The Cambridge Behavioral Inventory: validation and application in a memory clinic

Trajectories of behavior and social cognition in behavioral variant frontotemporal dementia and primary psychiatric disorders: A call for better operationalization of socioemotional changes

BACKGROUND AND PURPOSE

Behavioral variant frontotemporal dementia (bvFTD) and primary psychiatric disorders (PPD), such as mood, psychotic, and autism spectrum disorders, share similar clinical characteristics of behavior and social cognition. Better understanding of clinical progression in bvFTD and PPD is essential for adequate disease monitoring and trial design.

METHODS

In this longitudinal study (N = 89), patients with bvFTD and PPD with at least one follow-up assessment were included from the Social Brain Project of the Alzheimer Center Amsterdam. Behavioral change and social cognitive decline were assessed via informant-rated questionnaires (Cambridge Behavioral Inventory-Revised, Frontal Behavioral Inventory [FBI], Stereotypy Rating Inventory, Frontotemporal Dementia Rating Scale, Revised Self-Monitoring Scale [RSMS]-caregiver) and patient assessment (Ekman 60-Faces Test, RSMS-patient, Emotional Contagion Scale). Clinical trajectories (median = 1.4 years, interquartile range = 1.0-2.2) were examined using linear mixed models. In a subsample, associations with baseline serum neurofilament light (sNfL) were examined.

RESULTS

At baseline, behavioral and social cognitive symptoms were similar between diagnosis groups, except for poorer emotion recognition in bvFTD. Over time, behavioral symptoms worsened in bvFTD, whereas most measures remained stable and the FBI improved in PPD. Regarding social cognition, emotion recognition and caregiver-reported socioemotional sensitivity worsened in bvFTD and remained stable in PPD. Patient-reported social cognitive measures did not change over time. Higher sNfL was associated with faster behavioral change.

CONCLUSIONS

Trajectories of behavior and social cognition differentiate bvFTD from PPD, provided that social cognition is not patient-reported. Therefore, we stress the need to optimize longitudinal social cognitive assessment in bvFTD. sNfL may be a useful prognostic marker of behavioral progression in neuropsychiatric populations.

Assessing eating ability and mealtime behaviors of persons living with dementia: A systematic review of instruments

This systematic review aimed to describe the characteristics of instruments that assess eating ability and/or mealtime behaviors in persons living with dementia, and evaluate their psychometric properties. Five databases were searched for relevant records between 1/1/1980 and 5/25/2023. Records included instruments assessing eating ability and/or mealtime behaviors of people with dementia. The psychometric quality of the instruments was evaluated using the Psychometric Assessment for Self-report and Observational Tools (PAT). 45 eligible instruments were identified from 115 records. While 38 instruments were scored as having low psychometric quality, 7 had moderate quality. Edinburgh Feeding Evaluation in Dementia (EdFED), Mealtime Difficulty Scale for older adults with Dementia (MDSD), and Dementia Hyperphagic Behavior Scale (DHBS) were scored as having the highest quality (total PAT score = 9). Further refinement of existing instruments and additional psychometric testing in larger, diverse samples will improve pragmatic use in dementia mealtime care research and practice.

The pursuit for markers of disease progression in behavioral variant frontotemporal dementia: a scoping review to optimize outcome measures for clinical trials

Behavioral variant frontotemporal dementia (bvFTD) is a neurodegenerative disorder characterized by diverse and prominent changes in behavior and personality. One of the greatest challenges in bvFTD is to capture, measure and predict its disease progression, due to clinical, pathological and genetic heterogeneity. Availability of reliable outcome measures is pivotal for future clinical trials and disease monitoring. Detection of change should be objective, clinically meaningful and easily assessed, preferably associated with a biological process. The purpose of this scoping review is to examine the status of longitudinal studies in bvFTD, evaluate current assessment tools and propose potential progression markers. A systematic literature search (in PubMed and Embase.com) was performed. Literature on disease trajectories and longitudinal validity of frequently-used measures was organized in five domains: global functioning, behavior, (social) cognition, neuroimaging and fluid biomarkers. Evaluating current longitudinal data, we propose an adaptive battery, combining a set of sensitive clinical, neuroimaging and fluid markers, adjusted for genetic and sporadic variants, for adequate detection of disease progression in bvFTD.

