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Collerton D, Barnes J, Diederich NJ, Dudley R, Ffytche D, Friston K, Goetz CG, Goldman JG, Jardri R, Kulisevsky J, Lewis SJG, Nara S, O'Callaghan C, Onofrj M, Pagonabarraga J, Parr T, Shine JM, Stebbins G, Taylor JP, Tsuda I, Weil RS. Understanding visual hallucinations: a new synthesis. Neurosci Biobehav Rev 2023; 150:105208. [PMID: 37141962 DOI: 10.1016/j.neubiorev.2023.105208] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/03/2023] [Accepted: 04/30/2023] [Indexed: 05/06/2023]
Abstract
Despite decades of research, we do not definitively know how people sometimes see things that are not there. Eight models of complex visual hallucinations have been published since 2000, including Deafferentation, Reality Monitoring, Perception and Attention Deficit, Activation, Input, and Modulation, Hodological, Attentional Networks, Active inference, and Thalamocortical Dysrhythmia Default Mode Network Decoupling. Each was derived from different understandings of brain organisation. To reduce this variability, representatives from each research group agreed an integrated Visual Hallucination Framework that is consistent with current theories of veridical and hallucinatory vision. The Framework delineates cognitive systems relevant to hallucinations. It allows a systematic, consistent, investigation of relationships between the phenomenology of visual hallucinations and changes in underpinning cognitive structures. The episodic nature of hallucinations highlights separate factors associated with the onset, persistence, and end of specific hallucinations suggesting a complex relationship between state and trait markers of hallucination risk. In addition to a harmonised interpretation of existing evidence, the Framework highlights new avenues of research, and potentially, new approaches to treating distressing hallucinations.
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Affiliation(s)
- Daniel Collerton
- School of Psychology, Faculty of Medical Sciences, Third Floor, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL UK.
| | - James Barnes
- Fatima College of Health Sciences, Department of Psychology, Al Mafraq, Abu Dhabi, UAE.
| | - Nico J Diederich
- Department of Neurology, Centre Hospitalier de Luxembourg, 4, rue Barblé, L-1210 Luxembourg-City, Luxembourg.
| | - Rob Dudley
- Department of Psychology, University of York, York, YO10 5DD, UK.
| | - Dominic Ffytche
- Institute of Psychiatry, Psychology, and Neuroscience, King's College London, de Crespigny Park, London, SE5 8AF, UK.
| | - Karl Friston
- Wellcome Centre for Human Neuroimaging, Queen Square Institute of Neurology, University College London, London, WC1N 3AR.
| | - Christopher G Goetz
- Rush University Medical Center, Suite 755, 1725 W Harrison St, Chicago IL 60612 USA.
| | - Jennifer G Goldman
- Departments of Physical Medicine and Rehabilitation and Neurology; Shirley Ryan AbilityLab, Parkinson's Disease and Movement Disorders; Feinberg School of Medicine Northwestern University, 355 E. Erie Street, Chicago, IL 60611 USA.
| | - Renaud Jardri
- Lille University, INSERM U-1172, Centre Lille Neuroscience & Cognition, CURE platform, Fontan Hospital, CHU Lille, France.
| | - Jaime Kulisevsky
- Movement Disorders Unit, Sant Pau Hospital, Hospital Sant Pau. C/ Mas Casanovas 90. Barcelona (08041) and Universitat Autònoma de Barcelona; CIBERNED (Network Centre for Neurodegenerative Diseases), Spain.
| | - Simon J G Lewis
- ForeFront Parkinson's Disease Research Clinic, 100 Mallett Street, Brain and Mind Centre, School of Medical Sciences, University of Sydney, Camperdown, NSW 2050, Australia.
| | - Shigetoshi Nara
- Dept. Electrical & Electronic Engineering, Okayama University, Tsushima-naka, 3-1-1, Okayama 700-8530, Japan.
| | - Claire O'Callaghan
- ForeFront Parkinson's Disease Research Clinic, 100 Mallett Street, Brain and Mind Centre, School of Medical Sciences, University of Sydney, Camperdown, NSW 2050, Australia.
| | - Marco Onofrj
- Clinica Neurologica, Department of Neuroscience, Imaging and Clinical Science, University "G.d'Annunzio" of Chieti-Pescara, via Polacchi 39,66100, Chieti, Italy.
| | - Javier Pagonabarraga
- Movement Disorders Unit, Sant Pau Hospital, Hospital Sant Pau. C/ Mas Casanovas 90. Barcelona (08041) and Universitat Autònoma de Barcelona; CIBERNED (Network Centre for Neurodegenerative Diseases), Spain.
| | - Thomas Parr
- Wellcome Centre for Human Neuroimaging, Queen Square Institute of Neurology, University College London, London, WC1N 3AR.
| | - James M Shine
- ForeFront Parkinson's Disease Research Clinic, 100 Mallett Street, Brain and Mind Centre, School of Medical Sciences, University of Sydney, Camperdown, NSW 2050, Australia.
| | - Glenn Stebbins
- Rush University Medical Center, Suite 755, 1725 W Harrison St, Chicago IL 60612 USA.
| | - John-Paul Taylor
- Newcastle Biomedical Research Centre, Campus for Ageing and Vitality, Newcastle University NE4 5PL, UK.
| | - Ichiro Tsuda
- Chubu University Academy of Emerging Sciences and Center for Mathematical Science and Artificial Intelligence, Chubu University, Kasugai, Aichi 487-8501, Japan.
| | - Rimona S Weil
- Wellcome Centre for Human Neuroimaging, Queen Square Institute of Neurology, University College London, London, WC1N 3AR; Dementia Research Centre; Movement Disorders Centre, University College London, London, WC1N 3BG UK.
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Elder GJ, Lazar AS, Alfonso‐Miller P, Taylor J. Sleep disturbances in Lewy body dementia: A systematic review. Int J Geriatr Psychiatry 2022; 37:10.1002/gps.5814. [PMID: 36168299 PMCID: PMC9827922 DOI: 10.1002/gps.5814] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/13/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Lewy body dementia (LBD) refers to both dementia with Lewy bodies (DLB) and Parkinson's disease with dementia (PDD). Sleep disturbances are common in LBD, and can include poor sleep quality, excessive daytime sleepiness (EDS), and rapid eye movement behaviour disorder (RBD). Despite the high clinical prevalence of sleep disturbances in LBD, they are under-studied relative to other dementias. The aim of the present systematic review was to examine the nature of sleep disturbances in LBD, summarise the effect of treatment studies upon sleep, and highlight specific and necessary directions for future research. METHODS Published studies in English were located by searching PubMED and PSYCArticles databases (until 10 June 2022). The search protocol was pre-registered in PROSPERO (CRD42021293490) and performed in accordance with PRISMA guidelines. RESULTS Following full-text review, a final total of 70 articles were included. These included 20 studies focussing on subjective sleep, 14 on RBD, 8 on EDS, 7 on objective sleep, and 1 on circadian rhythms. The majority of the 18 treatment studies used pharmacological interventions (n = 12), had an open-label design (n = 8), and were of low-to-moderate quality. Most studies (n = 55) included only patients with DLB. Due to the heterogeneity of the studies, we reported a narrative synthesis without meta-analysis. CONCLUSIONS At least one form of sleep disturbance may be present in as many as 90% of people with LBD. Subjectively poor sleep quality, excessive daytime sleepiness, and RBD are more common and severe in LBD relative to other dementias.
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Affiliation(s)
- Greg J. Elder
- Northumbria Sleep ResearchDepartment of PsychologyFaculty of Health and Life SciencesNorthumbria UniversityNewcastle upon TyneUK
| | - Alpar S. Lazar
- Sleep and Brain Research UnitFaculty of Medicine and Health SciencesUniversity of East AngliaNorwichUK
| | - Pam Alfonso‐Miller
- Northumbria Sleep ResearchDepartment of PsychologyFaculty of Health and Life SciencesNorthumbria UniversityNewcastle upon TyneUK
| | - John‐Paul Taylor
- Translational and Clinical Research InstituteNewcastle UniversityCampus for Ageing and VitalityNewcastle Upon TyneUK
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Murayama T, Kobayashi S, Ishida T, Utsumi K, Kawanishi C. Associations Between Regional Cerebral Blood Flow and Psychiatric Symptoms in Dementia With Lewy Bodies Without Parkinsonism. Am J Alzheimers Dis Other Demen 2022; 37:15333175221075109. [PMID: 35171729 PMCID: PMC10581150 DOI: 10.1177/15333175221075109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Because dementia with Lewy bodies (DLB) has various psychiatric symptoms, early diagnosis in patients without parkinsonism is difficult. To reveal associations between regional brain perfusion and psychiatric symptoms in DLB patients without parkinsonism, we quantified brain perfusion using an automated brain perfusion single-photon emission computed tomography analysis program, FineSRT. We statistically analyzed the differences in brain perfusion between groups, divided by the presence or absence of psychiatric symptoms. In DLB patients with depression, there were significant brain perfusion increases in the left angular gyrus and right upper precuneus. In DLB patients with visual hallucinations, there were significant decreases in the left inferior parietal lobule, left superior temporal gyrus, and right primary visual cortex. In DLB patients with auditory hallucinations, there were significant increases in the right middle occipital and right inferior occipital gyri. Our findings provide clues about the pathomechanisms of psychiatric symptoms and may enable early diagnosis of DLB in the future.
