Prevalence and cognitive performances of clinical dementia rating 0.5 and mild cognitive impairment in Japan. The Tajiri project

Vietnamese Insights into Cognitive Aging Program (VIP): Objectives, study design, and cohort description

Introduction

There is a dearth of research on cognitive aging and dementia in Asian Americans, particularly in Vietnamese Americans, the fourth largest Asian subgroup in the United States.

Methods

The Vietnamese Insights into Cognitive Aging Program (VIP) investigates early life adversity and war-related trauma and their associations with cognitive health in a community-based sample of older Vietnamese Americans in Northern California (i.e., Sacramento and Santa Clara counties). Baseline measurements include a comprehensive neuropsychological battery, including measures of global cognition along with executive function, semantic memory, and episodic memory. Data also include measures of functioning, early life adversity and trauma exposure, and psychosocial and traditional cardiovascular disease risk factors. Cognitive assessments will be repeated twice over the course of the data collection period, approximately 12- and 24- months post-baseline. Blood samples collected during Wave 2 will be assayed for biochemical risk factors.

Results

Baseline assessments were conducted from January 2022 to November 2023, with N = 548 Vietnamese Americans; mean age ± SD was 73 ± 5.31 years and 55% of participants were women. There were significant differences in social factors by site, with Santa Clara participants having higher education (some college or higher: Sacramento, ≈25%; Santa Clara: ≈48%) and marginally higher incomes compared to Sacramento participants. A higher percentage of Santa Clara participants reported speaking English well or very well (24%) compared to Sacramento participants (13%), although the majority of the entire sample (81%) reported speaking some to no English (response options: not at all; some/a little bit; well/very well).

Discussion

This longitudinal study providea a unique opportunity to more fully delineate psychosocial factors that contribute to dementia disparities in diverse and under-engaged populations. Future work will examine cognition, the prevalence of mild cognitive impairment and dementia, and other health outcomes, while controlling for site differences in all analyses.

Highlights

Vietnamese Insights into Cognitive Aging Program (VIP) is a new study.VIP has detailed early life and health data on 548 older Vietnamese Americans.History of war and trauma may contribute to Alzheimer's disease and related dementias (ADRD)-related burden.VIP may provide insight into ADRD burden in other understudied groups.

Blood-Derived Progenitor Cells Are Depleted in Older Adults with Cognitive Impairment: A Role for Vascular Resilience?

BACKGROUND

Depletion of blood-derived progenitor cells, including so called "early endothelial progenitor cells", has been observed in individuals with early stage Alzheimer's disease relative to matched older control subjects. These findings could implicate the loss of angiogenic support from hematopoietic progenitors or endothelial progenitors in cognitive dysfunction.

OBJECTIVE

To investigate links between progenitor cell proliferation and mild levels of cognitive dysfunction.

METHODS

We conducted in vitro studies of blood-derived progenitor cells using blood samples from sixty-five older adults who were free of stroke or dementia. Peripheral blood mononuclear cells from venous blood samples were cultured in CFU-Hill media and the number of colony forming units were counted after 5 days in vitro. Neuropsychological testing was administered to all participants.

RESULTS

Fewer colony forming units were observed in samples from older adults with a Clinical Dementia Rating global score of 0.5 versus 0. Older adults whose samples developed fewer colony forming units exhibited worse performance on neuropsychological measures of memory, executive functioning, and language ability.

CONCLUSION

These data suggest blood progenitors may represent a vascular resilience marker related to cognitive dysfunction in older adults.

The complex burden of determining prevalence rates of mild cognitive impairment: A systematic review

Mild cognitive impairment (MCI) is a syndrome characterized by a decline in cognitive performance greater than expected for an individual's age and education level, but that does not interfere much with daily life activities. Establishing the prevalence of MCI is very important for both clinical and research fields. In fact, in a certain percentage of cases, MCI represents a prodromal condition for the development of dementia. Accordingly, it is important to identify the characteristics of MCI that allow us to predict the development of dementia. Also, initial detection of cognitive decline can allow the early implementation of prevention programs aimed at counteracting or slowing it down. To this end, it is important to have a clear picture of the prevalence of MCI and, consequently, of the diagnostic criteria used. According to these issues, this systematic review aims to analyze MCI prevalence, exploring the methods for diagnosing MCI that determine its prevalence. The review process was conducted according to the PRISMA statement. Three thousand one hundred twenty-one international articles were screened, and sixty-six were retained. In these studies, which involved 157,035 subjects, the prevalence of MCI ranged from 1.2 to 87%. The review results showed a large heterogeneity among studies due to differences in the subjects' recruitment, the diagnostic criteria, the assessed cognitive domains, and other methodological aspects that account for a higher range of MCI prevalence. This large heterogeneity prevents drawing any firm conclusion about the prevalence of MCI.

Decreased Time on the Nondominant One-Leg Standing Test Associated with Repeated Falls in Older Residents with Healthy Aging, Mild Cognitive Impairment, and Dementia: The Wakuya Project

Introduction

The aim of this study is to clarify the association between repeated falls and the dominant/nondominant side in the open-eyed one-leg standing (OLS) test among people who are healthy or have mild cognitive impairment (MCI) or dementia in a community setting. We recruited 180 participants from 39 areas in the town of Wakuya.

Methods

This is a cross-sectional study. Participants were classified into 3 Clinical Dementia Rating (CDR) groups, i.e., CDR 0 (healthy, n = 71), CDR 0.5 (MCI, n = 85), and CDR 1+ (n = 23), and they were investigated for motor function (grip strength, 6-m normal gait speed, timed up and go test, and OLS test) and falls during the past year.

Results

Subjects with a CDR of 0.5 had higher rates of single and repeated falls (13.0 and 23.4%, respectively) than the CDR 0 group (12.1 and 4.5%, respectively), as did those in CDR 1+ group (15.0 and 30.0%). For the CDR 0.5 group, the frequency of falls was negatively (biologically meaningful direction) correlated with the left OLS time. No significant correlations with falls were found for other motor function tests. Another analysis separating the CDR 0.5 group into 2 subgroups (repeated falls vs. no or a single fall) also showed that the left OLS time was lower in subjects with repeated falls.

Conclusion

People with MCI who had fallen repeatedly in the year before the assessment had a significantly lower left OLS time compared to those who had not fallen or had had 1 fall with MCI. None of the other physical measures were associated with past repeat falls including OLS on the dominant right side. No such findings were noted in the CDR 0 and CDR 0+ groups.

The Prevalence of Mild Cognitive Impairment among Chinese People: A Meta-Analysis

BACKGROUND

Mild cognitive impairment (MCI) induced the majority number of dementia patients. The prevalence of MCI in China varied across studies with different screening tools and diagnostic criteria.

OBJECTIVE

A systematic review and meta-analysis was conducted to estimate the pooled MCI prevalence among the population aged 55 years and older in China.

METHODS

PubMed, EMBASE, CNKI, Wanfang, CQVIP, and CBMdisc were searched for studies on prevalence of MCI among Chinese elderly between January 1, 1980, and February 10, 2020. The quality assessment was conducted via external validity, internal validity, and informativity, the pooled prevalence was calculated through the random-effect model, and the homogeneity was evaluated by Cochran's Q test and I2.

