The Frontal Assessment Battery (FAB): normative values in an Italian population sample

Olfaction and taste in Parkinson's disease: the association with mild cognitive impairment and the single cognitive domain dysfunction

Mild cognitive impairment (MCI) and chemosensory dysfunction are non-motor symptoms of Parkinson's disease (PD), but their association is unclear. We explored if MCI and the involvement of single cognitive domains influence olfaction and taste in PD. The role of demographic, clinical and neuropsychiatric variables was tested. We recruited 50 PD patients without dementia, no other reasons for cognitive impairment, no condition that could influence evaluation of cognition, olfaction and taste. They underwent a full neuropsychological and chemosensory (i.e., olfaction and taste) test with the Sniffin' Sticks Extended test (SSET), Whole Mouth test (WMT) and Taste Strips test (TST). Fifty age- and sex-matched healthy subjects served as controls. Olfactory function and sweet identification were worse in PD than controls. MCI negatively influenced odor identification. Factors associated with poor olfactory function were age, overall cognition, apathy, and visuospatial dysfunction. Sour identification was affected by MCI and executive dysfunction, and salty identification by executive dysfunction. MCI, age and executive dysfunction worsened TST score. Awareness of olfactory dysfunction was impaired in PD with MCI. Education positively influenced SSET and TST scores. Our data confirmed that olfaction is abnormal in PD, while taste was only slightly impaired. Olfaction was worse in PD patients with visuospatial dysfunction, while sour and salty identification was worse in those with MCI and executive dysfunction, suggesting different underlying anatomical abnormalities. Future studies should incorporate neuroimaging and cerebrospinal fluid data to confirm this hypothesis. SSET odor identification and TST sour identification could be explored as quick screening tests for PD-MCI.

Closing-In Behavior and Motor Distractibility in Persons with Brain Injury

OBJECTIVE

This study investigates closing-in behavior (CIB), a phenomenon observed in graphic copying tasks when responses encroach upon or overlap the model. The behavior is most common amongst individuals with dementia and amongst pre-school children. We explored the relationship between CIB and the 'distractor effect' in reaching, whereby salient visual stimuli can influence the spatial trajectory of the reach.

METHOD

A group of individuals with overlap-CIB (n = 9), without CIB (n = 9) and healthy controls (HC; n = 6) underwent a task-irrelevant and a task-relevant distractors and the deviation of the movement trajectory towards the distractor location was measured in both tasks.

RESULTS

Individuals with graphic CIB showed more distractor-directed veering during reaching than did individuals without CIB or HC, provided that the distractor was relevant for the reaching task.

CONCLUSIONS

These results strengthen the relationship between CIB and the distractor effect and reinforce the hypothesis that CIB represents a disinhibited tendency to act towards the focus of attention.

Executive Dysfunction Detected with the Frontal Assessment Battery in Alzheimer's Disease Versus Vascular Dementia

Alzheimer's disease (AD) and vascular dementia (VaD) lead to progressive decline in executive function. We estimated the prevalence of executive dysfunction in AD and VaD patients, investigating cognitive, functional, and clinical correlates and also using a multidimensional approach based on a standardized comprehensive geriatric assessment (CGA). We included 215 patients (115 AD patients and 100 VaD patients) consecutively evaluated with a complete cognitive and affective assessment, a CGA, and the Frontal Assessment Battery (FAB) with six subtests investigating conceptualization, mental flexibility, motor programming, sensitivity to interference, inhibitory control, and environmental autonomy. The prevalence of dysexecutive syndrome screened with a FAB score <12 points was high in both AD (97 patients) and VaD (77 patients) (84.3% versus 77.0%, p = 0.171). AD patients were significantly younger, with higher grade of cognitive impairment and less severe comorbidity and polypharmacy than VaD patients. AD patients showed a significantly higher impairment in FAB total score and five FAB subtests (conceptualization, motor programming, sensitivity to interference, inhibitory control, and environmental autonomy) than VaD patients. These findings were largely confirmed in a sub-analysis conducted subdividing the sample in mild and moderate-to-severe demented patients and suggesting that in moderate-to-severe AD there was higher impairment in FAB total score and four FAB subtests (conceptualization, sensitivity to interference, inhibitory control, and environmental autonomy). Executive dysfunction could be greater in AD patients with moderate-to-severe dementia compared to VaD patients, although our groups were also not matched for age, comorbidity or polypharmacy, which could also exert an effect.

Comparison of alternate and original forms of the Montreal Cognitive Assessment (MoCA): an Italian normative study

OBJECTIVE

The Montreal Cognitive Assessment (MoCA) is a screening test widely used in clinical practice and suited for detection of Mild Cognitive Impairment. Alternate forms of the MoCA were developed to avoid "learning effect" in serial assessments, and the present study aimed at investigating inter-form parallelism and at providing normative values for the Italian versions of MoCAs 2 and 3.

METHOD

Three separate convenience samples were recruited: the first (n = 78) completed three alternate MoCA versions for ascertaining inter-form parallelism; the second (n = 302) and the third (n = 413) samples were administered MoCA 2 or 3 to compute normative data.

RESULTS

A three-step procedure complemented by confirmatory factor analysis and a mixed factorial ANOVA suggested that the three MoCA versions are not strictly parallel. Multiple linear regression analysis revealed that age and education significantly influenced MoCA 2 and 3 total scores. No significant effect of sex was found. From the derived linear equation, correction grids for MoCA 2 and 3 raw scores were built and equivalent scores computed. Inferential cutoff for adjusted scores, estimated using a non-parametric technique, were 17.49 for MoCA 2 and 18.34 for MoCA 3. Correlation analysis showed strong correlations of MoCA 2 (r = 0.69, p < .001) and MoCA 3 (r = 0.61, p < .001) adjusted total scores with MMSE adjusted scores.

CONCLUSION

The three MoCA forms are not strictly parallel. Specifically developed normative data must be adopted for using MoCA in serial cognitive assessments for clinical and research studies.

Transcranial direct current stimulation enhances theory of mind in Parkinson's disease patients with mild cognitive impairment: a randomized, double-blind, sham-controlled study

Background

Parkinson’s Disease (PD) with mild cognitive impairment (MCI) (PD-MCI) represents one of the most dreaded complications for patients with PD and is associated with a higher risk of developing dementia. Although transcranial direct current stimulation (tDCS) has been demonstrated to improve motor and non-motor symptoms in PD, to date, no study has investigated the effects of tDCS on Theory of Mind (ToM), i.e., the ability to understand and predict other people’s behaviours, in PD-MCI.

Methods

In this randomized, double-blind, sham-controlled study, we applied active tDCS over the medial frontal cortex (MFC) to modulate ToM performance in twenty patients with PD-MCI. Twenty matched healthy controls (HC) were also enrolled and were asked to perform the ToM task without receiving tDCS.

Results

In the patients with PD-MCI, i) ToM performance was worse than that in the HC, ii) ToM abilities were poorer in those with fronto-executive difficulties, and iii) tDCS over the MFC led to significant shortening of latency for ToM tasks.

Conclusions

We show for the first time that active tDCS over the MFC enhances ToM in patients with PD-MCI, and suggest that non-invasive brain stimulation could be used to ameliorate ToM deficits observed in these patients.