A caregiver's perspective on clinically relevant symptoms in behavioural variant frontotemporal dementia: tools for disease management and trial design

BACKGROUND

Adequate detection of symptoms and disease progression in behavioural variant frontotemporal dementia (bvFTD) is complex. Dementia cohorts usually utilize cognitive and functional measures, which fail to detect dominant behavioural and social cognitive deficits in bvFTD. Moreover, since patients typically have a loss of insight, caregivers are important informants. This is the first qualitative study to investigate caregiver relevant symptoms during the disease course of bvFTD, aiming to improve tools for diagnosis, progression, and future clinical trials.

METHODS

Informal caregivers of patients in different disease stages of bvFTD (N = 20) were recruited from the neurology outpatient clinic of the Amsterdam UMC and a patient organization for peer support in the Netherlands. Their perspectives on clinical relevance were thoroughly explored during individual semi-structured interviews. Inductive content analysis with open coding was performed by two researchers independently to establish overarching themes and patterns.

RESULTS

Caregivers reported a variety of symptoms, in which (i) loss of emotional connection, (ii) preoccupation and restlessness, and (iii) apathy and dependency compose major themes of relevance for diagnosis and treatment. Within heterogeneous disease trajectories, symptom presence differed between stages and among individuals, which is relevant in the context of progression and outcome measures. Significant socio-emotional changes dominated in early stages, while severe cognitive, behavioural, and physical deterioration shifted focus from predominant personality change to quality of life in later stages.

CONCLUSIONS

Caregiver perspectives on target symptoms in bvFTD differ according to clinical stage and patient-caregiver characteristics, with significant socio-emotional changes characterizing early stages. These findings call for more appropriate tools and symptomatic treatments, as well as a personalized approach in treatment of bvFTD and a focus on early stage interventions in clinical trial design.

Clinical Phenotypes of Behavioral Variant Frontotemporal Dementia by Age at Onset

Background:

Behavioral variant frontotemporal dementia (bvFTD) is generally considered a young-onset dementia, although age at onset is highly variable. While several studies indicate clinical differences regarding age at onset, no biomarker validated cohort studies with updated clinical criteria have been performed.

Objective:

We aimed to examine behavior, cognition, and mortality over the full age spectrum in a cohort of bvFTD patients with neuroimaging, genetic, or histopathological confirmation and exclusion of positive Alzheimer’s disease biomarkers or severe cerebrovascular damage.

Methods:

In total, 315 patients with a clinical diagnosis of probable or definite bvFTD were included from the Amsterdam Dementia Cohort and grouped into quartiles by age-at-diagnosis. Neuropsychiatric symptoms and cognitive functioning were assessed with the neuropsychiatric inventory, the geriatric depression scale and a neuropsychological test battery. Data on mortality was obtained from the Dutch municipal register. Associations between age-at-diagnosis and clinical features and mortality risk were examined.

Results:

Age-at-diagnosis ranged from 26 to 85 years and established quartiles with mean ages of 52±6, 61±2, 66±2, and 74±3 years. In the total sample, 44.4%exceeded an age of 65 years at time of diagnosis. Earlier age-at-diagnosis was associated with more severe behavioral symptoms, while later age-at-diagnosis was associated with more severe memory impairment. Unexpectedly, mortality risk was not associated with age-at-diagnosis.

Conclusion:

In bvFTD, symptom profile is associated with age-at-diagnosis. This should be taken into account with regard to diagnostics, patient management, and trial design. Additionally, based on our sample, the prevalence of late-onset bvFTD is higher than generally thought.