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Affiliation(s)
- Tomonori Murayama
- Department of Neuropsychiatry, Graduate School of Medicine, Sapporo Medical University, Sapporo, Japan
- Department of Psychiatry, Kushiro Red Cross Hospital, Kushiro, Japan
| | - Seiju Kobayashi
- Department of Neuropsychiatry, Graduate School of Medicine, Sapporo Medical University, Sapporo, Japan
- Shinyukai Nakae Hospital, Sapporo, Japan
| | - Tomotaka Ishida
- Department of Psychiatry, Sunagawa City Medical Center, Sunagawa, Japan
| | - Kumiko Utsumi
- Department of Psychiatry, Sunagawa City Medical Center, Sunagawa, Japan
| | - Chiaki Kawanishi
- Department of Neuropsychiatry, Graduate School of Medicine, Sapporo Medical University, Sapporo, Japan
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Alenikova OA. [Visual hallucinations in Parkinson's disease]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:106-113. [PMID: 34283539 DOI: 10.17116/jnevro2021121061106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Visual hallucinations have a negative effect on the course of Parkinson's disease (PD), being a source of stress for the patients themselves and caregivers. The article discusses the basic theories and pathogenetic mechanisms of the development of visual hallucinations in PD consisting of the following components: impairment of the visual information received from the retina with subsequent disruption of its processing in the central parts of the visual system; lack of suppression of internally generated images through the ponto-geniculo-occipital system; the invasion of REM sleep patterns in wakefulness; decreased ability of the brain stem structures to implement appropriate information filtering as well as excessive drug-induced activation of the mesolimbic system. Particular attention is paid to visual impairment and changes in the transmission of information along the retino-hypothalamic tract. In this connection, dysfunction in the «retina - hypothalamus» system can also be considered as one of the factors that determines the time and rhythm of occurrence or exacerbation of visual hallucinations in PD. Attracting attention to this aspect opens new therapeutic possibilities where the circadian system can be positioned as a target of additional exposure in the treatment of visual hallucinations in PD.
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Affiliation(s)
- O A Alenikova
- Republican Scientific and Practical Center of Neurology and Neurosurgery, Minsk, Republic of Belarus
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Hamilton CA, Matthews FE, Donaghy PC, Taylor JP, O'Brien JT, Barnett N, Olsen K, Durcan R, Roberts G, Ciafone J, Barker SAH, Firbank M, McKeith IG, Thomas AJ. Progression to Dementia in Mild Cognitive Impairment With Lewy Bodies or Alzheimer Disease. Neurology 2021; 96:e2685-e2693. [PMID: 33875556 PMCID: PMC8205466 DOI: 10.1212/wnl.0000000000012024] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 03/02/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To determine whether mild cognitive impairment with Lewy bodies or mild cognitive impairment with Alzheimer disease differ in their rates of clinical progression to dementia, we undertook longitudinal observation of mild cognitive impairment cases with detailed clinical assessment of Lewy body diagnostic characteristics. METHODS Two prospective longitudinal cohorts including 111 individuals ≥60 years of age with mild cognitive impairment were assessed annually to track cognitive and clinical progression, including the presence or absence of core clinical features and proposed biomarkers of dementia with Lewy bodies. Multistate modeling was used to assess the associations of diagnostic characteristics of dementia with Lewy bodies with clinical progression from mild cognitive impairment to dementia, with death as a competing outcome. RESULTS After a mean follow-up of 2.2 years (range 1-6.7 years), 38 of the 111 (34%) participants progressed to dementia: 10 with AD, 3 with possible dementia with Lewy bodies, and 25 with probable dementia with Lewy bodies. The presence of any Lewy body disease characteristic was associated with an increased hazard of transition to dementia; this risk further increased as more diagnostic characteristics were observed (hazard ratio 1.33 per characteristic, 95% confidence interval [CI] 1.11-1.60) and was especially high for those experiencing complex visual hallucinations (hazard ratio 1.98, 95% CI 0.92-4.29) or cognitive fluctuations (hazard ratio 3.99, 95% CI 2.03-7.84). CONCLUSIONS Diagnostic characteristics of Lewy body disease are associated with an increased risk of transition from mild cognitive impairment to dementia.
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Affiliation(s)
- Calum A Hamilton
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK.
| | - Fiona E Matthews
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - Paul C Donaghy
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - John-Paul Taylor
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - John T O'Brien
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - Nicola Barnett
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - Kirsty Olsen
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - Rory Durcan
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - Gemma Roberts
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - Joanna Ciafone
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - Sally A H Barker
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - Michael Firbank
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - Ian G McKeith
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
| | - Alan J Thomas
- From the Translational and Clinical Research Institute (C.A.H., P.C.D., J.-P.T., N.B., K.O., R.D., G.R., J.C., S.A.H.B., M.F., I.G.M., A.J.T.) and Population Health Sciences Institute (F.E.M.), Newcastle University; and Department of Psychiatry (J.T.O.), University of Cambridge School of Clinical Medicine, UK
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Nicastro N, Stripeikyte G, Assal F, Garibotto V, Blanke O. Premotor and fronto-striatal mechanisms associated with presence hallucinations in dementia with Lewy bodies. NEUROIMAGE: CLINICAL 2021; 32:102791. [PMID: 34461436 PMCID: PMC8403753 DOI: 10.1016/j.nicl.2021.102791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 08/11/2021] [Accepted: 08/13/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION presence hallucinations (PH) are frequent in dementia with Lewy bodies (DLB), but their cortico-subcortical origin is unknown. Recent studies have defined key frontal and temporal areas contributing to the occurrence of PH (PH-network) and tested their relevance in subjects with Parkinson's disease (PD). With the present study, we aimed at disentangling the metabolic and dopaminergic correlates of pH as well as their relation to a recently defined PH brain network in DLB. METHODS for the present study, we included 34 DLB subjects (10 with PH (PH + ); 24 without PH (PH-)), who underwent 18F-FDG PET and 123I-FP-CIT SPECT imaging. We performed 18F-FDG PET group comparisons, as well as interregional correlation analyses using 18F-FDG PH-network regions as a seed. RESULTS PH + versus PH- had reduced 18F-FDG uptake in precentral, superior frontal and parietal gyri, involving ventral premotor cortex (vPMC) of the PH-network that showed strongly reduced functional connectivity with bilateral cortical regions. 18F-FDG vPMC uptake was negatively correlated with caudate 123I-FP-CIT uptake in PH+ (p = 0.028) and interregional correlation analysis seeding from the vPMC showed widespread fronto-parietal 18F-FDG decreases in PH + . DISCUSSION these findings uncover the pivotal role of vPMC (involved in a PH-network) and its cortico-striatal connections in association with PH in DLB, improving our understanding of psychosis in neurodegeneration.
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Affiliation(s)
- Nicolas Nicastro
- Division of Neurology, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland.
| | - Giedre Stripeikyte
- Center for Neuroprosthetics, Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland; Brain Mind Institute, Faculty of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Frédéric Assal
- Division of Neurology, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Switzerland
| | - Valentina Garibotto
- Faculty of Medicine, University of Geneva, Switzerland; Division of Nuclear Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Olaf Blanke
- Division of Neurology, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland; Center for Neuroprosthetics, Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland; Brain Mind Institute, Faculty of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
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Chabran E, Noblet V, Loureiro de Sousa P, Demuynck C, Philippi N, Mutter C, Anthony P, Martin-Hunyadi C, Cretin B, Blanc F. Changes in gray matter volume and functional connectivity in dementia with Lewy bodies compared to Alzheimer's disease and normal aging: implications for fluctuations. Alzheimers Res Ther 2020; 12:9. [PMID: 31907068 PMCID: PMC6945518 DOI: 10.1186/s13195-019-0575-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 12/23/2019] [Indexed: 12/02/2022]
Abstract
BACKGROUND Fluctuations are one of the core clinical features characterizing dementia with Lewy bodies (DLB). They represent a determining factor for its diagnosis and strongly impact the quality of life of patients and their caregivers. However, the neural correlates of this complex symptom remain poorly understood. This study aimed to investigate the structural and functional changes in DLB patients, compared to Alzheimer's disease (AD) patients and healthy elderly subjects, and their potential links with fluctuations. METHODS Structural and resting-state functional MRI data were collected from 92 DLB patients, 70 AD patients, and 22 control subjects, who also underwent a detailed clinical examination including the Mayo Clinic Fluctuation Scale. Gray matter volume changes were analyzed using whole-brain voxel-based morphometry, and resting-state functional connectivity was investigated using a seed-based analysis, with regions of interest corresponding to the main nodes of the salience network (SN), frontoparietal network (FPN), dorsal attention network (DAN), and default mode network (DMN). RESULTS At the structural level, fluctuation scores in DLB patients did not relate to the atrophy of insular, temporal, and frontal regions typically found in this pathology, but instead showed a weak correlation with more subtle volume reductions in different regions of the cholinergic system. At the functional level, the DLB group was characterized by a decreased connectivity within the SN and attentional networks, while the AD group showed decreases within the SN and DMN. In addition, higher fluctuation scores in DLB patients were correlated to a greater connectivity of the SN with the DAN and left thalamus, along with a decreased connectivity between the SN and DMN, and between the right thalamus and both the FPN and DMN. CONCLUSIONS Functional connectivity changes, rather than significant gray matter loss, could play an important role in the emergence of fluctuations in DLB. Notably, fluctuations in DLB patients appeared to be related to a disturbed external functional connectivity of the SN, which may lead to less relevant transitions between different cognitive states in response to internal and environmental stimuli. Our results also suggest that the thalamus could be a key region for the occurrence of this symptom.
