The effect of Amyloid and Tau Co-pathology on disease progression in Lewy body dementia: A systematic review

Co-morbid Alzheimer's disease (AD) pathology (amyloid-beta and tau) is commonly observed in Lewy body dementia (LBD), and this may affect clinical outcomes. A systematic review of the effect of AD co-pathology on longitudinal clinical outcomes in LBD was conducted. A search of MEDLINE and EMBASE (October 2024) yielded n = 3558 records that were screened by two independent reviewers. Included studies (n = 31) assessed AD co-pathology in LBD by neuropathologic examination (n = 10), positron emission tomography (PET) imaging (n = 7), cerebrospinal fluid (CSF) (n = 8) or plasma biomarkers (n = 6); and reported longitudinal clinical outcomes including cognitive and functional decline, mortality, or treatment response. Most neuropathology, PET and plasma studies reviewed demonstrated poorer prognosis in LBD + compared to LBD-, but discrepant findings were seen among CSF studies. No included study reported better outcomes in LBD+. The risk of bias was assessed with the Quality in Prognosis Studies tool. All studies rated as low risk of bias (n = 12) reported that the presence of AD co-pathology in LBD (LBD+) was associated with accelerated cognitive decline (n = 7/7), accelerated functional decline (n = 3/3), greater mortality (n = 2/2) and poorer response to treatment (n = 1/1). Among these studies, LBD+ was associated with an additional decline of -0.53 to -2.9 MMSE points/year compared to LBD-, while one study reported an adjusted hazard ratio for mortality in LBD + as 3.70. We conclude that AD co-pathology is associated with worse clinical outcomes in LBD whether assessed by greater cognitive decline, increased mortality or greater decline on functional assessment scales.

A systematic review of diffusion tensor imaging and tractography in dementia with Lewy bodies and Parkinson's disease dementia

We reviewed studies using diffusion tensor imaging (DTI) and tractography to characterise white matter changes in Dementia with Lewy Bodies (DLB) and Parkinson's Disease Dementia (PDD). The search included MEDLINE and EMBASE, and we used a narrative strategy to synthesise the evidence. Data was extracted from 57 studies, of which the majority were considered 'good quality'. Subjects with DLB and PDD had widespread white matter changes compared to healthy controls and Parkinson's disease without cognitive impairment, with a relative sparing of the hippocampus. Compared to subjects with Alzheimer's disease (AD), DLB had greater changes in thalamic connectivity and in the nigroputaminal tract, while AD had greater changes in the parahippocampal white matter and fornix. Cognition was associated with widespread white matter changes, visual hallucinations with thalamic and cholinergic connectivity, and parkinsonism with changes in structures involved in motor control. DTI and tractography may therefore be well suited for discriminating DLB and PDD from other types of dementia, and for studying the aetiology of common symptoms.

Managing cognitive impairment in Parkinson's disease: an update of the literature

INTRODUCTION

Cognitive impairment in Parkinson's disease (PD) substantially affects patient outcomes, function, and quality of life. PD-related cognitive dysfunction is often heterogeneous in clinical presentation and rates of progression. As cognitive changes occur in many people with PD, it is essential to evaluate cognition, provide education, and implement management strategies for cognitive symptoms.

AREAS COVERED

This article describes the symptomatology, epidemiology, risk factors, and pathobiology of cognitive impairment in PD. Additionally, the article provides an overview of evidence-based management and other therapeutic and coping strategies for cognitive impairment and dementia in PD. Comment is offered on challenges and opportunities for trials and emerging therapeutics targeting cognitive symptoms or decline.

EXPERT OPINION

While our understanding of cognitive dysfunction in PD has grown, effective and safe therapeutics are still needed to not only treat cognitive impairment and dementia symptomatically but also slow down or prevent cognitive decline. Further research is needed to elucidate the pathobiology of PD cognitive impairment, develop validated biomarkers reflecting cognitive change, and ultimately, integrate clinical and biological frameworks. Consensus regarding cognitive evaluations, definitions, and criteria of cognitive impairment, evaluating functional abilities in the context of cognitive impairment, and determining optimal outcome measures for clinical trials remain unmet needs.

Parkinson's Disease Carepartners' Perceptions of the Challenges and Rewards of Caregiving

BACKGROUND

Multiple debilitating symptoms and the progressive nature of Parkinson's disease (PD) affect carepartners' quality of life. Although, there is abundant knowledge on caregiver burden there is limited knowledge on PD carepartners' perceptions of caregiving.

AIM

To understand family members' perception of their role, and of the challenges and rewards of PD caregiving.

METHOD

Using a qualitative descriptive research design, we conducted semi-structured interviews with current and former PD carepartners (n = 16). Interviews were audio-recorded, de-identified, and transcribed verbatim. Data were coded and analyzed to identify themes.

RESULTS

We identified 5 themes: (a) Unpredictability is the hardest part of caregiving. It was hard to cope with the unpredictable daily and longer-term fluctuations in PD symptoms; (b) Disease progression and multiple symptoms contribute to carepartners' emotional distress. Carepartners felt unprepared and were saddened by the patient's and their own losses; (c) Caring for a family member is not a "burden." Though stressful, carepartners resisted associating caregiving with the term "burden"; (d) Caregiving is a partnership. Carepartners saw their role as being less of "givers" and more of partners in disease management; and (e) Caregiving is an opportunity for personal satisfaction, joy, and growth. Caregiving was seen as a "gift" that enabled carepartners to express love and experience personal growth.

CONCLUSIONS

Despite challenges PD carepartners view their role as "partners" in the management of the disease and find meaning and strength in caregiving. A palliative care approach emphasizing the positives and challenges of caregiving may provide carepartners with better support.

Understanding the nature and impact of cognitive fluctuations and sleep disturbances in dementia with Lewy bodies: A qualitative caregiver study

Objectives

Dementia with Lewy bodies is characterised by rapid fluctuations in attention, which are known as "cognitive fluctuations." Despite the fact that cognitive fluctuations are considered to be a core dementia with Lewy bodies symptom, they are very difficult to define and measure using existing quantitative subjective measurement tools, which are typically completed by caregivers. Cognitive fluctuations are also likely to be influenced by various aspects of sleep, but this is as yet unexplored. The primary aim of this qualitative study was to investigate the phenomenology of cognitive fluctuations in dementia with Lewy bodies by understanding caregiver experiences.

Methods

Seven caregivers of people with dementia with Lewy bodies completed one-to-one semistructured interviews, which were conducted by telephone. Caregivers were asked to describe the nature, frequency, duration and potential triggers of cognitive fluctuations that were experienced by the individual with dementia with Lewy bodies. Caregivers were also asked about the subjective sleep experience of the individual with dementia with Lewy bodies, and about their own sleep experiences. Interviews were audio recorded, transcribed verbatim and analysed using Thematic Analysis.

Results

Caregivers reported that there was a great deal of individual variation in the frequency, duration and severity of cognitive fluctuations. Patient sleep disturbances, including excessive daytime sleepiness, nocturnal awakenings, restless legs and sleep apnoea, were common. However, the impact of sleep alterations or experiences upon the fluctuations was reported to be less clear. Caregivers also reported that their own sleep was negatively affected, potentially due to actively listening for overnight events and behaviours.

Conclusions

Qualitatively, caregivers report that dementia with Lewy bodies cognitive fluctuations show large individual variations in terms of their frequency, duration and severity, but that subjectively, sleep may not consistently influence this symptom. Specific, caregiver-focussed interventions are likely to be necessary to maintain good sleep health in dementia with Lewy bodies caregivers.