Cognitive and behavioural inhibition deficits in neurodegenerative dementias

Disinhibition, mainly caused by damage in frontotemporal brain regions, is one of the major causes of caregiver distress in neurodegenerative dementias. Behavioural inhibition deficits are usually described as a loss of social conduct and impulsivity, whereas cognitive inhibition deficits refer to impairments in the suppression of prepotent verbal responses and resistance to distractor interference. In this review, we aim to discuss inhibition deficits in neurodegenerative dementias through behavioural, cognitive, neuroanatomical and neurophysiological exploration. We also discuss impulsivity and compulsivity behaviours as related to disinhibition. We will therefore describe different tests available to assess both behavioural and cognitive disinhibition and summarise different manifestations of disinhibition across several neurodegenerative diseases (behavioural variant of frontotemporal dementia, Alzheimer's disease, Parkinson's disease, progressive supranuclear palsy, Huntington's disease). Finally, we will present the latest findings about structural, metabolic, functional, neurophysiological and also neuropathological correlates of inhibition impairments. We will briefly conclude by mentioning some of the latest pharmacological and non pharmacological treatment options available for disinhibition. Within this framework, we aim to highlight i) the current interests and limits of tests and questionnaires available to assess behavioural and cognitive inhibition in clinical practice and in clinical research; ii) the interpretation of impulsivity and compulsivity within the spectrum of inhibition deficits; and iii) the brain regions and networks involved in such behaviours.

Apathy and Disinhibition Related to Neuropathology in Amnestic Versus Behavioral Dementias

OBJECTIVES

Investigating the frequency of apathy and disinhibition in patients clinically diagnosed with dementia of the Alzheimer type (DAT) or behavioral variant frontotemporal dementia (bvFTD) with neuropathology of either Alzheimer disease (AD) or frontotemporal lobar degeneration (FTLD).

METHODS

Retrospective data from 887 cases were analyzed, and the frequencies of apathy and disinhibition were compared at baseline and longitudinally in 4 groups: DAT/AD, DAT/FTLD, bvFTD/FTLD, and bvFTD/AD.

RESULTS

Apathy alone was more common in AD (33%) than FTLD (25%), and the combination of apathy and disinhibition was more common in FTLD (43%) than AD (14%; P < .0001). Over time, apathy became more frequent in AD with increasing dementia severity (33%-41%; P < .006).

CONCLUSIONS

Alzheimer disease neuropathology had the closest association with the neuropsychiatric symptom of apathy, while FTLD was most associated with the combination of apathy and disinhibition. Over time, the frequency of those with apathy increased in both AD and FTLD neuropathology.

Neuropsychiatric Manifestations of Cognitively Advanced Idiopathic Normal Pressure Hydrocephalus

Background

Neuropsychiatric manifestations of patients with idiopathic normal pressure hydrocephalus (iNPH) have not been studied in a systematic way.

Aim

To study the spectrum of neuropsychiatric abnormalities in patients with iNPH.

Patient Selection and Evaluation

Patients attending 3 different tertiary care centers during three consecutive time periods spanning from 2010 to 2015 were analyzed for neuropsychiatric manifestations. Patients diagnosed as having probable or possible iNPH as per the consensus criteria were included in the study. Neuropsychiatric manifestations were captured by a comprehensive inventory (Cambridge Behavioral Inventory, CBI).

Results

The CBI score was available for 41 patients. The mean Mini-Mental State Examination score was 15.37 (SD 7.2) and the Addenbrooke's Cognitive Examination score was 34.95 (SD 19.67), thereby indicating cognitively advanced iNPH. All patients had impairment in one or more items on the CBI. The mean score was 55.46 (SD 27) out of 180, thereby indicating a mild degree of impairment. Among the subscores, impairment with motivation was the most observed abnormality followed by memory impairment. When the CBI total score and subscores were compared, all of them (except motivation) were higher for Alzheimer's disease; however, none was statistically significant. Even though the motivation score was higher for iNPH, the difference did not reach statistical significance.

