The relationship between extrapyramidal signs and cognitive performance in patients with Alzheimer's disease enrolled in the CERAD Study. Consortium to Establish a Registry for Alzheimer's Disease

Association between Motor Signs and Cognitive Performance in Cognitively Unimpaired Older Adults: A Cross-Sectional Study Using the NACC Database

Aiming to examine whether specific motor signs are associated with worse performance in specific cognitive domains among cognitively unimpaired (CU) individuals, we performed a cross-sectional analysis of data from the baseline evaluations of older, CU participants from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set. In total, 8149 CU (≥60 years) participants were included. Of these, 905 individuals scored ≥ 2 on at least one of the motor domains of the Unified Parkinson's Disease Rating Scale part III (UPDRSIII). Cognitively impaired individuals, participants with psychiatric disorders and/or under treatment with antipsychotic, anxiolytic, sedative or hypnotic agents were excluded. Nine motor signs were examined: hypophonia, masked facies, resting tremor, action/postural tremor, rigidity, bradykinesia, impaired chair rise, impaired posture/gait and postural instability. Their association with performance on episodic memory, semantic memory, language, attention, processing speed or executive function was assessed using crude and adjusted linear regression models. Individuals with impaired chair rise had worse episodic memory, semantic memory, processing speed and executive function, while those with bradykinesia had worse language, processing speed and executive function. Sensitivity analyses, by excluding participants with cerebrovascular disease or PD, or other Parkinsonism, produced similar results with the exception of the relationship between bradykinesia and language performance.

Extrapyramidal signs and Alzheimer's disease prognosis in a multiethnic, community-based sample of demented elders

INTRODUCTION

Extrapyramidal signs (EPS) are a common feature of Alzheimer's disease associated with worse outcomes in observational studies of dementia. Less research has been conducted on ethnic minority and non-clinic-based populations.

METHODS

One hundred and forty-two multiethnic community-dwelling participants with dementia were selected. Adjusted Cox models were fitted for mortality, cognitive (Mini Mental State Examination ≤10), functional (Blessed Dementia Rating Scale ≥10), and dependency (needs full-time care) endpoints with baseline EPS as predictor.

RESULTS

Thirty-seven participants (26.06%) had EPS at baseline. EPS predicted more rapid time to death (hazard ratio [HR] = 2.76, 95% confidence interval [CI] = 1.49, 5.42), and functional endpoint (HR = 3.88, 95% CI = 1.75, 8.62) but not cognitive and dependency endpoints. No evidence of interaction by ethnicity, age, sex, education, or apolipoprotein E ε4 polymorphism was found.

DISCUSSION

Our results partially confirm previous studies on predominantly White, clinic-based samples. Further research is needed to better understand the etiological role of EPS in AD.

Fragile X Gray Zone Alleles Are Associated With Signs of Parkinsonism and Earlier Death

BACKGROUND

Premutation size (55-199 CGG repeats) in the fragile X mental retardation 1 (FMR1) gene cause fragile X-associated tremor/ataxia syndrome, but it is unclear whether smaller "gray" zone expansions of 41-54 repeats are also associated with movement disorders. The objectives of this study were to determine the association between the FMR1 gene gray zone expansions, AGG interspersions, and the presence of parkinsonism and motor and cognitive function in an elderly community-based population.

METHODS

Automated FMR1 polymerase chain reaction was performed on existing samples from 2 longitudinal aging studies whose subjects agreed to brain donation. A detailed clinical evaluation including a modified Unified Parkinson's Disease Rating Scale score, a composite score of global motor function, 17 cognitive tests summarized as a global measure of cognition, and neuropathological examination were obtained for genotyped participants.

RESULTS

The average age of the population (n = 2362) was 85.9 ± 7.3 years, and average age at death was 88.6 ± 6.4 years (n = 1326), with 72% women. The prevalence of FMR1 gray zone alleles was 5.2% (122 of 2362). There was no difference between participants with gray zone expansions or those lacking AGG interspersions compared with normal participants in global cognition, global motor function, clinical diagnosis, or pathological changes. Gray zone alleles were associated with signs of parkinsonism in men (P = 0.01), and gray zone carrier men were more likely to die (hazard ratio, 2.34; 95% confidence interval, 1.31-4.16).

