FAB-D: German version of the Frontal Assessment Battery

Cognitive, Mental Health, Functional, and Quality of Life Outcomes 1 Year After Spontaneous Subarachnoid Hemorrhage: A Prospective Observational Study

BACKGROUND

Patients with spontaneous subarachnoid hemorrhage (SAH) frequently encounter cognitive dysfunction and mental health issues with negative effects on health-related quality of life (HR-QoL). Here, we aimed to describe the prevalence of cognitive deficits, mental health problems, and HR-QoL impairments 1 year after SAH.

METHODS

In this prospective observational study, 177 patients with SAH admitted to our neurointensive care unit over a time span of ten years followed the invitation for an in-person 1-year follow-up, including a standardized neuropsychological test battery. Mental health issues (anxiety and depression) and HR-QoL were evaluated using questionnaires (Hospital Anxiety and Depression Scale; 36-item Short Form questionnaire). Functional outcome was assessed with the modified Rankin Scale (mRS) score.

RESULTS

Patients were 54 years of age (interquartile range 47-62 years) and presented with a median Hunt and Hess score of 2 (interquartile range 1-3) at admission. Most patients (93%) achieved good functional 1-year outcomes (mRS score 0-2). Seventy-one percent of patients had deficits in at least one cognitive domain, with memory deficits being the most prevalent (51%), followed by deficits in executive functions (36%), visuoconstruction (34%), and attention (21%). Even patients with perimesencephalic SAH (18%) or with full functional recovery (mRS score = 0, 46%) had a comparable prevalence of cognitive deficits (61% and 60%, respectively). Symptoms of depression and anxiety were reported by 16% and 33% of patients, respectively. HR-QoL was impaired in 37% (55 of 147). Patients with cognitive deficits (p = 0.001) or mental health issues (p < 0.001) more frequently reported impaired HR-QoL.

CONCLUSIONS

Most patients with SAH have cognitive deficits and mental health issues 1 year after SAH. These deficits impair patients' quality of life.

Impaired executive functioning mediates the association between aging and deterministic sequence learning

Sensitivity to the fixed ordering of actions and events, or deterministic sequence learning, is an important skill throughout adulthood. Yet, it remains unclear whether age deficits in sequencing exist, and we lack a firm understanding of which factors might contribute to age-related impairments when they arise. Though debated, executive functioning, governed by the frontal lobe, may underlie age-related sequence learning deficits in older adults. The present study asked if age predicts errors in deterministic sequence learning across the older adult lifespan (ages 55-89), and whether executive functioning accounts for any age-related declines. Healthy older adults completed a comprehensive measure of frontal-based executive abilities as well as a deterministic sequence learning task that required the step-by-step acquisition of associations through trial-and-error feedback. Among those who met a performance-based criterion, increasing age was positively correlated with higher sequencing errors; however, this relationship was no longer significant after controlling for executive functioning. Moreover, frontal-based executive abilities mediated the relationship between age and sequence learning performance. These findings suggest that executive or frontal functioning may underlie age deficits in learning judgment-based, deterministic serial operations.

"Try to Build This Bunny as Fast as Possible without Using Red or Pink Bricks": How Simple Assembly Tasks Might Aid in Detecting People with Mild Cognitive Impairment and Dementia

(1) Background: Dementia and mild cognitive impairment (MCI) are still underdiagnosed in the general population. Impaired odor identification has been identified as an early marker of MCI and dementia. We aim to investigate whether short tasks, in which simple forms must be assembled from single building blocks based on a template or while considering specific re-strictions, could increase the diagnostic quality of established cognitive screening tests in detecting MCI or dementia. (2) Methods: A brief assembly test, where participants had to assemble simple animal shapes from Lego® Duplo® building blocks, the Frontal Assessment Battery, and the Mini-Mental State Exam (MMSE) were administered to a consecutive series of 197 patients (89 with mild dementia, 62 with mild cognitive impairment, and 46 without cognitive impairment) referred for neuropsychological testing. (3) Results: Both participants with dementia and with MCI performed badly in the assembly tasks. The assembly tasks and the Frontal Assessment Battery were substantially correlated. Complementing MMSE scores with the assembly tasks improved the diagnostic accuracy of individuals with dementia and MCI. (4) Conclusions: People with suspected dementia or MCI may already benefit from simple assembly tasks. Although these tests require little additional time, they can notably increase sensitivity for dementia or MCI.

"Mmm, Smells like Coffee!": How a Brief Odor Identification Test Could Help to Identify People with Mild Cognitive Impairment and Dementia

(1) Background: Dementia and mild cognitive impairment (MCI) are still underdiagnosed in the general population. Impaired odor identification has been identified as an early marker of MCI and dementia. We aimed to compare the additional diagnostic value of two odor identification tests to a cognitive screening test in detecting MCI or dementia. (2) Methods: The Sniffin' Sticks odor identification test (SS-OIT), a brief odor identification test (B-OIT) requiring the identification of coffee scent, and the Mini-Mental State Exam (MMSE) were administered to a consecutive series of 174 patients (93 with dementia, 42 with mild cognitive impairment, and 39 without cognitive impairment) referred for neuropsychological testing. (3) Results: Both participants with dementia and with MCI exhibited impairments in odor identification. The SS-OIT and the B-OIT were substantially correlated. Complementing MMSE scores with the SS-OIT or the B-OIT similarly improved the diagnostic accuracy of individuals with dementia and MCI. (4) Conclusions: People with suspected dementia or MCI may already benefit from brief odor identification tests. Although these tests require little additional time, they can notably increase sensitivity for dementia or MCI.

Cognition in older offenders in North Rhine-Westphalia: A comparison of prisoners and patients in forensic psychiatry hospitals

The number of elderly delinquent individuals living in prisons and forensic hospitals is increasing. For both settings, complex needs have been described for the elderly related to age-related changes and frequent somatic disorders as well as mental disorders, primarily depressive symptoms.. One of the biggest challenges are cognitive impairments which have been described for both groups, probably not least due to frequent risk factors (e.g., substance abuse, depressive symptoms). Given that the group of forensic patients has a manifest mental illness, which is usually treated with psychopharmaceuticals, the question arises as to what extent cognitive deficits are more frequent here. For both groups, the detection of cognitive deficits with regard to therapy and release planning is of relevance. In sum, studies on cognitive function in both populations are rare, and the results are hard to compare due to different instruments to assess cognition. Sociodemographic, health-, and incarceration-related data were collected as well as neuropsychological functions using established instruments to evaluate global cognitive functioning (Mini-Mental State Examination [MMSE], DemTect), executive function (Frontal Assessment Battery [FAB], and Trail Making Test [TMT]). In the final sample, 57 prisoners and 34 forensic inpatients from North Rhine Westphalia, Germany being 60 years and older were included. The groups were comparable in age (prisoners: M = 66.5 years, SD ± 5.3; forensic inpatients: M = 66.8 years, SD ± 7.5) and education (prisoners: M = 11.47, SD ± 2.91; forensic inpatients: M = 11.39, SD ± 3.64), but the offenders in forensic psychiatry had spent significantly more time in the correctional setting than prisoners (prisoners: M = 8.6, SD ± 10.8; forensic inpatients: M = 15.6 years, SD ± 11.9). In both groups cognitive deficits were frequent. Depending on the tests and population, between 42% and 64% showed impairments in global cognition, and between 22% and 70% were classified with impaired executive functioning. We found no significant differences in global cognition or executive functions assessed with the TMT between the two groups. However, forensic inpatients were significantly more impaired in the FAB compared to the prisoners. The results emphasize the high frequency of cognitive dysfunction in both settings and a possibly higher frequency of "frontal" dysfunction in forensic inpatients, and, thus, indicate the relevance of routine neuropsychological diagnostic and treatment procedures in these settings.