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Affiliation(s)
- Eléna Chabran
- ICube Laboratory UMR 7357 and FMTS (Fédération de Médecine Translationnelle de Strasbourg), Team IMIS, University of Strasbourg and CNRS, Strasbourg, France
| | - Vincent Noblet
- ICube Laboratory UMR 7357 and FMTS (Fédération de Médecine Translationnelle de Strasbourg), Team IMIS, University of Strasbourg and CNRS, Strasbourg, France
| | - Paulo Loureiro de Sousa
- ICube Laboratory UMR 7357 and FMTS (Fédération de Médecine Translationnelle de Strasbourg), Team IMIS, University of Strasbourg and CNRS, Strasbourg, France
| | - Catherine Demuynck
- CM2R (Research and Resources Memory Centre), Geriatrics Department, University Hospitals of Strasbourg, Geriatric Day Hospital and Neuropsychology Unit, Strasbourg, France
| | - Nathalie Philippi
- ICube Laboratory UMR 7357 and FMTS (Fédération de Médecine Translationnelle de Strasbourg), Team IMIS, University of Strasbourg and CNRS, Strasbourg, France
- CM2R (Research and Resources Memory Centre), Geriatrics Department, University Hospitals of Strasbourg, Geriatric Day Hospital and Neuropsychology Unit, Strasbourg, France
| | - Catherine Mutter
- INSERM Centre d’Investigation Clinique 1434, University Hospitals of Strasbourg, Strasbourg, France
| | - Pierre Anthony
- General Hospital Centre, Geriatrics Department, CM2R, Geriatric Day Hospital, Colmar, France
| | - Catherine Martin-Hunyadi
- CM2R (Research and Resources Memory Centre), Geriatrics Department, University Hospitals of Strasbourg, Geriatric Day Hospital and Neuropsychology Unit, Strasbourg, France
| | - Benjamin Cretin
- ICube Laboratory UMR 7357 and FMTS (Fédération de Médecine Translationnelle de Strasbourg), Team IMIS, University of Strasbourg and CNRS, Strasbourg, France
- CM2R (Research and Resources Memory Centre), Geriatrics Department, University Hospitals of Strasbourg, Geriatric Day Hospital and Neuropsychology Unit, Strasbourg, France
| | - Frédéric Blanc
- ICube Laboratory UMR 7357 and FMTS (Fédération de Médecine Translationnelle de Strasbourg), Team IMIS, University of Strasbourg and CNRS, Strasbourg, France
- CM2R (Research and Resources Memory Centre), Geriatrics Department, University Hospitals of Strasbourg, Geriatric Day Hospital and Neuropsychology Unit, Strasbourg, France
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Russo M, Carrarini C, Dono F, Rispoli MG, Di Pietro M, Di Stefano V, Ferri L, Bonanni L, Sensi SL, Onofrj M. The Pharmacology of Visual Hallucinations in Synucleinopathies. Front Pharmacol 2019; 10:1379. [PMID: 31920635 PMCID: PMC6913661 DOI: 10.3389/fphar.2019.01379] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/30/2019] [Indexed: 12/13/2022] Open
Abstract
Visual hallucinations (VH) are commonly found in the course of synucleinopathies like Parkinson's disease and dementia with Lewy bodies. The incidence of VH in these conditions is so high that the absence of VH in the course of the disease should raise questions about the diagnosis. VH may take the form of early and simple phenomena or appear with late and complex presentations that include hallucinatory production and delusions. VH are an unmet treatment need. The review analyzes the past and recent hypotheses that are related to the underlying mechanisms of VH and then discusses their pharmacological modulation. Recent models for VH have been centered on the role played by the decoupling of the default mode network (DMN) when is released from the control of the fronto-parietal and salience networks. According to the proposed model, the process results in the perception of priors that are stored in the unconscious memory and the uncontrolled emergence of intrinsic narrative produced by the DMN. This DMN activity is triggered by the altered functioning of the thalamus and involves the dysregulated activity of the brain neurotransmitters. Historically, dopamine has been indicated as a major driver for the production of VH in synucleinopathies. In that context, nigrostriatal dysfunctions have been associated with the VH onset. The efficacy of antipsychotic compounds in VH treatment has further supported the notion of major involvement of dopamine in the production of the hallucinatory phenomena. However, more recent studies and growing evidence are also pointing toward an important role played by serotonergic and cholinergic dysfunctions. In that respect, in vivo and post-mortem studies have now proved that serotonergic impairment is often an early event in synucleinopathies. The prominent cholinergic impairment in DLB is also well established. Finally, glutamatergic and gamma aminobutyric acid (GABA)ergic modulations and changes in the overall balance between excitatory and inhibitory signaling are also contributing factors. The review provides an extensive overview of the pharmacology of VH and offers an up to date analysis of treatment options.
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Affiliation(s)
- Mirella Russo
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Claudia Carrarini
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Fedele Dono
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Marianna Gabriella Rispoli
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Martina Di Pietro
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Vincenzo Di Stefano
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Laura Ferri
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Laura Bonanni
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Stefano Luca Sensi
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
- Behavioral Neurology and Molecular Neurology Units, Center of Excellence on Aging and Translational Medicine—CeSI-MeT, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
- Departments of Neurology and Pharmacology, Institute for Mind Impairments and Neurological Disorders—iMIND, University of California, Irvine, Irvine, CA, United States
| | - Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
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9
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Clinical features of Lewy body dementia: insights into diagnosis and pathophysiology. J Neurol 2019; 267:380-389. [DOI: 10.1007/s00415-019-09583-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/11/2019] [Accepted: 10/14/2019] [Indexed: 12/18/2022]
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10
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Matar E, Shine JM, Halliday GM, Lewis SJG. Cognitive fluctuations in Lewy body dementia: towards a pathophysiological framework. Brain 2019; 143:31-46. [DOI: 10.1093/brain/awz311] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/21/2019] [Accepted: 08/16/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Fluctuating cognition is a complex and disabling symptom that is seen most frequently in the context of Lewy body dementias encompassing dementia with Lewy bodies and Parkinson’s disease dementia. In fact, since their description over three decades ago, cognitive fluctuations have remained a core diagnostic feature of dementia with Lewy bodies, the second most common dementia in the elderly. In the absence of reliable biomarkers for Lewy body pathology, the inclusion of such patients in therapeutic trials depends on the accurate identification of such core clinical features. Yet despite their diagnostic relevance, cognitive fluctuations remain poorly understood, in part due to the lack of a cohesive clinical and scientific explanation of the phenomenon itself. Motivated by this challenge, the present review examines the history, clinical phenomenology and assessment of cognitive fluctuations in the Lewy body dementias. Based on these data, the key neuropsychological, neurophysiological and neuroimaging correlates of cognitive fluctuations are described and integrated into a novel testable heuristic framework from which new insights may be gained.
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Affiliation(s)
- Elie Matar
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia
- Parkinson’s Disease Research Clinic, Brain and Mind Centre, University of Sydney, NSW, Australia
| | - James M Shine
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia
- Parkinson’s Disease Research Clinic, Brain and Mind Centre, University of Sydney, NSW, Australia
| | - Glenda M Halliday
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia
| | - Simon J G Lewis
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, NSW Australia
- Parkinson’s Disease Research Clinic, Brain and Mind Centre, University of Sydney, NSW, Australia
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11
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Sun M, Mainland BJ, Ornstein TJ, Mallya S, Fiocco AJ, Sin GL, Shulman KI, Herrmann N. The association between cognitive fluctuations and activities of daily living and quality of life among institutionalized patients with dementia. Int J Geriatr Psychiatry 2018; 33:e280-e285. [PMID: 28940504 DOI: 10.1002/gps.4788] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 08/08/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Cognitive fluctuations (CFs) occur commonly in dementia of all types. While it is generally accepted that CFs can affect the clinical rating of dementia severity and neuropsychological performance, little is known about their impact on patients' activities of daily living (ADLs) and quality of life (QOL). Our study aims to explore the impact of CFs on ADLs and QOL among institutionalized patients with dementia. METHODS The present study examined the nature and frequency of CFs in 55 institutionalized dementia patients. We used the Dementia Cognitive Fluctuation Scale (DCFS) to assess the presence and severity of CFs. The Alzheimer's Disease Functional Assessment of Change Scale (ADFACS) was used to assess patients' ADLs, and the Quality of Life in Late Stage Dementia scale (QUALID) was used to assess QOL. Linear regression models were used to assess the relationships between CFs, ADLs, and QOL. RESULTS The mean age of the patients was 90.41 years (SD = 2.84). Their mean Aggressive Behavior Scale score was 1.13 (SD = 1.59), mean Severe Impairment Battery total score was 86.65 (SD = 13.77), and mean DCFS score was 10.07 (SD = 3.04). The mean ADFACS-ADL score was 10.88 (SD = 6.37), mean ADFACS-IADL score was 16.61 (SD = 9.54), and mean QUALID total score was 18.25 (SD = 5.70). DCFS significantly predicted ADFACS-ADL score (R2 = 0.39, β = 0.30, P = .011) although the relationship between ADFACS-IADL score and DCFS score was not significant (R2 = 0.16, P = .111). DCFS significantly predicted QUALID score (R2 = 0.08, β = 0.29, P = .033). CONCLUSION More severe CFs in patients with dementia were significantly associated with impaired ability to engage in ADLs and poorer QOL.
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Affiliation(s)
- Meng Sun
- Department of Psychiatry, The Second Xianga Hospital, Central South University; National Clinical Research Center on Mental Health Disorders (Xiangya); National Technology Institute on Mental Disorders, Hunan Technology Institute of Psychiatry, Hunan; Key Laboratory of Psychiatry and Mental Health, Mental Health Institute of Central South University, China.,Division of Geriatric Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre; Department of Psychiatry, University of Toronto, Canada
| | | | | | - Sasha Mallya
- Department of Psychology, Ryerson University, Toronto, Canada
| | | | - Gwen Li Sin
- Department of Psychiatry, Singapore General Hospital, Singapore
| | - Kenneth I Shulman
- Division of Geriatric Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre; Department of Psychiatry, University of Toronto, Canada
| | - Nathan Herrmann
- Division of Geriatric Psychiatry, Department of Psychiatry, Sunnybrook Health Sciences Centre; Department of Psychiatry, University of Toronto, Canada
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12
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Watson R, Colloby SJ, Blamire AM, Wesnes KA, Wood J, O'Brien JT. Does attentional dysfunction and thalamic atrophy predict decline in dementia with Lewy bodies? Parkinsonism Relat Disord 2017; 45:69-74. [DOI: 10.1016/j.parkreldis.2017.10.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/27/2017] [Accepted: 10/08/2017] [Indexed: 11/25/2022]
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13
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Pezzoli S, Cagnin A, Bandmann O, Venneri A. Structural and Functional Neuroimaging of Visual Hallucinations in Lewy Body Disease: A Systematic Literature Review. Brain Sci 2017; 7:E84. [PMID: 28714891 PMCID: PMC5532597 DOI: 10.3390/brainsci7070084] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 06/27/2017] [Accepted: 07/09/2017] [Indexed: 01/01/2023] Open
Abstract
Patients with Lewy body disease (LBD) frequently experience visual hallucinations (VH), well-formed images perceived without the presence of real stimuli. The structural and functional brain mechanisms underlying VH in LBD are still unclear. The present review summarises the current literature on the neural correlates of VH in LBD, namely Parkinson's disease (PD), and dementia with Lewy bodies (DLB). Following a systematic literature search, 56 neuroimaging studies of VH in PD and DLB were critically reviewed and evaluated for quality assessment. The main structural neuroimaging results on VH in LBD revealed grey matter loss in frontal areas in patients with dementia, and parietal and occipito-temporal regions in PD without dementia. Parietal and temporal hypometabolism was also reported in hallucinating PD patients. Disrupted functional connectivity was detected especially in the default mode network and fronto-parietal regions. However, evidence on structural and functional connectivity is still limited and requires further investigation. The current literature is in line with integrative models of VH suggesting a role of attention and perception deficits in the development of VH. However, despite the close relationship between VH and cognitive impairment, its associations with brain structure and function have been explored only by a limited number of studies.
