

Although the scientific community has focused on the effects of concussions in contact sports, the role of subconcussive impacts, as it can occur during soccer heading, has recently gained attention, considering that it may represent an additional mechanism of cumulative brain injury. The aim of this study is to investigate the effects of soccer heading on cognitive functioning in active professional soccer players. Male soccer players (n = 44), from two soccer teams that play in the Brazilian A Series Championship, and non-athletes (n = 47), comparable in age and education, were submitted to cognitive assessment, consisting of computerized and conventional neuropsychological testing (Neupsilin battery). In the computerized cognitive assessment, soccer players performed better than controls on reaction time measures in general motor coordination, executive functioning and memory tests, and on accuracy measures in executive functioning tests. There were no significant differences between groups on the Neupsilin battery. A comparison between two sub-groups of soccer players, based on the self-reported number of headings, did not show significant differences on tests performance. No significant correlations were found between an estimate of exposure to heading during professional soccer career and cognitive performance. Our data demonstrate no evidence of cognitive impairment in soccer players, compared to non-athletes, and no association between heading exposure and performance on neuropsychological tests. Longitudinal investigations, including neuroimaging assessment, will help to clarify whether soccer heading may be associated with brain injury and cognitive dysfunction.

Cognitive Impairment Following Acute Mild Traumatic Brain Injury

Patients with mild traumatic brain injury (mTBI) may present cognitive deficits within the first 24 h after trauma, herein called "acute phase," which in turn may lead to long-term functional impairment and decrease in quality of life. Few studies investigated cognition in mTBI patients during the acute phase. The objectives of this study were to investigate the cognitive profile of patients with mTBI during the acute phase, compared to controls and normative data, and whether loss of consciousness (LOC), previous TBI and level of education influence cognition at this stage. Fifty-three patients with mTBI (aged 19-64 years) and 28 healthy controls participated in the study. All patients were evaluated at bedside within 24 h post-injury. Demographic and clinical data were registered. Cognitive function was assessed with the Mini-mental state examination (MMSE), the Frontal Assessment Battery (FAB), Digit Span (working memory), and the Visual Memory Test/Brief Cognitive Battery (for episodic memory). The clinical sample was composed mainly by men (58.5%). The mean age was 39 years-old and 64.3% of the patients had more than 8 years of education. The most common causes of mTBI were fall from own height (28.3%), aggression (24.5%), and fall from variable heights (24.5%). Compared to controls, mTBI patients exhibited significantly worse performance on MMSE, FAB, naming, incidental memory, immediate memory, learning, and delayed recall. Compared to normative data, 26.4% of patients had reduced global cognition as measured by the MMSE. Episodic memory impairment (13.2%) was more frequent than executive dysfunction (9.4%). No significant differences were found in cognitive performance when comparing patients with or without LOC or those with or without history of previous TBI. Patients with lower educational level had higher rates of cognitive impairment (VMT naming-28.6 vs. 4.2%; VMT immediate memory-32 vs. 4.2%; VMT learning-39.3 vs. 4.2%, all p < 0.05). In sum, we found significant cognitive impairment in the acute phase of mTBI, which was not associated with LOC or history of TBI, but appeared more frequently in patients with lower educational level.

Primary School Education May Be Sufficient to Moderate a Memory-Hippocampal Relationship

According to the cognitive reserve theory, intellectual stimuli acquired during life can prevent against developing cognitive impairment. The underlying cognitive reserve mechanisms were underexplored in low-educated individuals. Because episodic memory impairment due to hippocampal dysfunction is a key feature of Alzheimer's dementia (AD), we sought to look at a possible cognitive reserve mechanism by determining whether few years of education moderated the relationship between the hippocampal volumes and the episodic-memory scores. The sample was composed by 183 older adults, 40.1% male, with the median age of 78[76,82] years and the median years of education of 4[2,10] who had undergone an episodic-memory test and a 3-Tesla MRI scan to access the hippocampal volumes. Overall, 112 were cognitively healthy, 26 had cognitive impairment-no dementia (CIND) and 45 had dementia. We used multiple linear regression to assess whether the interaction between years of education and each hippocampal volume significantly predicted the episodic-memory scores' variance, controlling for cognitive diagnosis and nuisance variables. The interaction term with the left hippocampus (ß = 0.2, p = 0.043, CI = 1.0, 1.4), but not with the right (ß = 0.1, p = 0.218, CI = 0.9, 1.2) significantly predicted the variation on memory scores. The mechanism by which the left hippocampus seems to play a more important role on memory processing in more educated individuals needs to be further investigated and might be associated with a better use of mnemonic strategies or higher hippocampal connectivity. Because the sample's median years of education was four, which corresponds to primary school, we may infer that this level might be sufficient to contribute for building cognitive reserve.