RESULTS

Fifty-three studies with 123,766 subjects were included. The pooled prevalence of MCI among Chinese elderly was 15.4% (95% CI: 13.5-17.4%). Subgroup analyses indicated that the prevalence calculated with different screening tools was 20.2% (95% CI: 15.1-25.9%) for Montreal Cognitive Assessment (MoCA) and 13.0% (95% CI: 10.7-15.5%) for Mini-Mental State Examination (MMSE). According to different diagnostic criteria, the prevalence was 14.8% (95% CI: 12.2-17.6%) for Petersen criteria, 15.0% (95% CI: 12.7-17.5%) for DSM-IV, and 21.2% (95% CI: 17.5-25.2%) for Chinese Expert Consensus on Cognitive Impairment (CECCI). Besides, women, older adults, illiterate people, rural residents, and those who lived with unhealthy lifestyles and morbidity showed higher prevalence.

CONCLUSIONS

The prevalence of MCI in China was 15.4%, which varied by demographics, lifestyles, morbidity, screening tools, and diagnostic criteria. In further studies, screening tools and diagnosis criteria should be considered when estimating MCI prevalence.

Self-Reported Cognitive Decline Based on the Ascertain Dementia 8 Questionnaire May Be Effective for Detecting Mild Cognitive Impairment and Dementia in the Community: The Wakuya Project

Introduction

To assess cognitive impairment, self-awareness is an important issue. The Ascertain Dementia 8 questionnaire (AD8) is a brief observation checklist for detecting mild cognitive impairment (MCI) and dementia. After analyzing the reliability and validity of a self-reported Japanese version of the AD8 (AD8-J), we compared self- and informant-reported versions of the AD8-J.

Methods

A total of 93 community residents aged 75 years or older living in Wakuya, Northern Japan, agreed to participate in this study; 35 were rated as Clinical Dementia Rating (CDR) 0 (healthy), 46 as CDR 0.5 (defined herein as MCI), and 12 as CDR 1 or above (dementia, confirmed by the DSM-IV). We examined the reliability and validity using a receiver operating characteristic (ROC) curve. We analyzed the differences between self-reported and informant-reported AD8-J using a repeated measures ANOVA.

Results

The self-reported AD8-J showed a satisfactory reliability (i.e., Cronbach coefficient, α = 0.71; Guttman split half method coefficient = 0.60). For CDR 0 vs. CDR 0.5 or above, the area under the ROC curve was 0.74 and the cutoff score was 1/2, with a sensitivity of 70.7% and a specificity of 65.7%. Analysis of the subscores of AD8 suggested that, from the early stage of dementia, the subjects showed a subjective decline in memory and interest in hobbies/activities, as well as problems with judgment.

Conclusion

It is suggested that the self-reported AD8-J was effective in detecting MCI and dementia. We could use it for detecting MCI and dementia, including in those living alone, in the primary health checkup.

Global Clinical Dementia Rating Score of 0.5 May Not Be an Accurate Criterion to Identify Individuals with Mild Cognitive Impairment

Many studies use the global clinical dementia rating (CDR) of 0.5 as a criterion for mild cognitive impairment, but past studies have not fully discussed its validity. The authors developed the ABC Dementia Scale (ABC-DS) to accurately monitor the changes in activities for daily living, behavioral and psychological symptoms of dementia, and cognitive function. When we carried out a cluster analysis of ABC-DS scores of 110 individuals for whom global CDR was 0.5, there were three groups with different levels of activities for daily living and cognitive function. O’Bryant et al. proposed a new guideline to stage dementia using the CDR sum of boxes scores (CDR-SOB). We used their proposal and ABC-DS scores to evaluate the validity of CDR 0.5 as a definition of mild cognitive impairment (MCI). We concluded that the CDR-SOB scores and ABC-DS score are more accurate than global CDR of 0.5 for specifying individuals with MCI.

Impaired conflict monitoring in cognitive decline

Resolving conflicts is an important cognitive ability of executive function, and it may decrease with cognitive decline. The flanker task is a practical test used to assess the ability to suppress responses that are inappropriate in a particular context. The aims of the present study were to investigate conflict monitoring of cognitive control in subjects with different levels of cognitive impairment, and clarify the usefulness of the flanker task in screening cognitive decline. We recruited 50 subjects with mild cognitive impairment (MCI) and 34 patients with Alzheimer's disease (AD), and 44 mentally healthy elderly subjects as a control group. To evaluate cognitive performance, each participant underwent a neuropsychological assessment using the Cognitive Abilities Screening Instrument and a modified flanker task. Compared with the normal controls and those with MCI, the patients with AD had a significantly lower accuracy rate and longer reaction time in both congruent and incongruent trials. The diagnosis of AD predicted significantly poorer performances on the flanker tasks. Furthermore, behavioral data of the patients with AD were significantly correlated with the results of neuropsychological tests. Our results indicated that executive cognitive deficits in conflict monitoring as detected by the flanker task were significantly impaired in the patients with AD. The flanker task could be a quick and easier alternative tool for screening AD among elderly people with suspicious cognitive impairment.

Vascular Mild Cognitive Impairment: Identifying Disease in Community-Dwelling Older Adults, Reducing Risk Factors, and Providing Support. The Osaki-Tajiri and Kurihara Projects

Vascular mild cognitive impairment (MCI) is a critical disease. Its prognosis includes not only onset of vascular dementia, but also death by cardiovascular disease. The vascular risk factors for vascular MCI are treatable, and appropriate treatment can prevent or delay the progression to dementia. Therefore, this group is an excellent candidate for secondary prevention. However, community-dwelling older adults with vascular MCI are often undetected and are not clinically identified until they develop frank dementia. Furthermore, older adults with undetected vascular MCI often have decreased ability to follow their medication regimens and this poor medication adherence worsens their vascular comorbidities. This vicious cycle needs to be prevented through community-based interventions. There is evidence that treatment of hypertension or diabetes mellitus could lead to a reduced incidence of vascular MCI and dementia. In this review article, we first explain the background and etiology of vascular MCI. We then summarize phenotype of subcortical vascular dementia which is often unrecognized or "hidden" in the community. Then we introduce the Osaki-Tajiri and Kurihara Projects which have been conducted in Northern Japan, as an example of prevention projects aimed to identify early-stage vascular MCI in the community, reduce the risk factors and facilitate their treatment. Early identification of vascular MCI in the community could lead to a large reduction in the dementia burden worldwide. The outreach efforts presented here could be useful in developing secondary prevention strategies targeted to vascular MCI.

Effects of Tooth Loss and the Apolipoprotein E ɛ4 Allele on Mild Memory Impairment in the Fujiwara-kyo Study of Japan: A Nested Case-Control Study

Background: Several studies have suggested that periodontal disease can exacerbate the pro-inflammatory status of the brain. Tooth loss is one of the alternative evaluation indices of periodontal disease. There are few data on the relationship between tooth loss and memory impairment, depending on the apolipoprotein E (APOE) ɛ4 genotype.

Objective: To determine if tooth loss is associated with mild memory impairment (MMI) and if this association is modified by the presence of the APOEɛ4 allele.

Methods: A nested case-control study was conducted from 2007 to 2012 in Japan. Five hundred and thirty-seven Japanese subjects aged 65 years and over who were cognitively intact at baseline were analyzed. MMI at follow-up was evaluated.

Results: The median number of teeth at baseline was significantly lower in MMI participants (n = 179) than in controls (n = 358) (MMI: median 21.0, interquartile range 10.0–25.0 versus controls: 24.0, 14.0–27.0). After adjustment for demographics, vascular risk factors, and APOEɛ4 allele, the multivariate adjusted odds ratio (OR) of ≤8 teeth was 1.97 (95% confidence interval [CI], 1.13–3.44) compared to 25–32 teeth. Participants with both the presence of at least 1 APOEɛ4 allele and ≤8 teeth had a higher risk of MMI compared with those with neither (OR, 2.82; 95% CI, 1.15–6.91). Those with either risk factor alone did not have a higher risk of MMI.

