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Angelopoulou E, Koros C, Hatzimanolis A, Stefanis L, Scarmeas N, Papageorgiou SG. Exploring the Genetic Landscape of Mild Behavioral Impairment as an Early Marker of Cognitive Decline: An Updated Review Focusing on Alzheimer's Disease. Int J Mol Sci 2024; 25:2645. [PMID: 38473892 DOI: 10.3390/ijms25052645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
The clinical features and pathophysiology of neuropsychiatric symptoms (NPSs) in dementia have been extensively studied. However, the genetic architecture and underlying neurobiological mechanisms of NPSs at preclinical stages of cognitive decline and Alzheimer's disease (AD) remain largely unknown. Mild behavioral impairment (MBI) represents an at-risk state for incident cognitive impairment and is defined by the emergence of persistent NPSs among non-demented individuals in later life. These NPSs include affective dysregulation, decreased motivation, impulse dyscontrol, abnormal perception and thought content, and social inappropriateness. Accumulating evidence has recently begun to shed more light on the genetic background of MBI, focusing on its potential association with genetic factors related to AD. The Apolipoprotein E (APOE) genotype and the MS4A locus have been associated with affective dysregulation, ZCWPW1 with social inappropriateness and psychosis, BIN1 and EPHA1 with psychosis, and NME8 with apathy. The association between MBI and polygenic risk scores (PRSs) in terms of AD dementia has been also explored. Potential implicated mechanisms include neuroinflammation, synaptic dysfunction, epigenetic modifications, oxidative stress responses, proteosomal impairment, and abnormal immune responses. In this review, we summarize and critically discuss the available evidence on the genetic background of MBI with an emphasis on AD, aiming to gain insights into the potential underlying neurobiological mechanisms, which till now remain largely unexplored. In addition, we propose future areas of research in this emerging field, with the aim to better understand the molecular pathophysiology of MBI and its genetic links with cognitive decline.
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Affiliation(s)
- Efthalia Angelopoulou
- 1st Department of Neurology, Aiginition University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Christos Koros
- 1st Department of Neurology, Aiginition University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Alexandros Hatzimanolis
- 1st Department of Psychiatry, Aiginition University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, Aiginition University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Nikolaos Scarmeas
- 1st Department of Neurology, Aiginition University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
- Department of Neurology, Columbia University, New York, NY 10032, USA
| | - Sokratis G Papageorgiou
- 1st Department of Neurology, Aiginition University Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
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Ji X, Peng X, Tang H, Pan H, Wang W, Wu J, Chen J, Wei N. Alzheimer's disease phenotype based upon the carrier status of the apolipoprotein E ɛ4 allele. Brain Pathol 2024; 34:e13208. [PMID: 37646624 PMCID: PMC10711266 DOI: 10.1111/bpa.13208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 08/05/2023] [Indexed: 09/01/2023] Open
Abstract
The apolipoprotein E ɛ4 allele (APOE4) is universally acknowledged as the most potent genetic risk factor for Alzheimer's disease (AD). APOE4 promotes the initiation and progression of AD. Although the underlying mechanisms are unclearly understood, differences in lipid-bound affinity among the three APOE isoforms may constitute the basis. The protein APOE4 isoform has a high affinity with triglycerides and cholesterol. A distinction in lipid metabolism extensively impacts neurons, microglia, and astrocytes. APOE4 carriers exhibit phenotypic differences from non-carriers in clinical examinations and respond differently to multiple treatments. Therefore, we hypothesized that phenotypic classification of AD patients according to the status of APOE4 carrier will help specify research and promote its use in diagnosing and treating AD. Recent reviews have mainly evaluated the differences between APOE4 allele carriers and non-carriers from gene to protein structures, clinical features, neuroimaging, pathology, the neural network, and the response to various treatments, and have provided the feasibility of phenotypic group classification based on APOE4 carrier status. This review will facilitate the application of APOE phenomics concept in clinical practice and promote further medical research on AD.