BsmI polymorphism in the vitamin D receptor gene is associated with 25-hydroxy vitamin D levels in individuals with cognitive decline

ABSTRACT Elderly people are at a high risk of developing vitamin D (VitD) deficiency due to both decreased intake and cutaneous synthesis. Most of the biological actions of VitD are mediated by the vitamin D receptor (VDR), which is present in neurons and glial cells of the hippocampus, and in the cortex and subcortical nuclei, essential areas for cognition. It is known that VDR gene polymorphisms may decrease the VDR affinity for VitD. Objective: The present study aimed to investigate the influence of VitD levels on cognitive decline in patients with dementia due to Alzheimer's disease (AD, n = 32) and mild cognitive impairment (MCI, n = 15) compared to cognitively healthy elderly (n = 24). We also evaluated the association of VDR gene polymorphisms with cognitive disturbance. Methods: Four polymorphisms on the VDR gene were studied, namely, BsmI, ApaI, FokI and TaqI, by polymerase chain reaction-restriction fragment length polymorphism. Serum levels of 25-hydroxy vitamin D (25(OH)D) were determined by high performance liquid chromatography. Results: No significant difference in 25(OH)D levels or genotypic/allelic frequencies was observed between the groups. Deficiency of 25(OH)D was more frequently observed in women. The AA/AG genotypes of the BsmI polymorphism was associated with sufficient 25(OH)D levels, while the GG genotype of this same polymorphism was associated to insufficient levels in the cognitively-impaired group (individuals with AD or MCI). Conclusions: The data obtained do not confirm the relationship between reductions of VitD levels, polymorphisms in the VDR gene, and altered cognitive function in this sample. However, the data indicate that BsmI polymorphism in the VDR gene is associated with the VitD levels in individuals with cognitive decline.

Operationalized definition of older adults with high cognitive performance

Recently, there has been an increasing number of studies on exceptional cognitive aging. Herein, we aim to objectively provide the operationalized characterization of older adults with unusually high memory ability. Some authors have defined them as "SuperAgers", individuals aged 80 years or older with memory ability similar or superior to middle-aged subjects. On the other hand, the terminology "high-performing older adults" (HPOA) seems to appropriately conceptualize these individuals without exaggeration. A threshold for age is not a reliable criterion, but may be defined as 75 and 80 years of age for developing and developed countries, respectively. We propose that HPOA may exhibit episodic memory test scores equal to or greater than those of individuals aged 50-60 years, according to the validated tables for the respective country. This group must also have global cognition scores within expected average values for age and education. Executive functioning may play a central role in the exceptional memory performance of this group. Further studies are essential to confirm existing findings and may provide important evidence for cognitive aging theory and the neurobiology of dementia.

Parkinsonism in a population-based study of individuals aged 75+ years: The Pietà study

INTRODUCTION

Parkinsonism is one of the most prevalent neurological syndromes in the elderly. There are only a few epidemiological studies focusing on parkinsonism in oldest-old individuals, particularly in Latin America. This study aims to investigate the prevalence and characteristics of parkinsonism in subjects aged 75 + years living in the community.

METHODS

The Pietà study is a population-based investigation on brain aging conducted in Caeté, southeast Brazil. A sample composed of 610 community-dwelling individuals aged 75 + years (48.7% of the total population within this age range) underwent clinical, neurological, cognitive and functional assessments.

RESULTS

The sample comprised mostly women (61.5%), with mean age of 83.3 years and mean schooling of 2.5 years. Parkinsonism was identified in 65 subjects (crude prevalence = 10.7%). Parkinson's disease, Parkinsonism + dementia syndrome, drug-induced parkinsonism, vascular parkinsonism and Lewy-body dementia were identified in, respectively, 19 (29.2%), 19 (29.2%), 8 (12.3%), 4 (6.1%) and 1 (1.5%) subjects. In 14 individuals (21.5%), the etiology of parkinsonism could not be determined. The most important vascular risk factor was hypertension (64.6%). Cognitive evaluation disclosed dementia in 37 (56.9%) subjects. Mean Pfeffer's functional activities questionnaire score was 12.2 points and 22 (33.8%) subjects were impaired in basic activities of daily living.