CONCLUSIONS

This is the largest study to investigate gray zone alleles in a community population. The key findings are that in men, the gray zone allele is associated with signs of parkinsonism and higher risk of death, but not with intranuclear neuronal inclusions. © 2020 International Parkinson and Movement Disorder Society.

Tauopathy in basal ganglia involvement is exacerbated in a subset of patients with Alzheimer's disease: The Hisayama study

Introduction

We have conducted the pathological cohort study of autopsied cases of Hisayama residents to reveal a recent trend of dementia-related pathology. We noticed a trend of putaminal involvement of Alzheimer's disease (AD) with parkinsonism. Then, we investigated the accurate prevalence of neurological diseases with putaminal AD pathology in the general population.

Methods

We examined a series of 291 autopsies in the Hisayama study and performed image analysis of immunohistochemistry for microtubule-associated protein tau (MAPT) and amyloid β.

Results

Approximately 65.6% and 36.1% of cases showed putaminal MAPT and amyloid deposits, respectively. Diffuse deposits of them were mainly found in the AD cases. Putaminal MAPT was highly associated with AD-related pathological criteria. Four of 22 cases with severe putaminal MAPT deposition were documented as having developed parkinsonism.

Discussion

Severe MAPT accumulation in the basal ganglia was closely related to the development of AD pathology and could occur most frequently in AD cases without comorbidities.

Apolipoprotein E e4 allele is associated with extrapyramidal symptoms in Alzheimer's disease

BACKGROUND

Extrapyramidal symptoms (EPS) are not uncommon in Alzheimer's disease (AD). As apolipoprotein E(APOE) e4 allele is a major risk factor for late-onset AD, we intend to examine the association between APOE genotype and the development of EPS in AD.

METHOD

This study describes two hundred and fifty-five clinically diagnosed AD patients aged 72 to 80 years from 2010 to 2014. We reviewed the medical charts to determine the development of EPS. APOE genotypes were also confirmed.

RESULTS

APOE e4 allele was detected in 74 patients (29%) and rigidity was among the most common EPS (61%). After adjusting the age, gender, baseline clinical dementia rating, we found AD patients carrying APOE e4 allele are more likely to develop EPS (OR: 4.515, p=0.033).

CONCLUSION

This study demonstrates the higher coexistence of EPS in AD patients with APOE e4 allele. Furthermore, the identification of APOE e4 allele in the development of EPS in AD patients supports the hypothesis that EPS may be partially attributed to AD pathology.

Extrapyramidal symptoms and cognitive test performance in patients with schizophrenia

BACKGROUND

Movement disorders are common in individuals with schizophrenia, even in those who are not exposed to antipsychotic medications. Extrapyramidal symptoms (EPS) are among the most common abnormal movements in schizophrenia, but their relationship with other features of the illness such as cognition is not well characterized.

METHODS

Three hundred and twenty-five individuals with schizophrenia who were not receiving any antipsychotic or anticholinergic medication and participated in the baseline visit of the Clinical Antipsychotic Treatment of Intervention Effectiveness study were included in the present study. EPSs were assessed using the Simpson-Angus Scale, while cognition was measured with a comprehensive neuropsychological test battery. The relationship between EPS and cognitive test performance was evaluated both dimensionally and categorically.

RESULTS

Greater severity of EPS was significantly associated with worse cognitive test performance evaluated using a composite score. Eighty-six patients were identified as having parkinsonism and these patients performed worse on cognitive tests than non-parkinsonian patients. These findings remained significant even after accounting for other variables such as severity of psychopathology, sedation, akathisia and dyskinesia.

CONCLUSIONS

The present results demonstrate that severity of EPS is reliably linked with poorer scores on tests of cognition. While this may reflect a common pathophysiology underlying neuromotor and neurocognitive deficits, it may also be the case that parkinsonian symptoms such as rigidity and bradykinesia impede test taking ability. Regardless of mechanism, inferences regarding cognitive impairment should take into account the presence of EPS, as well as other variables that may mediate cognitive test findings.