Asymmetric Dopaminergic Degeneration and Attentional Resources in Parkinson's Disease

Background: Attention is crucial to voluntary perform actions in Parkinson's disease (PD), allowing patients to bypass the impaired habitual motor control. The asymmetrical degeneration of the dopaminergic system could affect the attentional functions. Objective: To investigate the relationship between the asymmetric dopaminergic degeneration and the attentional resources in Parkinsonian patients with right-side (RPD) and left-side (LPD) motor symptoms predominance. Methods: 50 RPD, 50 LPD, and 34 healthy controls underwent visual (V), auditory (A), and multiple choices (MC) reaction time (RTs) tasks. For PD patients, these tasks were performed before and after a 4-week intensive, motor-cognitive rehabilitation treatment (MIRT). The effectiveness of treatment was evaluated assessing Unified Parkinson's disease Rating Scale (UPDRS) III and Timed-up and Go Test (TUG). Results: RTs did not differ between PD patients and healthy controls. Before MIRT, no differences between LPD and RPD patients were observed in RTs (p = 0.20), UPDRS III (p = 0.60), and TUG (p = 0.38). No differences in dopaminergic medication were found between groups (p = 0.44 and p = 0.66 before and after MIRT, respectively). After MIRT, LPD patients showed a significant reduction in MC RTs (p = 0.05), V RTs (p = 0.02), and MC-V RTs. A significant association between changes in RTs and improvements in UPDRS III and TUG was observed in LPD patients. Conclusion: attention does not differ among RPD patients, LPD patients and healthy controls. Only LPD patients improved their performances on attentional tasks after MIRT. We argue that the increased early susceptibility of the left nigrostriatal system to degeneration affects differently the cognitive modifiability and the neuroplastic potential. Our results could provide insight into new therapeutic approaches, highlighting the importance to design different treatments for RPD patients and LPD patients.

The association of cognitive reserve with motor and cognitive functions for different stages of Parkinson's disease

INTRODUCTION

The cognitive reserve (CR) theory has been proposed to account for the mismatch between the degree of neuropathological changes and clinical outcome in dementias. Recently, it has also been applied to Parkinson's disease (PD) with promising results, but mostly just focusing on separate proxy measures of CR, such as education, working and leisure time activities, instead of adopting a more comprehensive approach. Using the Cognitive Reserve Index questionnaire (CRIq), this study examined the association of CR with motor functions and cognition in patients with medium-low (1-9 years) and medium-high (>9 years) PD duration.

METHODS

Fifty patients with PD underwent a neurological and a neuropsychological assessment, comprised of: Unified Parkinson's Disease Rating Scale- section III, Mini-Mental State Examination, Clock-Drawing Test, Rey auditory verbal learning test (immediate and delayed recall trials), Digit Span Forward, Corsi Span Forward, Frontal Assessment Battery, Raven's Colored Progressive Matrices, WAIS similarities subtest, Phonemic Fluency, Semantic Fluency and CRIq.

RESULTS

PD patients with a higher CRIq score showed a reduced motor impairment and a better global cognitive performance when compared to PD patients with a lower CRIq score, with an advantage especially observed on executive functions and short-term memory. The CR effect was even enhanced in the case of longer disease duration, as observed when considering the overall neuropsychological tests performance and non-verbal abstract reasoning in particular. The results obtained when considering education, as a single proxy measure of CR, provided no additional findings, nor did they reveal all the effects yielded by the adoption of the CRI score.

CONCLUSION

Our results support the beneficial role of CR against motor and cognitive dysfunctions in PD and suggest that its protective role may be mostly manifested at the later stages of the disease. A theoretical framework able to explain the different impact of CR on Alzheimer Disease and PD is discussed. Finally, our results stressed the importance of using a comprehensive measure of CR instead of focusing on just one of its proxies.

Measuring executive dysfunction in Parkinson's disease: Reliability and validity of the Spanish version of Frontal Assessment Battery (FAB-E)

Background

Deficits in executive functions (EFs) are frequently detected in patients with Parkinson’s disease (PD). The Frontal Assessment Battery (FAB) is a screening test for assessing EFs although it has not been so far adapted and validated in Spain. We evaluated the reliability and validity of the Spanish version of the FAB (FAB-E) in PD patients.

Materials and methods

Our study included 54 healthy subjects and 67 PD patients. Cognitive assessment of participants was conducted using the FAB-E, Mini-Mental State Examination (MMSE), Trail Making Test (TMT), Revised-Barcelona Test (RBT) and Executive Interview (EXIT-25). Internal consistency, intra- and test-retest reliabilities, concurrent and discriminant validity of the FAB-E were examined. To evaluate the influence of cognitive dysfunction in PD on the performance of the FAB-E, we also classified the PD patients into groups according to their cognitive status as measured by the MMSE using published criteria to identify cognitive deficits in PD.

Results

The FAB-E showed good internal consistency (α = 0.751). The intraclass correlation coefficients (ranging from 0.559 to 0.891) and Spearman correlations (from 0.494 to 0.864) of the FAB-E subtests indicated a good-strong reliability. The total and subtest scores generally showed a good concurrent validity, except for the prehension behaviour item of the FAB-E and the Interference and Go/no-go tasks of the EXIT-25 that presented low estimates. Excluding the prehension behaviour subtest, the performance of the FAB-E was higher in the control group than in PD patients. Cognitive dysfunction in PD patients also indicated significant poorer FAB-E scores excepting the motor and prehension behaviour subtests. Discriminant analysis determined a cut-off of 14.5 was optimal to differentiate healthy subjects from PD patients. Moreover, a cut-off <12.5 allocated satisfactorily those PD patients with cognitive impairment (MMSE<26) and scores <11.5 classified suitably those PD patients with dementia (MMSE<24).

Conclusion

The FAB-E is an accurate tool for evaluating EFs in patients with PD and can provide useful information for distinguishing PD patients with and without cognitive dysfunction at a bedside assessment.

Spatial disorientation and executive dysfunction in elderly nondemented patients with Parkinson's disease

OBJECTIVES

Patients with Parkinson's disease (PD) present with a wide range of cognitive deficits. Cognitive impairment is recognized as an independent nonmotor aspect of the disorder and has a critical role in functional outcome and conversion into PD dementia. To date, everyday memory impairment in elderly patients with PD is underinvestigated and its relationship with executive dysfunction was not clearly explained. Our study aims at clarifying the neuropsychological pattern of everyday memory and executive deterioration in elderly patients with PD.

METHODS

Forty nondemented PD patients (mean age 71.2 years; M:F = 29:11) and 30 well-matched controls (mean age 70.7 years; M:F = 15:15) were assessed on everyday memory (Rivermead Behavioral Memory Test [RBMT]) and executive functioning (Frontal Assessment Battery [FAB]) measures. Mann-Whitney U-tests (Bonferroni corrected) were used to compare groups on these measures and Spearman's rank correlations were performed to highlight their associations.

RESULTS

PD patients performed worse than controls on recall for novel tasks and geographic recall (RMBT) as well as lexical fluency and mental flexibility (FAB). Particularly, spatial orientation depending on egocentric navigation seems to be altered in PD patients. The clinical group showed poorer performances than controls in mental flexibility, sensitivity to interference, and inhibitory control. Such measures were associated with immediate and delayed recall, picture recognition, prospective memory, and orientation tasks of everyday memory.

CONCLUSION

Executive-type difficulties and memory-type difficulties have an impact on cognitive performances of elderly patients with PD. We recommend using the RBMT and the FAB as part of routinely neuropsychological battery for assessing PD patients.

Effects of Combined Physical and Cognitive Virtual Reality-Based Training on Cognitive Impairment and Oxidative Stress in MCI Patients: A Pilot Study

The growing elderly population and the increased incidence of mild cognitive impairment (MCI) and Alzheimer's disease (AD) call for the improvement of the quality and the efficacy of the healthcare and social support services. Exercise and cognitive stimulation have been demonstrated to mitigate cognitive impairment and oxidative stress (OxS) has been recognized as a factor that contributes to the advancement of neurodegenerative diseases. Taking these aspects into account, the impact of a novel virtual reality (VR)-based program combining aerobic exercise and cognitive training has been evaluated in the pilot study proposed here. Ten patients (aged 73.3 ± 5.7 years) with MCI (Mini-Mental State Examination, MMSE: 23.0 ± 3.4) were randomly assigned to either 6 weeks physical and cognitive training (EXP) or control (CTR) group. Evaluations of cognitive profile, by a neuropsychological tests battery, and OxS, by collection of blood and urine samples, were performed before and at the end of the experimental period. The assessment of the patients' opinions toward the intervention was investigated through questionnaires. EXP group showed a tendency towards improvements in the MMSE, in visual-constructive test and visuo-spatial tests of attention, while CTR worsened. EXP group showed a greater improvement than CTR in the executive test, memory functions and verbal fluency. No statistical significance was obtained when comparing within and between both the groups, probably due to small number of subjects examined, which amplifies the effect of the slight heterogeneity in scores recorded. Despite a greater worsening of Daily Living Activities tests, all participants reported a better performance in real life, thanks to the elicited self-perceived improvement. After training intervention OxS (i.e., reactive oxygen species (ROS) production, oxidative damage of lipids and DNA) decreased resulting in significantly (range p < 0.05-0.001) lower in EXP vs. CTR group. Although not conclusive, the recorded effects in the present study are promising and suggest that this proposal would be a useful tool in support of cognitive training reducing OxS too. However, further studies on larger scale samples of patients are needed.