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Affiliation(s)
- Xiao‐Yu Ji
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
- Brain Function and Disease LaboratoryShantou University Medical CollegeGuangdongChina
| | - Xin‐Yuan Peng
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
| | - Hai‐Liang Tang
- Fudan University Huashan Hospital, Department of Neurosurgery, State Key Laboratory for Medical NeurobiologyInstitutes of Brain Science, Shanghai Medical College‐Fudan UniversityShanghaiChina
| | - Hui Pan
- Shantou Longhu People's HospitalShantouGuangdongChina
| | - Wei‐Tang Wang
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
| | - Jie Wu
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
- Brain Function and Disease LaboratoryShantou University Medical CollegeGuangdongChina
| | - Jian Chen
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
| | - Nai‐Li Wei
- Department of NeurosurgeryThe First Affiliated Hospital of Shantou University Medical CollegeGuangdongChina
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Modrego PJ, de Cerio LD, Lobo A. The Interface between Depression and Alzheimer's Disease. A Comprehensive Approach. Ann Indian Acad Neurol 2023; 26:315-325. [PMID: 37970263 PMCID: PMC10645209 DOI: 10.4103/aian.aian_326_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/04/2023] [Accepted: 07/04/2023] [Indexed: 11/17/2023] Open
Abstract
Depression and Alzheimer's disease (AD) are frequent interacting diseases in the elderly with a negative impact on the quality of life of patients and caregivers. Late-life depression may be regarded either as an early symptom of AD or a risk factor for AD, depending on the context. This review was focused on the latest developments in the fields of the neurobiological basis and treatment of depression in AD. We found that some plausible hypotheses are emerging to correlate with depression in AD, such as neuroinflammation and dysimmune regulation. It seems that depression is not related to amyloid deposition, but this issue is not completely resolved. The response to antidepressants is controversial according to the evidence from 10 small double-blind randomized placebo-controlled clinical trials with antidepressants in AD patients with depression: four with sertraline, one with three arms (sertraline, mirtazapine, placebo), one with fluoxetine, one with imipramine, one with clomipramine, one with escitalopram, and one with vortioxetine. The total number of treated patients completing the trials was 638. The main criterion of a positive response was a reduction in the scores of clinical scales for depression of at least 50%. The weighted OR (odds ratio) was calculated with the method of Mantel-Haenszel: 1.29; 95% CI: 0.77-2.16. No significant differences were found compared with placebo. Antidepressants did not have a meaningful negative influence on cognition, which was measured with the mini-mental state examination (MMSE) in 18 clinical trials. Alternatives other than drugs are also discussed. Although there have been important advances in this field, pathophysiology and treatment deserve further research.
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Affiliation(s)
- Pedro J. Modrego
- Servicio de Neurologia, Hospital Miguel Servet de Zaragoza, Spain
| | | | - Antonio Lobo
- Department of Psychiatry, University of Zaragoza, Spain
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Jiang J, Hong Y, Li W, Wang A, Jiang S, Jiang T, Wang Y, Wang L, Yang S, Ren Q, Zou X, Xu J. Chain Mediation Analysis of the Effects of Nutrition and Cognition on the Association of Apolipoprotein E ɛ4 with Neuropsychiatric Symptoms in Alzheimer's Disease. J Alzheimers Dis 2023; 96:669-681. [PMID: 37840496 DOI: 10.3233/jad-230577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND Apolipoprotein E (APOE) is the most recognized risk gene for cognitive decline and clinical progression of late-onset Alzheimer's disease (AD); nonetheless, its association with neuropsychiatric symptoms (NPSs) remains inconclusive. OBJECTIVE To investigate the association of APOE ɛ4 with NPSs and explore nutritional status and cognition as joint mediators of this association. METHODS Between June 2021 and October 2022, patients with amnestic mild cognitive impairment (aMCI) or AD were recruited from the Chinese Imaging, Biomarkers, and Lifestyle Study. NPSs were assessed using the Neuropsychiatric Inventory, while global cognition and nutritional status were evaluated using the Mini-Mental State Examination (MMSE) and Mini-Nutritional Assessment (MNA), respectively. Simple mediation and multiple chain mediation models were developed to examine the mediating effects of the MNA and MMSE scores on the relationship between APOE ɛ4 and specific neuropsychiatric symptom. RESULTS Among 310 patients, 229 (73.87%) had NPSs, and 110 (35.48%) carried APOE ɛ4. Patients with APOE ɛ4 were more likely to have hallucinations (p = 0.014), apathy (p = 0.008), and aberrant motor activity (p = 0.018). MNA and MMSE scores mediated the association between APOE ɛ4 and hallucinations (17.97% and 37.13%, respectively), APOE ɛ4 and apathy (30.73% and 57.72%, respectively), and APOE ɛ4 and aberrant motor activity (17.82% and 34.24%), respectively. Chain-mediating effects of MNA and MMSE scores on the association of APOE ɛ4 with hallucinations, apathy, and aberrant motor activity after adjusting for confounding factors were 6.84%, 11.54%, and 6.19%, respectively. CONCLUSION Nutritional status and cognition jointly mediate the association between APOE ɛ4 and neuropsychiatric symptoms in patients with aMCI or AD.