Sleepiness, parkinsonian features and sustained attention in mild Alzheimer's disease

BACKGROUND

we previously demonstrated that patients with mild Alzheimer's disease and parkinsonian features (AD + PF) are at a higher risk of having daytime sleepiness than mild AD patients without PF (AD - PF).

OBJECTIVE

to determine whether AD + PF patients demonstrate a known a consequence of daytime sleepiness, reduced performance-based sustained attention, compared with AD - PF patients.

METHODS

a nocturnal polysomnogram and a next-day multiple sleep latency test (MSLT) were performed. Between MSLT nap opportunities, a 10-min psychomotor vigilance test (PVT) was administered and analysed for reciprocal mean response times (IMEAN), number of lapses (LAPSE) and reciprocal mean slowest 10% (ISLOW).

RESULTS

a total of 35 patients met criteria (AD + PF, n = 16; AD - PF, n = 19). Comparatively, the AD + PF group had slower IMEAN results [F((1,28)) = 6.64, P < 0.05] and higher LAPSE rates [F((1,27)) = 7.57, P < 0.05]. ISLOW measures were not different between groups. When accounting for MSLT results, IMEAN and LAPSE results were no longer significantly different between groups during morning tests, but remained significantly different on afternoon tests.

CONCLUSION

PFs in mild AD are associated with decreased sustained attention as measured by the PVT. Sleepiness did not fully account for the impairment in sustained attention, suggesting that the presence of PFs has an independent negative association with sustained attention in mild AD.

Early AD pathology in a [C-11]PiB-negative case: a PiB-amyloid imaging, biochemical, and immunohistochemical study

Amyloid-β (Aβ) deposits are detectable in the brain in vivo using positron emission tomography (PET) and [C-11]-labeled Pittsburgh Compound B ([C-11]PiB); however, the sensitivity of this technique is not well understood. In this study, we examined Aβ pathology in an individual who had clinical diagnoses of probable dementia with Lewy bodies and possible Alzheimer's disease (AD) but with no detectable [C-11]PiB PET retention ([C-11]PiB(-)) when imaged 17 months prior to death. Brain samples were processed in parallel with region-matched samples from an individual with a clinical diagnosis of probable AD and a positive [C-11]PiB PET scan ([C-11]PiB(+)) when imaged 10 months prior to death. In the [C-11]PiB(-) case, Aβ plaques were sparse, occupying less than 2% cortical area, and were weakly labeled with 6-CN-PiB, a highly fluorescent derivative of PiB. In contrast, Aβ plaques occupied up to 12% cortical area in the [C-11]PiB(+) case, and were intensely labeled with 6-CN-PIB. The [C-11]PiB(-) case had low levels of [H-3]PiB binding (< 100 pmol/g) and Aβ1-42 (< 500 pmol/g) concentration except in the frontal cortex where Aβ1-42 values (788 pmol/g) approached cortical values in the [C-11]PiB(+) case (800-1, 700 pmol/g). In several cortical regions of the [C-11]PiB(-) case, Aβ1-40 levels were within the range of cortical Aβ1-40 values in the [C-11]PiB(+) case. Antemortem [C-11]PiB DVR values correlated well with region-matched postmortem measures of Aβ1-42 and Aβ1-40 in the [C-11]PiB(+), and with Aβ1-42 only in the [C-11]PiB(-) case. The low ratios of [H-3]PiB binding levels to Aβ concentrations and 6-CN-PiB to Aβ plaque loads in the [C-11]PiB(-) case indicate that Aβ pathology in the brain may be associated with low or undetectable levels of [C-11]PiB retention. Studies in greater numbers of [C-11]PiB PET autopsy cases are needed to define the Aβ concentration and [H-3]PiB binding levels required to produce a positive [C-11]PiB PET signal.