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Affiliation(s)
- Stefania Pezzoli
- Department of Neuroscience, University of Sheffield, Sheffield, S10 2RX, UK.
| | - Annachiara Cagnin
- Department of Neurosciences, University of Padua, 35128 Padua, Italy.
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Ospedale San Camillo, 30126 Venice, Italy.
| | - Oliver Bandmann
- Department of Neuroscience, University of Sheffield, Sheffield, S10 2RX, UK.
| | - Annalena Venneri
- Department of Neuroscience, University of Sheffield, Sheffield, S10 2RX, UK.
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14
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Kobayashi S, Makino K, Hatakeyama S, Ishii T, Tateno M, Iwamoto T, Tsujino H, Kawasaki K, Mikuni K, Ukai W, Murayama T, Hashimoto E, Utsumi K, Kawanishi C. The usefulness of combined brain perfusion single-photon emission computed tomography, Dopamine-transporter single-photon emission computed tomography, and 123 I-metaiodobenzylguanidine myocardial scintigraphy for the diagnosis of dementia with Lewy bodies. Psychogeriatrics 2017; 17:247-255. [PMID: 28130808 DOI: 10.1111/psyg.12227] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/08/2016] [Accepted: 08/31/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Current diagnostic criteria recommend neuroimaging as a diagnostic support tool for the clinical diagnosis of dementia with Lewy bodies (DLB). Because DLB causes characteristic impairments and disabilities, such as neuroleptic hypersensitivity, which may significantly increase morbidity and mortality, its prompt and correct diagnosis is very important. The aim of this study was to evaluate the extent to which diagnostic accuracy can be increased by using different combinations of brain perfusion single-photon emission computed tomography (bp-SPECT), 123 I-metaiodobenzylguanidine myocardial scintigraphy (MIBG scintigraphy), and DAT-SPECT. Taking finances and patient burden into consideration, we compared the tests to determine priority. METHODS Thirty-four patients with probable DLB (75.0 ± 8.3 years old; 14 men, 20 women) underwent bp-SPECT, MIBG scintigraphy, and DAT-SPECT. RESULTS Our comparison of three functional imaging techniques indicated that MIBG scintigraphy (79%) and Dopamine-transporter (DAT) SPECT (79%) had better sensitivity for characteristic abnormalities in DLB than bp-SPECT (53%). The combination of the three modalities could increase sensitivity for diagnosis of DLB to 100%. Additionally, the ratio of patients with rapid eye movement sleep behaviour disorder was significantly higher in the positive finding group on MIBG scintigraphy than in the negative finding group. CONCLUSIONS In terms of stand-alone diagnostic means, priority should be placed on MIBG scintigraphy or DAT-SPECT for the diagnosis of DLB. However, our results suggest that the combination of bp-SPECT, MIBG scintigraphy, and DAT-SPECT increased the accuracy of the clinical diagnosis of DLB.
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Affiliation(s)
- Seiju Kobayashi
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine , Sapporo, Japan
| | - Kanae Makino
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine , Sapporo, Japan
| | | | - Takao Ishii
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine , Sapporo, Japan
| | - Masaru Tateno
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine , Sapporo, Japan.,Tokiwa Child Development Center, Tokiwa Hospital, Sapporo, Japan
| | - Tomo Iwamoto
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine , Sapporo, Japan
| | - Hanako Tsujino
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine , Sapporo, Japan
| | - Kazuhito Kawasaki
- Department of Radiology, Sunagawa City Medical Center, Sunagawa, Japan
| | - Kouhei Mikuni
- Department of Radiology, Sunagawa City Medical Center, Sunagawa, Japan
| | - Wataru Ukai
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine , Sapporo, Japan
| | - Tomonori Murayama
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine , Sapporo, Japan
| | - Eri Hashimoto
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine , Sapporo, Japan
| | - Kumiko Utsumi
- Department of Psychiatry, Sunagawa City Medical Center, Sunagawa, Japan
| | - Chiaki Kawanishi
- Department of Neuropsychiatry, Sapporo Medical University Graduate School of Medicine , Sapporo, Japan
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15
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The role of the retina in visual hallucinations: A review of the literature and implications for psychosis. Neuropsychologia 2017; 99:128-138. [DOI: 10.1016/j.neuropsychologia.2017.03.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 02/09/2017] [Accepted: 03/01/2017] [Indexed: 12/14/2022]
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16
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Adwani S, Yadav R, Kumar K, Chandra SR, Pal PK. Neuropsychological profile in early Parkinson's disease: Comparison between patients with right side onset versus left side onset of motor symptoms. Ann Indian Acad Neurol 2016; 19:74-8. [PMID: 27011633 PMCID: PMC4782557 DOI: 10.4103/0972-2327.167711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims: Though impaired cognition in Parkinson's disease (PD) is well known, data in early PD is sparse. This study was designed to assess the cognitive profile in patients with early PD (motor symptoms <5 years and Hoehn and Yahr stage <2), and to compare the cognitive profile between these patients with right versus left side onset of motor symptoms. Materials and Methods: National Institute of National Health and Neurosciences (NIMHANS) neuropsychological battery was used to assess the cognitive profile in 50 patients with early PD and compared with 50 age-, education-, and gender-matched healthy controls. Within the PD group, the cognitive profile was also compared between patients with right side onset motor symptoms (RPD) versus those with left side onset (LPD). The neuropsychological tests assessed the executive functions, memory, attention, visuospatial functions, and psychomotor speed. Results: Among the 50 patients, 25 each were RPD and LPD. The two subgroups were matched for age, gender, education, age at disease onset, disease duration, and degree of motor disability. There was no significant difference between the groups on Hoehn and Yahr staging or Unified Parkinson Disease Rating Scale (UPDRS) motor score. Patients with early PD performed significantly worse in the tasks involving memory, executive functions, and attention compared to controls. However, there was no difference in the cognitive profile between RPD and LPD subgroups. Conclusions: Patients with early PD have cognitive dysfunction with predominant involvement of frontal and temporal lobes. Side of onset of motor symptoms probably does not have significant role in future development or profile of cognitive dysfunction in PD.
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Affiliation(s)
- Sikandar Adwani
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Ravi Yadav
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Keshav Kumar
- Department of Clinical Psychology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - S R Chandra
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Pramod Kumar Pal
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
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Neural correlates of visual hallucinations in dementia with Lewy bodies. ALZHEIMERS RESEARCH & THERAPY 2015; 7:6. [PMID: 25717349 PMCID: PMC4339752 DOI: 10.1186/s13195-014-0091-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 12/18/2014] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The aim of this study was to investigate the association between visual hallucinations in dementia with Lewy bodies (DLB) and brain perfusion using single-photon emission computed tomography. METHODS We retrospectively included 66 patients with DLB, 36 of whom were having visual hallucinations (DLB-hallu) and 30 of whom were not (DLB-c). We assessed visual hallucination severity on a 3-point scale of increasing severity: illusions, simple visual hallucinations and complex visual hallucinations. We performed voxel-level comparisons between the two groups and assessed correlations between perfusion and visual hallucinations severity. RESULTS We found a significant decrease in perfusion in the left anterior cingulate cortex, the left orbitofrontal cortex and the left cuneus in the DLB-hallu group compared with the DLB-c group. We also found a significant correlation between decreased bilateral anterior cingulate cortex, left orbitofrontal cortex, right parahippocampal gyrus, right inferior temporal cortex and left cuneus perfusion with the severity of hallucinations. CONCLUSIONS Visual hallucinations seem to be associated with the impairment of anterior and posterior regions (secondary visual areas, orbitofrontal cortex and anterior cingulate cortex) involved in a top-down and bottom-up mechanism, respectively. Furthermore, involvement of the bilateral anterior cingulate cortex and right parahippocampal gyrus seems to lead to more complex hallucinations.
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Blanc F, Noblet V, Philippi N, Cretin B, Foucher J, Armspach JP, Rousseau F. Right anterior insula: core region of hallucinations in cognitive neurodegenerative diseases. PLoS One 2014; 9:e114774. [PMID: 25479196 PMCID: PMC4257732 DOI: 10.1371/journal.pone.0114774] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 11/13/2014] [Indexed: 02/07/2023] Open
Abstract
Objectives We investigated the neural basis of hallucinations Alzheimer's disease (AD) by applying voxel-based morphometry (VBM) to anatomical and functional data from the AD Neuroimaging Initiative. Methods AD patients with hallucinations, based on the Neuropsychiatric Inventory (NPI-Q) (AD-hallu group; n = 39), were compared to AD patients without hallucinations matched for age, sex, educational level, handedness and MMSE (AD-c group; n = 39). Focal brain volume on MRI was analyzed and compared between the two groups according to the VBM method. We also performed voxel-level correlations between brain volume and hallucinations intensity. A similar paradigm was used for the PET analysis. “Core regions” (i.e. regions identified in both MRI and PET analyses, simply done by retaining the clusters obtained from the two analyses that are overlapping) were then determined. Results Regions with relative atrophy in association with hallucinations were: anterior part of the right insula, left superior frontal gyrus and lingual gyri. Regions with relative hypometabolism in association with hallucinations were a large right ventral and dorsolateral prefrontal area. "Core region" in association with hallucinations was the right anterior part of the insula. Correlations between intensity of hallucinations and brain volume were found in the right anterior insula, precentral gyrus, superior temporal gyrus, and left precuneus. Correlations between intensity of hallucinations and brain hypometabolism were found in the left midcingulate gyrus. We checked the neuropathological status and we found that the 4 patients autopsied in the AD-hallu group had the mixed pathology AD and Dementia with Lewy bodies (DLB). Conclusion Neural basis of hallucinations in cognitive neurodegenerative diseases (AD or AD and DLB) include a right predominant anterior-posterior network, and the anterior insula as the core region. This study is coherent with the top-down/bottom-up hypotheses on hallucinations but also hypotheses of the key involvement of the anterior insula in hallucinations in cognitive neurodegenerative diseases.