CONCLUSION

Parkinsonism was common in this oldest-old population, being associated with dementia and vascular risk factors, particularly hypertension. Different confounders, such as concomitant dementia and exposure to anti-dopaminergic drugs, were present in this population, challenging the definition of causes of parkinsonism.

Apathy and functional disability in behavioral variant frontotemporal dementia

Background

Behavioral variant frontotemporal dementia (bvFTD) has profound consequences on patients and their families. In this multicenter study, we investigated the contribution of cognitive and neuropsychiatric factors to everyday function at different levels of overall functional impairment.

Methods

In a retrospective cross-sectional study, 109 patients with bvFTD from 4 specialist frontotemporal dementia centers (Australia, England, India, and Brazil) were included. The measures administered evaluated everyday function (Disability Assessment for Dementia [DAD]), dementia staging (Clinical Dementia Rating [CDR]), general cognition (Addenbrooke's Cognitive Examination-revised [ACE-R]), and neuropsychiatric symptoms (Neuropsychiatric Inventory [NPI]). Patients were then subdivided according to functional impairment on the DAD into mild, moderate, severe, and very severe subgroups. Three separate multiple linear regression analyses were run, where (1) total DAD, (2) basic activities of daily living (BADL), and (3) instrumental activities of daily living (IADL) scores were dependent variables; ACE-R total score and selected NPI domains (agitation/aggression, euphoria, apathy, disinhibition, irritability, aberrant motor behavior) were used as independent variables. Age, sex, education, and country of origin were controlled for in the analyses.

Results

Cognitive deficits were similar across the mild, moderate, and severe subgroups but significantly worse in the very severe subgroup. NPI domain scores (agitation/aggression, euphoria, apathy, disinhibition, irritability, aberrant motor behavior) did not differ across the DAD subgroups. In the multiple regression analyses, a model including ACE-R and NPI apathy explained 32.5% of the variance for total DAD scores. For IADL, 35.6% of the variance was explained by the ACE-R only. No model emerged for BADL scores.

Conclusions

Cognitive deficits and apathy are key contributors to functional disability in bvFTD but factors underlying impairment in BADLs remain unclear. Treatments targeting reduction of disability need to address apathy and cognitive impairment to ensure greater efficacy, especially in regards to IADLs.

Integrity of white matter structure is related to episodic memory performance in the low-educated elderly

The low-educated elderly are a vulnerable population in whom studying the role of white matter integrity on memory may provide insights for understanding how memory declines with aging and disease.

METHODS

Thirty-one participants (22 women), 23 cognitively healthy and eight with cognitive impairment-no dementia, aged 80.4 ± 3.8 years, with 2.2 ± 1.9 years of education, underwent an MRI scan with diffusion tensor imaging (DTI) acquisition. We verified if there were correlations between the performance on the Brief Cognitive Screening Battery (BCSB) and the Rey Auditory Verbal Learning Test (RAVLT) with DTI parameters.

RESULTS

The BCSB delayed recall task correlated with frontotemporoparietal connection bundles, with the hippocampal part of the cingulum bilaterally and with the right superior longitudinal fasciculus. The RAVLT learning and delayed recall scores also correlated with the hippocampal part of the cingulum bilaterally.

CONCLUSIONS

Although preliminary, our study suggests that the integrity of white matter frontotemporoparietal fasciculi seems to play a role in episodic memory performance in the low-educated elderly. This finding opens opportunities to study potential targets for memory decline prevention in vulnerable populations.

Arquivos de Neuro-Psiquiatria: 75 years

This year marks the 75th year of publication of Arquivos de Neuro-Psiquiatria (ANP), the official journal of the Brazilian Academy of Neurology and one of the most important neuroscience journals in Latin America. ANP was initially edited by Oswaldo Lange, its founder, and subsequently by Antonio Spina-França Netto and, in recent years, by José Antonio Livramento and Luís dos Ramos Machado.