Further Evidence of Relationship Between Thiamine Blood Level and Cognition in Chronic Alcohol-Dependent Adults: Prospective Pilot Study of an Inpatient Detoxification with Oral Supplementation Protocol

BACKGROUND

The relationship between thiamine blood level (TBL) and cognition remains uncertain including amongst alcohol-dependent persons (ADP) AIM: To evaluate this relationship during protocol-driven inpatient alcohol detoxification treatment including thiamine supplementation (AD+Th) METHODS: Prospective 3-week study with 100 consecutively admitted detoxification-seeking ADP (47.7±11 years-old, 21% females) without superseding comorbidities requiring treatment. TBL and Montreal Cognitive Assessment (MoCA) were measured at admission (t₁, pre-AD+Th) and discharge (t₃, post-AD+Th). Frontal Assessment Battery (FAB) was performed at t₁. AD+Th included abstinence, pharmacological alcohol withdrawal syndrome treatment and oral thiamine supplementation (200 mg/day for 14 days). Regression and mediation analyses assessed TBL-cognition relationships.

RESULTS

We found no cases of Wernicke Encephalopathy (WE) and only one case of thiamine deficiency. Both MoCA and TBL significantly improved across AD+Th (with medium-to-large effect sizes). At t₁, TBL significantly predicted MoCA and FAB sum scores (medium effect sizes; extreme and very strong evidence, respectively). The clear TBL-MoCA association disappeared at t₃. In multivariate regression and mediation analyses exploring key influential factors of cognition (identified by LASSO regression), the TBL-MoCA interactions did not relevantly change at t₁ and t₃. Age, serum transaminases, vitamin D levels, drinking-years and depression score weakly modified the relationship.

CONCLUSION

TBL was a robust predictor of pre-detoxification cognitive impairment, and both TBL and cognition improved significantly during AD+Th (including abstinence) in our ADP population, supporting routine thiamine supplementation for ADP, even those at low WE-risk. TBL-cognition relationship was minimally confounded by age, alcohol-toxicity proxies, mood, and vitamin D levels.

CLINICAL TRIALS REGISTRATION

https://osf.io/b54eh/.

Brain microdialysate tau dynamics predict functional and neurocognitive recovery after poor-grade subarachnoid haemorrhage

Subarachnoid haemorrhage is a devastating disease that results in neurocognitive deficits and a poor functional outcome in a considerable proportion of patients. In this study, we investigated the prognostic value of microtubule-associated tau protein measured in the cerebral microdialysate for long-term functional and neuropsychological outcomes in poor-grade subarachnoid haemorrhage patients. We recruited 55 consecutive non-traumatic subarachnoid haemorrhage patients who underwent multimodal neuromonitoring, including cerebral microdialysis. Mitochondrial dysfunction was defined as lactate-to-pyruvate ratio >30 together with pyruvate >70 mmol/L and metabolic distress as lactate-to-pyruvate ratio >40. The multidimensional 12-month outcome was assessed by means of the modified Rankin scale (poor outcome: modified Rankin scale ≥4) and a standardized neuropsychological test battery. We used multivariable generalized estimating equation models to assess associations between total microdialysate-tau levels of the first 10 days after admission and hospital complications and outcomes. Patients were 56 ± 12 years old and presented with a median Hunt & Hess score of 5 (interquartile range: 3-5). Overall mean total microdialysate-tau concentrations were highest within the first 24 h (5585 ± 6291 pg/mL), decreased to a minimum of 2347 ± 4175 pg/mL on Day 4 (P < 0.001) and remained stable thereafter (P = 0.613). Higher total microdialysate-tau levels were associated with the occurrence of delayed cerebral ischaemia (P = 0.001), episodes of metabolic distress (P = 0.002) and mitochondrial dysfunction (P = 0.034). Patients with higher tau levels had higher odds for a poor 12-month functional outcome (adjusted odds ratio: 2.61; 95% confidence interval: 1.32-5.17; P = 0.006) and impaired results in the trail making test-B (adjusted odds ratio: 3.35; 95% confidence interval: 1.16-9.68; P = 0.026) indicative of cognitive flexibility. Total microdialysate-tau levels significantly decreased over the first 10 days (P < 0.05) in patients without delayed cerebral ischaemia or good functional outcomes and remained high in those with delayed cerebral ischaemia and poor 12-month outcomes, respectively. Dynamic changes of total tau in the cerebral microdialysate may be a useful biomarker for axonal damage associated with functional and neurocognitive recovery in poor-grade subarachnoid haemorrhage patients. In contrast, ongoing axonal damage beyond Day 3 after bleeding indicates a higher risk for delayed cerebral ischaemia as well as a poor functional outcome.

Psychometric properties of the Spanish version of the Frontal Assessment Battery (FAB-E) and normative values in a representative adult population sample

BACKGROUND

The Frontal Assessment Battery is a short bedside test used to assess executive functions (EF). The aims of the present study were, first, to evaluate the psychometric proprieties of the Spanish version of the FAB (FAB-E) in a representative sample, and second, to establish cut-off points for impairment in executive function according to age and education level.

METHODS

A sample of 798 healthy Spanish adult subjects aged 19 to 91 participated in this study. Neuropsychological assessment of participants was conducted using the FAB-E, Mini-Mental State Examination (MMSE) and Trail Making Test (TMT). We examined internal consistency, intraclass correlation, test-retest reliability, and concurrent and divergent validity. In addition, we established a cut-off point for detecting executive function impairment based on the 5th percentile by age group and education level.

RESULTS

The analysis of the psychometric properties of the FAB-E showed good internal consistency (Cronbach's α = 0.60), intraclass correlation (0.72), test-retest reliability (0.70) and concurrent and divergent validity between the TMT (r = -0.523), MMSE (r = 0.426) and the FAB-E. The cut-off points for each age group were 16 points for the ≤ 29 group, 15 points for the 30-39 group, 14 points for the 40-49 and 50-59 groups, 12 points for the 60-69 group, and 10 points for the ≥ 70 age group.

CONCLUSIONS

The psychometric analysis showed that the FAB-E has good validity and reliability. Thus, FAB-E may be a helpful tool to evaluate EF in a healthy Spanish population. In addition, this study provides information on reference data that will be very valuable for clinicians and researchers.

Neurofeedback in patients with frontal brain lesions: A randomized, controlled double-blind trial

Background

Frontal brain dysfunction is a major challenge in neurorehabilitation. Neurofeedback (NF), as an EEG-based brain training method, is currently applied in a wide spectrum of mental health conditions, including traumatic brain injury.

Objective

This study aimed to explore the capacity of Infra-Low Frequency Neurofeedback (ILF-NF) to promote the recovery of brain function in patients with frontal brain injury.

Materials and methods

Twenty patients hospitalized at a neurorehabilitation clinic in Switzerland with recently acquired, frontal and optionally other brain lesions were randomized to either receive NF or sham-NF. Cognitive improvement was assessed using the Frontal Assessment Battery (FAB) and the Test of Attentional Performance (TAP) tasks regarding intrinsic alertness, phasic alertness and impulse control.

Results

With respect to cognitive improvements, there was no significant difference between the two groups after 20 sessions of either NF or sham-NF. However, in a subgroup of patients with predominantly frontal brain lesions, the improvements measured by the FAB and intrinsic alertness were significantly higher in the NF-group.