Conclusions

It can be concluded that neurobehavioral abnormalities are common in patients with cognitively advanced normal pressure hydrocephalus. However, the intensity of involvement appeared less when compared to Alzheimer's disease. Apathy appears to be the most common impairment.

You stole my food! Eating alterations in frontotemporal dementia

Patients with different types of dementia may exhibit pathological eating habits, including food fads, hyperphagia, or even ingestion of inanimate objects. Several findings reveal that such eating alterations are more common in patients with frontotemporal dementia (FTD) than other types of dementia. Moreover, eating alterations may differ between the two variants of the disease, namely the behavioral variant and semantic dementia (SD). In this review, we summarized evidences regarding four areas: eating and body weight alterations in FTD, the most common assessment methods, anatomical correlates of eating disorders, and finally, proposed underlying mechanisms. An increasing understanding of the factors that contribute to eating abnormalities may allow first, a better comprehension of the clinical features of the disease and second, shed light on the mechanism underlying eating behaviors in the normal population.

DAPHNE: A New Tool for the Assessment of the Behavioral Variant of Frontotemporal Dementia

BACKGROUND

The diagnosis of behavioral variant of frontotemporal dementia (bvFTD) relies primarily on clinical features and remains challenging. The specificity of the recently revised criteria can be disappointing, justifying development of new clinical tools.

OBJECTIVE

We produced a behavioral inventory named DAPHNE. This scale (adapted from Rascovsky's criteria) explores six domains: disinhibition, apathy, perseverations, hyperorality, personal neglect and loss of empathy. It is composed of ten items (five answer categories). The aim was (1) to assess the validity and reliability of DAPHNE and (2) to evaluate its contribution in differentiating patients.

METHODS

Two scores were computed: DAPHNE-6 (screening) from the six domains and DAPHNE-40 (diagnosis) from the ten items. Reliability and reproducibility were assessed. External validity was studied with the Frontal Behavioral Inventory (FBI) and the Frontotemporal Behavioral Scale (FBS). Finally, the diagnostic performance of DAPHNE was compared to revised criteria, FBI and FBS.

RESULTS

DAPHNE was administered to the caregivers of 89 patients, 36 with bvFTD, 22 with Alzheimer's disease, 15 with progressive supranuclear palsy and 16 with bipolar disorder. Reliability and reproducibility were excellent, as was external validity. DAPHNE-6 allowed bvFTD diagnosis (score ≥4) with a sensitivity of 92%, while DAPHNE-40 (score ≥15) had a specificity of 92%.

CONCLUSION

We demonstrate excellent psychometric features for DAPHNE. This quick tool could help for both diagnosing and screening bvFTD.

The merits and problems of Neuropsychiatric Inventory as an assessment tool in people with dementia and other neurological disorders

Objective

The Neuropsychiatric Inventory (NPI) is one of the most commonly used assessment scales for assessing symptoms in people with dementia and other neurological disorders. This paper analyzes its conceptual framework, measurement mode, psychometric properties, and merits and problems.

Method

All articles discussing the psychometric properties and factor structure of the NPI were searched for in Medline via Ovid. The abstracts of these papers were read to determine their relevance to the purpose of this paper. If deemed appropriate, a full paper was then obtained and read.

Results

The NPI has reasonably good content validity and internal consistency, and good test–retest and interrater reliability. There is limited information about its sensitivity, specificity, positive and negative predictive values, and, in particular, responsiveness. Merits of the NPI include being comprehensive, avoiding symptom overlap, ease of use, and flexibility. It has problems in scoring (no multiples of 5, 7, and 11) and, therefore, analysis using parametric tests may not be appropriate. The use of individual subscales also warrants further investigation.