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Affiliation(s)
- Frédéric Blanc
- University Hospital of Strasbourg, Neuropsychology Unit, Neurology Service, Strasbourg, France
- University of Strasbourg and CNRS, ICube laboratory UMR 7357, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Strasbourg, France
- University Hospital of Strasbourg, CMRR (Memory Resources and Research Centre), Strasbourg, France
- University Hospital of Strasbourg, Day Hospital of Geriatrics, Geriatrics Service, Strasbourg, France
- * E-mail:
| | - Vincent Noblet
- University of Strasbourg and CNRS, ICube laboratory UMR 7357, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Strasbourg, France
| | - Nathalie Philippi
- University Hospital of Strasbourg, Neuropsychology Unit, Neurology Service, Strasbourg, France
- University of Strasbourg and CNRS, ICube laboratory UMR 7357, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Strasbourg, France
- University Hospital of Strasbourg, CMRR (Memory Resources and Research Centre), Strasbourg, France
| | - Benjamin Cretin
- University Hospital of Strasbourg, Neuropsychology Unit, Neurology Service, Strasbourg, France
- University of Strasbourg and CNRS, ICube laboratory UMR 7357, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Strasbourg, France
- University Hospital of Strasbourg, CMRR (Memory Resources and Research Centre), Strasbourg, France
| | - Jack Foucher
- University of Strasbourg and CNRS, ICube laboratory UMR 7357, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Strasbourg, France
| | - Jean-Paul Armspach
- University of Strasbourg and CNRS, ICube laboratory UMR 7357, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Strasbourg, France
| | - François Rousseau
- University of Strasbourg and CNRS, ICube laboratory UMR 7357, FMTS (Fédération de Médecine Translationnelle de Strasbourg), Strasbourg, France
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Delli Pizzi S, Franciotti R, Taylor JP, Thomas A, Tartaro A, Onofrj M, Bonanni L. Thalamic Involvement in Fluctuating Cognition in Dementia with Lewy Bodies: Magnetic Resonance Evidences. Cereb Cortex 2014; 25:3682-9. [PMID: 25260701 PMCID: PMC4585510 DOI: 10.1093/cercor/bhu220] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Dementia with Lewy bodies (DLB) is characterized by fluctuation in cognition and attention. Thalamocortical connectivity and integrity of thalami are central to attentional function. We hypothesize that DLB patients with marked and frequent fluctuating cognition (flCog) have a loss of thalamocortical connectivity, an intrinsic disruption to thalamic structure and imbalances in thalamic neurotransmitter levels. To test this, magnetic resonance imaging (MRI), diffusion tensor imaging (DTI) and proton MR spectroscopy on thalami were performed on 16 DLB, 16 Alzheimer's disease (AD) and 13 healthy subjects. MRI and DTI were combined to subdivide thalami according to their cortical connectivity and to investigate microstructural changes in connectivity-defined thalamic regions. Compared with controls, lower N-acetyl-aspartate/total creatine (NAA/tCr) and higher total choline/total creatine (tCho/tCr) values were observed within thalami of DLB patients. tCho/tCr increase was found within right thalamus of DLB patients as compared with AD. This increase correlated with severity and frequency of flCog. As compared with controls, DLB patients showed bilateral damage within thalamic regions projecting to prefrontal and parieto-occipital cortices, whereas AD patients showed bilateral alteration within thalamic region projecting to temporal cortex. We posit that microstructural thalamic damage and cholinergic imbalance may be central to the etiology of flCog in DLB.
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Affiliation(s)
- Stefano Delli Pizzi
- Department of Neuroscience, Imaging and Clinical Sciences Aging Research Centre, Ce.S.I. and Institute for Advanced Biomedical Technologies (ITAB), "G. d'Annunzio" University, Chieti, Italy
| | - Raffaella Franciotti
- Department of Neuroscience, Imaging and Clinical Sciences Aging Research Centre, Ce.S.I. and Institute for Advanced Biomedical Technologies (ITAB), "G. d'Annunzio" University, Chieti, Italy
| | - John-Paul Taylor
- Institute for Ageing and Health, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne NE4 5PL, UK
| | - Astrid Thomas
- Department of Neuroscience, Imaging and Clinical Sciences Aging Research Centre, Ce.S.I. and
| | - Armando Tartaro
- Department of Neuroscience, Imaging and Clinical Sciences Institute for Advanced Biomedical Technologies (ITAB), "G. d'Annunzio" University, Chieti, Italy
| | - Marco Onofrj
- Department of Neuroscience, Imaging and Clinical Sciences Aging Research Centre, Ce.S.I. and
| | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Sciences Aging Research Centre, Ce.S.I. and
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Larson-Prior LJ, Ju YE, Galvin JE. Cortical-subcortical interactions in hypersomnia disorders: mechanisms underlying cognitive and behavioral aspects of the sleep-wake cycle. Front Neurol 2014; 5:165. [PMID: 25309500 PMCID: PMC4160996 DOI: 10.3389/fneur.2014.00165] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 08/18/2014] [Indexed: 01/01/2023] Open
Abstract
Subcortical circuits mediating sleep–wake functions have been well characterized in animal models, and corroborated by more recent human studies. Disruptions in these circuits have been identified in hypersomnia disorders (HDs) such as narcolepsy and Kleine–Levin Syndrome, as well as in neurodegenerative disorders expressing excessive daytime sleepiness. However, the behavioral expression of sleep–wake functions is not a simple on-or-off state determined by subcortical circuits, but encompasses a complex range of behaviors determined by the interaction between cortical networks and subcortical circuits. While conceived as disorders of sleep, HDs are equally disorders of wake, representing a fundamental instability in neural state characterized by lapses of alertness during wake. These episodic lapses in alertness and wakefulness are also frequently seen in neurodegenerative disorders where electroencephalogram demonstrates abnormal function in cortical regions associated with cognitive fluctuations (CFs). Moreover, functional connectivity MRI shows instability of cortical networks in individuals with CFs. We propose that the inability to stabilize neural state due to disruptions in the sleep–wake control networks is common to the sleep and cognitive dysfunctions seen in hypersomnia and neurodegenerative disorders.
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Affiliation(s)
- Linda J Larson-Prior
- Department of Radiology, Washington University School of Medicine , St. Louis, MO , USA ; Department of Neurology, Washington University School of Medicine , St. Louis, MO , USA
| | - Yo-El Ju
- Department of Neurology, Washington University School of Medicine , St. Louis, MO , USA
| | - James E Galvin
- Departments of Neurology, New York University Langone School of Medicine , New York, NY , USA ; Department of Psychiatry, New York University Langone School of Medicine , New York, NY , USA ; Department of Population Health, New York University Langone School of Medicine , New York, NY , USA
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Preclinical polymodal hallucinations for 13 years before dementia with Lewy bodies. Behav Neurol 2014; 2014:694296. [PMID: 24868122 PMCID: PMC4020531 DOI: 10.1155/2014/694296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 11/29/2013] [Indexed: 01/08/2023] Open
Abstract
Objective. We describe a case of dementia with Lewy bodies (DLB) that presented long-lasting preclinical complex polymodal hallucinations. Background. Few studies have deeply investigated the characteristics of hallucinations in DLB, especially in the preclinical phase. Moreover, the clinical phenotype of mild cognitive impairment-(MCI-) DLB is poorly understood. Methods. The patient was followed for 4 years and a selective phenomenological and cognitive study was performed at the predementia stage. Results. The phenomenological study showed the presence of hypnagogic and hypnopompic hallucinations that allowed us to make a differential diagnosis between DLB and Charles Bonnet syndrome (CBS). The neuropsychological evaluation showed a multiple domain without amnesia MCI subtype with prefrontal dysexecutive, visuoperceptual, and visuospatial impairments and simultanagnosia, which has not previously been reported in MCI-DLB. Conclusions. This study extends the prognostic value of hallucinations for DLB to the preclinical phases. It supports and refines the MCI-DLB concept and identifies simultanagnosia as a possible early cognitive marker. Finally, it confirms an association between hallucinations and visuoperceptual impairments at an intermediate stage of the disease course and strongly supports the hypothesis that hallucinations in the earliest stages of DLB may reflect a narcolepsy-like REM-sleep disorder.
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fMRI resting state networks and their association with cognitive fluctuations in dementia with Lewy bodies. NEUROIMAGE-CLINICAL 2014; 4:558-65. [PMID: 24818081 PMCID: PMC3984441 DOI: 10.1016/j.nicl.2014.03.013] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 03/27/2014] [Accepted: 03/27/2014] [Indexed: 11/26/2022]
Abstract
Cognitive fluctuations are a core symptom in dementia with Lewy bodies (DLB) and may relate to pathological alterations in distributed brain networks. To test this we analysed resting state fMRI changes in a cohort of fluctuating DLB patients (n = 16) compared with age matched controls (n = 17) with the aim of finding functional connectivity (FC) differences between these two groups and whether these associate with cognitive fluctuations in DLB. Resting state networks (RSNs) were estimated using independent component analysis and FC between the RSN maps and the entirety of the brain was assessed using dual regression. The default mode network (DMN) appeared unaffected in DLB compared to controls but significant cluster differences between DLB and controls were found for the left fronto-parietal, temporal, and sensory–motor networks. Desynchronization of a number of cortical and subcortical areas related to the left fronto-parietal network was associated with the severity and frequency of cognitive fluctuations. Our findings provide empirical evidence for the potential role of attention–executive networks in the aetiology of this core symptom in DLB. We report resting state network (RSN) alterations in dementia with Lewy bodies (DLB). The default mode network was intact in DLB compared to healthy controls (HC). Fronto-parietal, temporal, and sensory–motor RSNs showed differences (DLB < HC). The left fronto-parietal network (FPN) correlated with cognitive fluctuations in DLB. The FPN therefore may be a potential marker for cognitive fluctuations in DLB.