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Affiliation(s)
- Jiwei Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
| | - Yin Hong
- Department of Health Management, Beijing Tian Tan Hospital, Capital Medical University, Fengtai District, Beijing, China
| | - Wenyi Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
| | - Shirui Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
| | - Tianlin Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
| | - Yanli Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
| | - Linlin Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
| | - Shiyi Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
| | - Qiwei Ren
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
| | - Xinying Zou
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
| | - Jun Xu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Fengtai District, Beijing, China
- National Clinical Research Center for Neurological Diseases, Fengtai District, Beijing, China
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Guo P, Chen S, Wang H, Wang Y, Wang J. A Systematic Analysis on the Genes and Their Interaction Underlying the Comorbidity of Alzheimer's Disease and Major Depressive Disorder. Front Aging Neurosci 2022; 13:789698. [PMID: 35126089 PMCID: PMC8810513 DOI: 10.3389/fnagi.2021.789698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/20/2021] [Indexed: 12/21/2022] Open
Abstract
Background During the past years, clinical and epidemiological studies have indicated a close relationship between Alzheimer's disease (AD) and other mental disorders like major depressive disorder (MDD). At the same time, a number of genes genetically associated with AD or MDD have been detected. However, our knowledge on the mechanisms that link the two disorders is still incomplete, and controversies exist. In such a situation, a systematic analysis on these genes could provide clues to understand the molecular features of two disorders and their comorbidity. Methods In this study, we compiled the genes reported to be associated with AD or MDD by a comprehensive search of human genetic studies and genes curated in disease-related database. Then, we investigated the features of the shared genes between AD and MDD using the functional enrichment analysis. Furthermore, the major biochemical pathways enriched in the AD- or MDD-associated genes were identified, and the cross talks between the pathways were analyzed. In addition, novel candidate genes related to AD and MDD were predicted in the context of human protein-protein interactome. Results We obtained 650 AD-associated genes, 447 MDD-associated genes, and 77 shared genes between AD and MDD. The functional analysis revealed that biological processes involved in cognition, neural development, synaptic transmission, and immune-related processes were enriched in the common genes, indicating a complex mechanism underlying the comorbidity of the two diseases. In addition, we conducted the pathway enrichment analysis and found 102 shared pathways between AD and MDD, which involved in neuronal development, endocrine, cell growth, and immune response. By using the pathway cross-talk analysis, we found that these pathways could be roughly clustered into four modules, i.e., the immune response-related module, the neurodevelopmental module, the cancer or cell growth module, and the endocrine module. Furthermore, we obtained 37 novel candidate genes potentially related to AD and MDD with node degrees > 5.0 by mapping the shared genes to human protein-protein interaction network (PPIN). Finally, we found that 37 novel candidate genes are significantly expressed in the brain. Conclusion These results indicated shared biological processes and pathways between AD and MDD and provided hints for the comorbidity of AD and MDD.