Conclusions: A lower number of teeth is related to risk of MMI. This may be primarily true for those individuals with an APOEɛ4 allele.

Cognitive decline and slower reaction time in elderly individuals with mild cognitive impairment

AIM

The relationship between declining performance, as measured by changes in reaction time, and declining cognitive function has not been critically studied. The aim of the present study was to investigate the association between reaction time during a task and cognitive ability in elderly Taiwanese individuals.

METHODS

Patients aged 65 years or older with mild cognitive impairment (MCI) (n = 33) and Alzheimer's disease (n = 26) were recruited from the neurology clinic of a regional hospital in southern Taiwan. In addition, 28 healthy controls aged 65 years or older were recruited from the community. The cognitive performance of the study participants was assessed using the Cognitive Abilities Screening Instrument (CASI). A computer-administered simple reaction time (SRT) task and a flanker reaction time (FRT) task were administered to assess participants' cognitive function. A non-parametric Kruskal-Wallis test was performed to compare CASI scores, SRT, and FRT among the three groups. anova was also used to compare CASI scores, inverse-transformed SRT, and inverse-transformed FRT among the three groups, with adjustment for age and years of education. Additionally, Pearson's partial correlation coefficients were used to assess the association of CASI scores with inverse-transformed SRT, and inverse-transformed FRT within each of the three groups.

RESULTS

Significant differences in CASI scores, SRT, and FRT were found between the Alzheimer's disease group and the other two groups, either with or without adjustment for age or education. The reaction time of patients with Alzheimer's disease was significantly slower than the other two groups. Moreover, significant correlation between CASI and FRT was found in patients with MCI.

CONCLUSION

Altered performance in a speed task was observed in patients with MCI. The FRT task should further be explored for its role as a marker for cognitive decline in elderly individuals, particularly in those with MCI.

[Reliability and validity of the Japanese version of the AD8]

AIM

The AD8 is a brief, sensitive informant interview tool for detecting dementia. However, there are no reports of a Japanese version of the AD8. Our aim was to establish the reliability and validity of the AD8 for screening for dementia in older adults 75 years of age or older in Japan.

METHODS

We acquired the author's permission to translate the AD8 from English to Japanese. A total of 572 community residents 75 years of age or older living in Kurihara, Northern Japan agreed to participate in this study. Of these participants, 214 scored a Clinical Dementia Rating (CDR) of 0 (healthy), 289 scored a CDR of 0.5 (mild cognitive impairment) and 69 scored a CDR of 1 or above (dementia). Analysis 1. Reliability of the Japanese version of the AD8. Analysis 2. Validity of the AD8: Receiver operating characteristic (ROC) curve for nondemented (CDR 0+0.5) vs. demented (CDR 1 or above) individuals.

RESULTS

For the Japanese version of the AD8, the Cronbach' s coefficient alpha was 0.88 and the Guttman's split half method coefficient was 0.85. For the patients with CDR values of 0+0.5 vs. 1 or above, the area under the ROC curve was 0.89 (p<0.0001) and the cut-off score was 1/2, with a sensitivity of 88.4% and specificity of 68.4%.

CONCLUSIONS

We established the reliability and validity of the Japanese version of the AD8 for screening for dementia in older adults 75 years of age or older in the community.

[Correlates of Cognitive Impairment of Rheumatic Disease: Systematic Review and Meta-analysis]

PURPOSE

This study was conducted to synthesis the results of research on relationships of cognitive impairment with multi-dimensional correlates of rheumatic disease through a systematic literature review and meta-analysis.

METHODS

For the study purpose, 23 studies were selected through a systematic process of searching the literature.

RESULTS

The study results showed that among general characteristics, age and education were the variables having a significant relationship with cognitive impairment. Among health risk factors, obesity appeared to have a significant positive relationship with cognitive impairment. For past history, diabetes and hypertension were shown to have a significant positive relationship with cognitive impairment. It was noted also that aPL, one of the physiological factor, had significant association with cognitive impairment. None of the medication related factors had a significant relationship with cognitive impairment. Results showed that among disease related factors, disease activity had the highest relationship with cognitive impairment. Depression, among psychological factors, was the only variable having a significant relationship with cognitive impairment.

CONCLUSION

The findings indicate that the variables strongly impacting on cognitive impairment in rheumatic disease are depression and disease activity.

Prevalence and prognosis of prodromal Alzheimer's disease as assessed by magnetic resonance imaging and 18F-fluorodeoxyglucose-positron emission tomography in a community: reanalysis from the Osaki-Tajiri Project

BACKGROUND

Dubois et al. proposed the criteria for prodromal Alzheimer's disease (AD) to detect dementia in its very early stage. Because detection requires magnetic resonance imaging and (18) F-fluorodeoxyglucose-positron emission tomography (PET), the prevalence and prognosis have not been fully investigated.

METHODS

Our database included 346 healthy participants (Clinical Dementia Rating (CDR) 0), 119 with questionable dementia (CDR 0.5), and 32 dementia participants (CDR 1+) and was applied to investigate the prevalence of prodromal AD. Forty-four CDR 0.5 participants (37%) were randomly selected to undergo (18) F-fluorodeoxyglucose-PET. The same percentage was applied to select 128 CDR 0 and 12 CDR 1 + participants (total: n = 184) to calculate the prevalence. A neuroradiologist classified the PET images in a blinded manner based on the criteria of Silverman et al. Participants were considered to have prodromal AD if they exhibited 'parietal/temporal +/- frontal hypometabolism' (PET) with hippocampal atrophy (magnetic resonance imaging).

RESULTS

Eighteen CDR 0.5 participants (40.9%) met the criteria for prodromal AD, which was a prevalence rate of 9.8% among older adults aged ≥ 65 years. Thirteen prodromal AD participants (72%) converted to AD during the 5-year follow-up period.

DISCUSSION

The concept and criteria for prodromal AD are useful for predicting which subjects in a community will convert to AD.

Mild cognitive impairment: Profile of a cohort from a private sector memory clinic

BACKGROUND

Private hospital memory clinics might see a different clientele than university or academic institutes due to referral biases.

OBJECTIVE

To characterize the profile of patients with mild cognitive impairment (MCI) from a private sector memory clinic.

MATERIALS AND METHODS

MCI was diagnosed according to revised clinical criteria of Petersen et al. For a subset of patients with MCI medial temporal atrophy and cerebral small vessel disease (white matter lesions and lacunes) were rated on magnetic resonance imaging (MRI) scans and analyzed for their contribution towards cognitive impairment.

RESULTS

Subjects with MCI formed one-third (113/371) of this memory clinic sample from a private hospital. MCI could be effectively diagnosed and subtyped using a brief cognitive scale (Concise Cognitive Test (CONCOG)). The amnestic MCI (single and multiple domains) subtype comprised the majority of cases with MCI. In a subsample of 33 patients, lacunar infarcts were more common than white matter lesions and hippocampal atrophy and were inversely associated with verbal fluency.

CONCLUSIONS

MCI may be more commonly encountered in private hospital settings probably due to early referrals. It is possible to diagnose and subtype MCI using a brief cognitive instrument such as the CONCOG. In this sample, lacunar infarcts were more commonly encountered than medial temporal atrophy in such patients.