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Shine JM, O'Callaghan C, Halliday GM, Lewis SJG. Tricks of the mind: Visual hallucinations as disorders of attention. Prog Neurobiol 2014; 116:58-65. [PMID: 24525149 DOI: 10.1016/j.pneurobio.2014.01.004] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 01/29/2014] [Accepted: 01/30/2014] [Indexed: 10/25/2022]
Abstract
Visual hallucinations are common across a number of disorders but to date, a unifying pathophysiology underlying these phenomena has not been described. In this manuscript, we combine insights from neuropathological, neuropsychological and neuroimaging studies to propose a testable common neural mechanism for visual hallucinations. We propose that 'simple' visual hallucinations arise from disturbances within regions responsible for the primary processing of visual information, however with no further modulation of perceptual content by attention. In contrast, 'complex' visual hallucinations reflect dysfunction within and between the Attentional Control Networks, leading to the inappropriate interpretation of ambiguous percepts. The incorrect information perceived by hallucinators is often differentially interpreted depending on the time-course and the neuroarchitecture underlying the interpretation. Disorders with 'complex' hallucinations without retained insight are proposed to be associated with a reduction in the activity within the Dorsal Attention Network. The review concludes by showing that a variety of pathological processes can ultimately manifest in any of these three categories, depending on the precise location of the impairment.
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Affiliation(s)
- James M Shine
- Parkinson's Disease Research Clinic, Brain and Mind Research Institute, The University of Sydney, NSW, Australia.
| | - Claire O'Callaghan
- Parkinson's Disease Research Clinic, Brain and Mind Research Institute, The University of Sydney, NSW, Australia; Neuroscience Research Australia and the University of New South Wales, Sydney, NSW, Australia.
| | - Glenda M Halliday
- Neuroscience Research Australia and the University of New South Wales, Sydney, NSW, Australia.
| | - Simon J G Lewis
- Parkinson's Disease Research Clinic, Brain and Mind Research Institute, The University of Sydney, NSW, Australia.
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Taylor JP, Colloby SJ, McKeith IG, O'Brien JT. Covariant perfusion patterns provide clues to the origin of cognitive fluctuations and attentional dysfunction in dementia with Lewy bodies. Int Psychogeriatr 2013; 25:1917-28. [PMID: 24148774 PMCID: PMC3819183 DOI: 10.1017/s1041610213001488] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 07/24/2013] [Accepted: 07/24/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Fluctuating cognition (FC), particularly in attention, is a core and defining symptom in dementia with Lewy bodies (DLB) but is seen much less frequently in Alzheimer's dementia (AD). However, its neurobiological origin is poorly understood. The aim of our study was therefore to characterize perfusion patterns in DLB patients that are associated with the severity and frequency of FC as measured both clinically and using objective neuropsychological assessments. METHODS Spatial covariance analyses were applied to data derived from single photon emission computed tomography (SPECT) HMPAO brain imaging in 19 DLB and 23 AD patients. Patients underwent clinical assessment of their FC and cognitive function as well as objective testing of their attention. RESULTS Covariant perfusion principal components (PCs) were not associated with either FC or cognitive or attentional measures in AD. However, in DLB patients, the second PC (defined as DLB-cognitive motor pattern, DLB-PCI2) which was characterized by bilateral relative increases in cerebellum, basal ganglia, and supplementary motor areas and widespread bilateral decreases in parietal regions, positively correlated with poorer cognitive function, increased FC and worse attentional function measured both clinically and neurophysiologically (p < 0.05) as well as with the severity of bradykinesia (p = 0.04). CONCLUSIONS FC in DLB appears distinct from those seen in AD, and likely to be driven by internal neurobiological perturbations in brain circuitry as evidenced using spatial covariance analyses of cerebral perfusion. FC and certain aspects of attentional dysfunction in DLB may, in part, depend upon both distributed motor and non-motor networks.
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Affiliation(s)
- John-Paul Taylor
- Institute for Ageing and Health, Campus for Aging and Vitality, Newcastle University, Newcastle upon Tyne, UK
| | - Sean J. Colloby
- Institute for Ageing and Health, Campus for Aging and Vitality, Newcastle University, Newcastle upon Tyne, UK
| | - Ian G. McKeith
- Institute for Ageing and Health, Campus for Aging and Vitality, Newcastle University, Newcastle upon Tyne, UK
| | - John T. O'Brien
- Institute for Ageing and Health, Campus for Aging and Vitality, Newcastle University, Newcastle upon Tyne, UK
- Department of Psychiatry, University of Cambridge, Addenbrooke's Hospital, UK
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Lee DR, Taylor JP, Thomas AJ. Assessment of cognitive fluctuation in dementia: a systematic review of the literature. Int J Geriatr Psychiatry 2012; 27:989-98. [PMID: 22278997 DOI: 10.1002/gps.2823] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 09/01/2011] [Accepted: 10/20/2011] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Cognitive fluctuations (CF) are defined as spontaneous alterations in cognition, attention and arousal. They are a recognised feature of the dementias, especially dementia with Lewy bodies (DLB) and Parkinson's disease dementia. However, the accurate identification and assessment of CF presents a major clinical difficulty, with the operationalisation of the term 'cognitive fluctuation' remaining elusive, despite several attempts to identify, quantify and assess the phenomenon. No published reviews of CF in dementia exist despite this being an important clinical phenomenon and a core diagnostic feature of DLB. METHODS We systematically explored the literature and measures available for the definition, assessment and quantification of CF in the dementias. RESULTS We identified only three psychometric measures, which have been developed for the identification and assessment of CF, and these have not been adequately tested as yet for reliability and validity. DISCUSSION AND CONCLUSIONS We conclude that further research is warranted into the assessment of CF, and this is timely given the increasing recognition of the clinical importance of CF as a dementia symptom, particularly in the Lewy body dementias.
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Affiliation(s)
- David R Lee
- Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, UK.
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Abstract
Dementia with Lewy bodies (DLB) is a relative newcomer to the field of late-life dementia. Although a diversity of imaging methodologies is now available for the study of dementia, these have been applied most often to Alzheimer's disease (AD). Studies on DLB, although fewer, have yielded fascinating and important insights into the underlying pathophysiology of this condition and allowed clinical differentiation of DLB from other dementias. Imaging research on DLB has had significant ramifications in terms of raising the profile of DLB and helping define it as a distinctive and separate disease entity from AD.
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Affiliation(s)
- John-Paul Taylor
- Institute for Ageing and Health, Wolfson Research Centre, Campus for Aging and Vitality, Newcastle University, Newcastle Upon Tyne, NE4 5PL, UK.
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Jellinger KA. Cerebral correlates of psychotic syndromes in neurodegenerative diseases. J Cell Mol Med 2012; 16:995-1012. [PMID: 21418522 PMCID: PMC4365880 DOI: 10.1111/j.1582-4934.2011.01311.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 03/01/2011] [Indexed: 12/20/2022] Open
Abstract
Psychosis has been recognized as a common feature in neurodegenerative diseases and a core feature of dementia that worsens most clinical courses. It includes hallucinations, delusions including paranoia, aggressive behaviour, apathy and other psychotic phenomena that occur in a wide range of degenerative disorders including Alzheimer's disease, synucleinopathies (Parkinson's disease, dementia with Lewy bodies), Huntington's disease, frontotemporal degenerations, motoneuron and prion diseases. Many of these psychiatric manifestations may be early expressions of cognitive impairment, but often there is a dissociation between psychotic/behavioural symptoms and the rather linear decline in cognitive function, suggesting independent pathophysiological mechanisms. Strictly neuropathological explanations are likely to be insufficient to explain them, and a large group of heterogeneous factors (environmental, neurochemical changes, genetic factors, etc.) may influence their pathogenesis. Clinico-pathological evaluation of behavioural and psychotic symptoms (PS) in the setting of neurodegenerative and dementing disorders presents a significant challenge for modern neurosciences. Recognition and understanding of these manifestations may lead to the development of more effective preventive and therapeutic options that can serve to delay long-term progression of these devastating disorders and improve the patients' quality of life. A better understanding of the pathophysiology and distinctive pathological features underlying the development of PS in neurodegenerative diseases may provide important insights into psychotic processes in general.
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Abstract
THE MULTIPLE ETIOLOGIES OF SCHIZOPHRENIA PROMPT US TO RAISE THE QUESTION: what final common pathway can induce a convincing sense of the reality of the hallucinations in this disease? The observation that artificial stimulation of an intermediate order of neurons of a normal nervous system induces hallucinations indicates that the lateral entry of activity (not resulting from canonical synaptic transmission) at intermediate neuronal orders may provide a mechanism for hallucinations. Meaningful hallucinations can be de-constructed into an organized temporal sequence of internal sensations of associatively learned items that occur in the absence of any external stimuli. We hypothesize that these hallucinations are autonomously generated by the re-activation of pathological non-specific functional LINKs formed between the postsynaptic membranes at certain neuronal orders and are examined as a final common mechanism capable of explaining most of the features of the disease. Reversible and stabilizable hemi-fusion between simultaneously activated adjacent postsynaptic membranes is viewed as one of the normal mechanisms for functional LINK formation and is dependent on lipid membrane composition. Methods of removing the proteins that may traverse the non-specifically hemi-fused membrane segments and attempts to replace the phospholipid side chains to convert the membrane composition to a near-normal state may offer therapeutic opportunities.
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Affiliation(s)
- Kunjumon I Vadakkan
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, University of Manitoba Winnipeg, MB, Canada
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Clinicopathological correlates of behavioral and psychological symptoms of dementia. Acta Neuropathol 2011; 122:117-35. [PMID: 21455688 DOI: 10.1007/s00401-011-0821-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 03/18/2011] [Accepted: 03/21/2011] [Indexed: 10/18/2022]
Abstract
Behavioral and psychological symptoms are commonly observed in a majority of demented patients at some time during the course of their illness. Many of these psychiatric manifestations, especially those related to mood, may be early expressions of dementia and/or mild cognitive impairment. The literature suggests that behavioral and psychological symptoms of dementia (BPSD) are an integral part of the disease process. The dissociation, in many cases, between BPSD and the rather linear decline in cognitive functions suggests that independent pathophysiological mechanisms give rise to these symptoms. A review of the neuroimaging and neuropathology literature indicates that BPSD are the expression of regional rather than diffuse brain pathology. Psychotic symptoms in demented patients usually demonstrate preferential involvement of the frontal lobe and/or limbic regions. Visual hallucinations differentiate themselves from other psychotic symptoms by their tendency to involve the occipital lobes. There is a significant association between apathy and structural changes of the anterior cingulate gyrus. White matter hyperintensities occur in a significant number of depressed patients; otherwise, there is lack of association between depression and either specific brain changes or affected regions. Strictly neuropathological explanations are likely to be insufficient to explain BPSD. Environmental changes, neurochemical abnormalities, past psychiatric history (including premorbid personality), social history (e.g., intellectual achievement and life-long learning), family history, and genetic susceptibility are factors, among others, that influence BPSD.