Intensive Multimodal Training to Improve Gait Resistance, Mobility, Balance and Cognitive Function in Persons With Multiple Sclerosis: A Pilot Randomized Controlled Trial

Introduction: Persons with multiple sclerosis (MS) have deficits in many aspects of physical and cognitive functioning that can impact on mobility and participation in daily life. The effect of a 4 week intensive multimodal treadmill training on functional mobility, balance, executive functions and participation in persons with MS with moderate to severe disability was investigated.

Methods: Thirty eight persons with MS admitted to a rehabilitation center participated in a two arm randomized 2:1 controlled trial. Participants in the experimental group received supervised intensive treadmill training including cognitive and motor dual tasks (DT-group, N = 26), 5 sessions per week and a control group received the same amount of supervised strength training (S-group, N = 12). The participants were assessed before and after the rehabilitation period with the 2 Minutes Walking Test (2MWT), speed and, static and dynamic balance measures, the Frontal Assessment Battery and the Short Form-12 questionnaire. The main hypothesis was related to the superiority of the treadmill intervention based on a greater proportion of people making a clinically relevant gain (15% increase on 2MWT) in gait resistance following treatment. ANCOVA (Analysis of covariance) models adjusting for baseline measurement of the respective outcome variable, as well as sex and age, were used to evaluate differences in efficacy for all variables. P was set at 0.05.

Results: Nineteen out of 26 persons in the DT-group made a clinically relevant gain and two out of 12 in the S-Group (P = 0.001). The DT-group improved more in gait resistance, speed and mobility (P < 0.01). Balance and executive functions instead improved moderately in both groups following training while perception of health remained similar in both groups.

Conclusion: A four week multimodal training on treadmill was highly effective in augmenting gait resistance and mobility in moderately to severely affected persons with MS.

Fronto-Temporal Circuits in Musical Hallucinations: A PET-MR Case Study

The aim of the study is to investigate morphofunctional circuits underlying musical hallucinations (MH) in a 72-years old female that underwent a simultaneous 18fluoredeoxyglucose positron emission tomography (PET) and advanced magnetic resonance (MR) exam. This represents a particular case of MH occurred in an healthy subject, not displaying neurological or psychopathological disorders, and studied simultaneously with a multimodal approach. For the resting-state fMRI analysis a seed to seed approach was chosen. For the task-based fMRI, 4 different auditory stimuli were presented. Imaging findings were compared with data obtained by ten healthy controls matched for age and sex. Neuropsychological evaluation and questionnaires investigating depression and anxiety were also administered. PET findings showed hypermetabolism of: superior temporal gyri, anterior cingulate, left orbital frontal, and medial temporal cortices. Structural MRI did not show macroscopical lesions except for gliotic spots along the uncinate fascicle pathways with an increased cortical thickness for the right orbitofrontal cortex (p = 0.003). DTI showed increased fractional anisotropy values in the left uncinate fascicle, when compared to controls (p = 0.04). Resting-state fMRI showed increased functional connectivity between the left inferior frontal gyrus and the left temporal fusiform cortex (p = 0.01). Task-based fMRI confirmed PET findings showing an increased activation of the superior temporal gyrus in all the auditory tasks except for the monotone stimulus, with a significant activation of the left orbital frontal cortex only during the song in foreign language, object of MH. Results on cognitive test did not show cognitive impairment, excepting for the performance on Frontal Assessment Battery where the patient fails in the cognitive domains of conceptualization, sensitive to interference, and inhibitory control. The subject did not show depressive or anxiety symptoms. Summarizing, multimodal imaging analyses in the MH case showed a microstructural alteration of the left uncinate fascicle paralleled by an increased metabolism and functional connectivity of cortical regions that receive left uncinate projections (orbital frontal cortex, and medial temporal cortex). This alteration of fronto-hyppocampal circuits could be responsible of retrieval of known songs even in the absence of real stimuli.

Neuropsychological and Psychological Functioning Aspects in Myotonic Dystrophy Type 1 Patients in Italy

Introduction: Myotonic Dystrophy Type 1 (DM1) is an autosomal dominant genetic illness, characterized by a progressive loss of strength. Important deficits in cognitive functioning and a significant prevalence of psychiatric disorders have been previously reported.

Methods:A neuropsychological and psychological assessment was carried out in 31 DM1 patients (61% males) in order to measure the cognitive functioning and explore their personality profiles. The MMSE Mini-Mental State Examination, Frontal Assessment Battery (FAB), ENB-2 Battery assessing memory (short term, long term and working memory), integration capacities, visual-spatial ability, attention (selective, divided, shifting/switching) executive functions, praxis, discrimination and logic capabilities and psychopathology Symptom Check List 90-R (SCL-90-R) were administered. The neuropsychological and psychological evaluation of DM1 patients was carried out taking into consideration the clinical parameters (CTG repeat, age at onset, disease duration, Muscular Impairment Rate Scale (MIRS), Medical Research Council Scale (MRC) and the Epworth Sleepiness Scales (EPS)).

Results: Regarding psychopathology 19.4% of patients scored a moderate or high level of symptoms intensity index (GSI), 12.9% reported a high number of symptoms (PST) and 16.1% reported a high intensity level of the perceived symptoms (PSDI). Fatigue and daytime sleepiness resulted as being associated with higher levels of psychoticism (PSY). Only 1 patient reported a severe impairment in the spatial and temporal orientation, memory, language, praxis, attention and calculation. Longer disease duration was also associated with cognitive impairment evaluated through ENB-2 (p < 0.05).

Discussions and Conclusions:There are indications of the utility of neuropsychological and psychological screening and support for these patients and their families due to the link between disease duration and cognitive performances. A proposal of a clinical protocol, with an illustration of a clinical case report of a family is presented.

Closing-in Behavior and Parietal Lobe Deficits: Three Single Cases Exhibiting Different Manifestations of the Same Behavior

Closing-in behavior (CIB) is observed in copying tasks (graphic or gestural) when the copy is performed near or on the top of the model. This symptom has been classically considered to be a manifestation of constructional apraxia and is often associated with a visuospatial impairment. More recent work emphasizes the attentional and/or executive nature of the behavior and its association with frontal lobe dysfunction. We describe three patients in whom CIB was associated with posterior parietal deficits of different etiologies (stroke in Patient 1 and dementia in Patients 2 and 3). In copying figures, Patient 1 produced the shape with high accuracy but the rendering overlapped the model, while for Patients 2 and 3 the copies were distorted but overlapping or in close proximity to the target. In gesture imitation, Patient 2 performed the gestures toward the examiner's space, while Patient 1 showed a peculiar form of CIB: when he was asked to place the ipsilesional arm in a position that mirrored the contralesional hand, Patient 1 moved his hand toward his contralesional hand. Patient 3 did not present gestural CIB. While CIB in Patient 1 was associated with selective deficits in executive functions and attention, additional visuospatial deficits were observed in Patients 2 and 3. The latter two patients showed a general visuoconstructional deficit. These case studies support a primary attentional account of CIB but also suggest that visuoconstructional impairments may contribute to the emergence of CIB, in some subjects. This evidence argues for different types of CIB with different cognitive and neural underpinnings. Furthermore, the data support the hypothesis of a differential involvement of fronto-parietal network in CIB.

