Subtypes of dementia: a study from a memory clinic in India

Comprehensive Analysis of Dementia Types and Risk Factors: A Study From a Tertiary Care Center in India

Background and objective Dementia is a prevalent clinical syndrome characterized by memory impairment and cognitive dysfunction. Its global burden is expected to rise significantly, particularly in low- and middle-income countries. Understanding the spectrum of dementia types and associated risk factors is crucial for effective management. This study aims to elucidate the demographic profiles, clinical types, and risk factors of newly diagnosed dementia cases at a tertiary care hospital in India. Methods and materials A cross-sectional, hospital-based observational study was conducted on 81 patients at the Department of Medicine, Dr. D. Y. Patil Medical College, Hospital, and Research Centre, Pimpri, Pune, from February 2022 to January 2024. Ethical approval was obtained, and written consent was obtained from participants. Clinical diagnosis was based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria, supported by cognitive assessment tools and laboratory/radiological investigations. Inclusion criteria encompassed individuals aged 18 years or older, presenting with clinical symptoms suggestive of dementia, having a Mini-Mental State Examination (MMSE) score of less than 24 and Montreal Cognitive Assessment (MoCA) score of less than 25, according to DSM-V criteria for dementia. Exclusion criteria included individuals with a history of head trauma or those below 18 years of age. Results Of the 81 participants, the majority (74.1%) were over 60 years old, with females comprising 59.3% of the sample. Alzheimer's disease was the most prevalent dementia subtype (34.5%), followed by vascular dementia (19.7%) and mixed dementia (13.5%). Other causes included Lewy body dementia (2.46%), Parkinson's dementia (4.9%), frontotemporal dementia (4.9%), and Creutzfeldt-Jakob disease (1.2%). Reversible causes accounted for a significant proportion of cases: alcohol-associated dementia (6.1%), hypothyroid-associated dementia (3.7%), HIV-associated dementia (2.46%), herpes simplex dementia (1.2%), neurosyphilis-associated dementia (1.2%), and normal pressure hydrocephalus (NPH)-associated dementia (2.4%). Analysis of risk factors revealed distinct patterns among different dementia types, emphasizing the role of cardiovascular and metabolic health. Conclusion This study provides insights into the demographic profiles, clinical types, and dementia risk factors in India. Addressing causes and managing cardiovascular/metabolic health is crucial for dementia prevention and management. Comprehensive care strategies and ongoing research efforts are essential for improving dementia outcomes and enhancing the quality of life for affected individuals and their families.

Clinical profile and survival analysis of Alzheimer's disease patients in a Brazilian cohort

OBJECTIVE

To investigate the clinical and epidemiological characteristics of a large sample of patients with dementia due to Alzheimer's disease (AD) who were followed up at a cognitive neurology outpatient clinic.

METHODS

Retrospective, longitudinal, and descriptive design. We collected data from patients with dementia due to AD who visited the outpatient clinic of the SARAH Network of Rehabilitation Hospitals in Rio de Janeiro, Brazil, between May 2009 and June 2019. The evaluated characteristics included age of onset, sex, education, family history, comorbidities, time until diagnosis, and survival rates.

RESULTS

Overall, 1434 patients were evaluated, 74% of whom were women, with a mean age at symptom onset of 72.7 years and 75.8 at diagnosis. A positive family history was reported in 602 patients, with a first-degree relative in 86.3% of them. Hypertension was the most prevalent comorbidity, affecting 61.2% of the sample, and 16.2% were classified as having early-onset AD. The mean survival rate for the sample population was 112.8 months (9.4 years). The sample population was positively affected by dyslipidaemia.

CONCLUSIONS

This study presents a clinical and epidemiological analysis of a large and diverse group of patients with AD. The study confirms previous observations such as a higher prevalence of AD in women, low education among sufferers, and the presence of a family history. The study also found that comorbidities significantly affected patient survival and provides new data on the survival rates of patients with early and late AD in the Brazilian population.

Dementia subtypes, cognitive decline and survival among older adults attending a memory clinic in Cape Town, South Africa: a retrospective study

BACKGROUND

There are no published longitudinal studies from Africa of people with dementia seen in memory clinics. The aim of this study was to determine the proportions of the different dementia subtypes, rates of cognitive decline, and predictors of survival in patients diagnosed with dementia and seen in a memory clinic.

METHODS

Data were collected retrospectively from clinic records of patients aged ≥ 60 seen in the memory clinic at Groote Schuur Hospital, Cape Town, South Africa over a 10-year period. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria were used to identify patients with Major Neurocognitive Disorders (dementia). Additional diagnostic criteria were used to determine the specific subtypes of dementia. Linear regression analysis was used to determine crude rates of cognitive decline, expressed as mini-mental state examination (MMSE) points lost per year. Changes in MMSE scores were derived using mixed effects modelling to curvilinear models of cognitive change, with time as the dependent variable. Multivariable cox survival analysis was used to determine factors at baseline that predicted mortality.

RESULTS

Of the 165 patients who met inclusion criteria, 117(70.9%) had Major Neurocognitive Disorder due to Alzheimer's disease (AD), 24(14.6%) Vascular Neurocognitive Disorder (VND), 6(3.6%) Dementia with Lewy Bodies (DLB), 5(3%) Parkinson disease-associated dementia (PDD), 3(1.8%) fronto-temporal dementia, 4(2.4%) mixed dementia and 6(3.6%) other types of dementia. The average annual decline in MMSE points was 2.2(DLB/PDD), 2.1(AD) and 1.3(VND). Cognitive scores at baseline were significantly lower in patients with 8 compared to 13 years of education and in those with VND compared with AD. Factors associated with shorter survival included age at onset greater than 65 (HR = 1.82, 95% C.I. 1.11, 2.99, p = 0.017), lower baseline MMSE (HR = 1.05, 95% C.I. 1.01, 1.10, p = 0.029), Charlson's comorbidity scores of 3 to 4 (HR = 1.88, 95% C.I. 1.14, 3.10, p = 0.014), scores of 5 or more (HR = 1.97, 95% C.I. 1.16, 3.34, p = 0.012) and DLB/PDD (HR = 3.07, 95% C.I. 1.50, 6.29, p = 0.002). Being female (HR = 0.59, 95% C.I.0.36, 0.95, p = 0.029) was associated with longer survival.

CONCLUSIONS

Knowledge of dementia subtypes, the rate and factors affecting cognitive decline and survival outcomes will help inform decisions about patient selection for potential future therapies and for planning dementia services in resource-poor settings.

Sex differences in alpha-synucleinopathies: a systematic review

Background

Past research indicates a higher prevalence, incidence, and severe clinical manifestations of alpha-synucleinopathies in men, leading to a suggestion of neuroprotective properties of female sex hormones (especially estrogen). The potential pathomechanisms of any such effect on alpha-synucleinopathies, however, are far from understood. With that aim, we undertook to systematically review, and to critically assess, contemporary evidence on sex and gender differences in alpha-synucleinopathies using a bench-to-bedside approach.

Methods

In this systematic review, studies investigating sex and gender differences in alpha-synucleinopathies (Rapid Eye Movement (REM) Behavior Disorder (RBD), Parkinson's Disease (PD), Dementia with Lewy Bodies (DLB), Multiple System Atrophy (MSA)) from 2012 to 2022 were identified using electronic database searches of PubMed, Embase and Ovid.

Results

One hundred sixty-two studies were included; 5 RBD, 6 MSA, 20 DLB and 131 PD studies. Overall, there is conclusive evidence to suggest sex-and gender-specific manifestation in demographics, biomarkers, genetics, clinical features, interventions, and quality of life in alpha-synucleinopathies. Only limited data exists on the effects of distinct sex hormones, with majority of studies concentrating on estrogen and its speculated neuroprotective effects.

Conclusion

Future studies disentangling the underlying sex-specific mechanisms of alpha-synucleinopathies are urgently needed in order to enable novel sex-specific therapeutics.

The Prevalence of Comorbidities and Associated Factors among Patients with Dementia in the Indian Setting: Meta-analysis of Observational Studies

BACKGROUND

Patients with dementia usually have multiple comorbidities. The presence of comorbidities may exacerbate the progression of dementia and decreases the patient's ability to participate in health maintenance activities. However, there is hardly any meta-analysis estimating the magnitude of comorbidities among patients with dementia in the Indian context.

METHODS

We searched PubMed, Scopus, and Google Scholar, and relevant studies conducted in India were included. The risk of bias was assessed and a random-effects meta-analysis model was used in which I2 statistics were calculated to measure heterogeneity among studies.