Clinical utility of the functional independence measure for assessment of patients with Alzheimer's disease and vascular dementia

AIM

The aim of this study was to investigate the clinical utility of the Functional Independence Measure (FIM), and especially FIM-Cognition (FIM-C) scores, in patients with Alzheimer's disease (AD) and vascular dementia (VaD), and to determine the influence of behavioural and psychological symptoms of dementia (BPSD) on FIM-C scores.

METHODS

This was a cross-sectional survey of 37 AD and 40 VaD patients. Cognitive function was assessed with the Cognitive Abilities Screening Instrument. Activities of daily living were evaluated with the FIM and the Barthel Index. BPSD were assessed with the Behavioural Pathology in Alzheimer's Disease Frequency Weighted Severity Scale.

RESULTS

For both groups, Spearman's correlations were found between FIM-Motor and Barthel Index scores and between FIM-C and Mini Mental State Examination scores. Each FIM-C subscore was correlated with Cognitive Abilities Screening Instrument scores in both groups, except for the FIM-C Social interaction subscore in VaD. VaD patients showing Activity Disturbance and Aggressiveness on the Behavioural Pathology in Alzheimer's Disease Frequency Weighted Severity Scale had significantly lower FIM-C Memory and Social interaction subscores than those without BPSD.

CONCLUSION

The results suggest that the FIM-Motor and FIM-C scales are useful measures of physical and cognitive disabilities in patients with AD and VaD. The FIM-C profile of AD may reflect global cognitive function, while that of VaD may be more influenced by BPSD.

Reliability and Validity of the Clinical Dementia Rating for Community-Living Elderly Subjects without an Informant

Background

The Clinical Dementia Rating (CDR) scale is widely used to assess cognitive impairment in Alzheimer's disease. It requires collateral information from a reliable informant who is not available in many instances. We adapted the original CDR scale for use with elderly subjects without an informant (CDR-NI) and evaluated its reliability and validity for assessing mild cognitive impairment (MCI) and dementia among community-dwelling elderly subjects.

Method

At two consecutive visits 1 week apart, nurses trained in CDR assessment interviewed, observed and rated cognitive and functional performance according to a protocol in 90 elderly subjects with suboptimal cognitive performance [Mini-Mental State Examination (MMSE) <26 and/or Montreal Cognitive Assessment (MOCA) <26] and without informants according to a protocol. CDR domains and global scores were assigned after the second visit based upon corroborative information from the subjects' responses to questions, role-play, and observed performance in specifically assigned tasks at home and within the community.

Results

The CDR-NI scores (0, 0.5, 1) showed good internal consistency (Crohnbach's α 0.83-0.84), inter-rater reliability (κ 0.77-1.00 for six domains and 0.95 for global rating) and test-retest reliability (κ 0.75-1.00 for six domains and 0.80 for global rating), good agreement (κ 0.79) with the clinical assessment status of MCI (n = 37) and dementia (n = 4) and significant differences in the mean scores for MMSE, MOCA and Instrumental Activities of Daily Living (ANOVA global p < 0.001).

Conclusion

Owing to the protocol of the interviews, assessments and structured observations gathered during the two visits, CDR-NI provides valid and reliable assessment of MCI and dementia in community-living elderly subjects without an informant.

Vascular dementia with left thalamic infarction: neuropsychological and behavioral implications suggested by involvement of the thalamic nucleus and the remote effect on cerebral cortex. The Osaki-Tajiri project

Vascular dementia (VaD) is a condition whereby decreased cerebral perfusion causes cognitive deterioration. We hypothesized that lesions of the anterior nucleus (AN) including the mammillo-thalamic tract cause a decline in the recollection of past episodes/events, and that the left thalamic infarction can cause frontal dysfunction through the "diaschisis." We investigated 18 VaD cases with only left thalamic infarction. (99m)Tc-ECD single photon emission computed tomography (SPECT) was used to assess regional cerebral blood flow (CBF). To test the first hypothesis, the scores on the Cognitive Abilities Screening Instrument (CASI) domain Recent memory or the rating on the Clinical Dementia Rating (CDR) domain Memory were analyzed. To test the second hypothesis, we selected the six regions of interest that correlated with the two measures, i.e., word fluency and/or depressive state, as assessed with the Geriatric Depression Scale (GDS). We found that all patients had amnesia, especially in the AN group, six of the eight patients had scores of 1+ on the CDR Memory scale, and all but one disclosed the CASI domain Recent memory impairment. There were significant correlations between the left anterior cingulate CBF and word fluency scores, and between the right rectal gyrus CBF and GDS scores. We suggest that these observations are due to a remote effect of the thalamic lesion.

Trends in the prevalence of dementia in Japan

There is a paucity of data regarding trends in dementia and its subtype prevalence in Japan. Our aims in the current paper are to: (1) summarize epidemiological studies of dementia in Japan including relevant details of study protocol and diagnostic criteria, (2) compare the age-specific prevalence of all-cause dementia among studies, and (3) assess the trends in Alzheimer's disease (AD) versus vascular dementia (VaD) over time. We reviewed diagnostic criteria, all-cause dementia prevalence, and the AD/VaD ratio from 8 large population studies of dementia in Japan. Compared with the Okinawa 1992 study, studies conducted in 1994, 1998, 2005, and 2008 had a higher prevalence of all-cause dementia using Poisson regression models, after controlling for age and sex. In contrast to the US and some European countries, all-cause dementia prevalence is increasing in Japan. The prevalence of AD as opposed to VaD seems to be increasing over time, but large variability in diagnostic criteria, possible regional variability, and differences in prevalence of subtypes of dementia between men and women make it difficult to draw a conclusion about this trend at the national level. Further studies, for example, comparing the population attributable risk of vascular diseases to the prevalence and incidence of dementia could help to clarify the regional variations in etiological subtypes.

Mild cognitive impairment: disparity of incidence and prevalence estimates

BACKGROUND

The purpose of conducting this study was to identify areas of concordance and sources of variation for the published rates of prevalence and incidence associated with various definitions for mild cognitive impairment (MCI).

METHODS

The study used systematic review of studies published in English since 1984. Studies were identified by searching MEDLINE and EMBASE databases. Population-based observational studies of incidence or prevalence of MCI and related terms were eligible for inclusion.

RESULTS

A total of 3,705 citations were identified, and 42 were accepted for inclusion; 35 included data on prevalence and 13 on incidence. The following four terms predominated: age-associated memory impairment (AAMI); cognitive impairment no dementia (CIND); MCI; and amnestic MCI (aMCI). Within each term, the operational definition varied. Substantial variation was observed for both incidence (MCI: 21.5-71.3; aMCI: 8.5-25.9 per 1,000 person-years) and prevalence of each definition of cognitive impairment (AAMI 3.6%-38.4%; CIND 5.1%-35.9%; MCI 3%-42%; aMCI 0.5%-31.9%). CIND and MCI showed increasing prevalence among older age groups, whereas age-specific rates of aMCI were lower and without any apparent age relationship.

CONCLUSIONS

Prevalence and incidence estimates associated with MCI vary greatly both between definitions and within a definition across the 42 publications. These wide differences pose a significant challenge to our understanding of the social burden of this disease. Enhancement and standardization of operational definitions of the subtypes of cognitive impairment could improve estimates of disease burden and provide a mechanism to assist in the identification of individuals at risk for future Alzheimer's disease and other dementias.