Using Artificial Neural Networks for Identifying Patients with Mild Cognitive Impairment Associated with Depression Using Neuropsychological Test Features

Depression and cognitive impairment are intimately associated, especially in elderly people. However, the association between late-life depression (LLD) and mild cognitive impairment (MCI) is complex and currently unclear. In general, it can be said that LLD and cognitive impairment can be due to a common cause, such as a vascular disease, or simply co-exist in time but have different causes. To contribute to the understanding of the evolution and prognosis of these two diseases, this study’s primary intent was to explore the ability of artificial neural networks (ANNs) to identify an MCI subtype associated with depression as an entity by using the scores of an extensive neurological examination. The sample consisted of 96 patients classified into two groups: 42 MCI with depression and 54 MCI without depression. According to our results, ANNs can identify an MCI that is highly associated with depression distinguishable from the non-depressed MCI patients (accuracy = 86%, sensitivity = 82%, specificity = 89%). These results provide data in favor of a cognitive frontal profile of patients with LLD, distinct and distinguishable from other cognitive impairments. Therefore, it should be taken into account in the classification of MCI subtypes for future research, including depression as an essential variable in the classification of a patient with cognitive impairment.

Integrated Cognitive and Neuromotor Rehabilitation in Multiple Sclerosis: A Pragmatic Study

Background: Few studies examined the effects of combined motor and cognitive rehabilitation in patients with multiple sclerosis (MS). The present prospective, multicenter, observational study aimed to determine the efficacy of an integrated cognitive and neuromotor rehabilitation program versus a traditional neuromotor training on walking, balance, cognition and emotional functioning in MS patients.

Methods: Sixty three MS patients were selected and assigned either to the Integrated Treatment Group (ITG; n = 32), receiving neuropsychological treatment (performed by ERICA software and paper–pencil tasks) complemented by conventional neuromotor rehabilitation, or to the Motor Treatment Group (n = 31) receiving neuromotor rehabilitation only. The intervention included two 60-min sessions per week for 24 weeks. At baseline and at end of the training all patients underwent a wide-range neuropsychological, psychological/emotional, and motor assessment.

Results: At baseline the two groups did not differ for demographic, neuropsychological, psychological/emotional, and motor features significantly. After rehabilitation, only ITG group significantly (p-corrected for False Discovery Rate) improved on test tapping spatial memory, attention and cognitive flexibility, as well as on scales assessing depression and motor performance (balance and gait). A regression analysis showed that neuropsychological and motor improvement was not related to improvements in fatigue and depression.

Conclusion: The present study demonstrated positive effects in emotional, motor, and cognitive aspects in MS patients who received an integrated cognitive and neuromotor training. Overall, results are supportive of interventions combining motor and cognitive training for MS.

Anodal frontal tDCS for chronic cluster headache treatment: a proof-of-concept trial targeting the anterior cingulate cortex and searching for nociceptive correlates

BACKGROUND

Percutaneous occipital nerve stimulation (ONS) is effective in refractory chronic cluster headache (rCCH) patients. Responders to ONS differ from non-responders by greater glucose metabolism in subgenual anterior cingulate cortex (sgACC). We reasoned that transcranial direct current stimulation (tDCS), a non-invasive approach, might be able to activate this area and thus improve rCCH patients. Our objective was to explore in a pilot trial the therapeutic potential of tDCS (anode at Fz, cathode over C7) and its possible effects on pain perception, frontal executive functions and mood in rCCH patients.

METHODS

Thirty-one patients were asked to apply daily 20-min sessions of 2 mA tDCS for 4 or 8 weeks after a 1-month baseline. CH attacks were monitored with paper diaries. The primary outcome measure was change in weekly attacks between baseline and the last week of tDCS. Twenty-three patients were available for a modified ITT analysis, 21 for per-protocol analysis. We also explored treatment-related changes in thermal pain thresholds and nociceptive blink reflexes (nBR), frontal lobe function and mood scales.

RESULTS

In the per-protocol analysis there was a mean 35% decrease of attack frequency (p = 0.0001) with 41% of patients having a ≥ 50% decrease. Attack duration and intensity were also significantly reduced. After 8 weeks (n = 10), the 50% responder rate was 45%, but at follow-up 2 weeks after tDCS (n = 16) mean attack frequency had returned to baseline levels. The treatment effect was significant in patients with high baseline thermal pain thresholds in the forehead (n = 12), but not in those with low thresholds (n = 9). The Frontal Assessment Battery score increased after tDCS (p = 0.01), while there was no change in depression scores or nBR.

CONCLUSION

tDCS with a Fz-C7 montage may have a preventive effect in rCCH patients, especially those with low pain sensitivity, suggesting that a sham-controlled trial in cluster headache is worthwhile. Whether the therapeutic effect is due to activation of the sgACC that can in theory be reached by the electrical field, or of other prefrontal cortical areas remains to be determined.

Cognitive estimation: Performance of patients with focal frontal and posterior lesions

The Cognitive Estimation Test (CET) is a widely used test to investigate estimation abilities requiring complex processes such as reasoning, the development and application of appropriate strategies, response plausibility checking as well as general knowledge and numeracy (e.g., Shallice and Evans, 1978; MacPherson et al., 2014). Thus far, it remains unknown whether the CET is both sensitive and specific to frontal lobe dysfunction. Neuroimaging techniques may not represent a useful methodology for answering this question since the complex processes involved are likely to be associated with a large network of brain regions, some of which are not functionally necessary to successfully carry out the CET. Instead, neuropsychological studies may represent a more promising investigation tool for identifying the brain areas necessary for CET performance. We recently developed two new versions of the CET (CET-A and CET-B; MacPherson et al., 2014). We investigated the overall performance and conducted an error analysis on CET-A in patients with focal, unilateral, frontal (n = 38) or posterior (n = 22) lesions and healthy controls (n = 39). We found that frontal patients' performance was impaired compared to healthy controls on CET. We also found that frontal patients generated significantly poorer estimates than posterior patients on CET-A. This could not be explained by impairments in fluid intelligence. The error analyses suggested that for CET-A, extreme and very extreme responses are impaired following frontal lobe damage. However, only very extreme responses are significantly more impaired following frontal lobe than posterior damage and so represent a measure restricted to frontal "executive" impairment, in addition to overall CET performance.

A new MAPT deletion in a case of speech apraxia leading to corticobasal syndrome

Speech apraxia is a disorder of speech motor planning/programming leading to slow rate, articulatory distortion, and distorted sound substitutions. We describe the clinical profile evolution of a patient presenting with slowly progressive isolated speech apraxia that eventually led to the diagnosis of corticobasal syndrome (CBS), supporting the evidence that this rare speech disorder can be the first presentation of CBS. Moreover, we found a novel variant in MAPT gene, which is hypothesized to be disease-causing mutation. These results underscore the importance of genetic analysis - particularly in selected atypical cases - for in vivo understanding of possible pathophysiological disease process.

Come together: human-avatar on-line interactions boost joint-action performance in apraxic patients

Limb apraxia (LA) is a high-order motor disorder linked to left-hemisphere damage. It is characterized by defective execution of purposeful actions upon delayed imitation, or verbal command when the actions are performed in isolated, non-naturalistic, conditions. Whether interpersonal interactions provide social affordances that activate neural resources different from those requested by individual action execution, which may improve LA performance, is unknown. To fill this gap, we measured interaction performance, behavioral and kinematic indexes of left-brain damaged patients with/without LA in a social reach-to-grasp task involving two different degrees of spatio-temporal interactivity with an avatar. We found that LA patients' impairment in coordinating with the virtual partner was abolished in highly interactive conditions (where patients selected their actions on-line based on the behavior of the virtual partner) with respect to low interactive conditions (where actions were selected beforehand based on abstract instructions). Voxel-based-Lesion-Symptom-Mapping indicated that impairments in low-interactive conditions were underpinned by lesions of premotor, motor and insular areas, and of the basal ganglia. Our approach expands current understanding of the behavioral and neural correlates of interactive motor performance by highlighting the important role of social affordances, and provides novel, potentially important, views on rehabilitation of higher-order motor cognition disorders.