Conclusion

In terms of its content and concurrent validity, intra- and interrater reliability, test–retest reliability, and internal consistency, the NPI can be considered as valid and reliable, and can be used across different ethnic groups. The tool is most likely unable to deliver as good a performance in terms of discriminating between different disorders. More studies are required to further evaluate its psychometric properties, particularly in the areas of factor structure and responsiveness. The clinical utility of the NPI also needs to be further explored.

Neuropsychiatric symptom profile differs based on pathology in patients with clinically diagnosed behavioral variant frontotemporal dementia

BACKGROUND

Behavioral variant frontotemporal dementia (bvFTD) is pathologically heterogeneous. With emerging therapeutics, determining underlying pathology during life is increasingly important. Neuropsychiatric symptoms are prevalent and diagnostic in bvFTD.

METHODS

We assessed the neuropsychiatric profile of patients with clinically diagnosed bvFTD as a function of pathology at autopsy. Patients with a clinical diagnosis of bvFTD at the initial visit were selected from the National Alzheimer's Coordinating Center (NACC) database. Neuropsychiatric symptoms endorsed on the Neuropsychiatric Inventory Questionnaire (NPI-Q) were analyzed.

RESULTS

Of 149 patients with clinically diagnosed bvFTD, pathology was primarily Alzheimer's disease (AD) in 20.5%. These patients differed from those with underlying frontotemporal lobar degeneration: patients with AD pathology (plaques and tangles) were more likely to have hallucinations, delusions, or agitation. Patients were further differentiated into tau-positive (30% of cases, including Pick's disease, FTD and parkinsonism with tau-positive or argyrophilic inclusions, and other tauopathies) or tau-negative cases (70% of cases, including bvFTD tau-negative ubiquitin-positive inclusions). These patients also differed in some of the neuropsychiatric symptoms seen. Tau-negative cases were more likely to demonstrate depression, delusions, and changes in appetite and eating.

CONCLUSIONS

These preliminary findings contribute to our increasing ability to predict, using simple clinical tools, the neuropathological underpinnings of bvFTD during life.

When one loses empathy: its effect on carers of patients with dementia

The effects of empathy loss in frontotemporal dementia (FTD) and Alzheimer disease (AD) on carer symptomatology were investigated. Carers of patients with 2 clinical subtypes of FTD (behavioral-variant FTD [bvFTD] = 18; semantic dementia [SD] = 14) and AD (n = 18) completed the Interpersonal Reactivity Index (IRI), a standardized questionnaire of empathy as well as a measure of perceived burden (Zarit Burden Interview) and the quality of the marital relationship (Intimate Bond Measure). Patient ratings were also obtained on the IRI. Loss of empathy was most striking in the bvFTD group with a marked discrepancy observed between carer and patient ratings for change in emotional warmth and the ability to take the perspective of others. Empathy loss in bvFTD was associated with a loss of a caring marital relationship. Empathic deficits in SD were milder by comparison to bvFTD and correlated with disease severity and increased perceived carer burden. The behavioral pattern observed in AD differed from the FTD syndromes; deficits were observed only for measures of personal distress with carers reporting that patients were less able to handle emotionally evocative situations. Results highlight that changes in aspects of empathy differ across dementia syndromes and are associated with differing carer and clinical variables. These findings might be explained by the progression of atrophy in regions that are known to be critical for empathy and social behavior and has implications for the delivery and planning of services in dementia.

Language and behavior domains enhance the value of the clinical dementia rating scale

BACKGROUND

The six domain standard Clinical Dementia Rating Scale (CDRstd) has been successful for staging patients with the clinical syndrome of probable Alzheimer's disease (AD). The CDRstd does not specifically address language dysfunction or alteration in personality and social behaviors which are prominent in behavioral variant frontotemporal dementia (bvFTD) and primary progressive aphasia (PPA).

OBJECTIVE

To determine the value of adding domains of Language (LANG), and Behavior, Comportment, and Personality (BEHAV) to the CDRstd for the evaluation of patients with bvFTD and PPA.