Understanding REM Sleep Behavior Disorder through Functional MRI: A Systematic Review

Neuroimaging studies in rapid eye movement sleep behavior disorder (RBD) can inform fundamental questions about the pathogenesis of Parkinson's disease (PD). Across modalities, functional magnetic resonance imaging (fMRI) may be better suited to identify changes between neural networks in the earliest stages of Lewy body diseases when structural changes may be subtle or absent. This review synthesizes the findings from all fMRI studies of RBD to gain further insight into the pathophysiology and progression of Lewy body diseases. A total of 32 studies were identified using a systematic review conducted according to PRISMA guidelines between January 2000 to February 2024 for original fMRI studies in patients with either isolated RBD (iRBD) or RBD secondary to PD. Common functional alterations were detectable in iRBD patients compared with healthy controls across brainstem nuclei, basal ganglia, frontal and occipital lobes, and whole brain network measures. Patients with established PD and RBD demonstrated decreased functional connectivity across the whole brain and brainstem nuclei, but increased functional connectivity in the cerebellum and frontal lobe compared with those PD patients without RBD. Finally, longitudinal changes in resting state functional connectivity were found to track with disease progression. Currently, fMRI studies in RBD have demonstrated early signatures of neurodegeneration across both motor and non-motor pathways. Although more work is needed, such findings have the potential to inform our understanding of disease, help to distinguish between prodromal PD and prodromal dementia with Lewy bodies, and support the development of fMRI-based outcome measures of phenoconversion and progression in future disease modifying trials. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Resting-State Functional MRI Approaches to Parkinsonisms and Related Dementia

PURPOSE OF THE REVIEW

In this review, we attempt to summarize the most updated studies that applied resting-state functional magnetic resonance imaging (rs-fMRI) in the field of Parkinsonisms and related dementia.

RECENT FINDINGS

Over the past decades, increasing interest has emerged on investigating the presence and pathophysiology of cognitive symptoms in Parkinsonisms and their possible role as predictive biomarkers of neurodegenerative brain processes. In recent years, evidence has been provided, applying mainly three methodological approaches (i.e. seed-based, network-based and graph-analysis) on rs-fMRI data, with promising results. Neural correlates of cognitive impairment and dementia have been detected in patients with Parkinsonisms along the diseases course. Interestingly, early functional connectivity signatures were proposed to track and predict future progression of neurodegenerative processes. However, longitudinal studies are still sparce and further investigations are needed to overcome this knowledge gap.

Episodic Coma in Lewy Body Disorders: An Observational Report

Background

and Purpose: Episodes of unresponsiveness are one of several criteria used to diagnose dementia with Lewy bodies and are also seen in people with Parkinson's disease dementia. Patients examined during episodes of coma, whose evaluations found no other explanation than the neurological disorder, have not been described. This paper describes four cases, seen in the past two years. The objective is to bring this uncommon phenomenon to the attention of hospital based neurologists and to demonstrate that this may not be due to autonomic dysfunction.

Methods

These are brief case descriptions by medical personnel observing affected patients supplemented by family reports of similar episodes described on the internet.

Results

Four cases are described, all older men with either dementia with Lewy bodies or Parkinson's disease dementia, who had single, or multiple episodes of otherwise unexplained coma and were examined during a spell. IRB approval waived.

Conclusions

Episodic coma may occur in demented patients with an alpha-synucleinopathy and is the likely explanation when evaluations have found no other cause. This information will reassure the family and patient that this is the likely explanation but that spells may recur.

Pain in non-communicative older adults beyond dementia: a narrative review

Aging is associated with an increased risk of developing pain, especially in the presence of concurrent chronic clinical conditions. Similarly, multimorbidity can affect the perception and ability of older adults to appropriately respond to and communicate pain, and there is a clinical heterogeneity in the processing of painful sensations in different neurological conditions. The present narrative review is aimed at assessing the prevalent diseases associated with poor communication and pain in older adults, together with the available diagnostic instruments for the clinical assessment of pain in such a vulnerable population. Dementia was the most described pathology identified in the current literature associated with poor communication in older adults affected by pain, along with Parkinson's disease and stroke. Notably, a common pattern of pain behaviors in these neurological disorders also emerged, indicating potential similarities in the clinical presentation and appropriate diagnostic workout. At the same time, there are many differences in the way patients express their pain according to their main neurological pathology. In addition to this, although a plethora of observation-based tools for pain in patients with dementia have been developed, there is no gold standard, and the clinical utility of such measurements is still largely unaddressed. Meanwhile, there is substantially no standardized observation-based tool for pain in non-communicative patients with Parkinson's disease, and only a few for stroke. Overall, the present narrative review provides an update on the prevalent diseases beyond dementia associated with a communicative disability and a painful condition in older adults.

Health Fluctuations in Dementia and its Impact on the Assessment of Health-Related Quality of Life Using the EQ-5D-5L

OBJECTIVES

To quantify health fluctuations, identify affected health-related quality of life (HRQoL) dimensions, and evaluate if fluctuations affect the HRQoL instruments recall period adherence in people living with dementia (PlwD).

METHODS

Caregivers of PlwD completed a daily diary for 14 days, documenting if PlwD's health was better or worse than the day before and the affected HRQoL dimensions. Health fluctuation was categorized into low (0-4 fluctuations in 14 days), moderate (5-8), and high (9-14). Also, caregivers and PlwD completed the EQ-5D-5L (proxy- and self-reported) on days 1, 7, and 14. Subsequently, caregivers were interviewed to determine whether recurrent fluctuations were considered in the EQ-5D-5L assessment of today's health (recall period adherence).

RESULTS

Fluctuations were reported for 96% of PlwD, on average, for 7 of the 14 days. Dimensions most frequently triggering fluctuations included memory, mobility, concentration, sleep, pain, and usual activities. Fluctuations were associated with higher EQ-5D-5L health-states variation and nonadherence to the EQ-5D-5L recall period "today." PlwD with moderate to high fluctuation had the highest EQ-5D-5L utility change between day 1 and 14 (0.157 and 0.134) and recall period nonadherence (31% and 26%) compared with PlwD with low fluctuation (0.010; 17%). Recall period nonadherence was higher in PlwD with improved compared with those with deteriorated health in the diary (37% vs 9%).

CONCLUSIONS

Health fluctuations frequently occur in dementia and strongly affect HRQoL assessments. Further research is needed to evaluate if more extended recall periods and multiple, consecutive assessments could capture health fluctuations more appropriately in dementia.

"When she goes out, she feels better:" co-designing a Green Activity Program with Hispanic/Latino people living with memory challenges and care partners

Purpose

Utilizing a participatory approach, we sought to co-design a 12-week Green Activity Program (GAP) with Hispanic/Latino individuals living with memory challenges and their care partners, local outdoor professionals, and healthcare providers.

Methods

Participants were recruited via convenience and snowball sampling in the Bronx, New York with Hispanic/Latino persons living with memory challenges and care partners, outdoor activity professionals, and interdisciplinary healthcare providers/dementia experts. Co-design occurred iteratively with 5 focus groups and 4 individual interviews lasting 30-90 min and focused on program and research design. Sessions were recorded and transcribed. Utilizing directed content analysis data was coded using a priori codes program design and research design.

Results

21 participants completed co-design activities: (n = 8 outdoor activity professionals, n = 6 Hispanic/Latino persons living with memory challenges and care partners, and n = 7 interdisciplinary healthcare providers/dementia experts). Participant preferences for program design were captured by subcodes session duration (30-90 min), frequency (4-8 sessions), and delivery modes (in-person and phone). Participants' preferred nature activities included group exercise and outdoor crafts [crocheting], outcomes of social participation, connectedness to nature, decreased loneliness, and stewardship were identified. Preferred language for recruiting and describing the program were "memory challenges," "Hispanic/Latino," and "wellbeing." Referral pathways were identified including community-based organizations and primary care.

Conclusion

Co-design was a successful form of engagement for people living with memory challenges that enabled participants to help design key elements of the GAP and research design. Our processes, findings, and recommendations for tailoring co-design to engage Hispanic/Latino people living with memory challenges can inform the development of other programs for this population.