Neural Correlates of Anosognosia in Alzheimer's Disease and Mild Cognitive Impairment: A Multi-Method Assessment

Patients with Alzheimer's Disease (AD) and Mild Cognitive Impairment (MCI) may present anosognosia for their cognitive deficits. Three different methods have been usually used to measure anosognosia in patients with AD and MCI, but no studies have established if they share similar neuroanatomical correlates. The purpose of this study was to investigate if anosognosia scores obtained with the three most commonly used methods to assess anosognosia relate to focal atrophy in AD and MCI patients, in order to improve understanding of the neural basis of anosognosia in dementia. Anosognosia was evaluated in 27 patients (15 MCI and 12 AD) through clinical rating (Clinical Insight Rating Scale, CIRS), patient-informant discrepancy (Anosognosia Questionnaire Dementia, AQ-D), and performance discrepancy on different cognitive domains (self-appraisal discrepancies, SADs). Voxel-based morphometry correlational analyses were performed on magnetic resonance imaging (MRI) data with each anosognosia score. Increasing anosognosia on any anosognosia measurement (CIRS, AQ-D, SADs) was associated with increasing gray matter atrophy in the medial temporal lobe including the right hippocampus. Our results support a unitary mechanism of anosognosia in AD and MCI, in which medial temporal lobes play a key role, irrespectively of the assessment method used. This is in accordance with models suggesting that anosognosia in AD is primarily caused by a decline in mnemonic processes.

Diagnostic accuracy of new and old cognitive screening tools for HIV-associated neurocognitive disorders

OBJECTIVES

Considering the similarities between HIV-associated neurocognitive disorders (HAND) and neurodegenerative dementias and the frequency of executive dysfunctions among HIV-positive patients, we evaluated the accuracy of the Frontal Assessment Battery and Clock-Drawing Test together with the Three Questions Test and International HIV Dementia Scale to screen for HAND.

METHODS

A cross-sectional monocentric study was conducted from 2010 to 2017. The index tests were represented by the four screening tools; the reference standard was represented by a comprehensive neurocognitive battery used to investigate 10 cognitive domains. Patients were screened by a trained infectious diseases physician and those showing International HIV Dementia Scale scores ≤ 10 and/or complaining of neurocognitive symptoms were then evaluated by a trained neuropsychologist.

RESULTS

A total of 650 patients were screened and 281 received the full neurocognitive evaluation. HAND was diagnosed in 140 individuals. The sensitivity, specificity, correct classification rate and area under the receiver operating characteristic curve (AUROC) were, respectively, as follows: Frontal Assessment Battery, 40.7%, 95.1%, 68.3% and 0.81; International HIV Dementia Scale, 74.4%, 56.8%, 65.4% and 0.73; Clock-Drawing Test, 30.9%, 73.4%, 53.8% and 0.56; and Three Questions Test, 37.3%, 54.1% and 45.7%. Raising the Frontal Assessment Battery's cut-off to ≤ 16 improved its sensitivity, specificity and correct classification rate to 78.0%, 63.9% and 70.8%, respectively.

CONCLUSIONS

We observed poor screening performances of the Three Questions and Clock-Drawing Tests. While the International HIV Dementia Scale showed a poor specificity, the Frontal Assessment Battery showed the highest correct classification rate and a promising performance at different exploratory cut-offs.

Reduced gray matter volume is correlated with frontal cognitive and behavioral impairments in Parkinson's disease

OBJECTIVE

To identify the brain-volume reductions associated with frontal cognitive and behavioral impairments in Parkinson's disease (PD).

METHODS

Forty PD patients without dementia or amnesia (Hoehn and Yahr stage 3) and 10 age-matched controls underwent brain magnetic resonance imaging. Cognitive and behavioral impairments were assessed by using the Frontal Assessment Battery (FAB) and Frontal Systems Behavioral Scale (FrSBe), respectively. We applied voxel-based morphometry to investigate the correlations of regional gray matter volume with FAB, FrSBe, and physical disability.

RESULTS

FAB was significantly lower in PD than in controls. FrSBe was significantly higher after PD onset than before, notably in the apathy subscale. FAB and FrSBe were significantly intercorrelated. In PD patients, left inferior frontal volume was positively correlated with FAB, whereas right precentral volume was negatively correlated with FrSBe total score. The brain volumes in both of these regions were not correlated with the Unified PD Rating Scale III.

CONCLUSION

Behavioral impairments in PD tended to coexist with progression of frontal cognitive impairment. Regional atrophy within the frontal lobe was associated with both frontal cognitive and behavioral impairments. However, the specific region responsible for behavioral impairment differed from that for frontal cognitive impairment. These associations were independent of physical disability.

The Closing-In Phenomenon in an Ecological Walking Task

OBJECTIVES

Alzheimer's disease (AD) patients may show the Closing-in (CI), a tendency to reproduce figures close to or superimposed on the model. AD patients with CI might manifest reduced functional independence compared to AD patients without CI, but no study directly assessed if CI can hamper common daily living activities. To address this issue here we investigated whether AD patients with CI veer their walking trajectory toward irrelevant objects more often than AD patients without CI.

METHODS

Fifty AD individuals, and 20 age- and education-matched healthy adults, underwent a graphic copying task to detect CI and a newly developed walking task to assess the tendency to veer toward irrelevant objects and to bump into them. All participants also completed a comprehensive neuropsychological battery to assess dementia severity; impairments in frontal/executive, visuo-spatial, visuo-constructional, and memory domains; and functional independence in daily living activities.

RESULTS

Graphic CI occurred in 34/50 (68%) AD patients (AD-CI group) who achieved significantly lower scores on frontal/executive abilities, and daily living functioning than AD individuals not showing CI. Most AD-CI patients (20/34; 58.8%) also showed at least one veering error in the walking task. Participants with CI and veering errors showed significantly poorer performance on Stroop test, and lower level of functional independence than AD individuals with CI in isolation.

CONCLUSIONS

CI on graphic tasks can identify difficulties in walking and in complying with everyday activities in AD patients. These observations demonstrate the value of assessing CI in copying tasks. (JINS, 2018, 24, 437-444).

Specific Patterns of White Matter Alterations Help Distinguishing Alzheimer's and Vascular Dementia

Alzheimer disease (AD) and vascular dementia (VaD) together represent the majority of dementia cases. Since their neuropsychological profiles often overlap and white matter lesions are observed in elderly subjects including AD, differentiating between VaD and AD can be difficult. Characterization of these different forms of dementia would benefit by identification of quantitative imaging biomarkers specifically sensitive to AD or VaD. Parameters of microstructural abnormalities derived from diffusion tensor imaging (DTI) have been reported to be helpful in differentiating between dementias, but only few studies have used them to compare AD and VaD with a voxelwise approach. Therefore, in this study a whole brain statistical analysis was performed on DTI data of 93 subjects (31 AD, 27 VaD, and 35 healthy controls—HC) to identify specific white matter patterns of alteration in patients affected by VaD and AD with respect to HC. Parahippocampal tracts were found to be mainly affected in AD, while VaD showed more spread white matter damages associated with thalamic radiations involvement. The genu of the corpus callosum was predominantly affected in VaD, while the splenium was predominantly affected in AD revealing the existence of specific patterns of alteration useful in distinguishing between VaD and AD. Therefore, DTI parameters of these regions could be informative to understand the pathogenesis and support the etiological diagnosis of dementia. Further studies on larger cohorts of subjects, characterized for brain amyloidosis, will allow to confirm and to integrate the present findings and, furthermore, to elucidate the mechanisms of mixed dementia. These steps will be essential to translate these advances to clinical practice.

Cognitive Function Does Not Impact Self-reported Health-Related Quality of Life in Heart Failure Patients

BACKGROUND

Adults with heart failure (HF) often demonstrate impairment across multiple domains of cognitive functioning and report poor health-related quality of life (HRQoL). Previous researchers have found that cognitive deficits were generally not associated with HRQoL in a carefully evaluated sample. The exception was memory, which was only weakly associated with HRQoL. However, cognitive deficits interfere with self-care and disease self-management, which could be expected to affect HRQoL.