Daytime sleepiness in mild Alzheimer's disease with and without parkinsonian features

BACKGROUND

Excessive daytime sleepiness (EDS) and nocturnal sleep disruption are common in Alzheimer's disease (AD). However, little is known regarding risk factors for developing EDS and sleep disruption in AD. In AD, EDS is associated with parkinsonian motor features (PF), which are associated with faster cognitive decline. The primary aim of this exploratory study was to evaluate whether differences in EDS and nocturnal sleep disruption exist between AD participants with versus without PF.

METHODS

Thirty-six participants with mild AD were evaluated for PF using the modified motor UPDRS (mmUPDRS) scoring system and classified according to absence (AD-PF, n=19) or presence (AD+PF, n=17) of PF. EDS was assessed using questionnaires and a multiple sleep latency test (MSLT) performed the day after nocturnal polysomnogram. Participants were considered "Sleepy" or "Not Sleepy" according to mean MSLT scores (cutoff score=10.4 min).

RESULTS

Results showed that the AD+PF group were sleepier than the AD-PF group by subjective and objective measures, despite similarities in nocturnal sleep. The AD+PF group had higher scores on the Epworth Sleepiness Scale (8.5 versus 3.9, p=.001). The AD+PF group also had higher percentage of participants that had "Sleepy" MSLT scores compared to the AD-PF group (75% versus 31.6%, respectively; χ(2)=6.56, p=.01).

CONCLUSIONS

The presence of parkinsonian features may be an independent risk factor for sleepiness in mild AD.

Mild cognitive impairment in Parkinson's disease: subtypes and motor characteristics

The aims of this project were to determine the risk factors for and clinical characteristics of mild cognitive impairment (MCI) in Parkinson's disease (PD). We performed a retrospective record review of 72 non-demented PD patients (age: 57.79 +/- 10.57, duration of PD: 7.32 +/- 4.97) who completed a standardized neurological assessment, including a full neuropsychological battery, as part of their diagnostic work-up. Of these participants, 47.2% were cognitively normal and 52.8% met criteria for MCI. The majority of MCI patients had single domain MCI (23/38), the affected domains being memory (n = 9), executive function (n = 6), visuospatial skills (n = 6), and language (n = 2). The MCI group had longer duration of disease and higher postural instability and gait disorder subscale scores than the cognitively normal group. This report provides further support for use of the concept of MCI in PD research. There may be certain disease characteristics that could alert practitioners to the emergence of cognitive changes in patients. Future studies should focus on additional risk factors for MCI subtypes and their possible progression to frank dementia.

Predicting progression of Alzheimer's disease

Introduction

Clinicians need to predict prognosis of Alzheimer's disease (AD), and researchers need models of progression to develop biomarkers and clinical trials designs. We tested a calculated initial progression rate to see whether it predicted performance on cognition, function and behavior over time, and to see whether it predicted survival.

Methods

We used standardized approaches to assess baseline characteristics and to estimate disease duration, and calculated the initial (pre-progression) rate in 597 AD patients followed for up to 15 years. We designated slow, intermediate and rapidly progressing groups. Using mixed effects regression analysis, we examined the predictive value of a pre-progression group for longitudinal performance on standardized measures. We used Cox survival analysis to compare survival time by progression group.

Results

Patients in the slow and intermediate groups maintained better performance on the cognitive (ADAScog and VSAT), global (CDR-SB) and complex activities of daily living measures (IADL) (P values < 0.001 slow versus fast; P values < 0.003 to 0.03 intermediate versus fast). Interaction terms indicated that slopes of ADAScog and PSMS change for the slow group were smaller than for the fast group, and that rates of change on the ADAScog were also slower for the intermediate group, but that CDR-SB rates increased in this group relative to the fast group. Slow progressors survived longer than fast progressors (P = 0.024).

Conclusions

A simple, calculated progression rate at the initial visit gives reliable information regarding performance over time on cognition, global performance and activities of daily living. The slowest progression group also survives longer. This baseline measure should be considered in the design of long duration Alzheimer's disease clinical trials.