Differentiating Prodromal Dementia with Lewy Bodies from Prodromal Alzheimer's Disease: A Pragmatic Review for Clinicians

This pragmatic review synthesises the current understanding of prodromal dementia with Lewy bodies (pDLB) and prodromal Alzheimer's disease (pAD), including clinical presentations, neuropsychological profiles, neuropsychiatric symptoms, biomarkers, and indications for disease management. The core clinical features of dementia with Lewy bodies (DLB)-parkinsonism, complex visual hallucinations, cognitive fluctuations, and REM sleep behaviour disorder are common prodromal symptoms. Supportive clinical features of pDLB include severe neuroleptic sensitivity, as well as autonomic and neuropsychiatric symptoms. The neuropsychological profile in mild cognitive impairment attributable to Lewy body pathology (MCI-LB) tends to include impairment in visuospatial skills and executive functioning, distinguishing it from MCI due to AD, which typically presents with impairment in memory. pDLB may present with cognitive impairment, psychiatric symptoms, and/or recurrent episodes of delirium, indicating that it is not necessarily synonymous with MCI-LB. Imaging, fluid and other biomarkers may play a crucial role in differentiating pDLB from pAD. The current MCI-LB criteria recognise low dopamine transporter uptake using positron emission tomography or single photon emission computed tomography (SPECT), loss of REM atonia on polysomnography, and sympathetic cardiac denervation using meta-iodobenzylguanidine SPECT as indicative biomarkers with slowing of dominant frequency on EEG among others as supportive biomarkers. This review also highlights the emergence of fluid and skin-based biomarkers. There is little research evidence for the treatment of pDLB, but pharmacological and non-pharmacological treatments for DLB may be discussed with patients. Non-pharmacological interventions such as diet, exercise, and cognitive stimulation may provide benefit, while evaluation and management of contributing factors like medications and sleep disturbances are vital. There is a need to expand research across diverse patient populations to address existing disparities in clinical trial participation. In conclusion, an early and accurate diagnosis of pDLB or pAD presents an opportunity for tailored interventions, improved healthcare outcomes, and enhanced quality of life for patients and care partners.

Sustained attention in mild cognitive impairment with Lewy bodies and Alzheimer's disease

OBJECTIVE

Attentional impairments are common in dementia with Lewy bodies and its prodromal stage of mild cognitive impairment (MCI) with Lewy bodies (MCI-LB). People with MCI may be capable of compensating for subtle attentional deficits in most circumstances, and so these may present as occasional lapses of attention. We aimed to assess the utility of a continuous performance task (CPT), which requires sustained attention for several minutes, for measuring attentional performance in MCI-LB in comparison to Alzheimer's disease (MCI-AD), and any performance deficits which emerged with sustained effort.

METHOD

We included longitudinal data on a CPT sustained attention task for 89 participants with MCI-LB or MCI-AD and 31 healthy controls, estimating ex-Gaussian response time parameters, omission and commission errors. Performance trajectories were estimated both cross-sectionally (intra-task progress from start to end) and longitudinally (change in performance over years).

RESULTS

While response times in successful trials were broadly similar, with slight slowing associated with clinical parkinsonism, those with MCI-LB made considerably more errors. Omission errors were more common throughout the task in MCI-LB than MCI-AD (OR 2.3, 95% CI: 1.1-4.7), while commission errors became more common after several minutes of sustained attention. Within MCI-LB, omission errors were more common in those with clinical parkinsonism (OR 1.9, 95% CI: 1.3-2.9) or cognitive fluctuations (OR 4.3, 95% CI: 2.2-8.8).

CONCLUSIONS

Sustained attention deficits in MCI-LB may emerge in the form of attentional lapses leading to omissions, and a breakdown in inhibitory control leading to commission errors.

Association Between Hypnotics and Dementia: A Mini Narrative Review

OBJECTIVE

This narrative review aims to provide a comprehensive assessment of the existing literature on the relationship between hypnotics and dementia, considering both potential link and inconclusive or lack of association.

METHODS

Data from studies that investigate the association between hypnotic medications and dementia were reviewed. Studies included both cohort studies and systematic reviews, participants with various type of dementia and hypnotics including benzodiazepines (BZDs) and Z-drugs (ZDs).

RESULTS

The existing literatures presents conflicting evidence regarding the association between hypnotics, including BZDs and ZDs, and the risk of dementia. Some studies suggest a potential link between prolonged use of hypnotics and an increased risk of dementia. However, other studies indicate inconclusive or lacking evidence regarding this association. Factors such as study design, sample characteristics, and control of confounding variables contribute to the variability in findings.

CONCLUSION

The relationship between hypnotics and dementia remains complex and controversial. While some studies suggest a potential association, others find inconclusive or conflicting evidence. Future research should focus on addressing methodological limitations, considering classifying dementia subtypes, and try to adjust medication lag time.

Digital Neuropsychology beyond Computerized Cognitive Assessment: Applications of Novel Digital Technologies

Compared with other health disciplines, there is a stagnation in technological innovation in the field of clinical neuropsychology. Traditional paper-and-pencil tests have a number of shortcomings, such as low-frequency data collection and limitations in ecological validity. While computerized cognitive assessment may help overcome some of these issues, current computerized paradigms do not address the majority of these limitations. In this paper, we review recent literature on the applications of novel digital health approaches, including ecological momentary assessment, smartphone-based assessment and sensors, wearable devices, passive driving sensors, smart homes, voice biomarkers, and electronic health record mining, in neurological populations. We describe how each digital tool may be applied to neurologic care and overcome limitations of traditional neuropsychological assessment. Ethical considerations, limitations of current research, as well as our proposed future of neuropsychological practice are also discussed.

Ecological validity of cognitive fluctuations in dementia with Lewy bodies

OBJECTIVES

Cognitive fluctuations are a core clinical feature of dementia with Lewy bodies (DLB), but their contribution to the everyday functioning difficulties evident DLB are not well understood. The current study evaluated whether intraindividual variability across a battery of neurocognitive tests (intraindividual variability-dispersion) and daily cognitive fluctuations as measured by informant report are associated with worse daily functioning in DLB.

METHODS

The study sample included 97 participants with consensus-defined DLB from the National Alzheimer's Coordinating Center (NACC). Intraindividual variability-dispersion was measured using the coefficient of variation, which divides the standard deviation of an individual's performance scores across 12 normed neurocognitive indices from the NACC neuropsychological battery by that individual's performance mean. Informants reported on daily cognitive fluctuations using the Mayo Fluctuations Scale (MFS) and on daily functioning using the functional activities questionnaire (FAQ).

RESULTS

Logistic regression identified a large univariate association of intraindividual variability-dispersion and presence of daily cognitive fluctuations on the MFS (Odds Ratio = 73.27, 95% Confidence Interval = 1.38, 3,895.05). Multiple linear regression demonstrated that higher intraindividual variability-dispersion and presence of daily cognitive fluctuations as assessed by the MFS were significantly and independently related to worse daily functioning (FAQ scores).

CONCLUSIONS

Among those with DLB, informant-rated daily cognitive fluctuations and cognitive fluctuations measured in the clinic (as indexed by intraindividual variability-dispersion across a battery of tests) were independently associated with poorer everyday functioning. These data demonstrate ecological validity in measures of cognitive fluctuations in DLB.

The Role of Electroconvulsive Therapy in the Treatment of Catatonia Associated With Lewy Body Dementia: A Case Report

Catatonia is a complex amalgamation of neuropsychiatric symptoms that can manifest in both psychiatric and neurological conditions. The treatment of catatonia related to psychiatric illnesses is well documented as it typically responds to benzodiazepines and electroconvulsive therapy (ECT). However, the treatment of catatonia related to neurological disorders has shown to be more difficult, particularly when associated with Lewy Body Dementia (LBD). Here, we present the case of a 78-year-old woman with LBD, Bipolar I, depressive type, who successfully underwent twelve ECT sessions to treat catatonia refractory to benzodiazepine therapy. The effectiveness of the treatment was measured using the Bush-Françis Catatonia Scale (BFCS) to measure her catatonic symptoms as she progressed through the therapy. This report highlights the importance of considering ECT as a leading therapeutic approach in this particular subset of patients who do not respond adequately to pharmaceutical therapy and medical titrations.