OBJECTIVE

We sought to verify this counterintuitive finding in a large well-characterized sample of HF patients using a well-validated neuropsychological battery.

METHODS

Participants were 302 adults (63% male) predominately white (72.5%) HF patients (68.7 ± 9.6 years) recruited from 2 medical centers. Self-reported HRQoL was assessed using the Kansas City Cardiomyopathy Questionnaire. Participants completed a neuropsychological battery examining attention, executive function, memory, and visuospatial functioning. Hierarchical multiple linear regression was used for analyses.

RESULTS

Mild global cognitive impairment was observed in 29.5% of the sample (Modified Mini-Mental State [3MS] Examination score <90). Controlling for gender, depression, HF severity, premorbid IQ, comorbidities, and education, only executive function predicted HRQoL, β = .17, P < .05. However, executive function accounted for only 0.6% of the variance in HRQoL.

CONCLUSION

Cognitive function generally did not predict HRQoL in HF patients. The correlates of HRQoL in HF do not appear to include mild cognitive impairment. Other factors may play a bigger role such as disease severity, age, and depressive symptoms. Future studies should investigate modifiable determinants of HRQoL in HF patients, toward the goal of finding interventions that preserve HRQoL during this chronic illness.

Biomarkers study in atypical dementia: proof of a diagnostic work-up

BACKGROUND

An early differentiation between Alzheimer's Disease (AD) and other dementias is crucial for an adequate patients' management, albeit it may result difficult for the occurrence of "atypical presentations." Current diagnostic criteria recognize the importance of biomarkers for AD diagnosis, but still an optimal diagnostic work-up isn't available.

OBJECTIVE

Evaluate the utility and reproducibility of biomarkers and propose an "optimal" diagnostic work-up in atypical dementia.

METHODS

(1) a retrospective selection of "atypical dementia cases"; (2) a repetition of diagnostic assessment by two neurologists following two different diagnostic work-ups, each consisting of multiple steps; (3) a comparison between diagnostic accuracy and confidence reached at each step by both neurologists and evaluation of the inter-rater agreement.

RESULTS

In AD, regardless of the undertaken diagnostic work-up, a significant gain in accuracy was reached by both neurologists after the second step, whereas in frontotemporal dementia (FTD), adding subsequent steps was not always sufficient to increase significantly the baseline accuracy. A relevant increment in diagnostic confidence was detectable after studying pathophysiological markers in AD, and after assessing brain metabolism in FTD. The inter-rater agreement was higher at the second step for the AD group when the pathophysiological markers were available and for the FTD group when the results of FDG-PET were accessible.

CONCLUSIONS

In atypical cases of dementia, biomarkers significantly raise diagnostic accuracy, confidence, and agreement. This study introduces a proof of diagnostic work-up that combines imaging and CSF biomarkers and suggests distinct ways to proceed on the basis of a greater diagnostic likelihood.

Use of neuropsychological tests for the diagnosis of dementia: a survey of Italian memory clinics

AIM

Providing an overview of the neuropsychological tests used in Italian memory clinics (defined as Centers for Cognitive Disorders and Dementias-CCDD in Italy) for the diagnosis of cognitive disorders and dementias.

METHODS

A total of 501 CCDD, out of all 536 active CCDD, were surveyed between February 2014 and August 2015 to verify the characteristics of the centres who performed a comprehensive neuropsychological assessment (NPA), defined as the administration of at least one test for verbal and visual episodic memory, attention, constructional praxis, verbal fluency and executive functions (minimum core tests-MCTs), as part of the diagnostic process.

RESULTS

A total of 45.7% of Italian CCDD performed a comprehensive MCT as part of the diagnostic process. The logistic regression model showed that the probability of including at least one psychologist in the team was higher in the CCDD that reported using a comprehensive NPA (OR 4.55; 95% CI 2.92 to 7.1), that CCDD in Southern Italy had a lower probability of using an MCT (OR 0.56; 95% CI 0.35 to 0.89) and that the use of an MCT was higher in university/Institute for Scientific Research and Healthcare CCDD (OR 10.97; 95% CI 3.85 to 31.25).

CONCLUSION

Almost half of the CCDD administered a set of MCTs; while the remaining centres only performed few tests or screening procedures. The neuropsychological tests used in Italian CCDD were comparable with those used in other European countries. Performing a comprehensive NPA remains the best way to assess and monitor cognitive deficits over time, thus further debate on the current status of NPAs in clinical practice is needed.

Conjunctive rehabilitation of multiple cognitive domains for chronic stroke patients in virtual reality

Classically, cognitive deficits have been studied and treated in isolation from each other. A stroke patient is classified as being memory impaired, having executive dysfunction or showing attentional deficits after which a dedicated rehabilitation therapy is given. Studies seldom looked at the relationship between these different cognitive domains and syndromes, although, there is evidence that they might share common neuronal substrates and do not occur in isolation. Here, we propose a novel rehabilitation method in virtual reality to treat cognitive deficits in conjunction and report the preliminary results of an ongoing randomized controlled clinical trial. The current results suggest that in a homogeneous patient group the cognitive deficits are correlated and that the individual impairment level can be optimally addressed through an adaptive training paradigm.

Impact of Nitric Oxide Bioavailability on the Progressive Cerebral and Peripheral Circulatory Impairments During Aging and Alzheimer's Disease

Advanced aging, vascular dysfunction, and nitric oxide (NO) bioavailability are recognized risk factors for Alzheimer's disease (AD). However, the contribution of AD, per se, to this putative pathophysiological mechanism is still unclear. To better answer this point, we quantified cortical perfusion with arterial spin labeling (PVC-CBF), measured ultrasound internal carotid (ICA), and femoral (FA) artery blood flow in a group of patients with similar age (~78 years) but different cognitive impairment (i.e., mild cognitive impairment MCI, mild AD-AD1, moderate AD-AD2, and severe AD-AD3) and compared them to young and healthy old (aged-matched) controls. NO-metabolites and passive leg-movement (PLM) induced hyperemia were used to assess systemic vascular function. Ninety-eight individuals were recruited for this study. PVC-CBF, ICA, and FA blood flow were markedly (range of 9–17%) and significantly (all p < 0.05) reduced across the spectrum from YG to OLD, MCI, AD1, AD2, AD3 subjects. Similarly, plasma level of nitrates and the values of PLM were significantly reduced (range of 8–26%; p < 0.05) among the six groups. Significant correlations were retrieved between plasma nitrates, PLM and PVC-CBF, CA, and FA blood flow. This integrative and comprehensive approach to vascular changes in aging and AD showed progressive changes in NO bioavailability and cortical, extracranial, and peripheral circulation in patients with AD and suggested that they are directly associated with AD and not to aging. Moreover, these results suggest that AD-related impairments of circulation are progressive and not confined to the brain. The link between cardiovascular and the central nervous systems degenerative processes in patients at different severity of AD is likely related to the depletion of NO.

Cognitive Estimation in Non-demented Parkinson's Disease

Objective

The Cognitive Estimation Test (CET) is widely used in clinical and research settings to assess the ability to produce reasonable estimates to items that individuals would not know that the exact answer (e.g., "How fast do race horses run?"). We examined the performance of non-demented Parkinson's disease (PD) patients on the CET, because previous studies reported heterogeneous results about possible cognitive estimation impairments in PD. We also examined whether PD patients improve their performance if given the chance to reconsider their initial CET responses.

Methods

Thirty non-demented idiopathic PD patients and 30 healthy controls matched in age, gender and years of education performed the two parallel forms of Italian CET. The estimation scores for initial and final responses as well as the number of times individuals changed their answers were examined. Additional neuropsychological tests, evaluating intellectual, frontal executive, speed of processing, naming and arithmetical abilities, were also administered.

Results

The PD group were not significantly poorer than healthy controls at estimating the answers to items on either CET versions. Moreover, PD patients did not significantly differ in their initial and final responses or number of response changes. Performance on the CET was significantly related to performance on a global measure of executive function, processing speed and arithmetic. However, PD patients were impaired compared to controls on the component involving mainly, but not exclusively, length-related estimations.