Impaired memory and executive function associated with decreased medial temporal and prefrontal blood flow in Clinical Dementia Rating 0.5 status: the Osaki-Tajiri project

AIM

The Clinical Dementia Rating (CDR) is an assessment of dementia severity based on observations of activities of daily living, and a CDR of 0.5 (CDR 0.5) represents questionable dementia. A combination of the Cognitive Abilities Screening Instrument (CASI) and the Trail Making Test (TMT) scores discriminated CDR 0.5 subjects from healthy participants with a high degree of accuracy. We investigated the neurological background of CDR 0.5 subjects by correlating CASI and TMT scores with regional cerebral blood flow (rCBF) as measured by single photon emission computed tomography (SPECT).

METHODS

From a community-based cohort, 22 CDR 0.5 participants were recruited. CASI and TMT scores, rCBF measure using [(123) I]-N-isopropyl-p-iodoamphetamine and SPECT were obtained. We evaluated the relationships between the CASI domain scores, between TMT scores and rCBF in a regions-of-interest-based analysis, and voxel-based analysis using Statistical Parametric Mapping 5 software.

RESULTS

We found that lower rCBF in the left medial temporal cortex correlated with a decreased CASI domain recent memory score both in the regions-of-interest and statistical parametric mapping analysis. In both the regions-of-interest and statistical parametric mapping analysis, the rCBF in the left prefrontal cortex correlated with CASI domain remote memory and mental manipulation and concentration.

CONCLUSIONS

Our results indicate that some CDR 0.5 subjects have functional impairments in the medial temporal lobe as well as in the prefrontal cortex, as reflected in the cognitive decline measured by CASI and TMT.

Prevalence, distribution, and impact of mild cognitive impairment in Latin America, China, and India: a 10/66 population-based study

BACKGROUND

Rapid demographic ageing is a growing public health issue in many low- and middle-income countries (LAMICs). Mild cognitive impairment (MCI) is a construct frequently used to define groups of people who may be at risk of developing dementia, crucial for targeting preventative interventions. However, little is known about the prevalence or impact of MCI in LAMIC settings.

METHODS AND FINDINGS

Data were analysed from cross-sectional surveys established by the 10/66 Dementia Research Group and carried out in Cuba, Dominican Republic, Peru, Mexico, Venezuela, Puerto Rico, China, and India on 15,376 individuals aged 65+ without dementia. Standardised assessments of mental and physical health, and cognitive function were carried out including informant interviews. An algorithm was developed to define Mayo Clinic amnestic MCI (aMCI). Disability (12-item World Health Organization disability assessment schedule [WHODAS]) and informant-reported neuropsychiatric symptoms (neuropsychiatric inventory [NPI-Q]) were measured. After adjustment, aMCI was associated with disability, anxiety, apathy, and irritability (but not depression); between-country heterogeneity in these associations was only significant for disability. The crude prevalence of aMCI ranged from 0.8% in China to 4.3% in India. Country differences changed little (range 0.6%-4.6%) after standardization for age, gender, and education level. In pooled estimates, aMCI was modestly associated with male gender and fewer assets but was not associated with age or education. There was no significant between-country variation in these demographic associations.

CONCLUSIONS

An algorithm-derived diagnosis of aMCI showed few sociodemographic associations but was consistently associated with higher disability and neuropsychiatric symptoms in addition to showing substantial variation in prevalence across LAMIC populations. Longitudinal data are needed to confirm findings-in particular, to investigate the predictive validity of aMCI in these settings and risk/protective factors for progression to dementia; however, the large number affected has important implications in these rapidly ageing settings.

Prevalence of Dementia and Mild Cognitive Impairment in the Rural Island Town of Ama-cho, Japan

AIMS

In order to determine the prevalence of dementia and mild cognitive impairment (MCI), we conducted a population-based study in Japan.

METHODS

Participants included 924 subjects aged 65 years or older who resided in the town of Ama-cho. In phase 1 of the study, the Mini-Mental State Examination and Clinical Dementia Rating were administered for screening purposes. In phase 2 of the study, the subjects who screened positive were further examined by neurologists. Dementia and MCI were diagnosed by means of DSM-IV and International Working Group on MCI criteria, respectively.

RESULTS

By the prevalence date of June 1, 2010, 24 subjects had deceased or lived outside the town. In total, 723 of the remaining 900 subjects received a phase 1 test. In phase 2, 98 subjects were diagnosed with amnestic MCI, 113 subjects with non-amnestic MCI, and 82 subjects with dementia. Of the subjects who did not receive the phase 1 test, 66 subjects were diagnosed as having dementia according to data from their town medical card or the Long-term Care Insurance System. The crude prevalence of amnestic MCI, non-amnestic MCI, and dementia were 10.9, 12.6, and 16.4%, respectively.

CONCLUSION

Consistent with the striking increase in the number of elderly individuals, we report higher prevalence of MCI and dementia in Japan than previously described.

Cognitive impairment in nondemented oldest-old: prevalence and relationship to cardiovascular risk factors

OBJECTIVE

To determine the prevalence and types of cognitive impairment in a sample of nondemented participants aged ≥90 (the oldest-old) and to examine the relationships between cognitive impairment and cardiovascular risk factors.

PARTICIPANTS

The participants were 420 nondemented individuals from The 90+ Study, a study of aging and dementia in the oldest-old. These participants were categorized into four nonoverlapping groups: normal cognition, amnestic mild cognitive impairment (aMCI), nonamnestic MCI (naMCI), and other cognitive impairment (OCI). History of cardiovascular risk factors was assessed through self-report.

RESULTS

The overall prevalence of cognitive impairment in nondemented participants was 34.0% (95% CI: 29.5-38.5). The prevalence of OCI was highest (17.4%; 95% CI: 13.9-21.4), followed by aMCI (8.3%; 95% CI: 5.9-11.4) and naMCI (8.3%; 95% CI: 5.9-11.4). Normal cognition was present in 66.0% (95% CI: 61.2-70.5) of participants. History of hypertension and stroke were the only risk factors that varied between the groups, occurring more frequently in participants with naMCI (χ(2) = 3.82; P < .05) and OCI (χ(2) = 5.51; P < .05).

CONCLUSIONS

This study found a high prevalence of cognitive impairment in a sample of nondemented oldest-old. We did not find a strong relationship between cardiovascular risk factors and the cognitive impairment groups, other than between hypertension and naMCI and stroke and OCI. Future studies comparing the incidence of dementia in these groups will ultimately determine their predictive utility in the oldest-old.

Combined evaluation of FDG-PET and MRI improves detection and differentiation of dementia

Introduction

Various biomarkers have been reported in recent literature regarding imaging abnormalities in different types of dementia. These biomarkers have helped to significantly improve early detection and also differentiation of various dementia syndromes. In this study, we systematically applied whole-brain and region-of-interest (ROI) based support vector machine classification separately and on combined information from different imaging modalities to improve the detection and differentiation of different types of dementia.

Methods

Patients with clinically diagnosed Alzheimer's disease (AD: n = 21), with frontotemporal lobar degeneration (FTLD: n = 14) and control subjects (n = 13) underwent both [F18]fluorodeoxyglucose positron emission tomography (FDG-PET) scanning and magnetic resonance imaging (MRI), together with clinical and behavioral assessment. FDG-PET and MRI data were commonly processed to get a precise overlap of all regions in both modalities. Support vector machine classification was applied with varying parameters separately for both modalities and to combined information obtained from MR and FDG-PET images. ROIs were extracted from comprehensive systematic and quantitative meta-analyses investigating both disorders.