Sleep disorders in Lewy body dementia: Mechanisms, clinical relevance, and unanswered questions

In Lewy body dementia (LBD), disturbances of sleep and/or arousal including insomnia, excessive daytime sleepiness, rapid eye movement (REM) sleep behavior disorder, obstructive sleep apnea, and restless leg syndrome are common. These disorders can each exert a significant negative impact on both patient and caregiver quality of life; however, their etiology is poorly understood. Little guidance is available for assessing and managing sleep disorders in LBD, and they remain under-diagnosed and under-treated. This review aims to (1) describe the specific sleep disorders which occur in LBD, considering their putative or potential mechanisms; (2) describe the history and diagnostic process for these disorders in LBD; and (3) summarize current evidence for their management in LBD and consider some of the ongoing and unanswered questions in this field and future research directions.

Case report: Successful autologous hematopoietic stem cell transplantation in a patient with GAD antibody-spectrum disorder with rapidly progressive dementia

The prevalence of neurological syndromes associated with antibodies to glutamic acid decarboxylase is increasing. While cognitive impairment is a common feature of this condition, it seldom emerges as the primary symptom. In this study, we discuss a case of refractory dementia associated with the glutamic acid decarboxylase spectrum disorder. Interestingly, this case showed a favorable outcome following autologous hematopoietic stem cell transplantation. We also provide an in-depth review of the current literature on the use of this therapeutic approach for the treatment of this disease.

Is the clinical phenotype impact the prognosis in dementia with Lewy bodies?

INTRODUCTION

The first predominant clinical symptoms of dementia with Lewy bodies (DLB) are highly variable; however, the prognosis based on initial predominant symptoms remains poorly understood.

METHODS

Multicenter retrospective study in 4 French expert neurological centers. Patients were categorized in 3 groups according to their first more predominant symptoms: cognitive, psychiatric, or motor.

RESULTS

Analysis of 310 DLB patients. The mean age was 73.5 years old (SD 7.5) including 32.3% of women. The mean follow-up was 7.25 years (SD 3.6). We observed that the full clinical picture was more frequent in the motor group than in the cognitive group (p = 0.01); male gender and age at onset were associated with a significant excess risk of instantaneous mortality (p = 0.01).

CONCLUSION

Initial symptoms may affect the clinical course of patients, but no significant difference in mortality was observed.

Depression in dementia with Lewy bodies: a critical update

Depression with an estimated prevalence of 35% is a frequent manifestation of dementia with Lewy bodies (DLB), having negative effects on cognitive performance and life expectancy, yet the underlying neurobiology is poorly understood and most likely heterogeneous. Depressive symptoms in DLB can occur during the clinical course and, together with apathy, is a common prodromal neuropsychiatric symptom of this neurocognitive disorder in the group of Lewy body synucleinopathies. There are no essential differences in the frequency of depression in DLB and Parkinson disease-dementia (PDD), while its severity is up to twice as high as in Alzheimer disease (AD). Depression in DLB that is frequently underdiagnosed and undertreated, has been related to a variety of pathogenic mechanisms associated with the basic neurodegenerative process, in particular dysfunctions of neurotransmitter systems (decreased monoaminergic/serotonergic, noradrenergic and dopaminergic metabolism), α-synuclein pathology, synaptic zinc dysregulation, proteasome inhibition, gray matter volume loss in prefrontal and temporal areas as well as dysfunction of neuronal circuits with decreased functional connectivity of specific brain networks. Pharmacotherapy should avoid tricyclic antidepressants (anticholinergic adverse effects), second-generation antidepressants being a better choice, while modified electroconvulsive therapy, transcranial magnetic stimulation therapy and deep brain stimulation may be effective for pharmacotherapy-resistant cases. Since compared to depression in other dementias like Alzheimer disease and other parkinsonian syndromes, our knowledge of its molecular basis is limited, and further studies to elucidate the heterogeneous pathogenesis of depression in DLB are warranted.

Subclinical Epileptiform Activity in Dementia with Lewy Bodies

BACKGROUND

Patients with dementia with Lewy bodies (DLB) have a higher probability of seizures than in normal aging and in other types of neurodegenerative disorders. Depositions of α-synuclein, a pathological hallmark of DLB, can induce network excitability, which can escalate into seizure activity. Indicator of seizures are epileptiform discharges as observed using electroencephalography (EEG). However, no studies have so far investigated the occurrence of interictal epileptiform discharges (IED) in patients with DLB.

OBJECTIVES

To investigate if IED as measured with ear-EEG occurs with a higher frequency in patients with DLB compared to healthy controls (HC).

METHODS

In this longitudinal observational exploratory study, 10 patients with DLB and 15 HC were included in the analysis. Patients with DLB underwent up to three ear-EEG recordings, each lasting up to 2 days, over a period of 6 months.

RESULTS

At baseline, IED were detected in 80% of patients with DLB and in 46.7% of HC. The spike frequency (spikes or sharp waves/24 hours) was significantly higher in patients with DLB as compared to HC with a risk ratio of 2.52 (CI, 1.42-4.61; P-value = 0.001). Most IED occurred at night.

CONCLUSIONS

Long-term outpatient ear-EEG monitoring detects IED in most patients with DLB with an increased spike frequency compared to HC. This study extends the spectrum of neurodegenerative disorders in which epileptiform discharges occurs at an elevated frequency. It is possible that epileptiform discharges are, therefore, a consequence of neurodegeneration. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Web-based cognitive assessment in older adults: Where do we stand?

PURPOSE OF REVIEW

The use of digital tools for remote cognitive measurement of older adults is generating increasing interest due to the numerous advantages offered for accessibility and scalability. However, these tools also pose distinctive challenges, necessitating a thorough analysis of their psychometric properties, feasibility and acceptability.

RECENT FINDINGS

In this narrative review, we present the recent literature on the use of web-based cognitive assessment to characterize cognition in older adults and to contribute to the diagnosis of age-related neurodegenerative diseases. We present and discuss three types of web-based cognitive assessments: conventional cognitive tests administered through videoconferencing; unsupervised web-based assessments conducted on a computer; and unsupervised web-based assessments performed on smartphones.

SUMMARY

There have been considerable progress documenting the properties, strengths and limitations of web-based cognitive assessments. For the three types of assessments reported here, the findings support their promising potential for older adults. However, certain aspects, such as the construct validity of these tools and the development of robust norms, remain less well documented. Nonetheless, the beneficial potential of these tools, and their current validation and feasibility data, justify their application [see Supplementary Digital Content (SDC), http://links.lww.com/CONR/A69 ].

Adherence type impacts completion rates of frequent mobile cognitive assessments among older adults with and without cognitive impairment

Background

Prior to a diagnosis of Alzheimer's disease, many individuals experience cognitive and behavioral fluctuations that are not detected during a single session of traditional neuropsychological assessment. Mobile applications now enable high-frequency cognitive data to be collected remotely, introducing new opportunities and challenges. Emerging evidence suggests cognitively impaired older adults are capable of completing mobile assessments frequently, but no study has observed whether completion rates vary by assessment frequency or adherence type.

Methods

Thirty-three older adults were recruited from the Boston University Alzheimer's Disease Research Center (mean age = 73.5 years; 27.3% cognitively impaired; 57.6% female; 81.8% White, 18.2% Black). Participants remotely downloaded and completed the DANA Brain Vital application on their own mobile devices throughout the study. The study schedule included seventeen assessments to be completed over the course of a year. Specific periods during which assessments were expected to be completed were defined as subsegments, while segments consisted of multiple subsegments. The first segment included three subsegments to be completed within one week, the second segment included weekly subsegments and spanned three weeks, and the third and fourth segments included monthly subsegments spanning five and six months, respectively. Three distinct adherence types - subsegment adherence, segment adherence, and cumulative adherence - were examined to determine how completion rates varied depending on assessment frequency and adherence type.