Consortium to Establish a Registry for Alzheimer's Disease (CERAD): the first twenty years

The Consortium to Establish a Registry for Alzheimer's Disease (CERAD) was funded by the National Institute on Aging in 1986 to develop standardized, validated measures for the assessment of Alzheimer's disease (AD). The present report describes the measures that CERAD developed during its first decade and their continued use in their original and translated forms. These measures include clinical, neuropsychological, neuropathologic, and behavioral assessments of AD and also assessment of family history and parkinsonism in AD. An approach to evaluating neuroimages did not meet the standards desired. Further evaluations that could not be completed because of lack of funding (but where some materials are available) include evaluation of very severe AD and of service use and need by patient and caregiver. The information that was developed in the U.S. and abroad permits standardized assessment of AD in clinical practice, facilitates epidemiologic studies, and provides information valuable for individual and public health planning. CERAD materials and data remain available for those wishing to use them.

Screening Potential Therapies

In Parkinson Disease (PD) as well as in stroke research there is an urgent need to both optimize the use of resources (number of patients, costs, and time) and select potential effective neuroprotective agents. The processes used to identify and study new therapies for PD may be applicable to the search for new therapies in stroke. The National Institute of Neurological Disorders and Stroke (NINDS) organized the Committee to Identify Neuroprotective Agents for Parkinson’s (CINAPS). CINAPS broadly solicited suggestions for agents and evaluated these agents using rigorous criteria. NINDS also created the NIH Exploratory Trials in PD program (NET-PD), a clinical network where CINAPS recommendations could be tested. Given multiple recommended agents, NET-PD investigators used Phase II futility designs with calibration controls, tested against an historical standard, to screen agents for testing in Phase III trials. Investigators also used the Phase II trial to assess ancillary outcome measures for use in Phase III. The observed value for the calibration controls in the first NET-PD Phase II trial was outside the 95% CI for the historical standard. Using bootstrap methodology it appeared unlikely this outcome happened by chance. The historical standard was updated using more contemporaneous data than were available at the start of the futility trials and a re-evaluation using the new threshold was conducted. Assessment of ancillary outcome measures led to a reduced set of outcome measures for use in Phase III. The CINAPS process, and lessons learned from NET-PD futility studies, particularly with respect to calibration controls and assessment of outcome measures, could enhance the choice and testing of new agents for stroke treatment.

Association of daytime napping and Parkinsonian signs in Alzheimer's disease

BACKGROUND AND PURPOSE

Excessive daytime sleepiness (EDS) is reported in Alzheimer's disease (AD), with unstable sleep-wake rhythms that worsen with advancing disease stage. EDS is also very common in Parkinson's disease (PD), regardless of disease severity. The purpose of this study was to determine whether more Parkinsonian motor signs exist in AD patients with more reported daytime napping compared to AD patients without daytime napping.

PATIENTS AND METHODS

AD patients ((National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer's Disease and Related Disorders Association) NINCDS/ADRDA criteria) were prospectively evaluated in a dementia clinic. Parkinsonian motor signs were assessed using a modified motor Unified Parkinson's Disease Rating Scale (mmUPDRS). AD patients were grouped according to daytime napping frequency: (1) minimal napping (AD-Naps), or (2) napping at least once a day (AD+Naps). Wilcoxon rank-sum tests and chi2-tests computed differences between groups for mmUPDRS, nighttime sleep disturbances, and the Mini Mental State Examination (MMSE). Statistical significance was set at P<0.05.

RESULTS

AD patients were classified as AD-Naps (n=155) or AD+Naps (n=180). Compared with AD-Naps patients, AD+Naps patients had higher total mmUPDRS scores (P<0.001), higher rigidity scores (P<0.005), and more gait impairment (P<0.001).

CONCLUSION

AD patients with more reported daytime napping had more Parkinsonian motor signs, suggesting that this subgroup may have an increased propensity for sleepiness resembling PD. Longitudinal studies with objective measures are needed to determine whether causal relationships exist between sleepiness and Parkinsonism in AD.

Interaction between inducible nitric oxide synthase and poly(ADP-ribose) polymerase in focal ischemic brain injury

BACKGROUND AND PURPOSE

Overactivation of the DNA repair enzyme poly(ADP-ribose) polymerase (PARP) contributes to ischemic brain injury. Because PARP upregulates proinflammatory genes, we investigated whether inducible nitric oxide synthase (iNOS), a gene involved in the deleterious effects of postischemic inflammation, participates in the mechanisms by which PARP activation contributes to cerebral ischemic injury.