METHODS

Two new domains, LANG and BEHAV, were constructed to parallel the six domains sampled in the CDRstd. Clinical and neuropsychological test data were obtained from the National Alzheimer's Coordinating Center. The dataset contained information on 2550 probable AD, 88 vascular dementia, 281 dementia with Lewy body, 234 bvFTD, and 137 PPA patients.

RESULTS

There were 76.5% of bvFTD and 99.3% of PPA patients with abnormal ratings (>0) on the LANG domain; 90.2% of bvFTD and 63.5% of PPA had abnormal ratings on the BEHAV domain. In patients with a CDRstd sum of boxes score of <4, 53.7% of bvFTD had BEHAV domain and 78.6% of PPA patients had LANG domain scores>1. Among probable AD patients, 3.7% had LANG ratings that were ≥1 and 3.8% had BEHAV ratings that were ≥1. Logistic regression analyses showed that adding either the LANG or BEHAV domains to the CDRstd sum of boxes score significantly improved the discrimination between probable AD, bvFTD, and PPA.

CONCLUSIONS

The new LANG and BEHAV domains add value to the CDRstd for the characterization of the nonamnestic symptoms that are prominent in patients with bvFTD and PPA but that also occur in those with probable AD.

Monitoring progression of primary progressive aphasia: current approaches and future directions

SUMMARY Primary progressive aphasia (PPA) is a gradually progressive syndrome that robs patients of the ability to communicate. There are a variety of diagnostic challenges; international consensus has only recently been reached on the nomenclature for specific subtypes and there are a variety of underlying neurodegenerative pathologies. There are at present no established treatments, and efforts to develop treatments have been hampered by the lack of standardized methods to monitor progression of the illness. Although measures developed from work with stroke aphasia and with disorders such as Alzheimer’s disease have provided a valuable foundation for monitoring progression, PPA presents unique challenges to clinicians aiming to counsel patients and families on clinical status and prognosis, and to experts aiming to design clinical trials of potential interventions. Here we review some of the issues facing the field of PPA clinical research, summarize our current approach to monitoring progression of PPA and outline some ideas regarding goals for the development of better tools for this purpose.

Neurobehavioral differences between Alzheimer's disease and frontotemporal dementia: a meta-analysis

The differential diagnosis of Alzheimer's disease (AD) and frontotemporal dementia (FTD) remains a difficult clinical issue. A recent meta-analysis by Hutchinson and Mathias (2007) found that many cognitive tests do not adequately differentiate between these types of dementia. However, their study did not examine the ability of neurobehavioral scales to distinguish between AD and FTD. The data from 33 studies, published between January 1994 and December 2008, examining the neurobehavioral symptoms of persons with AD (N = 2,305) and FTD (N = 971) were therefore analyzed. Weighted Cohen's d effect sizes, percentage overlap statistics, confidence intervals, and fail-safe Ns were calculated for each scale. The most discriminating measures were the Schedules for Clinical Assessment in Neuropsychiatry and the Scale for Emotional Blunting. The Middelheim Frontality Score and the Frontal Behavior Inventory also had excellent discriminative ability, surpassing the cognitive tests examined previously. Numerous other scales additionally showed large and significant differences between the AD and FTD groups, highlighting the importance of assessing neurobehavioral symptoms in this context. While these latter measures may be useful in providing a clinical profile of patients with dementia, greater overlap in the scores of patients with AD and FTD limits their usefulness in the context of differential diagnosis.