Conclusion

This is the first double-blind controlled study using NF in recovery from brain injury, and thus also the first such study of ILF NF. Although the result of the subgroup has limited significance because of the small number of participants, it accentuates the trend seen in the whole group regarding the FAB and intrinsic alertness (p = 0.068, p = 0.079, respectively). We therefore conclude that NF could be a promising candidate promoting the recoveryfrom frontal brain lesions. Further studies with larger numbers of patients and less lesion heterogeneity are needed to verify the usefulness of NF in the neurorehabilitation of patients with frontal brain injury (NCT02957695 ClinicalTrials.gov).

Parkinson's disease multimodal complex treatment improves gait performance: an exploratory wearable digital device-supported study

BACKGROUND

Wearable device-based parameters (DBP) objectively describe gait and balance impairment in Parkinson's disease (PD). We sought to investigate correlations between DBP of gait and balance and clinical scores, their respective changes throughout the inpatient multidisciplinary Parkinson's Disease Multimodal Complex Treatment (PD-MCT), and correlations between their changes.

METHODS

This exploratory observational study assessed 10 DBP and clinical scores at the start (T1) and end (T2) of a two-week PD-MCT of 25 PD in patients (mean age: 66.9 years, median HY stage: 2.5). Subjects performed four straight walking tasks under single- and dual-task conditions, and four balance tasks.

RESULTS

At T1, reduced gait velocity and larger sway area correlated with motor severity. Shorter strides during motor-motor dual-tasking correlated with motor complications. From T1 to T2, gait velocity improved, especially under dual-task conditions, stride length increased for motor-motor dual-tasking, and clinical scores measuring motor severity, balance, dexterity, executive functions, and motor complications changed favorably. Other gait parameters did not change significantly. Changes in motor complications, motor severity, and fear of falling correlated with changes in stride length, sway area, and measures of gait stability, respectively.

CONCLUSION

DBP of gait and balance reflect clinical scores, e.g., those of motor severity. PD-MCT significantly improves gait velocity and stride length and favorably affects additional DBP. Motor complications and fear of falling are factors that may influence the response to PD-MCT. A DBP-based assessment on admission to PD inpatient treatment could allow for more individualized therapy that can improve outcomes.

TRIAL REGISTRATION NUMBER AND DATE

DRKS00020948 number, 30-Mar-2020, retrospectively registered.

The relationship of the clinician-rated Functional Status Interview with executive functioning

Self/informant-report and performance-based instruments are typically used to measure activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Minimal attention has focused on clinician-rated measures. Executive functioning (EF) contributes significantly to functional independence, and the validity of functional status measures has been examined through its relationship to EF scores. The current study used a clinical sample of older U.S. Veterans who completed a neurocognitive evaluation (n = 266). The psychometric properties of a novel, clinician-rated Functional Status Interview (FSI) and its relationship to EF measures, including the Frontal Assessment Battery (FAB) and Trail Making Test (TMT-A and TMT-B), were explored. Two FSI factors (IADL and ADL) emerged with all items loading strongly onto the subscales as predicted. EF correlated strongly with IADL but had small to medium correlations with ADL. In regression models that controlled for sociodemographic variables, all EF measures uniquely contributed to the IADL model, but only FAB and TMT-A contributed to the model for ADL. Notably, results may have been limited by prominent floor effects on TMT-B. Overall, the FSI is a promising measure with demonstrated content validity. Thus, there is preliminary support for clinicians to incorporate multiple sources of information to rate functional status using the FSI.

Standardization and diagnostic utility of the Frontal Assessment Battery for healthy people and patients with dementia in the Chilean population

The Frontal Assessment Battery (FAB) is a screening test that measures executive functions. Although this instrument has been validated in several countries, its diagnostic utility in a Chilean population has not been studied yet.

Objectives

This study aimed to (1) adapt FAB in a Chilean population; (2) study the psychometric properties of the FAB in a Chilean population; (3) assess the sociodemographic influence in the performance of the FAB in a sample of healthy controls (HC); and (4) develop normative data for this healthy group.

Methods

A HC (n=344) and a group of patients with dementia (n=156) were assessed with the Chilean version of FAB.

Results

FAB showed good internal consistency (Cronbach's alpha=0.79) and acceptable validity based on the relationship with other variables. Factor analysis showed the unidimensionality of the instrument. Significant differences were found in the total FAB value between the HC and dementia groups. With the matched sample, the established cutoff point was 13.5, showing a sensitivity of 80.8% and a specificity of 90.4%. Regression analysis showed that education and age significantly predicted FAB performance in the healthy group. Finally, normative data are provided.

Conclusions

This study shows that FAB is a useful tool to discriminate between healthy people and people with dementia. However, further studies are needed to explore the capacity of the instrument to characterize the dysexecutive syndrome in people with dementia in the Chilean population.

Anticipating social incentives recruits alpha-beta oscillations in the human substantia nigra and invigorates behavior across the life span

Anticipating social and non-social incentives recruits shared brain structures and promotes behavior. However, little is known about possible age-related behavioral changes, and how the human substantia nigra (SN) signals positive and negative social information. Therefore, we recorded intracranial electroencephalography (iEEG) from the SN of Parkinson's Disease (PD) patients (n = 12, intraoperative, OFF medication) in combination with a social incentive delay task including photos of neutral, positive or negative human gestures and mimics as feedback. We also tested a group of non-operated PD patients (n = 24, ON and OFF medication), and a sample of healthy young (n = 51) and older (n = 52) adults with behavioral readouts only. Behaviorally, the anticipation of both positive and negative social feedback equally accelerated response times in contrast to neutral social feedback in healthy young and older adults. Although this effect was not significant in the group of operated PD patients - most likely due to the small sample size - iEEG recordings in their SN showed a significant increase in alpha-beta power (9-20 Hz) from 300 to 600 ms after cue onset again for both positive and negative cues. Finally, in non-operated PD patients, the behavioral effect was not modulated by medication status (ON vs OFF medication) suggesting that other processes than dopaminergic neuromodulation play a role in driving invigoration by social incentives. Together, our findings provide novel and direct evidence for a role of the SN in processing positive and negative social information via specific oscillatory mechanisms in the alpha-beta range, and they suggest that anticipating social value in simple cue-outcome associations is intact in healthy aging and PD.

The Frontal Assessment Battery 20 years later: normative data for a shortened version (FAB15)

OBJECTIVE

The Frontal Assessment Battery (FAB) is a neuropsychological tool largely used to assess executive functions. Prior studies found a marked ceiling effect for the prehension behavior subtest (PBT) in healthy and clinical populations. Aims of the present study were (i) to examine the psychometric properties of the FAB without the contribution of PBT and (ii) to provide normative data for a revised version of the FAB after exclusion of PBT (FAB15).

METHODS

The normative sample included 1,187 healthy participants. PBT had near-zero variance, poor content validity, and no discrimination power. Internal consistency increased when PBT was excluded. We assessed the FAB15 factorial structure, interrater, and test-retest reliabilities. Normative data  for the FAB15 were extracted through a regression-based procedure according to sex, age, and education.

RESULTS

The principal component analysis revealed a single "executive factor" or alternatively a bifactorial solution reflecting the different degree of discriminative capability vs. difficulty of the subtests. The FAB15 demonstrated excellent interrater and test-retest reliabilities. Regression analysis showed that sex (lowly educated women < lowly educated men), higher age, and lower education affected FAB15 score. Accordingly, three grids for adjustment of raw scores (men, women, and both) were constructed. The cut-off was fixed at the non-parametric outer tolerance limit on the fifth centile (9.36, 95% CI).

CONCLUSION

The observation of a ceiling effect in healthy subjects makes PBT not suitable for inclusion in a neuropsychological battery. The FAB15 may successfully replace the conventional FAB as a more severe and valid short screening tool to assess executive functioning.