RESULTS

Fourteen studies were included in the meta-analysis based on the inclusion and exclusion criteria. Altogether, we found the coexistence of comorbid conditions such as hypertension (51.10%), diabetes (27.58%), stroke (15.99%), and factors like tobacco use (26.81 %) and alcohol use (9.19%) among patients with dementia in this setting. The level of heterogeneity was high due to differences in the methodologies in the included studies.

CONCLUSIONS

Our study found hypertension as the most common comorbid condition among patients with dementia in India. The observed lacuna of methodological limitations in the studies included in the current meta-analysis provides the urgent need for good quality research to successfully meet the challenges ahead while devising appropriate strategies to treat the comorbidities among patients with dementia.

Assessment of clinical features and coexisting geriatric syndromes in newly diagnosed dementia with Lewy bodies: a retrospective study in a tertiary geriatrics setting in Turkey

PURPOSE

Identifying the associated clinical conditions in patients with newly diagnosed dementia with Lewy bodies (DLB) may contribute to the disease management. This study aimed to examine the clinical features and coexisting geriatric syndromes of patients with newly diagnosed DLB.

METHOD

This cross-sectional study included newly diagnosed DLB participants who were admitted to a tertiary geriatric outpatient clinic. Of the 857 patients with dementia, 116 DLB diagnoses were eligible for analysis. The core and supportive clinical features of DLB were recorded. Geriatric syndromes including polypharmacy, depression, insomnia, dependency, a history of delirium, falls, malnutrition, urinary incontinence, functional impairment, and living alone, were assessed and recorded at baseline.

RESULTS

The mean age was 79.0 ± 6.9 years, and 50.9% of the participants were female. The majority (63.8%) had mild dementia, 31.9% had moderate, and 4.3% had severe disease. Cognitive fluctuations (78.4%), visual hallucinations (77.6%), and Parkinsonism (73.3%) were the most common clinical features. Functional impairment (59.5%) and urinary incontinence (59.5%) were the leading geriatric syndromes, followed by polypharmacy (56.9%), depressive symptoms (54.7%), falls (52.6%), insomnia (49.1%), malnutrition (24.3%), and delirium (6.0%). Women had more functional impairment and depressive symptoms than men.

CONCLUSION

Although most patients had mild dementia, three-quarters of the DLB cohort had hallucinations, and nearly two-thirds were functionally impaired. The proportion of other serious health conditions also increased, indicating a high comorbidity and geriatric syndrome burden. Comprehensive geriatric assessment is strongly recommended for DLB patients from the time of diagnosis until death to reduce disability and comorbidities.

THE CLINICAL TRIAL REGISTRATION NUMBER

NCT05052450.

Indian Psychiatric Society multicentre study: Diagnostic patterns, comorbidity and prescription practices for patients with Dementia

BACKGROUND

There are more than 5 million people with dementia in India. Multicentre studies looking at details of treatment for people with dementia In India are lacking. Clinical audit is a quality improvement process which aims to systematically assess, evaluate, and improve patient care. Evaluating current practice is the key to a clinical audit cycle.

AIM

This study aimed to assess the diagnostic patterns and prescribing practices of psychiatrists for patients with dementia in India.

METHOD

A retrospective case file study was conducted across several centers in India.

RESULTS

Information from the case records of 586 patients with dementia was obtained. Mean age of the patients was 71.14 years (standard deviation = 9.42). Three hundred twenty one (54.8%) were men. Alzheimer's disease (349; 59.6%) was the most frequent diagnosis followed by vascular dementia (117; 20%). Three hundred fifty five (60.6%) patients had medical disorders and 47.4% patients were taking medications for their medical conditions. Eighty one (69.2%) patients with vascular dementia had cardiovascular problems. Majority of the patients (524; 89.4%) were on medications for dementia. Most frequently prescribed treatment was Donepezil (230; 39.2%) followed by Donepezil-Memantine combination (225; 38.4%). Overall, 380 (64.8%) patients were on antipsychotics. Quetiapine (213, 36.3%) was the most frequently used antipsychotic. Overall, 113 (19.3%) patients were on antidepressants, 80 (13.7%) patients were on sedatives/hypnotics, and 16 (2.7%) patients were on mood stabilizers. Three hundred nineteen (55.4%) patients and caregivers of 374 (65%) patients were receiving psychosocial interventions.

CONCLUSIONS

Diagnostic and prescription patterns in dementia which emerged from this study are comparable to other studies both nationally and internationally. Comparing current practices at individual and national levels against accepted guidelines, obtaining feedback, identifying gaps and instituting remedial measures help to improve the standard of care provided.

Do cerebral microbleeds increase the risk of dementia? A systematic review and meta-analysis

Background

Dementia is a neurological disorder that commonly affects the elderly. Cerebral microbleeds (CMBs) are small, tiny lesions of the cerebral blood vessels and have been suggested as a possible risk factor for dementia. However, data about the association between CMBs and dementia risk are inconsistent and inconclusive. Therefore, we conducted this systematic review and meta-analysis to investigate the association between CMBs and dementia and highlight the possible explanations.

Methods

We followed the standard PRISMA statement and the Cochrane Handbook guidelines to conduct this study. First, we searched medical electronic databases for relevant articles. Then, we screened the retrieved articles for eligibility, extracted the relevant data, and appraised the methodological quality using the Newcastle-Ottawa Scale. Finally, the extracted data were pooled as risk ratios (RR) and hazard ratios (HR) in the random-effects meta-analysis model using the Review Manager software.

Results

We included nine studies with 14,221 participants and follow-up periods > 18 months. Overall, CMBs significantly increased the risk of developing dementia (RR 1.84, 95% CI [1.27-2.65]). This association was significant in the subgroups of studies on high-risk populations (RR 2.00, 95% CI [1.41-2.83], n = 1657 participants) and those in the general population (RR 2.30, 95% CI [1.25-4.26], n = 12,087 participants) but not in the memory clinic patients. Further, CMBs increased the risk of progressing to incident dementia over time (HR 2, 95% CI [1.54-2.61]).

Conclusion

Individuals with CMBs have twice the risk of developing dementia or progressing to MCI than those without CMBs. The detection of CMBs will help identify the population at higher risk of developing dementia. Physicians should educate individuals with CMBs and their families on the possibility of progressing to dementia or MCI. Regular cognitive assessments, cognitive training, lifestyle modifications, and controlling other dementia risk factors are recommended for individuals with CMBs to decrease the risk of cognitive decline and dementia development.

Understanding, experiences and attitudes of dementia in India: A qualitative study

India is the world’s second-most populous country and there are about 5.3 million people with dementia in India. Only one out of ten people living with dementia in India ever gets a diagnosis, care or treatment. There are various obstacles to deliver dementia care and support to people living with dementia and their carers. Furthermore, there is inadequate understanding of dementia in the general public and within the health care professionals. Studies in India indicate that people with dementia experience stigmatisation in society as well as neglect from their families. Social prejudice associated with dementia makes it a challenging experience, in addition, it makes the persons with dementia and carers feel isolated and stigmatised. Focus groups and individual interviews were used to explore perceptions, beliefs and experiences of dementia across a number of stakeholders in India, with an effort to understand stigma towards people with dementia. Participants were recruited in two diverse cities of India (Chennai and Delhi), and were comprised of a range of key stakeholders, including persons with dementia ( n = 8), caregivers ( n = 19), health care professionals ( n = 16) and the general public ( n = 15). Following a thematic analysis, we identified three overachieving themes; (1) Poor awareness, (2) Stigma and (3) Barriers to accessing care. These all occurred within the context of socio-cultural beliefs. Whilst each stakeholder group had different experiences of dementia, it was common for all participant groups to use stigmatising language associated with dementia. In many cases, stigmatising beliefs and poor understanding of dementia resulted in poor care. There is an apparent need to raise awareness of dementia in India across all stakeholder groups; the fact that participants were able to self-identify that they had a lacked awareness of the condition may indicate that these groups are receptive to learning more about dementia.