Results

Adherence type significantly impacted whether the completion rates declined. When utilizing subsegment adherence, the completion rate significantly declined (p = 0.05) during the fourth segment. However, when considering completion rates from the perspective of segment adherence, a decline in completion rate was not observed. Overall adherence rates increased as adherence parameters were broadened from subsegment adherence (60.6%) to segment adherence (78.8%), to cumulative adherence (90.9%).

Conclusions

Older adults, including those with cognitive impairment, are able to complete remote cognitive assessments at a high-frequency, but may not necessarily adhere to prescribed schedules.

Behavioral and neural correlates of pareidolic illusions in dementia with Lewy bodies

INTRODUCTION

Pareidolia, a form of visual illusions phenomenologically similar to complex visual hallucinations, is a phenomenon that is associated with visual hallucinations in dementia with Lewy bodies (DLB). This study aimed to identify commonalities and differences in behavioral and neural correlates between pareidolic illusions and visual hallucinations in DLB.

METHODS

Forty-three patients with DLB underwent the scene pareidolia test, which evokes and measures pareidolic illusions, and standardized neuropsychological and behavioral assessments. Regional cerebral blood flow (rCBF) was measured by single-photon emission computed tomography. Factor analysis was performed to assess the relationships among pareidolic illusions, cognitive functions, and behavioral symptoms. Partial least squares correlation analysis was used to investigate the relationship between these symptoms and rCBF.

RESULTS

Factor analysis yielded three behavior factors: the first factor (hallucinations/fluctuations) consisted of pareidolic illusions, visual hallucinations, and fluctuating cognition; the second factor (general cognitive function) consisted of general cognitive function and working memory; and the third factor (visual processing) consisted of visual processing and pareidolic illusions. Partial least squares correlation analysis identified two brain-behavior correlation patterns: (1) rCBF reduction in the frontal and perisylvian/periventricular regions was associated with lower general cognitive function and lower visual processing; and (2) rCBF reduction in the bilateral occipitotemporal cortex was associated with more severe hallucinations/fluctuations and lower visual processing.

CONCLUSIONS

At the behavioral level, pareidolic illusions are associated with visual hallucinations, fluctuating cognition, and visual processing in DLB. At the neural level, pareidolic illusions may arise from the synergistic effects of global neuropathological changes and occipitotemporal cortical dysfunctions.

Unsupervised high-frequency smartphone-based cognitive assessments are reliable, valid, and feasible in older adults at risk for Alzheimer's disease

OBJECTIVE

Smartphones have the potential for capturing subtle changes in cognition that characterize preclinical Alzheimer's disease (AD) in older adults. The Ambulatory Research in Cognition (ARC) smartphone application is based on principles from ecological momentary assessment (EMA) and administers brief tests of associative memory, processing speed, and working memory up to 4 times per day over 7 consecutive days. ARC was designed to be administered unsupervised using participants' personal devices in their everyday environments.

METHODS

We evaluated the reliability and validity of ARC in a sample of 268 cognitively normal older adults (ages 65-97 years) and 22 individuals with very mild dementia (ages 61-88 years). Participants completed at least one 7-day cycle of ARC testing and conventional cognitive assessments; most also completed cerebrospinal fluid, amyloid and tau positron emission tomography, and structural magnetic resonance imaging studies.

RESULTS

First, ARC tasks were reliable as between-person reliability across the 7-day cycle and test-retest reliabilities at 6-month and 1-year follow-ups all exceeded 0.85. Second, ARC demonstrated construct validity as evidenced by correlations with conventional cognitive measures (r = 0.53 between composite scores). Third, ARC measures correlated with AD biomarker burden at baseline to a similar degree as conventional cognitive measures. Finally, the intensive 7-day cycle indicated that ARC was feasible (86.50% approached chose to enroll), well tolerated (80.42% adherence, 4.83% dropout), and was rated favorably by older adult participants.

CONCLUSIONS

Overall, the results suggest that ARC is reliable and valid and represents a feasible tool for assessing cognitive changes associated with the earliest stages of AD.

A short and simple bedside test to detect cognitive fluctuations in patients with dementia with Lewy bodies

BACKGROUND AND PURPOSE

The establishment of cognitive fluctuations is important when dementia with Lewy bodies (DLB) is suspected but can be especially difficult in the absence of a caregiver who lives with the patient. We examined the possibility of using fluctuating scores on a forward (FDS) and a backward digit span (BDS) test as a marker for cognitive fluctuation.

METHODS

Patients with DLB (21), other forms of dementia (14 with Alzheimer's disease, 8 with vascular dementia) and 20 controls were asked to perform an FDS and BDS twice, with an interval of 20 min.

RESULTS

Seventy percent of patients with DLB showed evidence of cognitive fluctuations for at least one test, while less than 10% of controls and patients with other dementias did. Evidence of cognitive fluctuations on at least one of both tests classified 83% of patients correctly (i.e. DLB or not), with a sensitivity of 70% and a specificity of 90%.

CONCLUSIONS

Repeated forward and backward digit span tests seem a valid, short, easy and inexpensive bedside tool to detect cognitive fluctuations in the diagnostic work-up of DLB, even in the absence of a caregiver, which limits the use of questionnaires.

Illuminating neurodegeneration: a future perspective on near-infrared spectroscopy in dementia research

SIGNIFICANCE

Dementia presents a global healthcare crisis, and neuroimaging is the main method for developing effective diagnoses and treatments. Yet currently, there is a lack of sensitive, portable, and low-cost neuroimaging tools. As dementia is associated with vascular and metabolic dysfunction, near-infrared spectroscopy (NIRS) has the potential to fill this gap.

AIM

This future perspective aims to briefly review the use of NIRS in dementia to date and identify the challenges involved in realizing the full impact of NIRS for dementia research, including device development, study design, and data analysis approaches.

APPROACH

We briefly appraised the current literature to assess the challenges, giving a critical analysis of the methods used. To assess the sensitivity of different NIRS device configurations to the brain with atrophy (as is common in most forms of dementia), we performed an optical modeling analysis to compare their cortical sensitivity.

RESULTS

The first NIRS dementia study was published in 1996, and the number of studies has increased over time. In general, these studies identified diminished hemodynamic responses in the frontal lobe and altered functional connectivity in dementia. Our analysis showed that traditional (low-density) NIRS arrays are sensitive to the brain with atrophy (although we see a mean decrease of 22% in the relative brain sensitivity with respect to the healthy brain), but there is a significant improvement (a factor of 50 sensitivity increase) with high-density arrays.

CONCLUSIONS

NIRS has a bright future in dementia research. Advances in technology - high-density devices and intelligent data analysis-will allow new, naturalistic task designs that may have more clinical relevance and increased reproducibility for longitudinal studies. The portable and low-cost nature of NIRS provides the potential for use in clinical and screening tests.

Fluctuations of health states in dementia diseases and their impact on the assessment of health today using the EQ-5D-5L: Protocol of a mixed-methods study

Introduction

The EQ-5D is a widely used health-related quality of life (HRQoL) instrument. The recall period “today” may miss out on recurrent health fluctuations often observed in people with dementia (PlwD). Thus, this study aims to assess the frequency of health fluctuations, affected HRQoL dimensions and the impact of the health fluctuations on the assessment of health today using the EQ-5D-5L.

Methods and analysis

This mixed-methods study will base on n=50 patient and caregiver dyads and four main study phases: (1) Baseline assessment of patients' socio-demographic and clinical characteristics; (2) caregivers self-completion of a daily diary for 14 days, documenting patient's today's health compared to yesterday, the affected HRQoL dimensions, and events that could have caused the fluctuations; (3) administration of the EQ-5D-5L as self- and proxy-rating at baseline, day seven and day 14; (4) interviewing caregivers on patient's health fluctuation, the consideration of past fluctuations in the assessment of health today using the EQ-5D-5L, and the appropriateness of recall periods to capture health fluctuations on day 14. Qualitative semi-structured interview data will be analyzed thematically. Quantitative analyses will be used to describe the frequency and intensity of health fluctuations, affected dimensions, and the association between health fluctuation and its consideration in the assessment of health today.