METHODS

The middle cerebral artery (MCA) was occluded in mice for 20 minutes using an intravascular filament, and injury volume was measured 72 hours later in Nissl-stained brain sections. mRNA expression was assessed in the postischemic brain by the quantitative "real-time" polymerase chain reaction.

RESULTS

The PARP inhibitor PJ34 reduced infarct volume and attenuated postischemic iNOS mRNA upregulation by 72%. To determine whether iNOS contributes to the toxicity of PARP, the iNOS inhibitor aminoguanidine was co-administered with PARP inhibitors. Unexpectedly, co-administration of PARP and iNOS inhibitors, or treatment of iNOS-null mice with PARP inhibitors, abrogated the protective effect afforded by iNOS or PARP inhibition alone. The loss of neuroprotection was associated with upregulation of the inflammatory genes iNOS, intercellular adhesion molecule-1, and gp91(phox).

CONCLUSIONS

The results suggest that iNOS expression contributes to the deleterious effects exerted by PARP activation in cerebral ischemia. However, iNOS activity is required for the protective effect of PARP inhibition and, conversely, PARP activity must be present for iNOS inhibition to be effective. The findings unveil a previously unrecognized deleterious interaction between iNOS and PARP that is relevant to the development of combination therapies for ischemic stroke.

Alpha-2 macroglobulin I1000 V polymorphism in Chinese sporadic Alzheimer's disease and Parkinson's disease

Several lines of evidence have revealed some overlapping pathologies in Alzheimer's disease (AD) and Parkinson's disease (PD). Although the alpha-2 macroglobulin gene (A2M) might be a risk factor of these two neurodegenerative diseases, conclusions from different studies have remained conflicting. Here we studied the role of A2M I1000 V polymorphism in both AD and PD in a Chinese Han population. We found that the A2M I/V genotype is associated with both AD (odds ratio (OR)=2.55, 95% confidential interval (95% CI): 1.20-5.43, attributable fraction (AF)=13.65%) and PD (OR=3.03, 95% CI: 1.30-7.02, AF=16.51%). After classifying according to the age of onset, this association is only detected in early-onset AD patients (OR=3.96, 95% CI: 1.28-12.26) and late-onset PD patients (OR=2.61, 95% CI: 0.97-7.09). Therefore, we conclude that in our samples, the A2M I/V genotype might be a susceptibility variant, even with minor effect, for both sporadic AD and PD.

Toward wisdom from failure: lessons from neuroprotective stroke trials and new therapeutic directions

BACKGROUND

Neuroprotective drugs for acute stroke have appeared to work in animals, only to fail when tested in humans. With the failure of so many clinical trials, the future of neuroprotective drug development is in jeopardy. Current hypotheses and methodologies must continue to be reevaluated, and new strategies need to be explored. Summary of Review- In part 1, we review key challenges and complexities in translational stroke research by focusing on the "disconnect" in the way that neuroprotective agents have traditionally been assessed in clinical trials compared with animal models. In preclinical studies, determination of neuroprotection has relied heavily on assessment of infarct volume measurements (instead of functional outcomes), short-term (instead of long-term) end points, transient (instead of permanent) ischemia models, short (instead of extended) time windows for drug administration, and protection of cerebral gray matter (instead of both gray and white matter). Clinical trials have often been limited by inappropriately long time windows, insufficient statistical power, insensitive outcome measures, inclusion of protocol violators, failure to target specific stroke subtypes, and failure to target the ischemic penumbra. In part 2, we explore new concepts in ischemic pathophysiology that should encourage us also to think beyond the hyperacute phase of ischemia and consider the design of trials that use multiagent therapy and exploit the capacity of the brain for neuroplasticity and repair.

CONCLUSIONS

By recognizing the strengths and limitations of animal models of stroke and the shortcomings of previous clinical trials, we hope to move translational research forward for the development of new therapies for the acute and subacute stages after stroke.