Vascular cognitive impairment in India: Challenges and opportunities for prevention and treatment

The burden of vascular contribution to cognitive impairment and dementia is substantially high in India. There are approximately 5.3 million dementia patients in India and nearly 40% are estimated to be due to vascular dementia. Several factors pose unique challenges to reducing the burden of vascular dementia and vascular cognitive impairment (VCI) in India. Wide heterogeneity in vascular risk factor profile, diversity in socioeconomic, ethnic and dietary factors, as well as regional and rural-urban differences impact uniform implementation of preventive and therapeutic strategies. There is limited evidence on the natural history of vascular disease from longitudinal cohorts in India. Additionally, the lack of advanced brain imaging and genetic information pose challenges to understanding pathophysiology and treatment response to VCI in India. Efforts are now being made to implement programmes to reduce cardiovascular risk and VCI at the population level. Cognitive and functional measures appropriate to the diverse linguistic and educational context have been developed to diagnose VCI across India. Multicentric clinical and research cohorts of stroke are also being established. Filling research gaps and developing intervention strategies for the Indian context are crucial to address the growing burden of VCI.

Bilingualism and Its Implications for Neuropsychological Evaluation

OBJECTIVE

In the background of a large population of bilinguals globally, the study aimed to develop standards of neuropsychological testing in the context of bilingualism. Because bilingualism is known to affect cognitive processes, bilinguals and monolinguals were compared on their performance on cognitive tests, to investigate the possibility of the need for separate normative data for the two groups.

METHOD

A comprehensive neuropsychological test battery, standardized across five Indian languages: the Indian Council of Medical Research-Neuro Cognitive Tool Box (ICMR-NCTB) was administered to 530 participants (267 monolingual and 263 bilinguals matched for age and education). A systematic method of testing cognition in bilinguals was developed; to identify the appropriate language for testing, ensure language proficiency of examiner, and to interpret the bilingual responses. Additionally, the performance of bilinguals on the ICMR-NCTB was compared with monolinguals.

RESULTS

Cognitive testing in the bilingual context was performed in the most proficient language of the participants, by examiners well versed with the language. Results from the language-based tests suggested that the frequent occurrence of borrowed- and language-mixed words required consideration while scoring. The reported bilingual effect on cognitive processes did not reflect as differences in the performance between bilinguals and monolinguals.

CONCLUSIONS

Observations from the study provide robust recommendations for neuropsychological testing in the context of bilingualism. Results indicate that separate normative data may not be required for bilinguals and monolinguals. The study will be relevant and provide a reference framework to address similar issues in the large population of bilinguals in other societies.

The Association Between Hyperhidrosis and Dementia: A Community-Based Research

BACKGROUND

Dementia and hyperhidrosis (HH) are common in the elderly while there is little research to investigate the association between them.

OBJECTIVE

To clarify a possible association between HH and dementia in population of adults ≥65 years old in China.

METHODS

A cross-sectional survey for elderly adults ≥65 years old was conducted from April to December 2019. A total of 5,958 participants were analyzed after two phases investigation. Goodness-of-fit tests (Pearson and deviance) were used to estimate the dispersion parameter and examine the adequacy of the models. Logistic and linear regression analyses were used to evaluate the association between HH and dementia.

RESULTS

The overall prevalence of all-cause dementia was 10.17%, that of dementia with Lewy bodies (DLB) was 1.41%, and HH was 14.97%. Prevalence rates of HH were higher in participants with dementia and DLB. There was a significant positive relationship between HH duration and MMSE score (r = 0.207, p < 0.001, Durbin-Watson test = 1.806). Participants with HH were 1.275 (95% CI: 1.015-1.601, p = 0.037) times to have dementia, and 3.616 (95% CI: 2.267-5.767, p < 0.001) times to suffer from DLB than those without HH. Pearson and deviance chi square tests did not indicate overdispersion (p > 0.05 in the logistic regression models).

CONCLUSION

HH was common in the Chinese population ≥65 years old. It can increase the risk of dementia, particularly in DLB, in the elderly. It is important to improve the awareness of HH among dermatologists and neurologists.

Semantic memory impairment in dementia: A cross-cultural adaptation study

BACKGROUND

Semantic memory deficits are frequently encountered in dementia and distinct patterns of semantic impairment characterize the subtypes of dementia. Life course and cultural experiences significantly influence semantic memory. Hence, there is a need to assess semantic memory using culturally appropriate tests, to aid accurate diagnosis of dementia and facilitate cross-cultural collaborative research.

AIMS

In this prospective study, we adapted and validated the Cambridge Semantic Memory (CSM) test battery to the Indian cultural context and studied the patterns of semantic memory impairment across dementia subtypes.

METHODS

The CSM battery was modified using standard methods and by incorporating culturally appropriate changes and new semantic categories relevant to India. The adapted Indian Semantic Memory (ISM) test battery was administered to a cohort of 121 subjects, consisting of controls and dementia: Alzheimer's disease (AD), progressive non-fluent aphasia (PNFA), semantic dementia (SD), and behavioral variant fronto-temporal dementia (BvFTD). Profile of semantic memory performance across groups was examined.

RESULTS

The ISM battery was found to be a valid measure of semantic memory. The novel semantic categories of gods/religious icons, vegetables, and food items added value to the diagnostic process. Distinct semantic memory profiles in SD, PNFA, AD, and BvFTD were demonstrated.

CONCLUSIONS

The cultural adaptation of a semantic memory battery for the Indian context provided sensitive evidence of semantic memory impairment in dementia and its subtypes. The clinical and research application of the ISM battery will enhance diagnostic evaluation that can aid in early and accurate identification of deficits and devising intervention strategies and enable research across cultures.

Identification of GBA mutations among neurodegenerative disease patients from eastern India

INTRODUCTION

GBA mutations have been reported in PD, PDD and DLB - but not associated with cognitive impairment for example in PSP, AD or MSA. However, frequencies of GBA mutations are ethnicity dependent. The present study aims to identify commonly reported GBA mutations (mostly from Asia), among eastern Indian patients with neurodegenerative disorders.

METHODS

The patient cohort consisting of 198 classical PD cases, 136 PD cases with cognitive impairment, 184 cases with Parkinson Plus syndrome, 46 AD and 241 unrelated controls, from eastern India. Subjects were analyzed for IVS2 + 1A > G, p.Arg120Trp, p.His255Gln, p.Arg257Gln, p.Glu326Lys, p.Asn370Ser, p.Asp409His, p.Leu444Pro, & RecNciI by PCR-RFLP techniques and confirmed by Sanger sequencing method.

RESULTS

We have identified only p.Leu444Pro variant among nine cases; three PDD, one DLB, two PD, two PSP and one AD patients in heterozygous condition. The highest frequency for p.Leu444Pro variant was found among PDD subgroup (3.95 %, P = 0.0134). An overall significant overrepresentation of positive family history (P = 0.000049), impaired recent memory (P = 0.0123) was observed among p.Leu444Pro carriers. Further, subgroup analysis for PD, PD-MCI and PDD, revealed statistically significant higher frequency of early age at onset (P = 0.0455), positive family history (P = 0.0025), higher UPDRS III score (off state) (P = 0.006), advanced H&Y stage (P = 0.045) and anxious behaviour (P = 0.0124) among p.Leu444Pro positive patients.

CONCLUSION

The p.Leu444Pro mutation of GBA was found in patients with PD, PDD, DLB, PSP and AD. An Overall higher frequency of positive family history and impaired recent memory are significantly associated with for p.Leu444Pro carriers from eastern India. Our study also ascertains contribution of p.Leu444Pro to an earlier onset of PD, PD-MCI and PDD, higher UPDRS III score (off state) against positive family history background. Furthermore, taking into consideration other Indian studies, we can conclude that p.Leu444Pro mutation plays a limited role in PD and other neurodegenerative disorders.

Social Cognition Deficits Are Pervasive across Both Classical and Overlap Frontotemporal Dementia Syndromes

Objectives

Frontotemporal dementia (FTD) syndromes are a complex group of disorders characterised by profound changes in behaviour and cognition. Many of the observed behavioural abnormalities are now recognised to be due to impaired social cognition. While deficits in emotion recognition and empathy are well-recognised in behavioural-variant (Bv)FTD, limited information exists about the nature of social cognitive impairment in the language variant primary progressive aphasia (PPA) that includes progressive non-fluent aphasia (PNFA) and semantic dementia (SD), and in the motor variants FTD amyotrophic lateral sclerosis (FTD-ALS) and FTD progressive supranuclear palsy (FTD-PSP). This prospective study sought to explore the nature and profile of social cognition deficits across the spectrum of FTD.

Methods

Sixty patients on the FTD spectrum, i.e., classical (16 with BvFTD and 20 with PPA) and overlap FTD syndromes (13 with FTD-ALS and 11 with FTD-PSP) were evaluated by means of the social cognition tasks, the Interpersonal Reactivity Index (IRI) for empathy, and pictures of facial affect (POFA) for emotion recognition. General cognition and behaviour were also assessed.