Discussion

This study aims to reveal insights into the health fluctuation in dementia, the affected dimensions, and underlying health events, as well as whether individuals adhere to the recall period of health today using the EQ-5D-5L. This study will also provide information about more appropriate recall periods that could better capture health fluctuations.

Trial registration

This study is registered in the German Clinical Trials Register (DRKS00027956).

Sex differences in dementia with Lewy bodies: Focused review of available evidence and future directions

In this review, we summarize the current knowledge on sex differences in dementia with Lewy bodies (DLB) relating to epidemiology, clinical features, neuropathology, biomarkers, disease progression, and caregiving. While many studies show a higher DLB prevalence in men, this finding is inconsistent and varies by study approach. Visual hallucinations may be more common and occur earlier in women with DLB, whereas REM sleep behavior disorder may be more common and occur earlier in men. Several studies report a higher frequency of parkinsonism in men with DLB, while the frequency of fluctuations appears similar between sexes. Women tend to be older, have greater cognitive impairment at their initial visit, and are delayed in meeting DLB criteria compared to men. Women are also more likely to have Lewy body disease with co-existing AD-related pathology than so-called "pure" Lewy body disease, while men may present with either. Research is mixed regarding the impact of sex on DLB progression. Biomarker and treatment research assessing for sex differences is lacking. Women provide the majority of caregiving in DLB but how this affects the caregiving experience is uncertain. Gaining a better understanding of sex differences will be instrumental in aiding future development of sex-specific strategies in DLB for early diagnosis, care, and drug development.

Disease Progression and Longitudinal Clinical Outcomes of Lewy Body Dementia in the NACC Database

INTRODUCTION

As the identification of Lewy body dementia (LBD) is often confirmed postmortem, there is a paucity of evidence on the progression of disease antemortem. This study aimed to comprehensively assess the course of LBD over time across cognitive, functional, and neuropsychiatric outcomes using real-world data.

METHODS

Adults with at least one visit to an Alzheimer's Disease Center with a diagnosis of mild cognitive impairment/dementia (index date), indication of LBD, and at least one follow-up visit were identified in the National Alzheimer's Coordinating Center database (September 2005-June 2020). Participant characteristics, medication use, comorbidities, and changes in outcomes were assessed over a 5-year follow-up period and stratified by disease severity based on the Clinical Dementia Rating (CDR®) Dementia Staging Instrument-Sum of Boxes (CDR-SB) score at index.

RESULTS

A total of 2052 participants with LBD (mean age at index 73.4 years) were included (mild, 219; moderate, 988; severe, 845). Mean annualized increase over 5 years was 0.9 points for CDR-Global Score, 5.6 points for CDR-SB, 10.4 points for the Functional Activities Questionnaire, and 2.0 points for the Neuropsychiatric Inventory-Questionnaire. Disease progression was greater among participants with moderate and severe LBD at index compared with those with mild LBD.

CONCLUSION

Participants with LBD experienced decline across all outcomes over time, and impairment increased with disease severity. Findings highlight the substantial clinical burden associated with LBD and the importance of earlier diagnosis and effective treatment. Further research is needed to understand the predictors of cognitive and functional decline in LBD which may help inform clinical trials.

The effect of antidepressant therapy on a patient with progressive supranuclear palsy accompanied by depression, anxiety and fluctuating dementia

Progressive supranuclear palsy (PSP) is a complex clinicopathologic disease which can only be definitively confirmed at autopsy. It belongs to a family of conditions exhibiting Parkinson's syndrome, including Lewy body dementia (LBD) or dementia with Lewy body (DLB), and Parkinson's disease dementia (PDD). In regards to clinical manifestations, these two dementias have many overlapping characteristics. The declines of cognition in older patients of dementia are generally accompanied by depression, anxiety, hallucinations, delusions, eating and sleep disorders. This can lead to the difficulty in distinguishing the types of dementia and accurately diagnosing the disease. Herein, we present a complex case of PSP with depression, anxiety, and fluctuating dementia in which DLB was initially suspected. Before antidepressant therapy, the patient showed extrapyramidal symptoms as well as major depression, which lead to greatly impaired movement. Moreover, this patient was an older person with depression disorders, implicating further complexities of late life depression. After two weeks of therapy with antidepressants, the patient had reduced depressive symptoms, and even the somatic symptoms were improved. This case demonstrated that antidepressant therapy can be effective in improving emotion and cognition among patients with late life depression.

Disease progression in dementia with Lewy bodies: A longitudinal study on clinical symptoms, quality of life and functional impairment

BACKGROUND AND OBJECTIVES

Dementia with Lewy Bodies (DLB) is a heterogeneous disease, with variable signs and symptoms across multiple domains. We aimed to identify associations with rate of change in cognition, everyday functioning (IADL) and quality of life (QoL).

METHODS

We included 121 DLB patients (69 ± 6 yrs, 14%F, MMSE: 25 ± 3) in our prospective cohort (follow-up 2 ± 1 yrs). We described progression of symptoms and cognitive decline over time. Mixed models were used to investigate whether changes in symptoms were associated to changes in IADL (FAQ), QoL (QoL-AD) and caregiver burden (ZBI). Last, we investigated whether baseline symptoms and biomarkers predicted decline in cognition (MMSE), IADL (FAQ) and QoL (QoL-AD).

RESULTS

Parkinsonism and RBD were most frequently present early in the disease course, while hallucinations were more likely to develop in a later stage. MMSE (annual change β ± SE = -2.06 ± 0.23), QoL-AD (-1.03 ± 0.20), and FAQ (3.04 ± 0.30) declined over time. Increasing severity of clinical symptoms was associated to increases in FAQ, QoL-AD and caregiver burden. Baseline clinical symptoms were not predictive for decline in these outcomes. By contrast, AD co-pathology (CSF pTau/Aβ42 ratio) was associated to steeper decline in MMSE (-1.23 ± 0.54). Medial temporal atrophy (-0.81 ± 0.26) and global cortical atrophy (-0.73 ± 0.36) predisposed for decline in QoL-AD.

CONCLUSIONS

Our findings imply that underlying disease processes, rather than clinical symptomatology aid in predicting decline. These findings are relevant for treatment strategies and the development of DLB specific outcome measures.

Dispersion-based cognitive intra-individual variability in dementia with Lewy bodies

OBJECTIVE

Cognitive fluctuations are characteristic of dementia with Lewy bodies (DLB) but challenging to measure. Dispersion-based intra-individual variability (IIV-d) captures neurocognitive performance fluctuations across a test battery and may be sensitive to cognitive fluctuations but has not been studied in DLB.

METHOD

We report on 5,976 participants that completed the uniform data set 3.0 neuropsychological battery (UDS3NB). IIV-d was calculated via the intra-individual standard deviation across 12 primary UDS3NB indicators. Separate models using mean USD3NB score and the Montreal cognitive assessment (MoCA) total score tested the reproducibility of the incremental value of IIV-d over-and-above global cognition. Binary logistic regressions tested whether IIV-d could classify individuals with and without clinician-rated cognitive fluctuations. Multinomial logistic regressions tested whether IIV-d could differentiate participants with DLB, participants with Alzheimer's disease (AD), and participants with healthy cognition (CH), as well as the incremental diagnostic utility of IIV-d over-and-above clinician-rated cognitive fluctuations.

RESULTS

IIV-d exhibited large univariate associations with clinician-rated and non-clinician-informant reported cognitive fluctuations, which persisted when adjusting for MoCA but not the full battery mean. Of diagnostic relevance, greater IIV-d was consistently associated with DLB and AD relative to CH over-and-above global cognition and clinician-rated cognitive fluctuations. Greater IIV-d was less consistently associated with an increased probability of DLB relative to AD when controlling for global cognition.