Genetic study of apolipoprotein E gene, alpha-1 antichymotrypsin gene in sporadic Parkinson disease

Several lines of evidence have suggested some common genetic risk factors for Alzheimer disease (AD) and Parkinson disease (PD) because there are some overlapping pathologies in these two neurodegenerative diseases. In the present study, we investigated the role of Apolipoprotein E gene polymorphism and the signal peptide polymorphism in alpha-1 antichymotrypsin (ACT) gene in idiopathic sporadic PD. The study was performed in a sample consisting of 68 PD cases and 160 healthy subjects in Shanghai China. We found no significant differences of ACT gene polymorphic distribution between PD cases and controls. The ApoE gene epsilon2/epsilon4 genotype was significantly more frequent in PD subjects (chi2 = 7.126, df = 1, P = 0.008) and conferred a 12.70 times susceptibility for PD (OR = 12.62, 95% CI: 1.445-110.17, chi2 = 5.259, P < 0.05, AF = 4.59%). No interaction of ApoE and ACT genes was detected in PD. Therefore, our data suggested that the ApoE epsilon2/epsilon4 genotype might be a susceptibility variant of moderate effect for sporadic idiopathic PD in our samples, whereas the ACT gene signal peptide polymorphism might not.

Extrapyramidal symptoms and signs in Alzheimer's disease: prevalence and correlation with the first symptom

OBJECTIVES

To determine the prevalence and clinical correlates of extrapyramidal signs (EPS) in outpatients with probable Alzheimer's disease (AD); to examine the appearance of EPS in association with the first symptom that led the patient or family to ask for medical help; to examine the association of the prevalence of EPS with gender, age at onset of the disease, duration of the disease, severity of dementia, functional disability, and potential use of neuroleptics; and to address the issue of the possible role of EPS as a predictive factor for the clinical course of the disease.

PATIENTS AND METHODS

We examined 126 patients meeting NINCDS-ADRDA* criteria for probable AD and 29 healthy, nondementia controls of comparable age and gender. Thirteen of the patients taking neuroleptics at the time of the examination were excluded from the main study group and formed a separate subgroup of AD/neuroleptics-positive. Twenty-eight of the AD/neuroleptics-free patients were re-examined during an 18-month period in order to determine the possible role of EPS as a predictive factor of the clinical course of the disease.

RESULTS

Only 8 percent of the AD/neuroleptics-free patients were free of EPS, while the corresponding percentage in the control group was 61.5 percent. The most common types of EPS presented in the patient group were hypomimia ([facial mask] 60 percent), difficulty in talking (53.66 percent), bradykinesia (51.4 percent), postural instability (47.33 percent), abnormal gait (34.66), and rigidity (26 percent), respectively. No significant differences were found when examining for the presence of resting tremor, other tremors, dystonias, and dyskinesias. With regard to the presence of EPS and the first symptom, no significant difference was found among patients whose first complaint was memory disorder (probable AD) and patients with other symptoms. When examining the association between the prevalence of EPS and gender or age at onset of the disease, no special correlation was detected. However, such a correlation was found between the prevalence of EPS and duration of the disease, as indicated by the fact that EPS appear in 78.9 percent of the patients with a duration of illness less than two years, but in 97 percent of the patients with a corresponding duration of two years or more. The mean duration of the disease in patients appearing with EPS is found to be 2.68 +/- 1.98 years. The presence of EPS increases proportionally with the progression of the disease and cognitive and functional decline. Patients with poor results in the MMSE (score of less than 11) appear to present EPS at a greater percentage than those with better performance on the examination (MMSE scores greater than 11). With regard to the association between EPS and functional ability in AD, it seems that the presence of EPS imposes difficulties in daily activities, as seen by the fact that patients with EPS have lower FRSSD scores (mean +/- SD: 14.87 +/- 10.53) than patients without EPS (5 +/- 2.58). After controlling for duration of the disease, the use of neuroleptics is found to influence the appearance of EPS in patients with AD. Almost all of the patients AD/neuroleptics-positive patients presented EPS (100 percent), while 92 percent of the AD/neuroleptics-free patients manifested such symptoms. Finally, we re-evaluated 28 patients, who were part of the initial AD/neuroleptics-free group, in order to determine whether the appearance of EPS could have prognostic value for the clinical course of the disease. Patients who presented EPS at initial examination appeared to deteriorate faster, mainly cognitively, but also functionally. The mean decrease in MMSE scores in patients with EPS was found to be 2.65 +/- 3.46; while in patients without EPS at initial visit, MMSE scores were 0.63 +/- 3.88. The functional decline seems to be less influenced by the presence of EPS. The corresponding mean decrease in FRSSD scores of the two groups was 2.1 +/- 5.55 and 1.8 +/- 2.1, respectively.