An unusual presentation of Huntington's disease

We describe the case of a 59-year-old woman who exhibited psychotic symptoms, cognitive dysfunction, and restlessness. While the clinical picture and 18F-FDG PET/CT suggested the presence of a tauopathy, especially frontotemporal dementia or progressive supranuclear palsy, genetic testing eventually revealed Huntington's disease.

Cognitive dysfunction in older prisoners in Germany: a cross-sectional pilot study

Purpose

The purpose of this study is to collect the first empirical data on the cognitive state of elderly prisoners in Germany and to examine associations between cognitive function and sociodemographic, clinical and incarceration characteristics.

Design/methodology/approach

All prisoners aged 60 years and older of five prisons in North Rhine-Westphalia, Germany, were asked to participate. The cognitive screening instruments mini-mental state examination (MMSE) and the DemTect were used to assess global cognition. Executive functions were tested with the trail making test and the frontal-assessment-battery. The Patient Health Questionnaire (PHQ-9) was used to assess participants’ affective state.

Findings

The sample of this study consisted of 58 prisoners with a mean age of 65.52 years (standard deviation = 6.03); 82.8% are male. Using the MMSE with age- and education-corrected z-scores, 36.9% of the prisoners showed marginal or impaired global cognition scores. Using the DemTect, 41.4% of the prisoners were classified as being cognitively impaired. Up to 40% of the prisoners showed deficits in executive functioning and around 60% of the prisoners showed depressive symptoms. The correlation analysis revealed significant associations between cognitive scores and age (rho = –0.335, p = 0.014), education (rho = 0.309, p = 0.020), sentence duration (rho = 0.409, p = 0.007) and duration of current incarceration (rho = 0.302, p = 0.043). The DemTect total score was significantly associated with the PHQ-9 (rho = –0.335, p = 0.016).

Practical implications

A large group of the prisoners showed a higher prevalence of cognitive dysfunction than that observed in same-age people who are not incarcerated. Taken together, there is an urgent need for an adequate management of older cognitively impaired prisoners including routine cognitive testing and guidelines-oriented treatment of cognitive symptoms.

Originality/value

This study has several strengths. To the best of the authors’ knowledge, this is the first study examining the cognitive and affective state in a German prison population. The authors considered female and male prisoners, as well as different prison settings, representing a realistic prison sample. The authors used several neuropsychological instruments to get a more detailed insight into the older prisoners’ cognitive status while trying to consider the economy of time and possible attention deficits to prevent dropouts during testing.

Evolution of Capgras syndrome in neurodegenerative disease: the multiplication phenomenon

Capgras syndrome (CS) is a delusional misidentification syndrome that is encountered in various pathologies. Here, we report the case of an 83-year-old woman affected by dementia with Lewy bodies who presented a CS during the disease. The neuropsychological assessment showed executive and face processing deficits. In this case, CS was characterized, in the beginning, by the duplication of a relative and then by its multiplication. To our knowledge, the description of the evolution of a CS in the course of a neurodegenerative disease is rare and we discuss this multiplication phenomenon in light of existing models of delusions.

Subarachnoid Hemorrhage is Followed by Pituitary Gland Volume Loss: A Volumetric MRI Observational Study

Background

Subarachnoid hemorrhage (SAH) is a devastating disease associated with high mortality and morbidity. Besides neurological sequelae, neuropsychological deficits largely contribute to patients’ long-term quality of life. Little is known about the pituitary gland volume (PGV) after SAH compared to healthy referents and the association of PGV with long-term outcome including cognitive function.

Methods

Sixty consecutive non-traumatic SAH patients admitted to the neurological intensive care unit between 2010 and 2014 were enrolled. 3-Tesla magnetic resonance imagining was performed at baseline (16 days) and 12 months after SAH to measure PGV semi-automatically using the software iPlan Net 3.5.0. PGV was compared to age and sex matched healthy referents. The difference between baseline and 1-year-PGV was classified as increase (> 20 mm³ PGV increase), stable (± 20 mm³), or decrease (> 20 mm³ PGV decrease). In addition, total intracerebral volume was calculated. Neuropsychological testing was applied in 43 SAH patients at 1-year follow up encompassing several domains (executive, attention, memory) and self-assessment (questionnaire for self-perceived deficits in attention [German: FEDA]) of distractibility in mental processes, fatigue and decrease in motivation. Multivariable regression with multivariable generalized linear models was used for comparison of PGVs and for subgroup analysis to evaluate a potential association between PGV and neuropsychological outcome.

Results

Patients were 53 years old (IQR = 44–63) and presented with a median Hunt&Hess grade of 2 (IQR = 1–3). SAH patients had a significantly lower PGV both at baseline (360 ± 19 mm³, p < 0.001) and 1 year (367 ± 18 mm³p < 0.001) as compared to matched referents (mean 505 ± 18 mm³). PGV decreased by 75 ± 8 mm³ in 28 patients, increased by 120 ± 22 mm³ in 22 patients and remained stable in 10 patients at 1-year follow-up. PGV in patients with PGV increase at 12 months was not different to healthy referents (p = 0.062). Low baseline PGV was associated with impaired executive functions at 1 year (adjOR = 8.81, 95%-CI = 1.46–53.10, p = 0.018) and PGV decrease within 1 year was associated with self-perceived worse motivation (FEDA; Wald-statistic = 6.6, df = 1, p = 0.010).

Conclusions

Our data indicate significantly lower PGVs following SAH. The association of sustained PGV decrease with impaired neuropsychological long-term outcome warrants further investigations including neuroendocrine hormone measurements.

Effects of Cognitive Functioning and Education on Later-Life Health Numeracy

INTRODUCTION

Previous studies have shown an association between a high health numeracy and good cognitive functioning.

OBJECTIVE

To investigate the moderation effect of education on this relationship and which brain structures support health numeracy.

METHODS

We examined 70 healthy older persons (66% females; mean ± SD: age, 75.73 ± 4.52 years; education, 12.21 ± 2.94 years). The participants underwent a T1-weighted 3-T MRI and a neuropsychological assessment including a health numeracy task. Statistical parametric mapping was applied to identify focal changes in cortical thickness throughout the entire brain and to correlate image parameters with behavioral measures.

RESULTS

Executive functions and mental calculation emerged as predictors of health numeracy (B = 0.22, p < 0.05, and B = 0.38, p < 0.01). An interaction was found between education and executive functions (B = -0.16, p = 0.01) and between education and mental calculation (B = -0.11, p < 0.05). Executive functions and mental calculation had an impact on health numeracy in participants with a low to intermediate edu-cation (≤12 years) but not in those with a higher education (>12 years). Health numeracy scores were associated with cortical thickness in the right dorsomedial prefrontal cortex and the right superior temporal gyrus (p = 0.01).

CONCLUSIONS

Older people with a higher education perform better in health numeracy tasks than those with a lower education. They have access to previously acquired knowledge about ratio concepts and do not need to rely on executive functions and computational skills. This is highly relevant when decisions about health care have to be made.

Adaptation of the Spanish version of the Frontal Assessment Battery for detection of executive dysfunction

BACKGROUND

The Frontal Assessment Battery (FAB) evaluates executive dysfunctions; however, there is no culturally adapted version of this instrument for the Spanish population. The aim of this study was the translation and cross-cultural adaptation of the original version of the FAB into Spanish and to pilot test this version.

METHODS

The cross-cultural adaptation was conducted following standard procedures. The final Spanish version of the FAB (FAB-E) was pilot tested with 19 healthy Spanish individuals. Total and subtest FAB-E scores were analysed to verify that the test could be understood and that the items assessed what they were intended to assess.