Results

A significant impairment in emotion recognition and empathy was detected in both the classical and overlap FTD syndromes. The recognition of positive emotions was relatively preserved compared to that of negative emotions. Among the FTD subtypes, maximal impairment of empathy was demonstrated in FTD-PSP.

Conclusion

Social cognition impairment is pervasive across the spectrum of FTD disorders, and tests of emotion recognition and empathy are clinically useful to identify the nature of behavioural problems in both classical and overlap FTD. Our findings also have implications for understanding the neural basis of social cognition in FTD.

Dementia Diagnosis in Seven Languages: The Addenbrooke’s Cognitive Examination-III in India

Objective

With the rising burden of dementia globally, there is a need to harmonize dementia research across diverse populations. The Addenbrooke’s Cognitive Examination-III (ACE-III) is a well-established cognitive screening tool to diagnose dementia. But there have been few efforts to standardize the use of ACE-III across cohorts speaking different languages. The present study aimed to standardize and validate ACE-III across seven Indian languages and to assess the diagnostic accuracy of the test to detect dementia and mild cognitive impairment (MCI) in the context of language heterogeneity.

Methods

The original ACE-III was adapted to Indian languages: Hindi, Telugu, Kannada, Malayalam, Urdu, Tamil, and Indian English by a multidisciplinary expert group. The ACE-III was standardized for use across all seven languages. In total, 757 controls, 242 dementia, and 204 MCI patients were recruited across five cities in India for the validation study. Psychometric properties of adapted versions were examined and their sensitivity and specificity were established.

Results

The sensitivity and specificity of ACE-III in identifying dementia ranged from 0.90 to 1, sensitivity for MCI ranged from 0.86 to 1, and specificity from 0.83 to 0.93. Education but not language was found to have an independent effect on ACE-III scores. Optimum cut-off scores were established separately for low education (≤10 years of education) and high education (&gt;10 years of education) groups.

Conclusions

The adapted versions of ACE-III have been standardized and validated for use across seven Indian languages, with high diagnostic accuracy in identifying dementia and MCI in a linguistically diverse context.

Standardising Dementia Diagnosis Across Linguistic and Educational Diversity: Study Design of the Indian Council of Medical Research-Neurocognitive Tool Box (ICMR-NCTB)

OBJECTIVES

While the burden of dementia is increasing in low- and middle-income countries, there is a low rate of diagnosis and paucity of research in these regions. A major challenge to study dementia is the limited availability of standardised diagnostic tools for use in populations with linguistic and educational diversity. The objectives of the study were to develop a standardised and comprehensive neurocognitive test battery to diagnose dementia and mild cognitive impairment (MCI) due to varied etiologies, across different languages and educational levels in India, to facilitate research efforts in diverse settings.

METHODS

A multidisciplinary expert group formed by Indian Council of Medical Research (ICMR) collaborated towards adapting and validating a neurocognitive test battery, that is, the ICMR Neurocognitive Tool Box (ICMR-NCTB) in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam), for illiterates and literates, to standardise diagnosis of dementia and MCI in India.

RESULTS

Following a review of existing international and national efforts at standardising dementia diagnosis, the ICMR-NCTB was developed and adapted to the Indian setting of sociolinguistic diversity. The battery consisted of tests of cognition, behaviour, and functional activities. A uniform protocol for diagnosis of normal cognition, MCI, and dementia due to neurodegenerative diseases and stroke was followed in six centres. A systematic plan for validating the ICMR-NCTB and establishing cut-off values in a diverse multicentric cohort was developed.

CONCLUSIONS

A key outcome was the development of a comprehensive diagnostic tool for diagnosis of dementia and MCI due to varied etiologies, in the diverse socio-demographic setting of India.

Usefulness of clock-drawing test in Indian older adults with diabetes mellitus

BACKGROUND

Clock-drawing test (CDT) is a simple, quick, and bedside cognitive screening test which measures different cognitive domains but has some limitations. The aim of this study was to examine the usefulness of CDT for Indian older adult based on a part of an ICMR-funded research project, New Delhi, India.

MATERIALS AND METHODS

Sample comprised seventy participants (38 controls and 32 cases) aged 60 years and above included according to the inclusion/exclusion criteria in a consecutive series. Participants, who gave written informed consent, residing permanently in the area of Chowk, Lucknow, constituted the study sample. Semistructured sociodemographic details and medical history pro forma, socioeconomic status scale, General Health Questionnaire-12 (GHQ-12), CDT, and Hindi cognitive screening test (HCST) were administered. Biochemical investigations were carried out, and blood glucose level (fasting ≤100 mg/dl and postprandial ≤140 mg/dl) was considered for having diabetes mellitus (DM). The participants were categorized into two groups: (1) case: participants with DM only and (2) control: participants without discernible abnormality of physical illness and GHQ negative. Data were analyzed using percentages, t-test, the Chi-square test, sensitivity, and specificity.

RESULTS

About 71.05% participants in control and 81.25% in the case group have cognitive impairment on CDT. Significantly higher illiterates (P < 0.05) were found to be significantly more cognitively impaired on HCST. CDT has a high level of sensitivity (0.71) and low specificity (0.23) when compared with HCST.

CONCLUSION

CDT had screening bias to Indian older adults as a higher number of literates (almost double) and illiterates (four times) were found to be cognitively impaired compared to on HCST. Usefulness of CDT to screen Indian older adults for cognitive impairment is debatable.

Diagnostic diversity among patients with cognitive complaints: A 3-year follow-up study in a memory clinic

OBJECTIVES

To describe the distribution and estimate the mortality risks of degenerative dementias and nondegenerative conditions in a memory clinic.

METHODS

We enrolled 727 consecutive patients with cognitive complaints who visited the memory clinic in Buddhist Tzu Chi General Hospital during 2013 to 2016. Three main diagnostic groups were defined: pure type dementia, in which only one type of dementia was diagnosed, such as Alzheimer disease (AD), vascular dementia (VaD), Parkinson disease with dementia (PDD), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD); mixed type dementia; and nondegenerative conditions. We described the frequency of different diagnoses and employed Cox proportional hazards regression models to examine the mortality risks for each diagnostic group after adjusting for age, sex, education, and cognitive status. All patients alive on or after September 30, 2018, were censored in the analysis.

RESULTS

Two-thirds of patients (n = 496, 68.2%) were diagnosed with degenerative dementias. Pure type to mixed type dementia ratio was about 2: 1. AD remained the most common pure dementia subtype, followed by VaD and PDD. Among all nondegenerative conditions, depression/anxiety and subjective cognitive decline were the most common diagnoses. During a mean follow-up of 3.4 years, 150 deaths were documented, and the mortality risk was 61 deaths/1000 person-years. Mortality risks were associated with age, sex, education, and cognitive function at diagnosis but did not differ by diagnostic group.

CONCLUSIONS

Clinical diagnoses for patients with cognitive complaints are diverse, and nearly one-third are of nondegenerative conditions. Baseline cognitive function is a stronger predictor for survival than clinical diagnosis.

Clinical profile of primary progressive aphasias in a tertiary care centre from India

Purpose: Progressive language dysfunction due to a selective neurodegeneration of the language networks is called primary progressive aphasia (PPA). However, demographic data on PPA is limited. In this study from India, we determined the prevalence and clinical profile of patients presenting with PPA and its subtypes.Method: Patients who were admitted to the neurosciences department during the period between January 2012 and December 2016 were screened, and patients who presented with slowly progressive aphasia for at least 2 years without other significant cognitive or behavioural symptoms and preservation of daily living activities were included. Patients had to fulfil the international consensus group criteria for PPA. All patients were evaluated with the mini-mental status examination (MMSE) and Strub and Black battery for neuropsychological testing. The language was tested using the progressive aphasia language scale (PALS).Result: During the study period from January 2012 to December 2016, 23 patients fulfilled the international consensus criteria for PPA. Of these, 16 (69.6%) patients were diagnosed with PPA-G, 6 (26%) patients had PPA-S and 1 (4.4%) patient had PPA-L.Conclusion: PPA is not an uncommon entity in India and the most common subtype in this study was PPA-G.

Autonomic dysfunction: A comparative study of patients with Alzheimer's and frontotemporal dementia - A pilot study

Introduction:

In frontotemporal dementia (FTD) and Alzheimer's disease (AD), central autonomic structures get affected early. An insight into autonomic functions in these patients is likely to be of diagnostic importance and thus help in prognosticating and also probably explain unexplained sudden death in some of these patients.