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Sanchez-Castaneda C, Rene R, Ramirez-Ruiz B, Campdelacreu J, Gascon J, Falcon C, Calopa M, Jauma S, Juncadella M, Junque C. Frontal and associative visual areas related to visual hallucinations in dementia with Lewy bodies and Parkinson's disease with dementia. Mov Disord 2010; 25:615-22. [PMID: 20175186 DOI: 10.1002/mds.22873] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Visual Hallucinations (VH) are among the core features of Dementia with Lewy Bodies (DLB), but are also very frequent in demented patients with Parkinson's Disease (PDD). The purpose of this study was to investigate the pattern of gray matter and cognitive impairment underlying VH in DLB and PDD. We applied voxel-based morphometry and behavioral assessment to 12 clinically diagnosed DLB patients and 15 PDD patients. Subjects with VH showed greater gray matter loss than non-hallucinators, specifically in the right inferior frontal gyrus (BA 45) in the DLB patients and in the left orbitofrontal lobe (BA 10) in the PDD patients. Comparing the two subgroups with VH, DLB patients had greater decrease of the bilateral premotor area (BA 6) than PDD patients. Furthermore, decreased volume in associative visual areas, namely left precuneus and inferior frontal lobe, correlated with VH in the DLB but not in PDD patients. VH were related to impaired verbal fluency, inhibitory control of attention and visuoperception in the DLB group and to visual memory in the PDD group. In conclusion, DLB and PDD patients with VH had more frontal gray matter atrophy than non-hallucinators, the impairment being greater in the DLB group. The patterns of structural and functional correlations were different in both pathologies.
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Escandon A, Al-Hammadi N, Galvin JE. Effect of cognitive fluctuation on neuropsychological performance in aging and dementia. Neurology 2010; 74:210-7. [PMID: 20083796 DOI: 10.1212/wnl.0b013e3181ca017d] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Cognitive fluctuations are spontaneous alterations in cognition, attention, and arousal. Fluctuations are a core feature of dementia with Lewy bodies, but the impact of fluctuations in healthy brain aging and Alzheimer disease (AD) are unknown. METHODS Research participants (n = 511, age 78.1 +/- 8 years, education 14.9 +/- 3 years) enrolled in a longitudinal study of memory and aging at the Washington University Alzheimer Disease Research Center were assessed for the presence and severity of dementia with the Clinical Dementia Rating (CDR) and a neuropsychological test battery. Informant assessments of fluctuations with the Mayo Fluctuations Questionnaire and daytime level of alertness with the Mayo Sleep Questionnaire were completed. RESULTS After controlling for age and alertness level, participants with cognitive fluctuations (3 or 4 individual symptoms) were 4.6 times more likely to have dementia (95% confidence interval: 2.05, 10.40). Participants who presented with disorganized, illogical thinking were 7.8 times more likely to be rated CDR >0. The risk of being rated CDR 0.5 among those with fluctuations was 13.4 times higher than among those without fluctuations. The risk of being rated CDR 1 increased 34-fold among participants with fluctuations. Compared with participants without fluctuations, the presence of cognitive fluctuations corresponds to a decrease in performance across individual neuropsychological tests as well as composite scores. CONCLUSIONS Cognitive fluctuations occur in Alzheimer disease and, when present, significantly affect both clinical rating of dementia severity and neuropsychological performance. Assessment of fluctuations should be considered in the evaluation of patients for cognitive disorders.
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Affiliation(s)
- Adriana Escandon
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
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Lam B, Hollingdrake E, Kennedy JL, Black SE, Masellis M. Cholinesterase inhibitors in Alzheimer's disease and Lewy body spectrum disorders: the emerging pharmacogenetic story. Hum Genomics 2010; 4:91-106. [PMID: 20038497 PMCID: PMC3525201 DOI: 10.1186/1479-7364-4-2-91] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
This review provides an update on the current state of pharmacogenetic research in the treatment of Alzheimer's disease (AD) and Lewy body disease (LBD) as it pertains to the use of cholinesterase inhibitors (ChEI). AD and LBD are first reviewed from clinical and pathophysiological perspectives. This is followed by a discussion of ChEIs used in the symptomatic treatment of these conditions, focusing on their unique and overlapping pharmacokinetic and pharmacodynamic profiles, which can be used to identify candidate genes for pharmacogenetics studies. The literature published to date is then reviewed and limitations are discussed. This is followed by a discussion of potential endophenotypes which may help to refine future pharmacogenetic studies of response and adverse effects to ChEIs.
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Affiliation(s)
- Benjamin Lam
- L.C. Campbell Cognitive Neurology Research Unit, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Kobayashi K, Sumiya H, Nakano H, Akiyama N, Urata K, Koshino Y. Detection of Lewy body disease in patients with late-onset depression, anxiety and psychotic disorder with myocardial meta-iodobenzylguanidine scintigraphy. Int J Geriatr Psychiatry 2010; 25:55-65. [PMID: 19637401 DOI: 10.1002/gps.2297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE Lewy body disease (LBD) is comprised of a spectrum of diseases that includes Parkinson's disease (PD), PD dementia (PDD) and dementia with LBD (DLBD), an array of dementia, and motor symptoms. Low uptake of myocardial meta-iodobenzylguanidine (MIBG) validates diagnosis of LBD. Psychiatric symptoms sometimes precede atypical Parkinsonian syndromes in LBD. Of 34 patients with low MIBG uptake, late-onset depressive, anxiety, or psychotic symptoms were analyzed in term of clinical profiles. METHOD Thirty-four patients were classed into three groups according to three main symptoms, 11 patients with visual hallucination (VH), 13 with depression-anxiety (DA), and 10 with psychosis with cognitive disturbance (PCD). Cutoff values of heart-to-mediastinum (HM) ratio of MIBG were set at 1.78 in early phase or 1.68 in late phase. RESULTS Group VH patients showed a trend toward higher age at onset and occipital lobe hypoperfusion. Group DA patients lacked central and core features of DLBD and five of them showed frontal lobe hypoperfusion. Group PCD patients had the highest frequencies of suggestive symptoms and UPDRS scores and showed temporal lobe hypoperfusion. HM ratio was not associated with clinical profiles of three groups. Cognitive function was more severely disturbed in atypical Parkinsonian syndrome cases at an initial visit. CONCLUSION Group VH was considered to DLBD, and Group PCD was regarded as PDD or DLBD with early psychotic presentation. Group DA has a possibility of early depression or anxiety disorder of LBD although it lacked DLBD criteria. Atypical Parkinsonian syndromes are associated with cognitive disturbance irrespective of psychiatric profiles.
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Affiliation(s)
- Katsuji Kobayashi
- Department of Psychiatry, Awazu Neuropsychiatric Sanatorium, 88 Yatano-machi, Komatsu-shi, Ishikawa-ken, 923-0342, Japan
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Nagahama Y, Okina T, Suzuki N, Matsuda M. Neural correlates of psychotic symptoms in dementia with Lewy bodies. ACTA ACUST UNITED AC 2009; 133:557-67. [PMID: 19920063 DOI: 10.1093/brain/awp295] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The aim of this study was to investigate the association between psychotic symptoms in dementia with Lewy bodies and brain perfusion on single photon emission tomography. Based on factor analysis in 145 patients, psychotic symptoms were classified into five symptom domains (factor 1 to 4-related symptoms and delusions). The relationship between each symptom domain and brain perfusion was assessed in 100 patients with dementia with Lewy bodies, while accounting for the effects of age, sex, dementia severity, parkinsonism and dysphoria. Factor 1 symptoms (Capgras syndrome, phantom boarder, reduplication of person and place and misidentification of person) represented misidentifications, and were significantly related to hypoperfusion in the left hippocampus, insula, ventral striatum and bilateral inferior frontal gyri. Factor 3 symptoms (visual hallucination of person and feeling of presence) represented hallucinations of person and were related to hypoperfusion in the left ventral occipital gyrus and bilateral parietal areas. Delusions of theft and persecution were associated with relative hyperperfusion in the right rostral medial frontal cortex, left medial superior frontal gyrus and bilateral dorsolateral frontal cortices. This study revealed that different psychotic symptoms in dementia with Lewy bodies were associated with distinguishable cerebral networks. Visual hallucinations were related to dysfunction of the parietal and occipital association cortices, misidentifications were related to dysfunction of the limbic-paralimbic structures and delusions were related to dysfunction of the frontal cortices. Our findings provide important insights into the pathophysiological mechanisms underlying psychotic symptoms in dementia with Lewy bodies.
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Affiliation(s)
- Yasuhiro Nagahama
- Department of Geriatric Neurology, Shiga Medical Centre, Moriyama-city, Shiga 524-8524, Japan.