CONCLUSIONS

IIV-d accurately differentiates DLB from CH over-and-above global cognition and clinician-rated cognitive fluctuations. IIV-d may supplement a thorough clinical interview of cognitive fluctuations and serve as a standardized performance-based indicator of this transdiagnostic phenomenon. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Sleep disturbances in Lewy body dementia: A systematic review

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.

Aggression Towards Caregivers in Parkinson's Disease and Related Disorders: A Mixed Methods Study

Background

Aggression is one manifestation of behavioral disturbances in neurodegenerative disease with emerging literature suggesting a high prevalence in Parkinson's disease and related disorders (PDRD).

Objectives

Our aim was to describe characteristics, associated factors, and consequences of aggression towards caregivers in PDRD.

Methods

This is a convergent mixed methods study, leveraging data from 296 PDRD patient-caregiver dyads in a clinical trial of palliative care and semi-structured interviews with a subgroup of 14 caregivers who reported aggression. The primary outcome was baseline caregiver-reported aggression. Using multivariate linear regression, baseline dyad characteristics (eg, measures of disease, psychosocial issues, caregiver strain) were examined to identify factors associated with aggression. Thematic analysis of interviews was used to augment these findings.

Results

Associated variables included disease duration (r = 0.15, P < 0.05), patient grief (r = 0.22, P< 0.001), symptom burden (r = 0.18, r < 0.01), resistance to care (r = 0.40, P < 0.01), caregivers' depression (r = 0.16, P < 0.05), and caregiving burden (r = 0.34, P < 0.001). We identified five themes: (1) Aggressive behaviors range from verbal abuse to threats of physical violence; (2) Caregivers believe that aggressive behaviors result from the difficulty patients experience in coping with disease progression and related losses; (3) Caregivers' stress and mental health are worsened by aggressive behaviors; (4) Aggressive behaviors negatively affect patient-caregiver relationships; (5) Caregivers are ill-prepared to manage aggressive behaviors and cope with the consequences on their own.

Conclusions

Aggression in PDRD is driven by diverse factors (eg, grief, fluctuations in cognition) with serious consequences for caregivers. Neurologists and movement specialists should consider screening for aggression while prioritizing caregiver education and wellbeing.

The Cognitive and Language Profile of Dementia with Lewy Bodies

Dementia with Lewy bodies (DLB) is a major neurocognitive disorder (MNCD) that is primarily characterized by motor, cognitive, and behavioral symptoms. Although not dominant in the clinical portrait of DLB, impairments affecting language processing have been reported. It is sometimes challenging to differentiate DLB from Alzheimer’s disease and dementia associated with Parkinson’s disease in clinical practice. Therefore, a better comprehension of the typical clinical presentation of DLB may be useful to ease the medical diagnosis. In this article, current data on cognitive and language disorders in DLB are reported, with special attention paid to their primary or secondary functional origin. The main elements that should be considered for the neuropsychological and speech-language assessment of individuals with possible or proven DLB are also highlighted. Additional studies are needed, especially for language impairment, to obtain a more accurate portrait of the clinical presentation of DLB and characterize its progression.

The neurophysiological effect of NMDA-R antagonism of frontotemporal lobar degeneration is conditional on individual GABA concentration

There is a pressing need to accelerate therapeutic strategies against the syndromes caused by frontotemporal lobar degeneration, including symptomatic treatments. One approach is for experimental medicine, coupling neurophysiological studies of the mechanisms of disease with pharmacological interventions aimed at restoring neurochemical deficits. Here we consider the role of glutamatergic deficits and their potential as targets for treatment. We performed a double-blind placebo-controlled crossover pharmaco-magnetoencephalography study in 20 people with symptomatic frontotemporal lobar degeneration (10 behavioural variant frontotemporal dementia, 10 progressive supranuclear palsy) and 19 healthy age- and gender-matched controls. Both magnetoencephalography sessions recorded a roving auditory oddball paradigm: on placebo or following 10 mg memantine, an uncompetitive NMDA-receptor antagonist. Ultra-high-field magnetic resonance spectroscopy confirmed lower concentrations of GABA in the right inferior frontal gyrus of people with frontotemporal lobar degeneration. While memantine showed a subtle effect on early-auditory processing in patients, there was no significant main effect of memantine on the magnitude of the mismatch negativity (MMN) response in the right frontotemporal cortex in patients or controls. However, the change in the right auditory cortex MMN response to memantine (vs. placebo) in patients correlated with individuals' prefrontal GABA concentration. There was no moderating effect of glutamate concentration or cortical atrophy. This proof-of-concept study demonstrates the potential for baseline dependency in the pharmacological restoration of neurotransmitter deficits to influence cognitive neurophysiology in neurodegenerative disease. With changes to multiple neurotransmitters in frontotemporal lobar degeneration, we suggest that individuals' balance of excitation and inhibition may determine drug efficacy, with implications for drug selection and patient stratification in future clinical trials.

Neuroscience from the comfort of your home: Repeated, self-administered wireless dry EEG measures brain function with high fidelity

Recent advances have enabled the creation of wireless, “dry” electroencephalography (EEG) recording systems, and easy-to-use engaging tasks, that can be operated repeatedly by naïve users, unsupervised in the home. Here, we evaluated the validity of dry-EEG, cognitive task gamification, and unsupervised home-based recordings used in combination. Two separate cohorts of participants—older and younger adults—collected data at home over several weeks using a wireless dry EEG system interfaced with a tablet for task presentation. Older adults (n = 50; 25 females; mean age = 67.8 years) collected data over a 6-week period. Younger male adults (n = 30; mean age = 25.6 years) collected data over a 4-week period. All participants were asked to complete gamified versions of a visual Oddball task and Flanker task 5–7 days per week. Usability of the EEG system was evaluated via participant adherence, percentage of sessions successfully completed, and quantitative feedback using the System Usability Scale. In total, 1,449 EEG sessions from older adults (mean = 28.9; SD = 6.64) and 684 sessions from younger adults (mean = 22.87; SD = 1.92) were collected. Older adults successfully completed 93% of sessions requested and reported a mean usability score of 84.5. Younger adults successfully completed 96% of sessions and reported a mean usability score of 88.3. Characteristic event-related potential (ERP) components—the P300 and error-related negativity—were observed in the Oddball and Flanker tasks, respectively. Using a conservative threshold for inclusion of artifact-free data, 50% of trials were rejected per at-home session. Aggregation of ERPs across sessions (2–4, depending on task) resulted in grand average signal quality with similar Standard Measurement Error values to those of single-session wet EEG data collected by experts in a laboratory setting from a young adult sample. Our results indicate that easy-to-use task-driven EEG can enable large-scale investigations in cognitive neuroscience. In future, this approach may be useful in clinical applications such as screening and tracking of treatment response.

Clinical outcome measures in dementia with Lewy bodies trials: critique and recommendations

The selection of appropriate outcome measures is fundamental to the design of any successful clinical trial. Although dementia with Lewy bodies (DLB) is one of the most common neurodegenerative conditions, assessment of therapeutic benefit in clinical trials often relies on tools developed for other conditions, such as Alzheimer's or Parkinson's disease. These may not be sufficiently valid or sensitive to treatment changes in DLB, decreasing their utility. In this review, we discuss the limitations and strengths of selected available tools used to measure DLB-associated outcomes in clinical trials and highlight the potential roles for more specific objective measures. We emphasize that the existing outcome measures require validation in the DLB population and that DLB-specific outcomes need to be developed. Finally, we highlight how the selection of outcome measures may vary between symptomatic and disease-modifying therapy trials.

Dementia care partners’ reported outcomes after adaptive riding: a theoretical thematic analysis

Purpose

This case study aims to explore the appropriateness of an adaptive riding program for persons living with dementia through examining family members’ (care partners) reported outcomes.

Design/methodology/approach

Using convenience sampling, persons living with dementia and their care partners were recruited in Northern Colorado; after meeting inclusion criteria, they were invited to participate in the adaptive riding program. The program occurred for weekly, hour-long sessions for eight weeks. Field notes were collected during each session, and semi-structured interviews were conducted with five care partners after the program and analyzed by using theoretical thematic analysis.