Objectives:

The objective of this study is to identify autonomic dysfunction prevailing in patients. Then, if there is dysfunction, is the pattern same or different in these two conditions. And if different it will serve as an additional biomarker for specific diagnosis.

Patients and Methods:

There were 25 patients and 25 controls and six patients and three controls in AD and FTD groups, respectively. The participants who were recruited were assessed for heart rate variability and conventional cardiac autonomic function testing. The parameters were analyzed using LabChart version 7 software and compared with control population using appropriate statistical methods using SPSS version 22 software.

Results:

The mean overall total power was low in the FTD group (P < 0.001), and there was significant reduction in the standard deviation of normal-to-normal intervals and root mean square of successive differences (P < 0.001) with elevated sympathovagal balance in the FTD group (P = 0.04). Patients with AD also showed sympathetic dominance, but there was in addition parasympathetic suppression unlike in the FTD group.

Conclusion:

This study reveals autonomic dysfunction in patients with FTD and AD. Both conditions show sympathetic dominance, probably consecutive to the involvement of central autonomic regulatory structures as a shared domain. It remains to be confirmed if these findings are the cause or effect of neurodegeneration and might open up newer territories of research based on the causal role of neurotransmitters in these regions and thus lead to novel therapeutic options such as yoga. The presence of parasympathetic suppression in AD in addition helps differentiate these two conditions.

Voxel-wise deviations from healthy aging for the detection of region-specific atrophy

The identification of pathological atrophy in MRI scans requires specialized training, which is scarce outside dedicated centers. We sought to investigate the clinical usefulness of computer-generated representations of local grey matter (GM) loss or increased volume of cerebral fluids (CSF) as normalized deviations (z-scores) from healthy aging to either aid human visual readings or directly detect pathological atrophy.

Two experienced neuroradiologists rated atrophy in 30 patients with Alzheimer's disease (AD), 30 patients with frontotemporal dementia (FTD), 30 with dementia due to Lewy-body disease (LBD) and 30 healthy controls (HC) on a three-point scale in 10 anatomical regions as reference gold standard. Seven raters, varying in their experience with MRI diagnostics rated all cases on the same scale once with and once without computer-generated volume deviation maps that were overlaid on anatomical slices. In addition, we investigated the predictive value of the computer generated deviation maps on their own for the detection of atrophy as identified by the gold standard raters.

Inter and intra-rater agreements of the two gold standard raters were substantial (Cohen's kappa κ > 0.62). The intra-rater agreement of the other raters ranged from fair (κ = 0.37) to substantial (κ = 0.72) and improved on average by 0.13 (0.57 < κ < 0.87) when volume deviation maps were displayed. The seven other raters showed good agreement with the gold standard in regions including the hippocampus but agreement was substantially lower in e.g. the parietal cortex and did not improve with the display of atrophy scores. Rating speed increased over the course of the study and irrespective of the presentation of voxel-wise deviations.

Automatically detected large deviations of local volume were consistently associated with gold standard atrophy reading as shown by an area under the receiver operator characteristic of up to 0.95 for the hippocampus region. When applying these test characteristics to prevalences typically found in a memory clinic, we observed a positive or negative predictive value close to or above 0.9 in the hippocampus for almost all of the expected cases. The volume deviation maps derived from CSF volume increase were generally better in detecting atrophy.

Our study demonstrates an agreement of visual ratings among non-experts not further increased by displaying, region-specific deviations of volume. The high predictive value of computer generated local deviations independent from human interaction and the consistent advantages of CSF-over GM-based estimations should be considered in the development of diagnostic tools and indicate clinical utility well beyond aiding visual assessments.

•

The visual identification of atrophy is most accurate in the temporal lobe.

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Voxel-wise deviations of tissue volume from normal aging is easy to implement.

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Displaying voxel-wise deviations subjectively but not objectively aids readers.

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Voxel-wise deviations themselves show high agreement with expert readings.

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Information on tissue deviations should be provided with cerebral MRI scans.

World dementia: One approach does not fit all

OBJECTIVE

To highlight the broad global diversity in the diagnosis, management, and research of dementia in different regions of the world.

METHODS

A critical review of the limited literature from the global South compared with advances that have emerged from key studies in the West and observations from the authors' experiences.

RESULTS

The last several decades have witnessed major advances in dementia research and include an understanding of epidemiologic trends in the global burden of disease, the development of biomarkers for Alzheimer disease, the identification of novel therapeutic targets, and the recognition of the role of protective life-course experiential factors. For the effective translation of these research advances into societies, a "world approach" to dementia is vital. Developing societies substantially differ from Western countries in their attitudes toward dementia, as well as their clinical manifestations and risk factor profiles, marked by lower education and socioeconomic status, a higher cardiovascular disease burden, and genetic variability. Emerging evidence emphasizes the interaction among ethnicity, genetics, epigenetics, environment, culture, and neurobiology in influencing manifestations of dementia. Therefore, the investigation of dementia in diverse settings, including a more global perspective, is crucial for a comprehensive understanding of the condition as well as the identification of novel solutions.

CONCLUSIONS

A world approach to dementia provides an opportunity to understand, manage, coordinate, and begin to prevent dementia through an integrated approach based on firm scientific evidence.

Comparative Effects of Education and Bilingualism on the Onset of Mild Cognitive Impairment

BACKGROUND

Increasing evidence suggests that life course factors such as education and bilingualism may have a protective role against dementia due to Alzheimer disease. This study aimed to compare the effects of education and bilingualism on the onset of cognitive decline at the stage of mild cognitive impairment (MCI).

METHODS

A total of 115 patients with MCI evaluated in a specialty memory clinic in Hyderabad, India, formed the cohort. MCI was diagnosed according to Petersen's criteria following clinical evaluation and brain imaging. Age at onset of MCI was compared between bilinguals and monolinguals, and across subjects with high and low levels of education, adjusting for possible confounding variables.

RESULTS

The bilingual MCI patients were found to have a clinical onset of cognitive complaints 7.4 years later than monolinguals (65.2 vs. 58.1 years; p = 0.004), while years of education was not associated with delayed onset (1-10 years of education, 59.1 years; 11-15 years of education, 62.6 years; >15 years of education, 62.2 years; p = 0.426).

CONCLUSION

The effect of bilingualism is protective against cognitive decline, and lies along a continuum from normal to pathological states. In comparison, the role of years of education is less robust.

Behavioural and Psychological Symptoms of Dementia: Correlates and Impact on Caregiver Distress

Aims

To evaluate the behavioural and psychological symptoms of dementia (BPSD), to determine their correlation with types and stages of dementia and patient demographics, and to assess the impact on caregiver distress.

Methods

This cross-sectional study recruited consecutive dementia patients and caregivers who attended our cognitive clinic. Standard criteria were used to classify types of dementia. BPSD were assessed with the Neuropsychiatric Inventory, and its distress scale was used for caregiver distress.

Results

Of a total 107 patients, nearly all (99.1%) had at least one BPSD; 71% had ≥4 symptoms. Most frequent were apathy and agitation, followed by irritability, sleep and appetite disorders, and mood disorders; disinhibition and euphoria were least frequent. BPSD were less prominent with increasing age; males showed more agitation. Apathy and eating disorders were more prevalent in the rural community. BPSD were highest in frontotemporal dementia (FTD), followed by dementia with Lewy bodies (DLB), and least in vascular dementia. Hallucinations were more common in DLB, aberrant motor behaviour in FTD. All domains of BPSD, except for anxiety and euphoria, were more prominent with increasing severity of dementia. Increasing BPSD (except for euphoria) caused higher caregiver distress.

Conclusion

BPSD are universally present, bear correlates with dementia type and severity, and cause significant caregiver distress.

Clinical Spectrum, Risk Factors, and Behavioral Abnormalities among Dementia Subtypes in a North Indian Population: A Hospital-Based Study

Background

As variability in the clinical profile of dementia subtypes had been reported with regional differences across the world, we conducted a retrospective hospital-based study in a North Indian population.

Methods

We retrieved patient records from 2007 to 2014 for details of clinical evaluation, diagnosis, neuroimaging, biochemical investigations, and follow-up of 1,876 patients with dementia (PwD), and the data were analyzed using descriptive statistics.