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Affiliation(s)
- Pan Guo
- School of Biomedical Engineering, Tianjin Medical University, Tianjin, China
| | - Shasha Chen
- School of Biomedical Engineering, Tianjin Medical University, Tianjin, China
| | - Hao Wang
- School of Biomedical Engineering, Tianjin Medical University, Tianjin, China
| | - Yaogang Wang
- School of Public Health, Tianjin Medical University, Tianjin, China
- *Correspondence: Yaogang Wang
| | - Ju Wang
- School of Biomedical Engineering, Tianjin Medical University, Tianjin, China
- Ju Wang
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Dissanayake AS, Tan YB, Bowie CR, Butters MA, Flint AJ, Gallagher D, Golas AC, Herrmann N, Ismail Z, Kennedy JL, Kumar S, Lanctot KL, Mah L, Mulsant BH, Pollock BG, Rajji TK, Tau M, Maraj A, Churchill NW, Tsuang D, Schweizer TA, Munoz DG, Fischer CE. Sex Modifies the Associations of APOEɛ4 with Neuropsychiatric Symptom Burden in Both At-Risk and Clinical Cohorts of Alzheimer's Disease. J Alzheimers Dis 2022; 90:1571-1588. [PMID: 36314203 DOI: 10.3233/jad-220586] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Recent work suggests that APOEɛ4/4 females with Alzheimer's disease (AD) are more susceptible to developing neuropsychiatric symptoms (NPS). OBJECTIVE To examine the interaction of sex and APOEɛ4 status on NPS burden using two independent cohorts: 1) patients at risk for AD with mild cognitive impairment and/or major depressive disorder (n = 252) and 2) patients with probable AD (n = 7,261). METHODS Regression models examined the interactive effects of sex and APOEɛ4 on the number of NPS experienced and NPS Severity. APOEɛ3/4 and APOEɛ4/4 were pooled in the at-risk cohort due to the sample size. RESULTS In the at-risk cohort, there was a significant sex*APOEɛ4 interaction (p = 0.007) such that the association of APOEɛ4 with NPS was greater in females than in males (incident rate ratio (IRR) = 2.0). APOEɛ4/4 females had the most NPS (mean = 1.9) and the highest severity scores (mean = 3.5) of any subgroup. In the clinical cohort, APOEɛ4/4 females had significantly more NPS (IRR = 1.1, p = 0.001, mean = 3.1) and higher severity scores (b = 0.31, p = 0.015, mean = 3.7) than APOEɛ3/3 females (meanNPS = 2.9, meanSeverity = 3.3). No association was found in males. CONCLUSION Our study suggests that sex modifies the association of APOEɛ4 on NPS burden. APOEɛ4/4 females may be particularly susceptible to increased NPS burden among individuals with AD and among individuals at risk for AD. Further investigation into the mechanisms behind these associations are needed.
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Affiliation(s)
- Andrew S Dissanayake
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
| | - Yu Bin Tan
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
| | - Christopher R Bowie
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Queen's University, Kingston, ON, Canada
| | - Meryl A Butters
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Alastair J Flint
- Centre for Mental Health, University Health Network, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Damien Gallagher
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Neuropsychopharmacology Research Group, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Angela C Golas
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nathan Herrmann
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Zahinoor Ismail
- Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - James L Kennedy
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sanjeev Kumar
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Krista L Lanctot
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Neuropsychopharmacology Research Group, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Linda Mah
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Rotman Research Institute, Baycrest Health Science Centre, Toronto, ON, Canada
| | - Benoit H Mulsant
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bruce G Pollock
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Division of Geriatric Psychiatry, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Toronto Dementia Research Alliance, University of Toronto, Toronto, ON, Canada
| | - Tarek K Rajji
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Toronto Dementia Research Alliance, University of Toronto, Toronto, ON, Canada
| | - Michael Tau
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Unity Health, St. Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anika Maraj
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Unity Health, St. Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Nathan W Churchill
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
- Unity Health, St. Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Debby Tsuang
- GRECC, VA Puget Sound and Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Tom A Schweizer
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
- Unity Health, St. Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David G Munoz
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
- Unity Health, St. Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Corinne E Fischer
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Unity Health, St. Michaels Hospital, University of Toronto, Toronto, Ontario, Canada