Emotion, social functioning and activities of daily living in frontotemporal dementia

Social functioning in FTD is profoundly affected, and forms the basis for the clinical diagnosis of the behavioural variant of the disease (bv-FTD). In particular, there are deficits in emotional processing, but the inter-relationship of such deficits to other aspects of social functioning remains unclear. We studied patients with bv-FTD (n = 14) and AD (n = 14), and compared their performance on a test of emotion recognition with their scores on two carer-based assessments: the Disability Assessment for Dementia (DAD) of activities in daily living (ADL), and the Cambridge Behavioural Inventory (CBI). The bv-FTD group had significantly greater impairments in ADLs, and had higher scores on the CBI, compared to the AD group. Despite a deficit in emotion recognition, particularly involving negative emotions, in the FTD group relative to AD and controls, performance on this task did not correlate with ADL ratings which instead, correlated highly with carer-rated apathy levels on the CBI. The study highlights the multifactorial nature of social dysfunction in FTD which is important in the management of these patients and in designing effective behavioural and therapeutic interventions. The relationship of emotional processing to other aspects of social cognition in FTD is reviewed.

Activities of daily living in behavioral variant frontotemporal dementia: differences in caregiver and performance-based assessments

Patients with the behavioral variant of frontotemporal dementia have marked impairment in everyday life, yet little is known about factors underlying this impairment. Moreover, a recently identified subgroup with normal brain imaging has an excellent prognosis (phenocopy cases) and their performance on activities of daily living (ADL) tasks is unknown. Eighteen behavioral variant frontotemporal dementia patients were assessed on 2 ADL measures, the Disability Assessment for Dementia, a caregiver-based interview, and the Assessment of Motor and Process Skills, a performance-based instrument. Behavior change, global cognition, executive function, and magnetic resonance imaging brain atrophy were also evaluated. There was no association between the 2 ADL measures. A model combining the Addenbrooke's Cognitive Examination Revised (global cognition) and Frontal Systems Behavior Scale (frontal dysfunction) explained the variance on ADL performance. A qualitative rating distinguished between pathologic and phenocopy patients better than the performance-based assessment. Degree of frontal dysfunction and overall dementia determined the level of ADL impairment. The phenocopy patients were clearly distinguishable when evaluated using a performance-based, and even better with a qualitative rating assessment.

Combined magnetic resonance imaging and positron emission tomography brain imaging in behavioural variant frontotemporal degeneration: refining the clinical phenotype

In patients with the behavioural variant of frontotemporal dementia, prognosis is often surprisingly good when there is normal structural imaging at presentation. Imaging abnormalities are not, however, mandatory for diagnosis, which in the absence of suitable biomarkers, remains entirely clinical. We aimed to test whether cases with normal structural imaging have hypometabolism suggestive of underlying neurodegeneration, or whether it is likely that such patients are false positive diagnoses of behavioural variant frontotemporal dementia. Patients with this disease (n = 24) and age-matched controls (n = 12) underwent both magnetic resonance imaging (MRI) and quantitative fluorodeoxyglucose-positron emission tomography (FDG-PET) scanning, together with clinical and behavioural assessments. Regions of interest were used to calculate metabolic rate in frontotemporal and control regions. Using a semi-quantitative visual rating scale, patients were divided into MRI-abnormal (n = 15) and MRI-normal groups (n = 9). There was definite frontotemporal hypometabolism in the MRI-abnormal group (particularly in the mesial and orbitofrontal regions) even after accounting for brain volume loss, whereas the MRI-normal group was similar to controls in all regions. In contrast, cognitive and behavioural indices did not separate the two behavioural variant frontotemporal dementia patient groups. The results suggest that the clinical syndrome of the behavioural variant of frontotemporal dementia may not be specific for a neurodegenerative disease, and we hypothesize the existence of a phenocopy. A number of alternative neuropsychiatric and developmental explanations are discussed. We advise caution in diagnosing the illness in patients without imaging abnormalities, and propose that imaging findings are included in criteria for diagnosis.

Measuring progression in frontotemporal dementia: implications for therapeutic interventions

BACKGROUND

There is a need for instruments which can measure progression of disease in frontotemporal dementia (FTD), particularly with respect to the assessment of potential therapeutic agents.