RESULTS

The FAB-E revealed that items/instructions were culturally appropriate and written clearly. Pilot testing showed that most of the participants had scores ranging between 2 and 3 points in all the items. The mean of the total FAB-E was 15.8 (SD=1.3) and the values ranged from 13 to 18. Age and educational level seemed to indicate differences in FAB-E scores.

CONCLUSION

Our findings support that the FAB-E can be used to screen for executive dysfunctions in a Spanish-speaking population.

LSVT-BIG therapy in Parkinson's disease: physiological evidence for proprioceptive recalibration

BACKGROUND

There is growing evidence for proprioceptive dysfunction in patients with Parkinson's disease (PD). The Lee Silvermann Voice Treatment-BIG therapy (LSVT-BIG), a special training program aiming at an increase of movement amplitudes in persons with PD (PwPD), has shown to be effective on motor symptoms. LSVT-BIG is conceptionally based on improving bradykinesia, in particular the decrement of repetitive movements, by proprioceptive recalibration.

OBJECTIVE

To assess proprioceptive impairment in PwPD as compared to matched controls and to probe potential recalibration effects of the LSVT-BIG therapy on proprioception.

METHODS

Proprioceptive performance and fine motor skills were assessed in 30 PwPD and 15 matched controls. Measurements with significant impairment in PwPD were chosen as outcome parameters for a standardized 4 weeks amplitude-based training intervention (LSVT-BIG) in 11 PwPD. Proprioceptive performance served as primary outcome measure. Secondary outcome measures included the motor part of the MDS-UPDRS, the nine-hole-peg test, and a questionnaire on quality of life. Post-interventional assessments were conducted at weeks 4 and 8.

RESULTS

Compared to the control group, PwPD showed significantly larger pointing errors. After 4 weeks of LSVT-BIG therapy and even more so after an additional 4 weeks of continued training, proprioceptive performance improved significantly. In addition, quality of life improved as indicated by a questionnaire.

CONCLUSION

LSVT-BIG training may achieve a recalibration of proprioceptive processing in PwPD. Our data indicates a probable physiological mechanism of a symptom-specific, amplitude-based behavioral intervention in PwPD.

Natural Reading in Parkinson's Disease With and Without Mild Cognitive Impairment

Background: Patients with Parkinson’s disease (PD) show eye movement abnormalities and frequently complain about difficulties in reading. So far, it is unclear whether basal ganglia dysfunction or cognitive impairment has a greater impact on eye movements during reading.

Objective: To analyze eye movement behavior during a natural reading task with respect to cognitive state and dopaminergic therapy in PD and healthy controls.

Methods: Eye movements of 59 PD patients and 29 age- and education-matched healthy controls were recorded during mute, self-paced reading of a text. 25 cognitively normal PD patients performed the task additionally in off medication state. Clinical assessment included a comprehensive neuropsychological test battery and the motor section of MDS—Unified Parkinson’s Disease Rating Scale (MDS-UPDRS).

Results: PD-mild cognitive impairment (MCI) was diagnosed in 21 patients. Reading speed was significantly reduced in PD-MCI compared to healthy controls and PD patients without MCI due to higher numbers of progressive saccades. Cognitively intact PD patients showed no significant alterations of reading speed or eye movement pattern during reading. The fixation duration tended to be prolonged in PD compared to healthy controls and decreased significantly after levodopa intake. Scores for executive functions, attention, and language correlated with reading speed in the PD group.

Conclusion: The present study is the first to reveal (1) reduced reading speed with altered reading pattern in PD with MCI and (2) a relevant impact of levodopa on fixation duration during reading in PD. Further research is needed to determine whether therapeutic interventions, e.g., levodopa or neuropsychological training, improve the subjective reading experience for patients with PD.

Normative data for the Slovak version of the Frontal Assessment Battery (FAB)

The Frontal Assessment Battery (FAB) is a well-established screening measure of frontal lobe pathology. The aim of this study is the development of normative data for healthy Slovak adults. The final sample consisted of 487 healthy adults (54% of them female). The mean age in our sample was M = 55.29 (SD = 19.96). For the whole sample, the mean score on the FAB was 16.46 and the SD was 1.64. The mean score on the MMSE for the whole sample was 28.39 and the SD was 1.43. All participants underwent a complex neuropsychological examination spanning the relevant cognitive domains. FAB scores were found to be negatively associated with age (rs = -0.464, p < 0.001) and positively associated with years of education (rs = 0.199, p < 0.001). FAB scores positively correlated with the performance in MMSE (rs = 0.266, p < 0.001). Statistically significant and theoretically meaningful associations to other neuropsychological tests used in this study suggested the adequate convergent validity of the Slovak version of the FAB. The present study provided accurate normative FAB data, which can be used for clinical and research purposes.

Instability Resistance Training improves Working Memory, Processing Speed and Response Inhibition in Healthy Older Adults: A Double-Blinded Randomised Controlled Trial

Aging is associated with declines in physical and cognitive performance. While there is no doubt about beneficial effects of physical exercise on proxies of strength and balance, the overall evidence for positive effects of resistance and balance training on executive functions is rather inconsistent. Whether the simultaneous exercising of strength and balance, i.e., instability resistance training, promotes executive functions in older adults is unknown. In the present trial, we tested the effects of unstable vs. stable resistance training on executive functions. Sixty-eight healthy older adults aged 65–79 years were randomly assigned to either an instability free-weight resistance training or one of two stable machine-based resistance training programs. Each group exercised twice a week on non-consecutive days for 10 weeks. Four tests to evaluate specific domains of executive functions were administered prior and following training: working memory, processing speed, response inhibition and set-shifting. The instability resistance training group improved working memory, processing speed and response inhibition from pre to post-test. In contrast, we found no improvements in executive functions for both stable resistance training groups. Our results demonstrate that 10 weeks of instability resistance training suffice to improve executive functions in older adults.

Cognition in multiple system atrophy: a single-center cohort study

OBJECTIVE

Cognitive impairment in multiple system atrophy (MSA) is common, but remain poorly characterized. We evaluated cognitive and behavioral features in MSA patients and assessed between-group differences for MSA subtypes and the effect of orthostatic hypotension (OH) on cognition.

METHODS

This retrospective study included 54 patients with clinical diagnosis of possible and probable MSA referred to the Department of Neurology at Medical University of Innsbruck between 2000 and 2018. Neurological work-up included comprehensive neuropsychological testing including Consortium to Establish a Registry for Alzheimer's Disease (CERAD-plus) test battery, Frontal Assessment Battery (FAB), digit span test (DST), clock drawing task (CLOX1), and Hospital Anxiety and Depression Scale (HADS-D).

RESULTS

The mean MMSE score was 27.6 points. Overall, slight to moderate cognitive impairment was noted in up to 40% of patients, with predominant impairment of executive function and verbal memory. Patients with the cerebellar variant performed significantly worse than patients with the parkinsonian type (P < 0.05) in a screening of executive functions (FAB) and in phonemic verbal fluency. Depression and anxiety scores were elevated in 28% and 22% of MSA patients, respectively. Cognitive profile, depression, and anxiety levels were comparable between patients with and without OH.

INTERPRETATION

Cognitive deficits are relatively frequent in MSA and primarily affect executive functions and verbal memory. Future comparative studies including Parkinson dementia, Lewy body disease, and MSA cases with and without OH are required to elucidate disease-specific cognitive profiles in these synucleinopathies and to examine the influence of cardiovascular autonomic dysfunction on cognitive function in MSA.