Results

Using single-modality whole-brain and ROI information FDG-PET provided highest accuracy rates for both, detection and differentiation of AD and FTLD compared to structural information from MRI. The ROI-based multimodal classification, combining FDG-PET and MRI information, was highly superior to the unimodal approach and to the whole-brain pattern classification. With this method, accuracy rate of up to 92% for the differentiation of the three groups and an accuracy of 94% for the differentiation of AD and FTLD patients was obtained.

Conclusion

Accuracy rate obtained using combined information from both imaging modalities is the highest reported up to now for differentiation of both types of dementia. Our results indicate a substantial gain in accuracy using combined FDG-PET and MRI information and suggest the incorporation of such approaches to clinical diagnosis and to differential diagnostic procedures of neurodegenerative disorders.

The identification of attention complaints in the general population and their effect on quality of life

OBJECTIVE

To provide more insight into subjective attention complaints in a healthy adult and elderly population and how these affect Quality of Life (QoL).

METHOD

A group of 1,550 healthy Dutch participants complete a postal questionnaire including items from the Maastricht Attention and Memory Checklist (MAC). The impact of attention complaints on QoL is investigated in a subsample of 499 participants.

RESULTS

Factor analysis (N = 1,550) reveals two factors: Attention and Memory. Attention complaints are related to depressed mood, anxiety, vitality, and sleep problems that can have serious consequences for daily life functioning and QoL (n = 499). Memory complaints are related to other aspects of health, such as pain and changes in health.

CONCLUSION

Attention complaints in the healthy population are common and related to depression, anxiety, and sleep and several aspects of QoL, such as problems with social functioning, emotional problems, and vitality.

Relationship of tooth loss to mild memory impairment and cognitive impairment: findings from the Fujiwara-kyo study

Background

This cross-sectional study investigated the relationship between the number of remaining teeth to mild memory impairment (MMI), which is a preclinical stage of dementia, and to cognitive impairment.

Methods

The subjects were aged 65 years or older and were grouped according to their score for the Mini-Mental State Examination (MMSE), the three-word delayed recall test in the MMSE, and the Geriatric Depression Scale into the control group (n = 3,696), the MMI group (n = 121), and the low MMSE score (23 or lower) group (n = 214). We collected data on the number of remaining teeth, the length of the edentulous period, health-related lifestyle, medical history, blood pressure, height, and body weight. Fasting venous blood samples were also obtained.

Results

Multiple logistic regression analysis, adjusted for depressive symptoms, age, sex, length of education, and other explanatory variables, revealed that the odds ratios of 0-10 remaining teeth to 22-32 remaining teeth were 1.679 (95% CI 1.073-2.627) for MMI and 2.177 (95% CI 1.510-3.140) for a low MMSE score. A significant relationship was also found between the length of the edentulous period and the risk of a low MMSE score (odds ratio 3.102, 95% CI 1.432-6.720) (15 years or more/less than 15 years).

Conclusions

Our findings suggest that tooth loss is associated with cognitive function.

Risk factors for incident mild cognitive impairment--results from the German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe)

OBJECTIVES

To provide age- and gender-specific incidence rates of MCI among elderly general practitioner (GP) patients (75+ years) and to identify risk factors for incident MCI.

METHOD

Data were derived from the longitudinal German Study on Ageing, Cognition and Dementia in Primary Care Patients (AgeCoDe). Incidence was calculated according to the 'person-years-at-risk' method. Risk factors were analysed using multivariate logistic regression models.

RESULTS

During the 3-year follow-up period, 350 (15.0%) of the 2331 patients whose data were included in the calculation of incidence developed MCI [person-years (PY) = 6198.20]. The overall incidence of MCI was 56.5 (95% confidence interval = 50.7-62.7) per 1000 PY. Older age, vascular diseases, the apoE epsilon4 allele and subjective memory complaints were identified as significant risk factors for future MCI.

CONCLUSION

Mild cognitive impairment is frequent in older GP patients. Subjective memory complaints predict incident MCI. Especially vascular risk factors provide the opportunity of preventive approaches.

Identification of high-risk dementia cohorts in a community sample of Japanese elderly

AIM

The aim of this study was to develop a simple diagnostic procedure for subjects at high risk of developing dementia using the Clinical Dementia Rating (CDR), which is applicable to community-based activities.

METHODS

This study divided 252 community-dwelling elderly with a CDR score of 0.5 into two groups based on the presence or absence of cognitive decline within the previous one year of the baseline, as assessed by a semi-structured interview. One hundred subjects were in the 'previously progressive group' (PP group) and 152 subjects were in the 'previously stable group' (PS group). After 6 years of observation, a total of 111 subjects were assessed in the follow-up investigation.

RESULTS

Among the 39 subjects from the PP group (82.9 +/- 6.8 years old, 11 male, 28 female), 34 developed dementia (87%). Among the 72 subjects from the PS group (84.4 +/- 6.0 years old, 22 male, 50 female), 44 developed dementia (61%). The relative risk of developing dementia for the PP group versus the PS group was 1.43. The rate of conversion to dementia was 12.9% per 100 person-years in the PP group, and 9.8% in the PS group. In the PP group, the Mini-Mental State Examination score was significantly lower and the CDR score was significantly higher than in the PS group.

CONCLUSION

Although there have been many attempts to identify subjects with high risk of dementia, this preliminary study suggests that information about temporal changes in cognitive function is useful when performing community-based surveys.

Health economic effect of donepezil treatment for CDR 0.5 converters to Alzheimer's disease as shown by the Markov model

The previous health economic simulation of donepezil based on the Markov model revealed the treatment for mild to moderate stage of Alzheimer disease (AD) to be cost-effective. Our aim was to examine the economic effect of donepezil treatment for mild cognitive impairment, from which about 15% convert to dementia per year. We constructed a new Markov model using three simulations. Namely, Simulation A hypothesized that mild AD patients, i.e., Clinical Dementia Rating (CDR) 1, received donepezil as in the previous study. Simulation B hypothesized that all CDR 0.5 subjects received donepezil, and Simulation C considered that only the CDR 0.5 converters to dementia received donepezil. We calculated the models as follows: Simulation B, supposes that the annual transition probabilities were reduced even from 15% to 10% by donepezil, however, the drug had a negative economic effect. By contrast, in Simulation C, the annual transition probability was reduced from only 15% to 12% by donepezil, there was a positive economic effect. Since it is necessary to reduce the annual transition probability from 15% to 12% in order to manifest a concomitant economic benefit, we consider that early detection of CDR 0.5 converters in the community is important for health policy planning.

Identifying mild cognitive impairment at baseline in the Ginkgo Evaluation of Memory (GEM) study

OBJECTIVES

To identify, characterize and compare the frequency of mild cognitive impairment (MCI) subtypes at baseline in a large, late-life cohort (n = 3063) recruited into a dementia prevention trial.

METHOD

A retrospective, data-algorithmic approach was used to classify participants as cognitively normal or MCI with corresponding subtype (e.g. amnestic vs. non-amnestic, single domain vs. multiple domain) based on a comprehensive battery of neuropsychological test scores, with and without Clinical Dementia Rating (CDR) global score included in the algorithm.

RESULTS

Overall, 15.7% of cases (n = 480) were classified as MCI. Amnestic MCI was characterized as unilateral memory impairment (i.e. only verbal or only visual memory impaired) or bilateral memory impairment (i.e. both verbal and visual memory impaired). All forms of amnestic MCI were almost twice as frequent as non-amnestic MCI (10.0% vs. 5.7%). Removing the CDR = 0.5 ('questionable dementia') criterion resulted in a near doubling of the overall MCI frequency to 28.1%.