Conclusions

Non-demented PD patients have mild impairments in cognitive estimation ability, which may depend on the estimations they are required to provide.

Mild cognitive impairment in Parkinson's disease: the Parkinson's disease cognitive study (PACOS)

Approximately 30% of Parkinson's disease (PD) patients show impaired cognitive performance, which is suggestive of Mild Cognitive Impairment (MCI), representing a predictor of dementia, especially when present at diagnosis. The objective of the study was to evaluate the frequency and clinical predictors of MCI in a large hospital-based cohort of PD patients. We collected cross-sectional data from the Parkinson's disease cognitive impairment study (PACOS), a multicenter study involving two Movement Disorder centers, which are located in south Italy. The PD subjects were diagnosed according to the UK Brain Bank criteria and they underwent an extensive neuropsychological assessment. PD-MCI was diagnosed according to the Movement Disorder Society task force criteria for MCI. PD severity was evaluated in accordance with the Unified PD Rating Scale-Motor Examination (UPDRS-ME) and the Hoehn and Yahr scales. The study included 659 PD patients (57.5% men; mean age 67.0 ± 9.7 years), with a mean disease duration of 3.8 ± 4.6 years and a mean UPRDS-ME score of 25.8 ± 12.3. PD-MCI was diagnosed in 261 (39.6%) subjects and in 82 (31.7%) of 259 newly diagnosed patients (disease duration ≤ 1 year). An amnestic MCI multidomain phenotype was the most frequent MCI subtype (39.1% of the overall sample and 43.9% in newly diagnosed PD). A positive significant association between MCI, age and motor scores was found at multivariate logistic regression analysis, while a negative association was observed between educational level and MCI. In conclusion and in agreement with the literature data, the prevalence of MCI recorded in the PACOS sample was approximately 40 and 32% amongst newly diagnosed patients.

Sensitivity and specificity of Frontal Assessment Battery in newly diagnosed and untreated obstructive sleep apnea patients

BACKGROUND

Executive dysfunction (ED) is often observed in subjects diagnosed with obstructive sleep apnea (OSA), but their assessment requires facilities that are not always available. We aim to evaluate the extent to which Frontal Assessment Battery (FAB) discriminates ED in newly diagnosed, untreated, and without-comorbidity OSA patients.

METHODS

Sixty subjects participated in the study. Of these, 40 (31 males and 9 females) were newly diagnosed for OSA through full-night polysomnography (apnea/hypopnea index; M = 39.01, SD = 27.16), untreated, with a mean age of 54.50 years (SD = 8.90), while the remaining 20 (15 males and 5 females) had no symptoms of OSA (M = 51.60 years, SD = 10.70). The instruments used were the following: Questionnaire for Sleep Apnea Risk, Epworth Sleepiness Scale, Mini-Mental State Examination, and FAB.

RESULTS

The group with OSA exhibited significantly lower values in the FAB global score (p = 0.003) and in Conceptualization (p = 0.001) and Mental Flexibility (p = 0.009) subtests. ROC analysis showed adequate discriminative capacity for the FAB global score (AUC = 0.74) and for Conceptualization (AUC = 0.75) and Mental Flexibility (AUC = 0.70) scores.

CONCLUSIONS

The FAB is a short and no-time-consuming tool that can be used to investigate the presence of ED in untreated OSA patients with no comorbidities, providing clinicians with a simple and effective way of detecting the presence of this dysfunction and allowing a more informed decision for the need of a full neuropsychological assessment.

Affordances after spinal cord injury

Spinal cord injury can cause cognitive impairments even when no cerebral lesion is appreciable. As patients are forced to explore the environment in a non-canonical position (i.e., seated on a wheelchair), a modified relation with space can explain motor-related cognitive differences compared to non-injured individuals. Peripersonal space is encoded in motor terms, that is, in relation to the representation of action abilities and is strictly related to the affordance of reachability. In turn, affordances, the action possibilities suggested by relevant properties of the environment, are related to the perceiver's peripersonal space and motor abilities. One might suppose that these motor-related cognitive abilities are compromised when an individual loses the ability to move. We shed light on this issue in 10 patients with paraplegia and 20 matched controls. All have been administered an affordances-related reachability judgement task adapted from Costantini, Ambrosini, Tieri, Sinigaglia, and Committeri (2010, Experimental Brain Research, 207, 95) and neuropsychological tests. Our findings demonstrate that patients and controls show the same level of accuracy in estimating the location of their peripersonal space boundaries, but only controls show the typical overestimation of reaching range. Secondly, patients show a higher variability in their judgements than controls. Importantly, this finding is related to the patients' ability to perform everyday tasks. Finally, patients are not faster in making their judgements on reachability in peripersonal space, while controls are. Our results suggest that not moving freely or as usual in the environment impact decoding of action-related properties even when the upper limbs are not compromised.

The IFS (INECO Frontal Screening) and level of education: Normative data

Level of education is known to confound neuropsychological test performance. The INECO Frontal Screening (IFS) is an easy-to-use and brief measure of several domains of executive function, which has previously shown reliably clinical usefulness and superior psychometric performance when compared to other frontal screening instruments. However, previous studies with the IFS have been limited to participants with high levels of education, preventing its generalizability to populations with less than 12 years of formal education. This is crucial, as less than half of the Latin American population and a large percentage of immigrants in developed countries attain high school education. The aim of this study was to generate IFS normative data in a sample stratified by age and education levels. One hundred and sixty one healthy adults were assessed with the IFS as well as measures of global cognitive screening, namely, the Addenbrooke Cognitive Examination Revised and the Mini-Mental State Examination. Multiple lineal regression analysis showed significant effects for education and nonsignificant effects for age. A correction grid for IFS raw scores was developed and cut-off scores were calculated. The correction grid and cut-off scores may be useful in the interpretation of IFS scores in participants with low education.

The frontal assessment battery in clinical practice: a systematic review

BACKGROUND

The frontal assessment battery (FAB) is a brief tool designed to evaluate executive function. Some studies have particularly focused on assessing its applicability addressing two issues: first, on detecting the brain regions responsible for the FAB performance, and second, on determining its capability for differential diagnosis. Our aim was to summarize and analyze critically the studies that assessed the neuroanatomical correspondence and the differential diagnostic value of the FAB in several study populations suffering from different pathologies.

METHODS

We completed a literature search in MEDLINE (via PubMed) database by using the term "frontal assessment battery" and the combination of this term with "applicability" or "use" or "usefulness". The search was limited to articles in English or Spanish languages, published between 1 September 2000 and 30 September 2016, human studies, and journal articles.

RESULTS

A total of 32 studies met inclusion criteria. Seventeen studies were aimed at identifying the brain regions or the neural substrates involved in executive functions measured by the FAB and 15 studies at verifying that the FAB was an appropriate tool for the differential diagnosis in neurological diseases.

CONCLUSION

Our study showed that the FAB may be an adequate assessment tool for executive function and may provide useful information for differential diagnosis in several diseases. Given that the FAB takes short time and is easy to administer, its usage may be of great interest as part of a full neuropsychological assessment in clinical settings. Copyright © 2017 John Wiley & Sons, Ltd.

Central pain processing in "drug-naïve" pain-free patients with Parkinson's disease

BACKGROUND

Despite its clinical relevance, the pathophysiology of pain in Parkinson's disease (PD) is still largely unknown, and both central and peripheral mechanisms have been invoked.

OBJECTIVES

To investigate whether central pain processing is altered in "drug-naive" pain-free PD (dnPD) patients.

METHODS

Using event-related functional MRI (fMRI), functional response to forearm heat stimulation (FHS) at two different intensities (41°C and 53°C) was investigated in 20 pain-free dnPD patients, compared with 18 healthy controls (HCs). Secondary analyses were performed to evaluate associations between BOLD signal changes and PD clinical features and behavioral responses.