Motor cortex disinhibition in Alzheimer's disease

OBJECTIVES

To explore subclinical disturbances in the motor cortex of patients with Alzheimer's disease (AD).

METHODS

We used transcranial magnetic stimulation in a paired pulse technique to test intracortical inhibition (ICI) and intracortical facilitation in mildly to moderately demented AD patients with a normal neurological examination. Patients were studied before and during treatment with the cholinesterase inhibitor donepezil.

RESULTS

AD patients had a reduced ICI compared to an age-matched control group. The amount of disinhibition correlated with the severity of dementia. Treatment with 10 mg donepezil daily was associated with an increase of ICI.

CONCLUSIONS

The subclinical motor cortex disinhibition in AD patients indicates a functional disturbance, and is probably associated with a cholinergic deficit.

'Yes' ifs, ands or buts: examining performance and correlates of the repetition task in the mini-mental state examination

The aim of this study was to examine whether the type of sentence used in the repetition task included in the Mini-Mental State Examination (MMSE) affected performance in a group of 79 demented and 19 non-demented Hebrew-speaking elderly persons. The cognitive functioning of the participants was assessed using the MMSE and CAMCOG examinations. The performance of the repetition task was evaluated by using three sentences: the literal translation of the English language expression used in the original MMSE; a well-known Hebrew proverb consisting of monosyllabic words and rhythmic effects; and another well-known Hebrew proverb without such attributes. Only a third of the participants successfully repeated the literally translated expression. It showed low predictive value and was highly affected by education. The well-known Hebrew monosyllabic proverb showed moderate predictive value but no discriminatory ability. The other well-known Hebrew proverb performed the best. The translation of the repetition task in the MMSE to other languages is problematic. Strict adherence to the original language proved to be the least desirable choice.

Diagnostic certainty of a voluntary bipolar disorder case registry

BACKGROUND

Strategies for identifying and recruiting persons with bipolar disorder are of importance as interest in studying this relatively uncommon, but highly disabling illness increases. The development and implementation of a bipolar disorder case registry and the assessment of diagnostic certainty of the resulting sample are described.

METHODS

Eight hundred and four individuals who self-reported a history of bipolar disorder were recruited. Telephone interviewers gathered demographic information and clinical, medical and treatment history information. One hundred randomly-selected registrants completed an in-person structured diagnostic interview. Self-report of diagnosis was compared to the results of the diagnostic interview.

RESULTS

Ninety three percent of registrants interviewed met criteria for a lifetime bipolar spectrum diagnosis; of those, 76.3% were diagnosed with bipolar I disorder. Agreement between self-reported and SCID diagnoses was 93%, indicating that self-report of a bipolar diagnosis is highly reliable. Two-thirds had experienced at least one other lifetime Axis I diagnosis, with substance abuse/dependence (55.9%) and panic disorder (19.4%) the most common comorbidities.

LIMITATIONS

Since nearly all of the sample have previously been diagnosed as having bipolar disorder by a professional, the sample's representativeness of the population as a whole may be somewhat limited.

CONCLUSIONS

Persons with bipolar disorder can accurately identify themselves as having the disorder via a telephone interview, indicating that a case registry method is a useful strategy for recruiting very large samples of persons with this disorder. Such large samples will allow for further study of treatment variations among patient subgroups, of pathways to treatment, and of the effectiveness of new treatments.