CONCLUSION

Combining CDR and cognitive test data to classify participants as MCI resulted in overall MCI and amnestic MCI frequencies consistent with other large community-based studies, most of which relied on the 'gold standard' of individual case review and diagnostic consensus. The present data-driven approach may prove to be an effective alternative for use in future large-scale dementia prevention trials.

Decreased cortical glucose metabolism in converters from CDR 0.5 to Alzheimer's disease in a community: the Osaki-Tajiri Project

BACKGROUND

Several follow-up [18F]fluorodeoxy glucose (FDG)-positron emission tomography (PET) studies have been performed in patients with mild cognitive impairment, but none have examined subjects with a Clinical Dementia Rating (CDR) of 0.5. Therefore, we used FDG-PET to investigate whether baseline glucose metabolism (CMRglc) in CDR 0.5 converters to dementia showed changes consistent with early Alzheimer's disease (AD).

METHODS

Based on our earlier study, which we refer to as Prevalence Study 1998, we were able to examine 14 CDR 0, 42 CDR 0.5, and 12 AD subjects with PET and follow these subjects for five years. Baseline neuropsychological and CMRglc values were compared among groups of CDR 0, CDR 0.5/converters, CDR 0.5/non-converters, and AD subjects.

RESULTS

All CDR 0 subjects were reassessed as CDR 0 after the five-year period. For CDR 0.5 subjects, 20 had converted to AD and 22 remained as CDR 0.5. In cognitive tests, CDR 0.5/converters showed significantly deteriorated recent memory function compared with CDR 0.5/non-converters at the baseline evaluation. Most brain areas showed decreased CMRglc in AD patients. CDR 0.5/converters had a significantly lower baseline CMRglc in the right cingulate, left inferior parietal and left temporal gyrus compared with CDR 0.5/non-converters.

CONCLUSIONS

Our findings suggest that CDR 0.5/converters have a baseline metabolic decline in areas that might be specific to AD.

Normative data on Benton Visual Form Discrimination Test for older adults and impaired scores in Clinical Dementia Rating 0.5 participants: community-based study. The Osaki-Tajiri Project

AIMS

The Benton Visual Form Discrimination test (VFD) is one of the non-verbal tests to assess the capacity for complex visual form discrimination. The purposes of the present study were to investigate the effects of age and education level of the VFD in healthy elderly subjects, rigorously excluding participants with Clinical Dementia Rating (CDR) 0.5, and the characteristics of VFD patterns in CDR 0.5 participants.

METHODS

The 597 participants included CDR 0 (healthy elderly, n = 405), CDR 0.5 (mild cognitive impairment, n = 161), and CDR 1 and 2 (dementia, n = 31). The VFD, Digit Forwards, Digit Backwards and Rey-Osterrieth Complex Figure Test (RCFT) copying were used for neuropsychological assessment.

RESULTS

There were significant effects of age and education level on the VFD in healthy participants, and the CDR 0.5 group had a lower score on the VFD than the healthy group. Low performance on the VFD was associated with Digit Backward and RCFT copying in both healthy and CDR 0.5 participants.

CONCLUSIONS

CDR 0.5 participants exhibit deficits of visual form discrimination related to attention, visual construction and organization.

Language performance in Alzheimer's disease and mild cognitive impairment: a comparative review

Mild cognitive impairment (MCI) manifests as memory impairment in the absence of dementia and progresses to Alzheimer's disease (AD) at a rate of around 15% per annum, versus 1-2% in the general population. It thus constitutes a primary target for investigation of early markers of AD. Language deficits occur early in AD, and performance on verbal tasks is an important diagnostic criterion for both AD and MCI. We review language performance in MCI, compare these findings to those seen in AD, and identify the primary issues in understanding language performance in MCI and selecting tasks with diagnostic and prognostic value.

TDP-43 protein in plasma may index TDP-43 brain pathology in Alzheimer's disease and frontotemporal lobar degeneration

Autopsy studies have shown that about 55% of patients with frontotemporal lobar degeneration (FTLD) and 25% of patients with Alzheimer’s disease (AD) harbour TDP-43 immunoreactive pathological changes in their brains. Using ELISA, we investigated whether we could detect the presence, or increased amounts, of TDP-43 in plasma of patients with FTLD and AD compared to normal control subjects. We detected elevated levels of TDP-43 protein in plasma of 46% patients with FTLD with clinical frontotemporal dementia (FTD) and 22% patients with AD, compared to 8% of control subjects. The proportions of patients with FTD and AD showing raised plasma TDP-43 levels correspond closely to those proportions known from autopsy studies to contain TDP-43 pathological changes in their brains. Raised TDP-43 plasma levels may thereby index TDP-43 pathology within the brain. Plasma TDP-43 levels may be a biomarker that can provide a laboratory test capable of identifying the presence of TDP-43 brain pathology in neurodegenerative disease during life. It may help to distinguish those cases of FTLD with ubiquitin/TDP-43 pathology in their brains from those with tauopathy. As a predictive test, plasma TDP-43 level may have great practical value in directing therapeutic strategies aimed at preventing or removing tau or TDP-43 pathological changes from the brain in FTLD and AD.

A 2-year follow-up of 233 very mild (CDR 0.5) Alzheimer's disease patients (REAL.FR cohort)

OBJECTIVES

Making an early diagnosis of Alzheimer's Disease (AD) is becoming increasingly important. The Clinical Dementia Rating scale (CDR), a semi-structured interview with patient and caregiver, is a global rating scale designed for use in staging dementia. The primary objective of our study was to examine the evolution of AD in individuals with very mild AD (CDR 0.5) across a 2-year follow up.

METHODS

A cohort of AD patients (n=682) living in the community were followed during 2 years in 16 centres of the French AD network. Each subject underwent extensive medical examination including the MMSE and CDR every 6 months.

RESULTS

Two hundred and thirty-three AD patients were rated CDR 0.5 at baseline (mean MMSE score: 23.15+/-2.57). They were younger and reported an average duration of symptoms of approximately 0.8 years less than patients with CDR >or= 1.During the 2-year follow-up, none of the AD CDR 0.5 subjects improved; 65% of them showed an increase in the CDR score. The rate of cognitive decline was similar between the AD CDR 0.5 and CDR >or= 1 groups. The ADL decline was more significant in patients with CDR >or= 1 at inclusion.

CONCLUSIONS

It is certainly possible to identify AD at a very early stage focusing on intra individual change in cognitive and functional impairment. Criteria with a high sensitivity and specificity for detecting AD at an early stage will help to further develop effective pharmacological and behavioural interventions for delaying the onset and progression of the disease.

Sensitivity and specificity of the clock drawing test, incorporating Rouleau scoring system, as a screening instrument for questionable and mild dementia: Scale development

OBJECTIVE

The objective of this study was to validate the Rouleau scoring system for the Clock Drawing Test (CDT) in northern Taiwan, a non-English speaking area, to increase its generalization by detecting subjects with questionable dementia (QD) from normal controls (NC) and subjects with mild dementia (AD). The system consists of two parts: a 10-point scoring and error types. A cross-sectional design was used. One hundred and sixteen subjects were recruited from a memory disorder clinic (n=40 NC; n=34 QD; n=42 AD). Reliability and validity were estimated, the predictive accuracy was calculated using the receiver operating characteristic (ROC) curve analysis, and the error types were counted.