RESULTS

During low-innocuous FHS (41°C), no activation differences were found between dnPD patients and HCs. During high-noxious FHS (53°C) a significantly increased activation in the left somatosensory cortex, left cerebellum, and right low pons was observed in dnPD patients compared to HCs. In the latter experimental condition, fMRI BOLD signal changes in the right low pons (p < .0001; R = -0.8) and in the cerebellum (p = .004; R = -0.7) were negatively correlated with pain intensity ratings only in dnPD patients. No statistically significant difference in experimental pain perception was detected between dnPD patients and HCs.

CONCLUSIONS

Our findings suggest that a functional remodulation of pain processing pathways occurs even in the absence of clinically overt pain symptoms in dnPD patients. These mechanisms may eventually become dysfunctional over time, contributing to the emergence of pain symptoms in more advanced PD stages. The comprehension of pain-related mechanisms may improve the clinical approach and therapeutic management of this disabling nonmotor symptom.

Assessing Executive Dysfunction in Neurodegenerative Disorders: A Critical Review of Brief Neuropsychological Tools

Executive function (EF) has been defined as a multifaceted construct that involves a variety of high-level cognitive abilities such as planning, working memory, mental flexibility, and inhibition. Being able to identify deficits in EF is important for the diagnosis and monitoring of several neurodegenerative disorders, and thus their assessment is a topic of much debate. In particular, there has been a growing interest in the development of neuropsychological screening tools that can potentially provide a reliable quick measure of EF. In this review, we critically discuss the four screening tools of EF currently available in the literature: Executive Interview-25 (EXIT 25), Frontal Assessment Battery (FAB), INECO Frontal Screening (IFS), and FRONTIER Executive Screen (FES). We first describe their features, and then evaluate their psychometric properties, the existing evidence on their neural correlates, and the empirical work that has been conducted in clinical populations. We conclude that the four screening tools generally present appropriate psychometric properties, and are sensitive to impairments in EF in several neurodegenerative conditions. However, more research will be needed mostly with respect to normative data and neural correlates, and to determine the extent to which these tools add specific information to the one provided by global cognition screening tests. More research directly comparing the available tools with each other will also be important to establish in which conditions each of them can be most useful.

Association of the New Variant Tyr424Asp at TBK1 Gene with Amyotrophic Lateral Sclerosis and Cognitive Decline

A new risk gene associated with amyotrophic lateral sclerosis (ALS) has recently been identified: the Tank-binding kinase 1 (TBK1) gene. Up to now, 90 TBK1 variants have been described in ALS patients with or without frontotemporal dementia (FTD), thus making TBK1 the third or fourth most frequent genetic cause of ALS and FTD. A point mutation analysis in a cohort of 69 Italian ALS patients was performed in order to analyze the frequency of TBK1 mutations and the correlation with clinical phenotypes. The analysis identified the novel variant p.Tyr424Asp in a patient with a rapid progression of the disease. Our data supports the implication of TBK1 in ALS pathogenesis in Italy.

MR Imaging Features of the Cerebellum in Adult-Onset Neuronal Intranuclear Inclusion Disease: 8 Cases

Neuronal intranuclear inclusion disease is a neurodegenerative disorder pathologically characterized by eosinophilic hyaline intranuclear inclusions. A high-intensity signal along the corticomedullary junction on DWI has been described as a specific MR imaging finding of the cerebrum in neuronal intranuclear inclusion disease. However, MR imaging findings of the cerebellum in neuronal intranuclear inclusion disease have not been fully evaluated. Here, we review MR imaging findings of the cerebellum in a series of 8 patients with pathologically confirmed neuronal intranuclear inclusion disease. The MR imaging results showed cerebellar atrophy (8/8 patients) and high-intensity signal on FLAIR images in the medial part of the cerebellar hemisphere right beside the vermis (the "paravermal area") (6/8) and in the middle cerebellar peduncle (4/8). The paravermal abnormal signals had a characteristic distribution, and they could be an indicator of the diagnosis of neuronal intranuclear inclusion disease even when using the results of past MR imaging examinations in which DWI findings were not examined.

Divergent Thinking in Parkinsonism: A Case-Control Study

BACKGROUND

Creativity is a multidimensional phenomenon and an important component of human capacities. This ability is characterized by the involvement of several cognitive functions particularly linked to the prefrontal cortex. We compared divergent thinking, a measure of creativity, in patients affected by progressive supranuclear palsy (PSP), other parkinsonian syndromes, and healthy controls (HCs).

METHODS

Creativity features were evaluated using the Abbreviated Torrance Test for Adults (ATTA). Consecutive PSP outpatients were screened for inclusion. Then, patients with multiple system atrophy (MSA) and Parkinson's disease (PD) and a group of HC were studied. All groups have preserved cognitive functions and were matched for gender, education, disease duration, and age at onset with exception of PD patients who were matched by disease severity rather than disease duration.

RESULTS

PSP patients were characterized by lower values in total ATTA and all subscales than HC and both MSA and PD patients. No differences were found comparing HC versus both MSA and PD patients. PSP patients were characterized by more impaired frontal functioning [assessed by means of Frontal Assessment Battery (FAB)] than HC and both PD and MSA patients.

CONCLUSION

In the present study, ATTA was significantly lower in PSP patients than in the other study groups. The worst performance in ATTA-total score and the lower score in FAB in PSP patients support the role of frontal function in creative processes.

The Impact of Frailty on the Risk of Conversion from Mild Cognitive Impairment to Alzheimer's Disease: Evidences from a 5-Year Observational Study

The frailty construct has increasingly been adopted in the field of cognitive disorders. The aim of the present study was to measure frailty in a cohort of individuals with mild cognitive impairment (MCI) and to explore whether frailty measures may consent to predict the risk of conversion to dementia. We retrospectively reviewed the clinical charts of outpatients with amnesic MCI (aMCI) consecutively recruited at our Department, and followed-up for 5 years. Individual frailty status was measured by means of a frailty index (FI) consisting of 39 deficits (including signs, symptoms, diagnoses, and disabilities). Univariate analyses were used to compare the socio-demographic and clinical characteristics between subjects converting or not converting to probable Alzheimer’s disease (AD) dementia over the follow-up. Risk for conversion to AD dementia was assessed using Cox regression models. Ninety-one subjects with aMCI (mean age 72.7, SD 7.1 years; women 49.5%) were consecutively recruited over a period of 12 months. Low levels of frailty were documented in the sample (mean FI score 10.0, SD 5.3). A statistically significant correlation between age and FI was observed. Overall, 58 participants converted to AD dementia over time. The Cox regression analysis showed that age (HR: 1.04, 95% CI: 1.00–1.08), male sex (HR: 0.52, 95% CI: 0.30–0.91), Mini–Mental State Examination score (HR: 0.85, 95% CI: 0.77–0.94), and FI (HR: 1.11, 95% CI: 1.05–1.18) were all significantly associated with the probability of MCI conversion. Individual’s frailty status may increase the risk of conversion from a condition of MCI to overt AD dementia. The adoption of constructs comprehensively reflecting the biological decline of the aging subject may add useful estimates and information in the clinical approach to cognitive disorders.

A case of reversible anti-NMDA-receptor encephalitis: neuropsychological and neuroradiological features

Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis is an autoimmune encephalitis mainly affecting young women. We report a case of a mild paraneoplastic anti-NMDAR encephalitis in a 31-year-old female with an ovarian immature teratoma. The patient exhibited a severe short-term episodic memory impairment and psychiatric symptoms. A detailed diagnostic work-up including complete clinical and laboratory examinations, neuropsychological assessments, and neuroradiological investigations has been done at the onset and during follow-up. The amnestic syndrome and MRI medial-temporal abnormalities reversed after medical and surgical treatment. The present report indicates that the disease can be rapidly reversible if promptly diagnosed and treated. While the disease has already been described elsewhere, the course of neurospychological deficits in adults is not as much known. Usually, when the diagnosis of anti-NMDAR encephalitis is made, the severity of the disease makes the assessment of the neuropsycological profile particulary challenging. The present report is of interest because it describes the complete neuropsychological profile of a mild form of anti-NMDAR encephalitis.