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Stella F, Pais MV, Loureiro JC, Radanovic M, Forlenza OV. Neuropsychiatric symptoms and cerebrovascular risk in non-demented elders: cross-sectional study using the mild behavioural impairment checklist (MBI-C). Psychogeriatrics 2022; 22:55-66. [PMID: 34704636 DOI: 10.1111/psyg.12776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/20/2021] [Accepted: 10/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Neuropsychiatric symptoms (NPS) may represent early clinical manifestations of evolving brain diseases. Studies underpin the occurrence of NPS in the context of mild cognitive impairment (MCI) and prodromal Alzheimer's disease, where symptoms referred to as 'mild behavioural impairment' (MBI) have been shown to predict conversion to dementia and to hasten cognitive/functional decline. However, the association between NPS and cerebrovascular risk factors has been poorly investigated, despite the high prevalence of the latter among individuals with MCI. The aim of the present study was to investigate the association between MBI and cerebrovascular risk in a clinical sample of non-demented elders. METHODS Sixty-five MCI and 15 cognitively unimpaired older adults were cross-sectionally assessed with the Mild Behavioural Impairment Checklist (MBI-C), using the cut-off score > 6.5 to define positive screening. Participants were submitted to the Hachinski Ischaemic Score (HIS) to account for cerebrovascular symptoms, vascular risk, and related comorbidities. Neuroimaging scans (magnetic resonance imaging and/or 18F-fluorodeoxyglucose-positron emission tomography) and apolipoprotein E genotype were obtained. RESULTS Positive associations were found between total MBI-C scores and increasing number of comorbidities present (0-2 comorbidities), but not with three comorbidities. Two domains of the MBI-C-impulse dyscontrol and social inappropriateness-followed the same trend of the MBI-C total score, with higher scores with the increasing numbers of comorbidities. No significant associations were found between MBI symptoms and HIS or cerebrovascular burden in neuroimaging assessment. CONCLUSION We found weak associations between MBI-C total score and the presence of comorbidities with cerebrovascular risk, but not with structural or functional neuroimaging abnormalities or HIS. This finding may represent that the presence of comorbidities adds limited risk to the occurrence of MBI in this sample of non-demented elders.
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Affiliation(s)
- Florindo Stella
- Laboratory of Neuroscience (LIM-27), Departamento e Instituto de Psiquiatria, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, Brazil.,Instituto Nacional de Biomarcadores em Neuropsiquiatria (InBion), Conselho Nacional de Desenvolvimento Científico e Tecnológico, Sao Paulo, Brazil.,UNESP-Universidade Estadual Paulista, Instituto de Biociências, Sao Paulo, Brazil
| | - Marcos V Pais
- Laboratory of Neuroscience (LIM-27), Departamento e Instituto de Psiquiatria, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, Brazil.,Instituto Nacional de Biomarcadores em Neuropsiquiatria (InBion), Conselho Nacional de Desenvolvimento Científico e Tecnológico, Sao Paulo, Brazil
| | - Júlia C Loureiro
- Laboratory of Neuroscience (LIM-27), Departamento e Instituto de Psiquiatria, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, Brazil.,Instituto Nacional de Biomarcadores em Neuropsiquiatria (InBion), Conselho Nacional de Desenvolvimento Científico e Tecnológico, Sao Paulo, Brazil
| | - Marcia Radanovic
- Laboratory of Neuroscience (LIM-27), Departamento e Instituto de Psiquiatria, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, Brazil.,Instituto Nacional de Biomarcadores em Neuropsiquiatria (InBion), Conselho Nacional de Desenvolvimento Científico e Tecnológico, Sao Paulo, Brazil
| | - Orestes V Forlenza
- Laboratory of Neuroscience (LIM-27), Departamento e Instituto de Psiquiatria, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, Brazil.,Instituto Nacional de Biomarcadores em Neuropsiquiatria (InBion), Conselho Nacional de Desenvolvimento Científico e Tecnológico, Sao Paulo, Brazil
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Apolipoprotein E ϵ4 allele and neuropsychiatric symptoms among older adults in Central Africa (EPIDEMCA study). Int Psychogeriatr 2021; 33:295-306. [PMID: 33715647 DOI: 10.1017/s1041610220003993] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To evaluate the association between neuropsychiatric symptoms and apolipoprotein E (APOE) ϵ4 allele among older people in Central African Republic (CAR) and the Republic of Congo (ROC). DESIGN Multicenter population-based study following a two-phase design. SETTING From 2011 to 2012, rural and urban areas of CAR and ROC. PARTICIPANTS People aged 65 and over. MEASUREMENTS Following screening using the Community Screening Interview for Dementia, participants with low cognitive scores (CSI-D ≤ 24.5) underwent clinical assessment. Dementia diagnosis followed the DSM-IV criteria and Peterson's criteria were considered for Mild Cognitive Impairment (MCI). Neuropsychiatric symptoms were evaluated through the brief version of the Neuropsychiatric Inventory (NPI-Q). Blood samples were taken from all consenting participants before APOE genotyping was performed by polymerase chain reaction (PCR). Logistic regression models were used to evaluate the association between the APOE ϵ4 allele and neuropsychiatric symptoms. RESULTS Overall, 322 participants had complete information on both neuropsychiatric symptoms and APOE status. Median age was 75.0 years and 81.1% were female. Neuropsychiatric symptoms were reported by 192 participants (59.8%) and at least 1 APOE ϵ4 allele was present in 135 (41.9%). APOE ϵ4 allele was not significantly associated with neuropsychiatric symptoms but showed a trend toward a protective effect in some models. CONCLUSION This study is the first one investigating the association between APOE ϵ4 and neuropsychiatric symptoms among older people in sub-Saharan Africa (SSA). Preliminary findings indicate that the APOE ϵ4 allele was not associated with neuropsychiatric symptoms. Further research seems, however, needed to investigate the protective trend found in this study.