RESULTS

The results indicated that most of the error types committed were conceptual deficiencies and graphic difficulties; more errors were found in the command condition (CDT-command) than in the copy condition (CDT-copy); 15% of the subjects drew smaller clock circles in CDT-command, which did not relate to any other errors. No small clock was found in CDT-copy because a pre-dawn circle was provided. The inter-rater reliability of the Rouleau scoring system was .87 and .83 for the CDT-command and -copy, respectively, while the discriminate accuracy of the scoring system was relatively low in detecting QD vs. NC, QD vs. AD, but somewhat better in distinguishing AD vs. NC groups for the areas under the ROC curves was equal to .72 for the CDT-command, and .73 for the CDT-copy. Visuospatial construction and executive functioning explained the largest score variance of the CDT in both conditions, while depressive symptoms were not significantly associated with the CDT performance.

CONCLUSION

The CDT using the Rouleau scoring system has been validated in mild AD subjects in Taiwan; however, to screen for QD sufferers, alternative scoring systems emphasizing hands or combining CDT with different neuropsychological tests such as the Clinical Abilities Screening Instrument are recommended.

Validity of the clinical dementia rating scale for the detection and staging of dementia in Brazilian patients

The aim of this study was to determine the diagnostic value and agreement analyses between Clinical Dementia Rating (CDR) and dementia diagnostic criteria (gold standard), Blessed Dementia Rating scale (BDRS), and Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised (DSM III-R) criteria for severity. In a sample of 343 Southern Brazilian participants, CDR was consecutively assessed in 295 dementia patients (Alzheimer disease, vascular dementia, and questionable) and 48 healthy elderly. The National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria for probable Alzheimer disease and the National Institute of Neurological Disorders and Stroke and Association Internationale pour la Recherché et l'Enseignement en Neurosciences (NINDS-AIREN) for probable vascular dementia were the gold standard. A battery of cognitive tests and the Mini Mental State Examination (as a screening test at study entry) were also applied. Sensitivity and specificity were obtained through contingency tables. Validity and reliability were measured through kappa coefficient, Kendall b, and percent agreement. CDR agreement among raters was demonstrated by percent agreement. Agreement to gold standard was good (kappa=0.75), as well as to the Blessed scale (kappa=0.73), and excellent to the DSM III-R (kappa=0.78). CDR detection of dementia among healthy elderly or questionable dementia was 86% and 80% sensitive, respectively, and 100% specific for both settings. In conclusion, agreement of CDR global score with the gold standard was good, and diagnostic values were high.

Cognitive impairment in later life in patients with early-onset bipolar disorder

OBJECTIVES

Cognitive impairment may interfere with psychosocial functioning in bipolar disorder (BD). There is limited information regarding the cognitive function of elderly bipolar patients with onset at a young age. The present study aimed to investigate the frequency and the determinants of cognitive impairment in elderly early-onset bipolar patients.

METHODS

Using the Clock-drawing Test (CDT), the Mini Mental State Examination (MMSE), and the Cognitive Abilities Screening Instrument (CASI), we examined euthymic patients with bipolar I disorder in Taiwan, aged 60 years and older. Clinical data were obtained by reviewing medical records and personal interviews with patients and their family members. The onset of BD prior to the age of 40 years is defined as 'early-onset'.

RESULTS

Of the 52 early-onset patients, 42.3% were determined to have cognitive impairment by exhibiting either abnormal CDT or education-adjusted MMSE scores. In a multiple regression model, years of education and the age at the last manic/hypomanic (but not depressive) episode accounted for the greatest variance in both MMSE and CASI scores. While educational level and the age at the last manic/hypomanic episode were not considered in the regression model, onset with depressive syndrome and current age explained 21.5% of the variance in MMSE scores. Age at the first depressive episode, the first manic episode before the age of 40 years, and comorbid diabetes accounted for 16.7% of the variance in CASI scores.

CONCLUSIONS

There appeared to be a sizable proportion of elderly early-onset bipolar patients having cognitive impairment. It is suggested that clinical manifestation of first-onset affective episode and impact of medical comorbidity affect the cognition of early-onset BD in later life.

Alzheimer's patients do not show left unilateral spatial neglect but exhibit peripheral inattention and simplification

The Rey-Osterrieth Complex Figure Test (RCFT) is widely used to measure visuoperceptual and visuoconstructional skills, while the Line Bisection (LB) test is commonly employed to assess unilateral spatial neglect (USN). Previous studies have suggested that Alzheimer’s disease (AD) patients may suffer from left USN.

[An overview and prospect of demented outpatient care in a department of geriatric medicine: report based on statistical review of the memory clinic at the geriatric outpatient unit of the Nagoya University Hospital]

AIM

Although there are many reports regarding the status of memory clinics in Japan, most are from the clinical departments of psychiatry or neurology, and there are few from the geriatric outpatient clinics. This study aimed to review the status of the memory clinic at the geriatric outpatient unit of a university hospital and also to compare the results with other reports.

METHODS

Patient records of the memory clinic at the geriatric outpatient unit of the Nagoya University Hospital between January 2000 and June 2006, which included clinical information and neuropsychological profiles were extensively reviewed for statistical analyses. Of the patients who first visited the memory clinic between January 2004 and June 2006, prior written consent are obtained from 232 outpatients, among which 223 individuals who had intact sets of data were subjected to detailed analyses.

RESULTS

During the period investigated, we had a total of 778 visits by 577 patients. The characteristics of patients were: age: 74.5+/-8.3 years; MMSE: 23.8+/-4.7; education year: 10.7+/-2.9. Clinical profiles of the patients who visited during the most recent 2.5 years were as follow: cognitively normal, 8.1%; dementia of Alzheimer's type, 45.3%; vascular type, 5.4%; mixed type, 2.2%; frontotemporal dementia, 3.1%; mild cognitive impairment, 15.7%, and others.

CONCLUSION

Compared with previous reports from other institutions, we observed that the visitors to our geriatric memory clinic had a relatively higher educational background with earlier stages of dementing disorders, which also included pre-clinical cognitive impairment.

Incidence of dementia and associated risk factors in Japan: The Osaki-Tajiri Project

The incidence of dementia and risk factors has not been fully investigated in Japan. Following a prevalence study in 1998, we investigated the incidence and associated factors in the same population in 2003 and 2005. Randomly selected 771 residents in Tajiri were targeted. The final participants included 204 (65.2%) healthy older adults (Clinical Dementia Rating, CDR 0) and 335 (73.1%) people with questionable dementia (CDR 0.5). We analyzed the incidence of dementia and dementing diseases, and possible risk factors. The risk factors included demographics, lifestyle-related factors, vascular risk factors, cognitive functions, and MRI findings. Overall, 3.9% of the CDR 0 and 37.0% of the CDR 0.5 participants developed dementia during the 5-year period, whereas 40.2% of the CDR 0.5 participants developed dementia during the 7-year period. Older adults had a higher incidence. Higher CDR Box scores had a higher incidence. Of the dementing diseases, 60.8% of participants developed Alzheimer' disease (AD), followed by vascular dementia (VaD), 17.9%. Logistic regression analyses showed that age, MMSE, cognitive functions such as recent memory, and generalized atrophy were significant predictors of progression to AD. Similarly, predictive factors for progression to VaD were age, MMSE, cognitive functions such as frontal function, and white matter lesions and cerebrovascular diseases. A comprehensive system including CDR, cognitive tests, and MRI, is recommended in community-based health policy planning.