Results

Of the total PwD, Alzheimer disease (AD) accounted for 30% followed by vascular dementia (VaD) 26%, mixed dementia (MD) 21%, Parkinson-related dementia 11%, frontotemporal dementia (FTD) 7%, and infective dementia 5%. Of all PwD excluding the infective group (n = 1,777), 63% were men, 39% were from rural areas, 87% had behavioral abnormalities along with cognitive deficits, and 73% had impaired ADLs. Among dementia subtypes, a positive family history, cardiovascular and metabolic risk factors, and behavioral abnormalities were found to be distributed. However, there existed a predominance of specific behavioral pattern in each subtype. The mean duration of follow-up varied from 2.9 ± 2.3 (VaD) to 3.6 ± 2.1 (AD) and greater than 30% were found to be stable on treatment (except in dementia with Lewy body).

Conclusions

This large hospital-based study provides a distribution pattern and clinical spectrum of dementia subtypes in a North Indian population.

Dementia registries around the globe and their applications: A systematic review

Patient registries are valuable tools helping to address significant challenges in research, care, and policy. Registries, well embedded in many fields of medicine and public health, are relatively new in dementia. This systematic review presents the current situation in regards to dementia registries worldwide. We identified 31 dementia registries operating on an international, national, or local level between 1986 and 2016. More than half of the registries aimed to conduct or facilitate research, including preclinical research registries and registries recruiting research volunteers. Other dementia registries collected epidemiological or quality of care data. We present evidence of practical and economic outcomes of registries for research, clinical practice and policy, and recommendations for future development. Global harmonization of recruitment methods and minimum data would facilitate international comparisons. Registries provide a positive return on investment; their establishment and maintenance require ongoing support by government, policy makers, research funding bodies, clinicians, and individuals with dementia and their caregivers.

Clinical and neuroimaging characteristics of Chinese dementia with Lewy bodies

Dementia with Lewy bodies (DLB) is the second most common subtype of degenerative dementia. To our knowledge, available information about the clinical features of DLB in China remains limited. Our study therefore aimed to address this issue. Thirty-seven Chinese patients with probable DLB were recruited for this study. All subjects underwent neuropsychological assessment by trained neurologists, as well as undergoing MRI, ¹¹C-PIB PET scans for Aβ deposition and ¹⁸F-FDG PET scans for regional cerebral glucose metabolism. Our results showed that the gender ratio of patients was 16:21 (F:M). The mean age of onset was 69.5 ± 9.0 years and the mean age at diagnosis was 71.8 ± 9.1 years. At diagnosis, the prevalence of three core clinical features of DLB was: 64.9% for fluctuating cognition, 73.0% for visual hallucinations and 62.2% for parkinsonism. The result from ¹¹C-PiB PET and ¹⁸F-FDG PET scans confirmed Aβ deposition in the cortex and demonstrated hypometabolism in the bilateral temporoparietooccipital region, the frontal lobe, the insular lobe, and the posterior cingulate, precuneus and caudate nuclei. Our study elucidated the clinical features of Chinese DLB patients, and will improve the understanding and the early diagnosis of DLB in Chinese patients.

Alzheimer's disease with cerebrovascular disease: current status in the Asia-Pacific region

BACKGROUND

There is growing awareness of the coexistence of Alzheimer's disease and cerebrovascular disease (AD+CVD), however, due to lack of well-defined criteria and treatment guidelines AD+CVD may be underdiagnosed in Asia.

METHODS

Sixteen dementia specialists from nine Asia Pacific countries completed a survey in September 2014 and met in November 2014 to review the epidemiology, diagnosis and treatment of AD+CVD in Asia. A consensus was reached by discussion, with evidence provided by published studies when available.

RESULTS

AD accounts for up to 60% and AD+CVD accounts for 10-20% of all dementia cases in Asia. The reasons for underdiagnosis of AD+CVD include lack of awareness as a result of a lack of diagnostic criteria, misdiagnosis as vascular dementia or AD, lack of diagnostic facilities, resource constraints and cost of investigations. There is variability in the tools used to diagnose AD+CVD in clinical practice. Diagnosis of AD+CVD should be performed in a stepwise manner of clinical evaluation followed by neuroimaging. Dementia patients should be assessed for cognition, behavioural and psychological symptoms, functional staging and instrumental activities of daily living. Neuroimaging should be performed using computed tomography or magnetic resonance imaging. The treatment goals are to stabilize or slow progression as well as to reduce behavioural and psychological symptoms, improve quality of life and reduce disease burden. First-line therapy is usually an acetylcholinesterase inhibitor such as donepezil.

CONCLUSION

AD+CVD is likely to be under-recognised in Asia. Further research is needed to establish the true prevalence of this treatable and potentially preventable disease.

Dementia Diagnosis, Treatment, and Care in Specialist Clinics in Two Scandinavian Countries: A Data Comparison between the Swedish Dementia Registry (SveDem) and the Danish Dementia Registry

BACKGROUND

Two dementia quality registries have been developed in Denmark and Sweden with the aim to assess quality of dementia care based on adherence to national guidelines.

OBJECTIVE

To compare patient characteristics, diagnostics, treatment, and quality indicators of dementia care among patients referred to specialist units in Sweden and Denmark.

METHODS

Data from the Swedish Dementia Registry (SveDem) and the Danish Dementia Registry were merged. Newly diagnosed dementia cases referred to memory clinics during 2007-2012 were included (19,629 Swedish and 6,576 Danish patients).

RESULTS

The median duration between initial assessment and confirmed diagnosis was 56 and 57 days in Sweden and Denmark, respectively. Brain imaging using MRI was twice as common in Sweden. A diagnosis of dementia was established at an average MMSE of 21. An etiological diagnosis was concluded in 89.6% of the Swedish and 87.3% of the Danish cases. Alzheimer's disease (AD) was the most common disorder (47.7% in Denmark and 36.6% in Sweden); however, more cases were diagnosed as mixed AD in Sweden (24.7% versus 10.6% ). More than 80% of patients with AD, dementia with Lewy bodies, and Parkinson's disease with dementia were treated with anti-dementia drugs.

CONCLUSION

The targets of several quality indicators in both registries were met, such that structural brain imaging and MMSE were performed in >90% and an etiological diagnosis was concluded in >80% of the patients. However, there were also results of concern. The diagnosis of dementia was established at a mean MMSE of 21, which is already late in the course of most dementia disorders. A higher chance of vascular findings following the higher rate of MRI in Sweden may have resulted in more mixed AD diagnosis, which could be one explanation for diagnostic differences but also highlights the need to harmonize diagnostic criteria.

The Prevalence and Incidence of Dementia with Lewy Bodies: a Systematic Review

Background

Population-based prevalence and incidence studies are essential for understanding the societal burden of dementia with Lewy bodies (DLB).

Methods

The MEDLINE and EMBASE databases were searched to identify publications addressing the incidence and/or prevalence of DLB. References of included articles and prior systematic reviews were searched for additional studies. Two reviewers screened all abstracts and full-text reviews, abstracted data and performed quality assessments.

Results

Twenty-two studies were included. Incidence rates ranged from 0.5 to 1.6 per 1000 person-years. DLB accounted for 3.2-7.1% of all dementia cases in the incidence studies. Point and period prevalence estimates ranged from 0.02 to 63.5 per 1000 persons. Increasing prevalence estimates were reported with increasing age. DLB accounted for from 0.3 to 24.4% of all cases of dementia in the prevalence studies.

Conclusions

DLB becomes more common with increasing age and accounts for about 5% of all dementia cases in older populations.

Car drivers with dementia: Different complications due to different etiologies?

OBJECTIVE

Older drivers with dementia are an at-risk group for unsafe driving. However, dementia refers to various etiologies and the question is whether dementias of different etiology have similar effects on driving ability.

METHODS

The literature on the effects of dementia of various etiologies on driving ability is reviewed. Studies addressing dementia etiologies and driving were identified through PubMed, PsychINFO, and Google Scholar.

RESULTS AND CONCLUSIONS

Early symptoms and prognoses differ between dementias of different etiology. Therefore, different etiologies may represent different likelihoods with regard to fitness to drive. Moreover, dementia etiologies could indicate the type of driving problems that can be expected to occur. However, there is a great lack of data and knowledge about the effects of almost all etiologies of dementia on driving. One could hypothesize that patients with Alzheimer's disease may well suffer from strategic difficulties such as finding a route, whereas patients with frontotemporal dementia are more inclined to make tactical-level errors because of impaired hazard perception. Patients with other dementia etiologies involving motor symptoms may suffer from problems on the operational level. Still, the effects of various etiologies of dementias on driving have thus far not been studied thoroughly. For the detection of driving difficulties in patients with dementia, structured interviews with patients but also their family members appear crucial. Neuropsychological assessment could support the identification of cognitive impairments. The impact of such impairments on driving could also be investigated in a driving simulator. In a driving simulator, strengths and weaknesses in driving behavior can be observed. With this knowledge, patients can be advised appropriately about their fitness to drive and options for support in driving (e.g., compensation techniques, car adaptations). However, as long as no valid, reliable, and widely accepted test battery is available for the assessment of fitness to drive, costly on-road test rides are inevitable. The development of a fitness-to-drive test battery for patients with dementia could provide an alternative for these on-road test rides, on condition that differences between dementia etiologies are taken into consideration.