METHODS

The Cambridge Early Onset Dementia Clinic database was reviewed for all prospectively enrolled cases of FTD with documented scores on the Mini-Mental State Examination (MMSE) or Addenbrooke's Cognitive Examination (ACE) on at least two occasions. We identified 50 cases fulfilling these criteria: pathologic confirmation was present in 11 of 16 patients who had died, 12 of the remainder had imaging abnormalities on their initial scans, and 22 had structural scans no different from controls. We compared these groups to a cohort with early AD (n = 25) and healthy controls (n = 10).

RESULTS

There was clear cognitive decline (measured by the MMSE and ACE) in patients who had died, and those with documented atrophy on initial MRI scan. In contrast, patients with FTD with normal scans showed no change in cognitive scores over a much longer interval, and serial ACE measurements paralleled those of controls. Power calculations showed that the inclusion of these patients with FTD would significantly increase the number of cases needed in any therapeutic trial.

CONCLUSION

Addenbrooke's Cognitive Examination is a simple monitoring tool which can detect progression of disease in frontotemporal dementia over a 1- to 2-year interval without the need for serial imaging. We estimated that a clinical trial that enrolled subjects with abnormal MR scans would require 135 subjects per group to detect a small effect, and 35 for a medium effect.

The Cambridge Behavioural Inventory revised

Neurobehavioural and psychiatric symptoms are common in a range of neurodegenerative disorders with distinct profiles which are helpful in the diagnosis and monitoring of these disorders. The Cambridge Behavioural Inventory (CBI) has been shown to distinguish frontotemporal dementia (FTD), Alzheimer’s disease (AD), Huntington’s disease (HD) and Parkinson’s disease (PD), but it is lengthy.

Focal posterior cingulate atrophy in incipient Alzheimer's disease

Severe posterior cingulate cortex hypometabolism is a feature of incipient, sporadic Alzheimer's disease (AD). The aim was to test the hypothesis that this region is focally atrophic in very early disease by studying AD patients at the mild cognitive impairment (MCI) stage, and, if so, to determine whether the amount of atrophy was comparable to that of the hippocampus. Twenty-four patients meeting criteria for amnestic MCI, who all subsequently progressed to fulfil AD criteria, and 28 age-matched controls, were imaged with volumetric MRI. Four regions of interest were manually traced in each hemisphere: two posterior cingulate regions (BA 23 and BA 29/30), the hippocampus (as a positive control) and the anterior cingulate (as a negative control). BA 23 and BA 29/30 were both significantly atrophic and this atrophy was comparable to that found in the hippocampus, in the absence of anterior cingulate cortex (ACC) atrophy. Contrary to previous reports, there was no evidence that posterior cingulate atrophy is specifically associated with early-onset AD. The results indicate that posterior cingulate cortex atrophy is present from the earliest clinical stage of sporadic AD and that this region is as vulnerable to neurodegeneration as the hippocampus.

Predicting rapid clinical progression in amnestic mild cognitive impairment

BACKGROUND/AIMS

We investigated whether an initial neuropsychological assessment could predict rapid progression over 12 months, from amnestic mild cognitive impairment (aMCI) to Alzheimer's disease (AD).

METHODS

A longitudinal study compared the neuropsychological profiles of 27 normal controls and 18 aMCI patients at baseline and 12 months.

RESULTS

At 12 months, 24 control subjects followed up remained cognitively normal. 7 aMCI patients (6 multiple-domain aMCI and 1 single-domain aMCI) progressed to AD, and 11 were non-progressors. Prognosis was best captured by a combination of associative learning, the paired associate learning task (PAL), and global cognition, the Addenbrooke's Cognitive Examination (ACE).

CONCLUSION

The PAL and ACE can sensitively detect meaningful differences in scores at baseline and may be used as prognostic indicators. Multiple-domain aMCI patients progressed rapidly to AD and may be more usefully labelled as early stage AD.