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Abstract
INTRODUCTION Cerebral perfusion imaging using magnetic resonance imaging (MRI) is widely used in the research and clinical fields to assess the profound changes in blood flow related to ischemic events such as acute stroke, chronic steno-occlusive disease, vasospasm, and abnormal vessel formations from congenital conditions or tumoral neovascularity. With continuing improvements in the precision of MRI-based perfusion techniques, it is increasingly feasible to use this tool in the study of the subtle brain perfusion changes occurring in psychiatric illnesses. This article aims to review the existing literature on applications of perfusion MRI in psychiatric disorder and substance abuse research. The article also provides a brief introductory overview of dynamic susceptibility contrast MRI and arterial spin labeling techniques. An outlook of necessary steps to bring perfusion MRI into the realm of clinical psychiatry as a diagnostic tool is brought forth. Opportunities for research in unexplored disorders and with higher field strengths are briefly examined. METHODS PubMed, ISI Web of Knowledge & Scopus were used to search the literature and cross reference several neuropsychiatric disorders with a search term construct, including "magnetic resonance imaging," "dynamic susceptibility contrast," "arterial spin labeling," perfusion or "cerebral blood flow" or "cerebral blood volume" or "mean transit time." The list of disorders used in the search included schizophrenia, depression and bipolar disorder, dementia and Alzheimer's disease, Parkinson's disease, posttraumatic stress disorder, autism, Asperger disease, attention deficit, Tourette syndrome, obsessive-compulsive disorder, Huntington's disease, bulimia nervosa, anorexia nervosa, and substance abuse. For each disorder for which perfusion MRI studies were found, a brief overview of the disorder symptoms, treatment, prevalence, and existing models is provided, and previous findings from nuclear medicine-based perfusion imaging are overviewed. Findings of perfusion MRI studies are then summarized, and overlap of findings are discussed. Overarching conclusions are made, or an outlook for future work in the area is offered, where appropriate. RESULTS Despite the now fairly broad availability of perfusion MRI, only a limited number of studies were found using this technology. The search produced 13 studies of schizophrenia, 7 studies in major depression, 12 studies in Alzheimer's disease, and 2 studies in Parkinson's disease. Drug abuse and other disorders have mainly been studied with nuclear medicine-based perfusion imaging. The literature concerning the use of perfusion imaging in psychiatry has not been reviewed in the last 5 years or more. The use of MRI for perfusion measurements in psychiatry has not been reviewed in 10 years. CONCLUSIONS Although MRI-based perfusion imaging in psychiatry has mainly been used as a research tool, a path is progressively being cleared for its application in clinical diagnostic and treatment monitoring. The precision of perfusion MRI methods now rivals that of nuclear medicine-based perfusion imaging techniques. Because of their noninvasive nature, arterial spin labeling methods have gained popularity in studies of neuropsychiatric disorders such as schizophrenia, depression, Alzheimer's, and Parkinson's diseases. Perfusion imaging measurements have yet to be included within the diagnostic criteria of neuropsychiatric disorders despite having shown to have great discriminant power in specific disorders. As this young methodology continues to improve and research studies demonstrate the correlation of measured perfusion abnormalities to microcirculatory abnormalities and neuropsychiatric symptomatology, the idea of including such a test within diagnostic criteria for certain mental illnesses becomes increasingly plausible.
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Shimizu S, Hanyu H, Hirao K, Sato T, Iwamoto T, Koizumi K. Value of analyzing deep gray matter and occipital lobe perfusion to differentiate dementia with Lewy bodies from Alzheimer’s disease. Ann Nucl Med 2009; 22:911-6. [DOI: 10.1007/s12149-008-0193-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Accepted: 07/09/2008] [Indexed: 12/01/2022]
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Hanson JC, Lippa CF. Chapter 11 Lewy Body Dementia. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2009; 84:215-28. [DOI: 10.1016/s0074-7742(09)00411-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Perneczky R, Drzezga A, Boecker H, Förstl H, Kurz A, Häussermann P. Cerebral metabolic dysfunction in patients with dementia with Lewy bodies and visual hallucinations. Dement Geriatr Cogn Disord 2008; 25:531-8. [PMID: 18477846 DOI: 10.1159/000132084] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2008] [Indexed: 11/19/2022] Open
Abstract
AIMS To identify the pattern of cerebral hypometabolism in patients with dementia with Lewy bodies (DLB) and visual hallucinations (VH). METHODS Fourteen patients with DLB and VH, 7 with DLB without VH and 16 healthy controls underwent clinical and (18)F-FDG PET evaluations. The 2 patient groups did not significantly differ in their clinical characteristics, except in the occurrence of VH. A voxel-wise comparison of (18)F-FDG PET scans was conducted between each of the 2 patient groups and the control group, and the patient groups among each other. RESULTS Compared with the control group, hypometabolic regions were more extensive and confluent in the patient group with VH than in the group without VH. The direct comparison between the 2 patient groups revealed a significant metabolic deficit in the group with VH at the right occipito-temporal junction and the right middle frontal gyrus. CONCLUSIONS These results suggest that hypometabolism in visual association areas rather than the primary visual cortex is involved in VH in DLB.
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Affiliation(s)
- Robert Perneczky
- Department of Psychiatry and Psychotherapy, Technical University Munich, Munich, Germany.
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Fernández Martínez M, Castro Flores J, Pérez de las Heras S, Mandaluniz Lekumberri A, Gordejuela Menocal M, Zarranz Imirizaldu JJ. Prevalence of neuropsychiatric symptoms in elderly patients with dementia in Mungialde County (Basque Country, Spain). Dement Geriatr Cogn Disord 2008; 25:103-8. [PMID: 18063866 DOI: 10.1159/000112215] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Determination of the prevalence of neuropsychiatric symptoms in elderly patients with dementia in Mungialde. METHODS 108 subjects with dementia, who participated in a door-to-door epidemiological study, were included. The 12-item Spanish version of the Neuropsychiatric Inventory was used to evaluate these symptoms. RESULTS The prevalence of at least 1 neuropsychiatric symptom was found to be 76.90% for all dementia types, 73.50% in patients with Alzheimer's disease (AD), 80% for the Parkinson-Lewy body dementia complex (PLBD), 78.60% for vascular dementia (VD) and 100% for frontotemporal dementia (FTD). Apathy was found to be the most prevalent symptom for all dementia types and in patients with AD (53.70 and 54.30%, respectively). The next most prevalent symptoms were anxiety, depression and sleep disturbances (35.20, 32.40 and 30.60%) for all dementia types, and anxiety and depression (32.10 and 30.90%) in patients with AD. The most prevalent symptoms in patients with PLBD were apathy, appetite changes, sleep disturbances and agitation (50% each); in patients with VD they were apathy, depression and anxiety (42.90% each), and in patients with FTD they were apathy, anxiety and aberrant motor activity (100% each). CONCLUSIONS Neuropsychiatric symptoms were found to be prevalent in patients with dementia, irrespective of dementia type.
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Perneczky R, Haussermann P, Diehl-Schmid J, Boecker H, Forstl H, Drzezga A, Kurz A. Metabolic correlates of brain reserve in dementia with Lewy bodies: an FDG PET study. Dement Geriatr Cogn Disord 2007; 23:416-22. [PMID: 17457029 DOI: 10.1159/000101956] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Studies suggest that brain reserve allows patients with more years of schooling to cope better with brain damage. Research has been mainly focussed on Alzheimer's disease and no studies exist on patients with dementia with Lewy bodies (DLB). The aim of this study was to provide evidence for brain reserve in DLB. METHODS Twenty-one consecutive patients with DLB and 16 age-matched healthy controls were included. The participants underwent cerebral (18)F-FDG PET imaging at rest. A group comparison was conducted in SPM2 between the patient and control groups. A linear regression analysis with glucose metabolism as the dependent and years of schooling as the independent variable was performed. Age, gender and a total score of the Consortium to Establish a Registry for Alzheimer's Disease neuropsychological battery were included as covariates into the analysis. RESULTS The patients showed a significant metabolic reduction in the frontal and posterior association cortices, the basal ganglia and the pulvinar of the thalami. Glucose metabolism and education showed an inverse relationship in an extensive cluster in the left temporo-parieto-occipital cortex. CONCLUSION Similar findings were previously reported in Alzheimer's disease and are regarded as evidence for brain reserve. Therefore, we suggest that brain reserve is also present in DLB.
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Affiliation(s)
- Robert Perneczky
- Department of Psychiatry and Psychotherapy, Technical University Munich, Munich, Germany.
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Whitwell JL, Weigand SD, Shiung MM, Boeve BF, Ferman TJ, Smith GE, Knopman DS, Petersen RC, Benarroch EE, Josephs KA, Jack CR. Focal atrophy in dementia with Lewy bodies on MRI: a distinct pattern from Alzheimer's disease. Brain 2007; 130:708-19. [PMID: 17267521 PMCID: PMC2730778 DOI: 10.1093/brain/awl388] [Citation(s) in RCA: 210] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Dementia with Lewy bodies (DLB) is the second most common cause of degenerative dementia after Alzheimer's disease. However, unlike the latter, the patterns of cerebral atrophy associated with DLB have not been well established. The aim of this study was to identify a signature pattern of cerebral atrophy in DLB and to compare it with the pattern found in Alzheimer's disease. Seventy-two patients that fulfilled clinical criteria for probable DLB were age- and gender-matched to 72 patients with probable Alzheimer's disease and 72 controls. Voxel-based morphometry (VBM) was used to assess patterns of grey matter (GM) atrophy in the two patient groups, relative to controls, after correction for multiple comparisons (P < 0.05). Study-specific templates and prior probability maps were used to avoid normalization and segmentation bias. Region-of-interest (ROI) analyses were also performed comparing loss of the midbrain, substantia innominata (SI), temporoparietal cortex and hippocampus between the groups. The DLB group showed very little cortical involvement on VBM with regional GM loss observed primarily in the dorsal midbrain, SI and hypothalamus. In comparison, the Alzheimer's disease group showed a widespread pattern of GM loss involving the temporoparietal association cortices and the medial temporal lobes. The SI and dorsal midbrain were involved in Alzheimer's disease; however, they were not identified as a cluster of loss discrete from uninvolved surrounding areas, as observed in the DLB group. On direct comparison between the two groups, the Alzheimer's disease group showed greater loss in the medial temporal lobe and inferior temporal regions than the DLB group. The ROI analysis showed reduced SI and midbrain GM in both patient groups, with a trend for more reduction of SI GM in Alzheimer's disease than DLB, and more reduction of midbrain in DLB than Alzheimer's disease. Significantly greater loss in the hippocampus and temporo-parietal cortex was observed in the Alzheimer's disease patients when the two patient groups were compared. A pattern of relatively focused atrophy of the midbrain, hypothalamus and SI, with a relative sparing of the hippocampus and temporoparietal cortex is, therefore, suggestive of DLB and this may aid in the differentiation of DLB from Alzheimer's disease. These findings support recent pathological studies showing an ascending pattern of Lewy body progression from brainstem to basal areas of the brain. Damage to this network of structures in DLB may affect a number of different neurotransmitter systems which in turn may contribute to a number of the core clinical features of DLB.
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