Motor, cognitive and mobility deficits in 1000 geriatric patients: protocol of a quantitative observational study before and after routine clinical geriatric treatment - the ComOn-study

BACKGROUND

Motor and cognitive deficits and consequently mobility problems are common in geriatric patients. The currently available methods for diagnosis and for the evaluation of treatment in this vulnerable cohort are limited. The aims of the ComOn (COgnitive and Motor interactions in the Older populatioN) study are (i) to define quantitative markers with clinical relevance for motor and cognitive deficits, (ii) to investigate the interaction between both motor and cognitive deficits and (iii) to assess health status as well as treatment outcome of 1000 geriatric inpatients in hospitals of Kiel (Germany), Brescia (Italy), Porto (Portugal), Curitiba (Brazil) and Bochum (Germany).

METHODS

This is a prospective, explorative observational multi-center study. In addition to the comprehensive geriatric assessment, quantitative measures of reduced mobility and motor and cognitive deficits are performed before and after a two week's inpatient stay. Components of the assessment are mobile technology-based assessments of gait, balance and transfer performance, neuropsychological tests, frailty, sarcopenia, autonomic dysfunction and sensation, and questionnaires to assess behavioral deficits, activities of daily living, quality of life, fear of falling and dysphagia. Structural MRI and an unsupervised 24/7 home assessment of mobility are performed in a subgroup of participants. The study will also investigate the minimal clinically relevant change of the investigated parameters.

DISCUSSION

This study will help form a better understanding of symptoms and their complex interactions and treatment effects in a large geriatric cohort.

New insights into facial emotion recognition in Parkinson's disease with and without mild cognitive impairment from visual scanning patterns

Background

Recognizing emotional facial expressions is crucial for social interactions. Cognitive impairment and oculomotor abnormalities are common features of Parkinson's disease (PD) which may contribute to the performance in facial emotion recognition (FER) in PD.

Objective

The aim of this study was to analyze eye movement behavior during a facial emotion recognition (FER) task with respect to cognitive state in PD patients and healthy controls.

Methods

Eye movements of 24 non-demented, non-depressed PD patients (12 with intact cognitive functions and 12 with Mild Cognitive Impairment (MCI) according to MDS task force criteria level 2), and 12 age-, sex and education-matched healthy controls were recorded during visual exploration of 28 emotional (happiness, surprise, disgust, anger, fear and sadness) and neutral faces. Participants were asked to identify the displayed emotion out of a sevenfold multiple choice question.

Results

PD-MCI patients showed reduced FER with specific impairment of anger recognition. Although the scanned area of PD patients with intact cognition was significantly restricted, they did not differ in FER from healthy subjects. While healthy subjects and cognitively intact PD patients scanned faces with preference for mouth and eyes, patients with PD-MCI tended to look at the center of the face and spent significantly less time fixating the mouth.

Conclusions

Ineffective visual exploration may contribute to impaired emotion recognition in PD. Visual scanning of emotional faces is altered in PD even in the absence of cognitive impairment. The progression to PD-MCI may result in further deterioration of scanning behavior and FER impairment.

Influencia de variables sociodemográficas en el rendimiento de la Frontal Assessment Battery en adultos mayores Argentinos

Introducción. La Frontal Assesment Battery (FAB) es una herramienta de screening de valoración rápida de las funciones ejecutivas. Estudios previos evidencian que variables sociodemográficas como la edad, el sexo y el nivel educativo podrían influir en el rendimiento de la FAB. El objetivo del estudio es analizar, en adultos mayores argentinos provenientes de la población general y sin deterioro cognitivo (evaluados según el Minimental, pruebas de fluidez verbal semántica y fonológica y el Test del Reloj) si existe diferencia en la FAB a partir de dichas variables. Metodología. Se analizó el rendimiento de 145 adultos mayores provenientes de la población general y sin deterioro cognitivo entre 60 y 90 años. Se realizaron estudios de diferencias de medias (t de Student y ANOVA), análisis univariante de la varianza, correlaciones (r de Pearson) y regresiones lineales simples para analizar la influencia de la edad, el sexo, el nivel educativo y el rendimiento cognitivo en la FAB. Resultados. Se observaron diferencias estadísticamente significativas en el puntaje total de la FAB en función del nivel educativo, pero no en función de la edad, ni el sexo.  Asimismo, se encontró que el puntaje de la FAB se correlacionó con otras pruebas de screening cognitivo, como el Minimental, el Test del Reloj y fluidez verbal (fonológica y semántica). Conclusiones. El presente estudio presenta resultados que señalan la importancia de considerar el nivel educativo en la valoración de la FAB

Instability Resistance Training Decreases Motor Noise During Challenging Walking Tasks in Older Adults: A 10-Week Double-Blinded RCT

Locomotor stability is challenged by internal perturbations, e.g., motor noise, and external perturbations, e.g., changes in surface compliance. One means to compensate for such perturbations is to employ motor synergies, defined here as co-variation among a set of elements that acts to stabilize, or provide similar trial-to-trial (or step-to-step) output, even in the presence of small variations in initial conditions. Whereas evidence exists that synergies related to the upper extremities can be trained, the extent to which lower limb synergies, such as those which may be needed to successfully locomote in complex environments, remains unknown. The purpose of this study was to evaluate if resistance training (RT) in unstable environments could promote coordination patterns associated with stronger synergies during gait. Sixty-eight participants between the age of 65 and 80 were randomly assigned to one of three different RT modalities: stable whole-limb machine-based RT (S-MRT), instability free-weight RT (I-FRT), and stable machine-based adductor/abductor RT (S-MRT_HIP). Before and after RT, participants walked across an even lab floor and a more challenging uneven surface with and without holding a weighted bag. The uncontrolled manifold control analysis (UCM) was used to calculate the synergy index (i.e., strength of the kinematic synergy) related to stabilization of our performance variable, the mediolateral trajectory of the swing foot, under each condition. Regardless of RT group, there was no effect of RT on the synergy index when walking across the even lab floor. However, the synergy index during the two uneven surface conditions was stronger after I-FRT but was not affected by the other RT modalities. The stronger synergy index for the I-FRT group was due to improved coordination as quantified by an overall increase in variability in elemental variable space but a decrease in the variability that negatively affects performance. The unstable environment offered by I-FRT allows for exploration of motor solutions in a manner that appears to transfer to challenging locomotor tasks. Introducing tasks that promote, rather than limit, exploration of motor solutions seems to be a valuable exercise modality to strengthen kinematic synergies that cannot be achieved with traditional strengthening paradigms (e.g., S-MRT).

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03017365.

[Implementation of the German S3 guidelines on dementia in clinical practice: wish or reality?]

BACKGROUND

Published in 2009, the German S3 guidelines on dementia define a milestone in quality improvement of the diagnostics and treatment of dementia. In clinical practice patients suffering from dementia are primarily treated by physicians in private practice; therefore, this study examined how the guidelines are implemented in outpatient clinical settings. Furthermore, it aimed at the identification of behavioral determinants that govern the actual diagnostic and therapeutic approach in clinical practice.

METHODS

Physicians involved in the primary care of dementia patients were asked to participate in a nationwide internet survey. The questionnaire covered aspects on the diagnostic and therapeutic care of dementia patients as recommended by the S3 guidelines. Behavioral determinants of the implementation of the guidelines (e. g. treatment decisions) were derived from an established psychological prediction model.