Polymorphisms in cytokine genes influence cognitive and functional performance in a population aged 75 years and above

OBJECTIVE

To investigate the frequency of the cytokine single nucleotide polymorphisms (SNPs) tumor necrosis factor (TNF)-α -308G > A, tumor growth factor (TGF)-β1 codon +10C > T, TGF-β1 codon +25G > C, interleukin (IL)-10 -1082A > G, IL-10 -819C > T, IL-10 -592C > A, IL-6 -174G > C, and IFN-γ +874T > A in a sample of healthy and cognitively impaired elderlies and to verify the probable association between these SNPs and cognitive and functional performance of subjects aged 75 years and above.

METHODS

259 Brazilian subjects were included, comprising 81 with cognitive impairment no dementia (CIND) and 54 demented seniors (together made up the cognitively impaired group, CI) and 124 age-matched and gender-matched cognitively healthy controls (CHS). The genotyping was performed by multiplex polymerase chain reaction. The cognitive performance was evaluated by Mini-Mental State Examination Brief Cognitive Screening Battery. The functional performance was accessed by Functional Activities Questionnaire.

RESULTS

The CC^lower genotype of TGF-β1 codon +25G > C was frequent in both patient groups. The TT^higher genotype of INF-γ +874T > A was less frequent in the dementia group. IL-10 haplotypes of lower expression were more frequent among CIND and demented patients. In CI, individuals with genetic variants that produce higher expression of TGF-β1, INF-γ, and IL-10 showed better normalized cognitive performance. Additionally, the A^lower allele of INF-γ +874T > A was related to worse functional performance in CI, while the A^lower allele of TNF-α -308G > A was associated with better cognitive and functional scores in the CIND group.

CONCLUSIONS

Our findings suggest a potential role for certain cytokine SNPs in the development of CIND and dementia, which may influence the functional and cognitive performance of these patients. Copyright © 2016 John Wiley & Sons, Ltd.

Accuracy of the 15-item Geriatric Depression Scale (GDS-15) in a community-dwelling oldest-old sample: the Pietà Study

Abstract Introduction Late-life depression (LLD) is common, but remains underdiagnosed. Validated screening tools for use with the oldest-old in clinical practice are still lacking, particularly in developing countries. Objectives To evaluate the accuracy of a screening tool for LLD in a community-dwelling oldest-old sample. Methods We evaluated 457 community-dwelling elderly subjects, aged ≥75 years and without dementia, with the Geriatric Depression Scale (GDS-15). Depression diagnosis was established according to DSM-IV criteria following a structured psychiatric interview with the Mini International Neuropsychiatric Interview (MINI). Results Fifty-two individuals (11.4%) were diagnosed with major depression. The area under the receiver operating characteristic (ROC) curve was 0.908 (p<0.001). Using a cut-off score of 5/6 (not depressed/depressed), 84 (18.4%) subjects were considered depressed by the GDS-15 (kappa coefficient = 53.8%, p<0.001). The 4/5 cut-off point achieved the best combination of sensitivity (86.5%) and specificity (82.7%) (Youden's index = 0.692), with robust negative (0.9802) and reasonable positive predictive values (0.3819). Conclusion GDS-15 showed good accuracy as a screening tool for major depression in this community-based sample of low-educated oldest-old individuals. Our findings support the use of the 4/5 cut-off score, which showed the best diagnostic capacity.

A critique of phrenology in Moby-Dick

Phrenology has a fascinating, although controversial, place in the history of localizationism of brain and mental functions. The 2 main proponents of phrenology were 2 German-speaking doctors, Joseph Gall (1758-1828) and Johann Spurzheim (1776-1832). According to their theory, a careful examination of skull morphology could disclose personality characters. Phrenology was initially restricted to medical circles and then diffused outside scientific societies, reaching nonscientific audiences in Europe and North America. Phrenology deeply penetrated popular culture in the 19th century and its tenets can be observed in British and American literature. Here we analyze the presence of phrenologic concepts in Moby-Dick; or, The Whale, by Herman Melville (1819-1891), one of the most prominent American writers. In his masterpiece, he demonstrates that he was familiarized with Gall and Spurzheim's writings, but referred to their theory as "semi-science" and "a passing fable." Of note, Melville's fine irony against phrenology is present in his attempt to perform a phrenologic and physiognomic examination of The Whale. Thus, Moby-Dick illustrates the diffusion of phrenology in Western culture, but may also reflect Melville's skepticism and criticism toward its main precepts.