Mild cognitive impairment: clinical and imaging profile in a memory clinic setting in India

BACKGROUND

Despite the increasing burden of dementia in developing countries, mild cognitive impairment (MCI) continues to be underexplored. MCI has conventionally been identified based on clinical profile, but recently, biomarkers suggestive of Alzheimer's disease pathology have been included in the revised National Institute on Aging and the Alzheimer's Association (NIA-AA) criteria. In this study, we evaluated the profile of MCI in a memory clinic in India and explored the applicability of the revised NIA-AA criteria in a limited resource setting.

METHODS

Consecutive subjects evaluated at the memory clinic for mild memory complaints were included and underwent clinical and neuropsychological examination as well as standard brain imaging. A subset of patients was subjected to imaging biomarker studies as a part of routine clinical practice.

RESULTS

Among the 1,190 patients evaluated during the study period, 226 (19.0%) presented with mild memory complaints. Cerebrovascular disease was a common secondary cause. Nearly half of the patients (109 of 226) had MCI according to the modified Petersen criteria. All MCI subjects were educated and the majority were male. A total of 12% of the cohort was classified by imaging biomarkers as having MCI with intermediate likelihood of AD according to the NIA-AA criteria.

CONCLUSION

In the setting of urban India, MCI is an emerging problem; therefore, it was feasible to operationalise the revised NIA-AA criteria in identifying subjects with MCI with intermediate likelihood of AD.

Dementia subtypes in Antalya, Turkey: a retrospective study

The frequency of dementia is increasing steadily, and it is currently estimated that 60% of patients suffering from this disease reside in developing countries. An improvement in health care services for this elderly patients must be anticipated to assist in reducing the patient burden to their communities, families, and health systems; alternately, contributions made by hospitals through their diagnostic efforts and treatment of patients are of great importance. The purpose of this study was to evaluate the health records (n = 246) of patients in a dementia clinic for data regarding age, sex, occupation, reason for presentation, laboratory findings, neuropsychological tests, diagnoses made at presentation, and follow-up visits. Patients aged ≥ 60 years with cognitive symptoms were included in the study; mean age was 74.4 (SD, 7.58) years, with a predominantly female population (n = 142; 57.7%). The main reason for patient presentation was memory problems (n = 238; 96.7%). Administration of the Mini-Mental State Examination (MMSE) revealed a mean score of 19.14 (SD, 8.24) across the patient population; Montreal Cognitive Assessment mean test scores were 20.9 (SD, 5.31); and Clock Drawing Test median score was 2 points (min-max, 0-4). The most common diagnoses were Alzheimer-type dementia (n = 167; 67.9%) and mild cognitive impairment (n = 49; 19.9%). During a 31-month period, the dementia outpatient clinic was visited an average of 2.79 (SD, 2.32) times. Findings indicated that women had higher vitamin B12 levels (P = 0.001), lower MMSE scores (P = 0.022), fewer follow-up visits (P = 0.006), and higher low-density lipoprotein cholesterol levels (P = 0.02).

Drug utilization pattern in patients with different types of dementia in Western India

Background. Dementia is one of the most frequent disorders among elderly patients, reaching to epidemic proportions with an estimated 4.6 million new cases globally annually. Partially effective treatments are available for dementia. Aims & Objectives. We aim to study drugs used in dementia and find out frequency of types of Dementia. Method. This was an observational study conducted at rurally based tertiary care hospital. Prospective data was collected from outpatient department, while retrospective data was collected from medical records. Descriptive statistics were used to analyze data. Result. Total 125 prescriptions of patients diagnosed with dementia were analyzed. Alzheimer's dementia was most common (65.6%), followed by vascular dementia (21.6%), and frontotemporal dementia (10.4%), with the rarest being Lewy body dementia in (2.4%) cases. 60.57% of patients were males. Mini Mental Score Examination mean score was 15.93 ± 1.37. Frontal Battery Assessment mean score was 4.75 ± 1.01. Prescribed drugs were Donepezil (68.49%), Rivastigmine (13.63%), Donepezil + Memantine (6.43%) and Galantamine (12.83%), Quetiapine (38.46%), Lorazepam (23.07%), Clozapine (11.53%), Escitalopram (10.25%), Haloperidol (3.84%), Zolpidem, Sertraline, Olanzepine (2.56%), Nitrazepine, Lamotrigine, Fluoxetine, Tianeptine (1.28%), Folic acid, and Vitamin B12, respectively. Conclusion. Alzheimer's is the most common type of dementia while Donepezil was the most frequent drug.

Cardiovascular medication burden in dementia disorders: a nationwide study of 19,743 dementia patients in the Swedish Dementia Registry

Introduction

Administration of several cardiovascular drugs has an effect on dementia. We aimed to investigate whether there are differences in the use of cardiovascular medication between different dementia disorders.

Methods

We obtained information about dementia patients from the Swedish Dementia Registry. Patients were diagnosed with one of these dementia disorders: Alzheimer’s disease (n = 8,139), mixed dementia (n = 5,203), vascular dementia (n = 4,982), Lewy body dementia (n = 605), frontotemporal dementia (n = 409) and Parkinson’s disease dementia (n = 405). Multivariate logistic regression analysis was performed to investigate the association between use of cardiovascular medication and dementia disorders, after adjustment for age, gender, living alone, cognitive status and total number of drugs (a proxy for overall co-morbidity).

Results

Seventy percent of all the dementia patients used cardiovascular medication. Use of cardiovascular drugs is common in patients with vascular and mixed dementia. Male gender, higher age, slightly better cognitive status and living with another person was associated with use of cardiovascular medication.

Conclusions

Cardiovascular medication is used extensively across dementia disorders and particularly in vascular and mixed dementia. Future research should investigate the tolerability and effectiveness of these drugs in the different dementia disorders.

Delaying onset of dementia: are two languages enough?

There is an emerging literature suggesting that speaking two or more languages may significantly delay the onset of dementia. Although the mechanisms are unknown, it has been suggested that these may involve cognitive reserve, a concept that has been associated with factors such as higher levels of education, occupational status, social networks, and physical exercise. In the case of bilingualism, cognitive reserve may involve reorganization and strengthening of neural networks that enhance executive control. We review evidence for protective effects of bilingualism from a multicultural perspective involving studies in Toronto and Montreal, Canada, and Hyderabad, India. Reports from Toronto and Hyderabad showed a significant effect of speaking two or more languages in delaying onset of Alzheimer's disease by up to 5 years, whereas the Montreal study showed a significant protective effect of speaking at least four languages and a protective effect of speaking at least two languages in immigrants. Although there were differences in results across studies, a common theme was the significant effect of language use history as one of the factors in determining the onset of Alzheimer's disease. Moreover, the Hyderabad study extended the findings to frontotemporal dementia and vascular dementia.

Dementia in developing countries: Does education play the same role in India as in the West?

Evidence suggests that education protects from dementia by enhancing cognitive reserve. However, this may be influenced by several socio-demographic factors. Rising numbers of dementia in India, high levels of illiteracy and heterogeneity in socio-demographic factors provide an opportunity to explore this relationship.

OBJECTIVE

To study the association between education and age at dementia onset, in relation to socio-demographic factors.

METHODS

Association between age at dementia onset and literacy was studied in relationship to potential confounding factors such as gender, bilingualism, place of dwelling, occupation, vascular risk factors, stroke, family history of dementia and dementia subtypes.

RESULTS

Case records of 648 dementia patients diagnosed in a specialist clinic in a University hospital in Hyderabad, India were examined. All patients were prospectively enrolled as part of an ongoing longitudinal project that aims to evaluate dementia subjects with detailed clinical, etiological, imaging, and follow-up studies. Of the 648 patients, 98 (15.1%) were illiterate. More than half of illiterate skilled workers were engaged in crafts and skilled agriculture unlike literates who were in trade or clerical jobs. Mean age at onset in illiterates was 60.1 years and in literates 64.5 years (p=0.0002). Factors independently associated with age at dementia onset were bilingualism, rural dwelling and stroke, but not education.