RESULTS

Out of a total of 2755 physicians contacted, the data of 225 participants could be used in this study. The diagnostic recommendations of the S3 guidelines were implemented in satisfactory measures (e.g. combined cognitive screening in at least 68%, cerebral neuroimaging in at least 93% and specific laboratory diagnostics in at least 27% of cases); however, only two thirds of the patients with indications for a guideline-conform therapy were treated in accordance with the S3 guidelines. There was a substantial prescription of non-recommended drugs and a notable long-term use of antipsychotic drugs (prescription by at least 14% of non-neurological medical specialists and by 8% of neurologists and psychiatrists). When considering the behavioral determinants in the implementation of the guidelines, normative assumptions ("my colleagues and patients expect me to comply with the guidelines") surprisingly had the highest impact, which was then followed by attitudes towards the behavior ("utilization of the guidelines improves diagnostics and therapy").

CONCLUSION

The German S3 guidelines on dementia were satisfactorily implemented in outpatient clinical practice; however, deficits existed in the frequency of the pharmaceutical treatment of patients with indications for therapy, the prescription of non-recommended drugs and the relatively common use of permanent neuroleptic medications. Interestingly, the motivation for implementation of the guidelines was not primarily influenced by the physicians' personal convictions but mainly stimulated by the expectations of others.

Eye-Tracking Provides a Sensitive Measure of Exploration Deficits After Acute Right MCA Stroke

The eye-tracking study aimed at assessing spatial biases in visual exploration in patients after acute right MCA (middle cerebral artery) stroke. Patients affected by unilateral neglect show less functional recovery and experience severe difficulties in everyday life. Thus, accurate diagnosis is essential, and specific treatment is required. Early assessment is of high importance as rehabilitative interventions are more effective when applied soon after stroke. Previous research has shown that deficits may be overlooked when classical paper-and-pencil tasks are used for diagnosis. Conversely, eye-tracking allows direct monitoring of visual exploration patterns. We hypothesized that the analysis of eye-tracking provides more sensitive measures for spatial exploration deficits after right middle cerebral artery stroke. Twenty-two patients with right MCA stroke (median 5 days after stroke) and 28 healthy controls were included. Lesions were confirmed by MRI/CCT. Groups performed comparably in the Mini-Mental State Examination (patients and controls median 29) and in a screening of executive functions. Eleven patients scored at ceiling in neglect screening tasks, 11 showed minimal to severe signs of unilateral visual neglect. An overlap plot based on MRI and CCT imaging showed lesions in the temporo-parieto-frontal cortex, basal ganglia, and adjacent white matter tracts. Visual exploration was evaluated in two eye-tracking tasks, one assessing free visual exploration of photographs, the other visual search using symbols and letters. An index of fixation asymmetries proved to be a sensitive measure of spatial exploration deficits. Both patient groups showed a marked exploration bias to the right when looking at complex photographs. A single case analysis confirmed that also most of those patients who showed no neglect in screening tasks performed outside the range of controls in free exploration. The analysis of patients' scoring at ceiling in neglect screening tasks is of special interest, as possible deficits may be overlooked and thus remain untreated. Our findings are in line with other studies suggesting considerable limitations of laboratory screening procedures to fully appreciate the occurrence of neglect symptoms. Future investigations are needed to explore the predictive value of the eye-tracking index and its validity in everyday situations.

Distinguishing neurocognitive deficits in adult patients with NP-C from early onset Alzheimer's dementia

BACKGROUND

Niemann-Pick disease type C (NP-C) is a rare, progressive neurodegenerative disease caused by mutations in the NPC1 or the NPC2 gene. Neurocognitive deficits are common in NP-C, particularly in patients with the adolescent/adult-onset form. As a disease-specific therapy is available, it is important to distinguish clinically between the cognitive profiles in NP-C and primary dementia (e.g., early Alzheimer's disease; eAD).

METHODS

In a prospective observational study, we directly compared the neurocognitive profiles of patients with confirmed NP-C (n = 7) and eAD (n = 15). All patients underwent neurocognitive assessment using dementia screening tests (mini-mental status examination [MMSE] and frontal assessment battery [FAB]) and an extensive battery of tests assessing verbal memory, visuoconstructive abilities, visual memory, executive functions and verbal fluency.

RESULTS

Overall cognitive impairment (MMSE) was significantly greater in eAD vs. NP-C (p = 0.010). The frequency of patients classified as cognitively 'impaired' was also significantly greater in eAD vs. NP-C (p = 0.025). Patients with NP-C showed relatively preserved verbal memory, but frequent impairment in visual memory, visuoconstruction, executive functions and in particular, verbal fluency. In the eAD group, a wider profile of more frequent and more severe neurocognitive deficits was seen, primarily featuring severe verbal and visual memory deficits along with major executive impairment. Delayed verbal memory recall was a particularly strong distinguishing factor between the two groups.

CONCLUSION

A combination of detailed yet easy-to-apply neurocognitive tests assessing verbal memory, executive functions and verbal fluency may help distinguish NP-C cases from those with primary dementia due to eAD.

Effects of Healthy Aging and Mild Cognitive Impairment on a Real-Life Decision-Making Task

In this study, we investigated the effects of age and of mild cognitive impairment (MCI) on decision making under risk by adopting a task representing real-life health-related situations and involving complex numerical information. Moreover, we assessed the relationship of real-life decision making to other cognitive functions such as number processing, executive functions, language, memory, and attention. For this reason, we compared the performance of 19 healthy, relatively younger adults with that of 18 healthy older adults and the performance of the 18 healthy older adults with that of 17 patients with MCI. Results indicated difficulties in real-life decision making for the healthy older adults compared with the healthy, relatively younger adults. Difficulties of patients with MCI relative to the healthy older adults arose in particular in difficult items requiring processing of frequencies and fractions. Significant effects of age and of MCI in processing frequencies were also evident in a ratio number comparison task. Decision-making performance of healthy participants and of the patient group correlated significantly with number processing. There was a further significant correlation with executive functions for the healthy participants and with reading comprehension for the patients. Our results suggest that healthy older individuals and patients with MCI make less advantageous decisions when the information is complex and high demands are put on executive functions and numerical abilities. Moreover, we show that executive functions and numerical abilities are not only essential in laboratory gambling tasks but also in more realistic and ecological decision situations within the health context.

Apraxia profiles-A single cognitive marker to discriminate all variants of frontotemporal lobar degeneration and Alzheimer's disease

INTRODUCTION

Apraxia is common in neurodegenerative dementias but underrepresented in clinical workup for differential diagnoses.

METHODS

Praxis-profiles were assessed with the Dementia Apraxia Test in 93 patients with early stages of biologically supported Alzheimer's disease or frontotemporal lobar degeneration: semantic primary-progressive aphasia, nonfluent primary-progressive aphasia, and behavioral variant frontotemporal dementia. Associations with core cognitive deficits of the dementia subtypes (i.e., visuospatial, sociocognitive, and semantic-linguistic) were explored.

RESULTS

Patients showed significant apraxia compared with healthy controls but also disease-specific praxis-profiles. Using only the Dementia Apraxia Test, all four dementia subtypes could be correctly discriminated in 64.4% of cases, and in 78.2% when only distinguishing Alzheimer's disease versus frontotemporal lobar degeneration. Praxis-profiles showed consistent associations with core cognitive impairments of the different dementia subtypes.

DISCUSSION

The Dementia Apraxia Test is a valid, time-efficient and versatile cognitive marker to delineate variants of frontotemporal lobar degeneration and Alzheimer's disease in clinical routine, facilitating differential diagnoses of dementia subtypes in early disease stages.

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.

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.

Frontal Assessment Battery in Parkinson's Disease: Validity and Morphological Correlates

OBJECTIVES

Executive dysfunction is a common feature in Parkinson's disease (PD). However, there is a lack of brief validated instruments for executive dysfunction in PD.