Findings

Care partners found the adaptive riding program appropriate. Reported outcomes comprised three themes: well-being, meaning through social connections and function in daily life and aligned with the positive emotions, engagement, relationships, meaning, accomplishment (PERMA) theory of well-being.

Originality/value

To the best of the authors’ knowledge, this is the first study to explore the appropriateness of an adaptive riding program for persons living with dementia and their care partners who broadened understandings of the emotional, social and physical benefits. Findings support the inclusion of care partners in adaptive riding and may inform health-care providers’ recommendations for such programs.

Caring for patients with cognitive dysfunction, fluctuations and dementia caused by Parkinson's disease

Cognitive dysfunction is one of the most prevalent non-motor symptoms in patients with Parkinson's disease (PD). While it tends to worsen in the later stages of disease, it can occur at any time, with 15-20% of patients exhibiting cognitive deficits at diagnosis (Aarsland et al., 2010; Goldman and Sieg, 2020). The characteristic features of cognitive dysfunction include impairment in executive function, visuospatial abilities, and attention, which vary in severity from subtle impairment to overt dementia (Martinez-Horta and Kulisevsky, 2019). To complicate matters, cognitive dysfunction is prone to fluctuate in PD patients, impacting diagnosis and the ability to assess progression and decision-making capacity. The diagnosis of cognitive impairment or dementia has a huge impact on patient independence, quality of life, life expectancy and caregiver burden (Corallo et al., 2017; Lawson et al., 2016; Leroi et al., 2012). It is therefore essential that physicians caring for patients with PD provide education, screening and treatment for this aspect of the disease. In this chapter, we provide a practical guide for the assessment and management of various degrees of cognitive dysfunction in patients with PD by approaching the disease at different stages. We address risk factors for cognitive dysfunction, prevention strategies prior to making the diagnosis, available tools for screening. Lastly, we review aspects of care, management and considerations, including decision-making capacity, that occur after the patient has been diagnosed with cognitive dysfunction or dementia.

Dynamic network impairments underlie cognitive fluctuations in Lewy body dementia

Cognitive fluctuations are a characteristic and distressing disturbance of attention and consciousness seen in patients with Dementia with Lewy bodies and Parkinson's disease dementia. It has been proposed that fluctuations result from disruption of key neuromodulatory systems supporting states of attention and wakefulness which are normally characterised by temporally variable and highly integrated functional network architectures. In this study, patients with DLB (n = 25) and age-matched controls (n = 49) were assessed using dynamic resting state fMRI. A dynamic network signature of reduced temporal variability and integration was identified in DLB patients compared to controls. Reduced temporal variability correlated significantly with fluctuation-related measures using a sustained attention task. A less integrated (more segregated) functional network architecture was seen in DLB patients compared to the control group, with regions of reduced integration observed across dorsal and ventral attention, sensorimotor, visual, cingulo-opercular and cingulo-parietal networks. Reduced network integration correlated positively with subjective and objective measures of fluctuations. Regions of reduced integration and unstable regional assignments significantly matched areas of expression of specific classes of noradrenergic and cholinergic receptors across the cerebral cortex. Correlating topological measures with maps of neurotransmitter/neuromodulator receptor gene expression, we found that regions of reduced integration and unstable modular assignments correlated significantly with the pattern of expression of subclasses of noradrenergic and cholinergic receptors across the cerebral cortex. Altogether, these findings demonstrate that cognitive fluctuations are associated with an imaging signature of dynamic network impairment linked to specific neurotransmitters/neuromodulators within the ascending arousal system, highlighting novel potential diagnostic and therapeutic approaches for this troubling symptom.

A53T α-synuclein induces neurogenesis impairment and cognitive dysfunction in line M83 transgenic mice and reduces the proliferation of embryonic neural stem cells

Dementia with Lewy body (DLB) is the second most common degenerative dementia after Alzheimer's disease. There is no therapeutic drug for DLB currently. It's urgent for us to understand the pathological mechanism of dementia mediated by α-synuclein, as the main component of Lewy body. Here, we found that the A53T α-synuclein transgenic mice showed decreased nesting behavior starting from the age of 1 month. The results in Morris water maze test suggested that the 6-month-old mice had learning memory deficits. Golgi staining indicated that the apical neuronal dendritic spines of hippocampal CA1 neurons were significantly reduced in 6-month-old homozygotes and heterozygotes, although MAP2 protein expression revealed no significant difference in the hippocampus among wild-type mice, homozygotes and heterozygotes. In vitro, we proved mutant A53T α-synuclein decreased the dendritic branches and dendrite spines on the embryonic mice hippocampal neurons. Furthermore, Ki67 immunofluorescence staining identified that the Ki67-positive cells of the hippocampal dentate gyrus and subventricular zone were significantly reduced in 6-month-old homozygotes and heterozygotes, compared with age-matched wild-type mice. Similarly, when 6-month-old mice were injected with BrdU for one day, the immunostaining results also confirmed that BrdU-positive cells were significantly reduced in homozygous and heterozygous mice. Lastly, we transfected primary embryonic hippocampal neural stem cells with lentivirus vector expressing A53T α-synuclein in vitro. Both BrdU staining and Western blotting showed that A53T α-synuclein significantly decreased the proliferation of embryonic neural stem cells. Taken together, these data suggest that A53T α-synuclein can induce adult neurogenesis impairment and cognitive dysfunction. The A53T α-synuclein transgenic mice may be used as an animal model for DLB. Promoting adult neurogenesis may be a promising approach to treat DLB pathogenesis.

Lewy Body Dementias: Controversies and Drug Development

Lewy body dementia (LBD) is one of the most common neurodegenerative dementias. Clinical trials for symptomatic and disease-modifying therapies in LBD remain a national research priority, but there are many challenges in both past and active drug developments in LBD. This review highlights the controversies in picking the appropriate populations, interventions, target selections, and outcome measures, which are all critical components of clinical trial implementation in LBD. The heterogeneity of LBD neuropathology and clinical presentations, limited understanding of core features such as cognitive fluctuations, and lack of validated LBD-specific outcome measures and biomarkers represent some of the major challenges in LBD trials.

What neurologists wish palliative care physicians knew

As the incidence of neurologic (particularly neurodegenerative) diseases continues to rise, so too will the palliative needs in this patient population. To appropriately care for these patients and families, neurologists and palliative care providers will need to strengthen collaboration. Palliative care providers not formally trained in neurology may feel ill-equipped to manage some of the distinct neuropalliative care needs of these patients. Here, we provide insights into the unique characteristics of patients with neurologic disease and emphasize the relevance of the palliative care skillset in this population to aid the collaboration between palliative care providers and neurologists.

Cortical circuit dysfunction in a mouse model of alpha-synucleinopathy in vivo

Considerable fluctuations in cognitive performance and eventual dementia are an important characteristic of alpha-synucleinopathies, such as Parkinson's disease and Lewy Body dementia and are linked to cortical dysfunction. The presence of misfolded and aggregated alpha-synuclein in the cerebral cortex of patients has been suggested to play a crucial role in this process. However, the consequences of a-synuclein accumulation on the function of cortical networks at cellular resolution in vivo are largely unknown. Here, we induced robust a-synuclein pathology in the cerebral cortex using the striatal seeding model in wild-type mice. Nine months after a single intrastriatal injection of a-synuclein preformed fibrils, we observed profound alterations of the function of layer 2/3 cortical neurons in somatosensory cortex by in vivo two-photon calcium imaging in awake mice. We detected increased spontaneous activity levels, an enhanced response to whisking and increased synchrony. Stereological analyses revealed a reduction in glutamic acid decarboxylase 67-positive inhibitory neurons in the somatosensory cortex of mice injected with preformed fibrils. Importantly, these findings point to a disturbed excitation/inhibition balance as a relevant driver of circuit dysfunction, potentially underlying cognitive changes in alpha-synucleinopathies.