CONCLUSION

Our study demonstrates that in India, rural dwelling, bilingualism, stroke and occupation modify the relationship between education and dementia.

The prevalence and incidence of dementia with Lewy bodies: a systematic review of population and clinical studies

BACKGROUND

Dementia with Lewy bodies (DLB) is increasingly recognized as a common cause of dementia in older people. However, its true frequency remains unclear, with previous studies reporting a prevalence range from zero to 22.8% of all dementia cases. This review aimed to establish the population prevalence and incidence for DLB and to compare this to its prevalence in secondary care settings.

METHOD

A literature review of all relevant population and clinical studies was conducted using PubMed. Additional references from papers found during that process were added to this.

RESULTS

DLB accounted for 4.2% of all diagnosed dementias in the community. In secondary care this increased to 7.5%. The incidence of DLB was 3.8% of new dementia cases. There was a significant increase in DLB diagnoses when using the revised (2005) International Consensus Criteria (ICC) for DLB compared to the original (1996) criteria.

CONCLUSIONS

DLB currently accounts for around one in 25 dementia cases diagnosed in the community and one in 13 cases in secondary care. The significantly higher rates of DLB in secondary care may reflect enhanced diagnostic accuracy in specialist settings and/or the increased morbidity and carer burden of the DLB syndrome compared to other dementias. However, the true prevalence is likely to be much higher because DLB diagnoses are often missed, although there is evidence that new criteria aid case identification.

Differences in drug therapy between dementia disorders in the Swedish dementia registry: a nationwide study of over 7,000 patients

BACKGROUND/AIMS

We aimed to study whether there are differences between dementia disorders and the use of anti-dementia drugs and antipsychotics (neuroleptics) in a large population of dementia patients.

METHODS

Information about dementia disorders was obtained from the national Swedish Dementia Registry (SveDem) 2007-2010 (n = 7,570). Multivariate logistic regression analysis was performed to investigate the association between dementia disorders and the use of anti-dementia drugs and antipsychotics, after adjustment for age, sex, residential setting, living alone, MMSE score and number of other drugs (a proxy for overall co-morbidity).

RESULTS

More than 80% of the Alzheimer's disease (AD) and 86% of dementia with Lewy bodies (DLB) patients used anti-dementia drugs. Women were more likely than men to be treated with cholinesterase inhibitors. A higher MMSE score was positively associated with the use of cholinesterase inhibitors, but negatively associated with NMDA receptor antagonists and antipsychotics. Use of antipsychotics was 6% overall; however, it was 16% in DLB patients with an adjusted odds ratio of 4.2 compared to AD patients.

CONCLUSION

Use of anti-dementia drugs in AD was in agreement with Swedish guidelines. However, use of antipsychotics in DLB patients was high, which might be worrying given the susceptibility of DLB patients to antipsychotics.

Transcranial magnetic stimulation in patients with early cortical dementia: A pilot study

Context:

The diagnostic accuracy of the currently available tools carries poor sensitivity resulting in significant delay in specific diagnosis of cortical dementias. Considering the properties of default mode networking of the brain it is highly probable that specific changes may be seen in frontotemporal dementias (FTDs) and Alzheimer's disease sufficiently early.

Aim:

The aim of this study is to look for changes in Transcranial Magnetic Stimulation (TMS) in cortical dementia.

Materials and Methods:

Evaluated with a single pulse TMS with the figure of eight coil and recorded from right first dorsal interossei (FDI). Resting Motor Threshold (RMT) was estimated on the opposite motor cortex (T1). Second site of stimulation was cervical spine at C7-T2. Central motor conduction time (CMCT) is equal toT1-T2. Silent Period (SP) identified by applying TMS pulse to contracting FDI.

Conclusions:

RMT was reduced in seven out of eight Alzheimer's dementias. CMCT was in the upper limit of normal in both patients with FTD. The most consistent observation was that SP was reduced and there were escape discharges noticed during the SP suggesting increased cortical excitability and decreased cortical inhibition. This suggests probable early asymptomatic changes in the gamma-aminobutyric acid (GABA) nergic and cholinergic system is taking place. This if confirmed may give some insight into early diagnosis and therapeutic role of GABA agonists in these disorders.

Assessing dementia in resource-poor regions

The numbers and proportions of elderly are increasing rapidly in developing countries, where prevalence of dementia is often high. Providing cost-effective services for dementia sufferers and their caregivers in these resource-poor regions poses numerous challenges; developing resources for diagnosis must be the first step. Capacity building for diagnosis involves training and education of healthcare providers, as well as the general public, development of infrastructure, and resolution of economic and ethical issues. Recent progress in some low-to-middle-income countries (LMICs) provides evidence that partnerships between wealthy and resource-poor countries, and between developing countries, can improve diagnostic capabilities. Without the involvement of the mental health community of developed countries in such capacity-building programs, dementia in the developing world is a disaster waiting to happen.

The epidemiology of frontotemporal dementia

Frontotemporal dementia, a heterogeneous neurodegenerative disorder, is a common cause of young onset dementia (i.e. dementia developing in midlife or earlier). The estimated point prevalence is 15-22/100,000, and incidence 2.7-4.1/100,000. Some 25% are late-life onset cases. Population studies show nearly equal distribution by gender, which contrasts with myriad clinical and neuropathology reports. FTD is frequently familial and hereditary; five genetic loci for causal mutations have been identified, all showing 100% penetrance. Non-genetic risk factors are yet to be identified. FTD shows poor life expectancy but with survival comparable to that of Alzheimer's disease. Recent progress includes the formulation of up-to-date diagnostic criteria for the behavioural and language variants, and the development of new and urgently needed instruments for monitoring and staging the illness. There is still need for descriptive population studies to fill gaps in our knowledge about minority groups and developing regions. More pressing, however, is the need for reliable physiological markers for disease. There is a present imperative to develop a translational science to form the conduit for transferring neurobiological discoveries and insights from bench to bedside.

Environmental dependency behaviours in frontotemporal dementia: have we been underrating them?

Environmental dependency (ED) behaviours, such as imitation behaviour (IB) and incidental utilization behaviour (UB), are considered pathognomonic of a frontal lesion and can play a unique role in diagnosing behavioural variant frontotemporal dementia (bvFTD). However, with only few focused observations of ED behaviour reported in earlier studies, their roles in the diagnosis of bvFTD have so far remained supportive. In this observational study, conducted in the cognitive clinic of a tertiary-care hospital, we explored the hypotheses that a focused and systematic search could uncover more ED behaviours in patients with bvFTD, and that the presence of ED behaviours such as incidental UB and IB should allow us to cleanly differentiate bvFTD from AD. Forty-one bvFTD patients and 75 probable AD patients, all diagnosed using accepted criteria, were seen by a neurologist and a neuropsychologist. Information regarding ED behaviour was obtained from the caregiver's history, observations for spontaneous behaviour and induction of the behaviour in the clinic. All ED behaviours were significantly more frequent in bvFTD compared with AD. UB (78 %; 66 % incidental) and IB (59 %) occurred exclusively in bvFTD. Multi-pronged and focused clinical assessment contributed to the high frequency of ED behaviours. Nearly two-thirds of bvFTD patients, but none with AD, showed three or more ED behaviours. We concluded that ED behaviours are more common in bvFTD than is currently recognized. UB, IB or three ED behaviours, if present, could clearly differentiate bvFTD from AD. A focused search should consistently uncover ED behaviours in bvFTD patients.

Characterizing cognitive deficits and dementia in an aging urban population in India

Rapid rise in the population of older adults in India will lead to the need for increased health care services related to diagnosis, management, and long-term care for those with dementia and cognitive impairment. A direct approach for service provision through memory clinics can be an effective, successful, and sustaining means of delivering specialized health care services. We have established a memory clinic in Mumbai, India by employing the diverse clinical skills available in Indian academic institutions, diagnostic and research expertise of clinicians and psychologists, and the support of the U.S. National Institutes of Health. Our project involved recruitment of patients, clinical and neuropsychological assessment, and standardized diagnostic procedures, demonstrating the feasibility of using research methods to develop a memory clinic. In this paper, we describe the development of a community-based memory clinic in urban India, including linguistic and cultural factors and present detailed results, including diagnostic characterization, on 194 subjects with various stages of cognitive deficits. Our findings support the feasibility of developing a memory clinic in a public hospital and successful use of research diagnostic criteria to categorize cognitive deficits observed in this population, which may be used to inform the development of other such clinics.