METHODS

The aim of the present study was to assess the relation of Frontal Assessment Battery (FAB) scores to age and education, to verify the utility of FAB in the evaluation of executive dysfunction in PD and to differentiate between controls (n=41), PD patients with normal cognition (PD-NC; n=41; Hoehn and Yahr stages 2-3) and PD with mild cognitive impairment (PD-MCI; n=32; Hoehn and Yahr stages 2-3). In addition, we studied the relation between voxel-based morphometric (VBM) data and FAB results in PD.

RESULTS

We found that FAB scores are significantly related to age and education. The FAB has shown discriminative validity for the differentiation of PD-MCI from PD-NC and controls (area under the curve >.80). Also, the VBM analysis revealed lower FAB scores are specifically related to lower gray matter density in the right ventromedial prefrontal areas and precuneus.

CONCLUSIONS

The FAB can be recommended as a valid instrument for PD-MCI Level I screening. FAB is sensitive to frontal lobe involvement in PD as reflected by lower gray matter density in prefrontal areas. (JINS, 2017, 23, 675-684).

Lower-extremity resistance training on unstable surfaces improves proxies of muscle strength, power and balance in healthy older adults: a randomised control trial

BACKGROUND

It is well documented that both balance and resistance training have the potential to mitigate intrinsic fall risk factors in older adults. However, knowledge about the effects of simultaneously executed balance and resistance training (i.e., resistance training conducted on unstable surfaces [URT]) on lower-extremity muscle strength, power and balance in older adults is insufficient. The objective of the present study was to compare the effects of machine-based stable resistance training (M-SRT) and two types of URT, i.e., machine-based (M-URT) and free-weight URT (F-URT), on measures of lower-extremity muscle strength, power and balance in older adults.

METHODS

Seventy-five healthy community-dwelling older adults aged 65-80 years, were assigned to three intervention groups: M-SRT, M-URT and F-URT. Over a period of ten weeks, all participants exercised two times per week with each session lasting ~60 min. Tests included assessment of leg muscle strength (e.g., maximal isometric leg extension strength), power (e.g., chair rise test) and balance (e.g., functional reach test), carried out before and after the training period. Furthermore, maximal training load of the squat-movement was assessed during the last training week.

RESULTS

Maximal training load of the squat-movement was significantly lower in F-URT in comparison to M-SRT and M-URT. However, lower-extremity resistance training conducted on even and uneven surfaces meaningfully improved proxies of strength, power and balance in all groups. M-URT produced the greatest improvements in leg extension strength and F-URT in the chair rise test and functional reach test.

CONCLUSION

Aside from two interaction effects, overall improvements in measures of lower-extremity muscle strength, power and balance were similar across training groups. Importantly, F-URT produced similar results with considerably lower training load as compared to M-SRT and M-URT. Concluding, F-URT seems an effective and safe alternative training program to mitigate intrinsic fall risk factors in older adults.

TRIAL REGISTRATION

This trial has been registered with clinicaltrials.gov ( NCT02555033 ) on 09/18/2015.

Frontal assessment battery: A tool for screening minimal hepatic encephalopathy?

AIM

To apply the Frontal Assessment Battery to cirrhotic patients with or without overt hepatic encephalopathy (OHE) and controls.

METHODS

The frontal assessment battery (FAB) was applied to 87 patients with liver cirrhosis (16 with and 71 without OHE) and 40 control subjects without cirrhosis treated at the alcohol and liver outpatient clinics and the gastroenterology ward of the Cassiano Antônio de Moraes University Hospital (Hospital Universitário Cassiano Antônio de Moraes - HUCAM), Espírito Santo, Brazil.

RESULTS

The average FAB score was lower for the cirrhotic than for the non-cirrhotic patients (10.6 ± 3.67 vs 12.25 ± 2.72, P = 0.015). The FAB score was lower for the cirrhotic patients with OHE than for the patients without OHE (8.25 ± 4.55 vs 11.14 ± 3.25, P = 0.027). The total FAB score was lower for the cirrhotic patients without OHE than for the non-cirrhotic patients, although this difference was not significant (11.14 ± 3.25 vs 12.25 ± 2.72, P = 0.067). Nevertheless, the difference in the scores on the subtest that assessed the ability to inhibit a response previously conditioned to a stimulus was significant (1.72 ± 0.93 vs 2.2 ± 0.85, P = 0.011).

CONCLUSION

The present study indicates that the FAB is a promising tool for outpatient minimal HE screening and the assessment of HE severity.

Longitudinal profile of iron accumulation in good-grade subarachnoid hemorrhage

OBJECTIVE

MRI parameters of iron concentration (R2*, transverse relaxation rate), microstructural integrity (mean diffusivity and fractional anisotropy), as well as gray and white matter volumes were analyzed in patients with subarachnoid hemorrhage (SAH) and uncomplicated clinical course to detect the evolution of brain tissue changes 3 weeks and 12 months after ictus.

METHODS

MRI scans of 14 SAH patients (aneurysm of the anterior communicating artery, n = 5; no aneurysm n = 9) were compared with 14 age-matched healthy control subjects. Statistical parametric mapping (SPM) was applied to objectively identify focal changes of MRI parameters throughout the entire brain and to correlate image parameters with neuropsychological measures.

RESULTS

SPM localized significant bilateral increases in R2* signal within the white matter compartment of the temporal and parietal lobe and the cingulate gyrus (P < 0.001) which did not change significantly at 12 months. Significant gray matter volume reduction of the left insula and superior temporal gyrus (P < 0.001), as well as decreases in fractional anisotropy of the cingulate gyrus (P < 0.01) were also evident at 12 months. Significant correlations were found between fractional anisotropy signal alterations adjacent to the left middle and superior frontal gyrus and cognitive parameters of executive dysfunction (P < 0.001).

INTERPRETATION

The study indicates that iron is trapped predominantly throughout large portions of the white matter compartment in SAH patients at 12 months postbleeding. Increased disintegration of fiber tracts colocalizing with iron overload and correlating with lower executive function performance suggests that the white matter compartment is primarily susceptible toward long-term damage in patients with good clinical grade SAH.

PROSPERA: a randomized, controlled trial evaluating rasagiline in progressive supranuclear palsy

To date, pharmacological treatment options for progressive supranuclear palsy (PSP), a neurodegenerative tauopathy, are limited. The MAO-B inhibitor rasagiline has shown neuroprotective effects in preclinical models of neurodegeneration. To evaluate the safety, tolerability and therapeutic effect of rasagiline on symptom progression in PSP. In this 1-year randomized, double-blind, placebo-controlled trial, 44 patients fulfilling the NINDS-PSP criteria were randomized to 1 mg/d rasagiline or placebo. The combined primary endpoint included symptom progression as measured by the PSP rating scale (PSP-RS) and the requirement of L-dopa rescue medication. Secondary endpoints included Schwab and England Activities of Daily Living (SEADL), Montgomery-Åsberg Depression Rating Scale, Mini Mental State Examination, Frontal Assessment Battery and posturographic measurements. Of the 44 patients randomized, 26 completed the trial per protocol. Rasagiline was well tolerated, with a slight increase of known side effects (hallucinations, ventricular extrasystoles). No effect on the primary endpoint (p = 0.496) was detected. Symptom progression averaged at 11.2 (rasagiline) and 10.8 (placebo) points per year (ΔPSP-RS). No difference was seen in SEADL, depression, cognitive function, frontal executive function and posturographic measurements. Post hoc analyses of PSP-RS subdomains indicate a potential beneficial effect in the "limb motor" subdomain, whereas performance appeared lower in the "mentation" and "history" subdomains in the treatment group. While rasagiline is well tolerated in PSP, a beneficial effect on overall symptom progression was not detected. Post hoc analyses suggest the implementation of more specific endpoints in future studies.