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Huang MF, Lee WJ, Yeh YC, Liao YC, Wang SJ, Yang YH, Chen CS, Fuh JL. Genetics of neuropsychiatric symptoms in patients with Alzheimer's disease: A 1-year follow-up study. Psychiatry Clin Neurosci 2020; 74:645-651. [PMID: 32909371 DOI: 10.1111/pcn.13150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/19/2020] [Accepted: 09/03/2020] [Indexed: 12/20/2022]
Abstract
AIM The aim of this study was to investigate the associations between candidate gene variants and domains of neuropsychiatric symptoms (NPS) and the changes in these associations over a 1-year period. METHODS Seven hundred and ninety-three Taiwanese participants (47.8% female) with Alzheimer's disease (AD) were enrolled. Genes associated with a risk of developing AD were selected as candidate genes. NPS were assessed using the Neuropsychiatric Inventory Questionnaire (NPI-Q), and the NPI-Q total score and sub-scores for the Psychosis, Mood, and Frontal Syndrome domains were calculated. RESULTS Patients with AD and the APOE ε4 allele exhibited more obvious symptoms of psychosis. Mood symptoms were associated with CD33 rs3865444 and EPHA1 rs11767557, and frontal symptoms were associated with SORL1 rs3824968. A 1-year Time × Alleles interaction effect of CD33 rs3865444 on mood symptoms was discerned. CONCLUSION Risk genes of AD, which are also associated with NPS, are APOE ε4 for psychosis, CD33 and EPHA1 for mood symptoms, and SORL1 for frontal symptoms. The association between CD33 and mood symptoms is dynamic and could change over 1 year; however, the results should be interpreted with caution because corrections for multiple comparisons were not performed.
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Affiliation(s)
- Mei-Feng Huang
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Psychiatry, School of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wei-Ju Lee
- Neurological Institute, Dementia and Parkinson's Disease Integrated Center, and Center for Geriatrics and Gerontology, Taichung Veterans General Hospital, Taichung, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, National Yang-Ming University Schools of Medicine, Taipei, Taiwan
| | - Yi-Chun Yeh
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Psychiatry, School of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yi-Chu Liao
- Faculty of Medicine, National Yang-Ming University Schools of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Faculty of Medicine, National Yang-Ming University Schools of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsin Yang
- National Institute of Cancer Research, National Health Research Institutes, Tainan, Taiwan
| | - Cheng-Sheng Chen
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.,Department of Psychiatry, School of Medicine and Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jong-Ling Fuh
- Faculty of Medicine, National Yang-Ming University Schools of Medicine, Taipei, Taiwan.,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
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10
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Bateman DR, Gill S, Hu S, Foster ED, Ruthirakuhan MT, Sellek AF, Mortby ME, Matušková V, Ng KP, Tarawneh RM, Freund-Levi Y, Kumar S, Gauthier S, Rosenberg PB, Ferreira de Oliveira F, Devanand DP, Ballard C, Ismail Z. Agitation and impulsivity in mid and late life as possible risk markers for incident dementia. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12016. [PMID: 32995467 PMCID: PMC7507499 DOI: 10.1002/trc2.12016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 02/17/2020] [Indexed: 12/14/2022]
Abstract
To identify knowledge gaps regarding new-onset agitation and impulsivity prior to onset of cognitive impairment or dementia the International Society to Advance Alzheimer's Research and Treatment Neuropsychiatric Syndromes (NPS) Professional Interest Area conducted a scoping review. Extending a series of reviews exploring the pre-dementia risk syndrome Mild Behavioral Impairment (MBI), we focused on late-onset agitation and impulsivity (the MBI impulse dyscontrol domain) and risk of incident cognitive decline and dementia. This scoping review of agitation and impulsivity pre-dementia syndromes summarizes the current biomedical literature in terms of epidemiology, diagnosis and measurement, neurobiology, neuroimaging, biomarkers, course and prognosis, treatment, and ongoing clinical trials. Validations for pre-dementia scales such as the MBI Checklist, and incorporation into longitudinal and intervention trials, are needed to better understand impulse dyscontrol as a risk factor for mild cognitive impairment and dementia.
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Affiliation(s)
- Daniel R Bateman
- Department of Psychiatry Indiana University School of Medicine Indianapolis Indiana
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana
| | - Sascha Gill
- Department of Clinical Neurosciences; and the Ron and Rene Ward Centre for Healthy Brain Aging Research; Hotchkiss Brain Institute University of Calgary Calgary Alberta Canada
| | - Sophie Hu
- Community Health Sciences, and O'Brien Institute for Public Health University of Calgary Calgary Alberta Canada
| | - Erin D Foster
- Ruth Lilly Medical Library Indiana University School of Medicine Indianapolis Indiana
- University of California Berkeley Berkeley CA
| | - Myuri T Ruthirakuhan
- Hurvitz Brain Sciences Research Program Sunnybrook Research Institute Toronto Ontario Canada
- Department of Pharmacology and Toxicology University of Toronto Ontario Canada
| | | | - Moyra E Mortby
- School of Psychology University of New South Wales Sydney New South Wales Australia
- Neuroscience Research Australia University of New South Wales Sydney New South Wales Australia
| | - Veronika Matušková
- International Clinical Research Center St. Anne's University Hospital Brno Brno Czech Republic
- Memory Disorders Clinic, Department of Neurology, 2nd Faculty of Medicine Charles University in Prague and Motol University Hospital Prague Czech Republic
| | - Kok Pin Ng
- Department of Neurology National Neuroscience Institute Singapore Singapore
| | - Rawan M Tarawneh
- Department of Neurology, College of Medicine The Ohio State University Columbus Ohio USA
| | - Yvonne Freund-Levi
- Center for Alzheimer Research, Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society Karolinska Institute Stockholm Sweden
- School of Medical Sciences Örebro University Örebro Sweden
| | - Sanjeev Kumar
- Centre for Addiction and Mental Health Toronto Ontario Canada
- Department of Psychiatry University of Toronto Ontario Canada
| | - Serge Gauthier
- McGill Center for Studies in Aging McGill University Montreal Quebec Canada
| | - Paul B Rosenberg
- Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral, Sciences Johns Hopkins University School of Medicine Baltimore Maryland
| | - Fabricio Ferreira de Oliveira
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina Federal University of São Paulo (UNIFESP), São Paulo São Paulo Brazil
| | - D P Devanand
- New York State Psychiatric Institute and Department of Psychiatry and Department of Psychiatry, College of Physicians and Surgeons Columbia University New York New York
| | - Clive Ballard
- College of Medicine and Health The University of Exeter Exeter UK
| | - Zahinoor Ismail
- Department of Clinical Neurosciences; and the Ron and Rene Ward Centre for Healthy Brain Aging Research; Hotchkiss Brain Institute University of Calgary Calgary Alberta Canada
- Community Health Sciences, and O'Brien Institute for Public Health University of Calgary Calgary Alberta Canada
- Department of Psychiatry, and the Mathison Centre for Mental Health Research & Education Cumming School of Medicine, University of Calgary Calgary Alberta Canada
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11
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Clinical Aspects of Neurobehavioral Symptoms of Dementia. Dement Neurocogn Disord 2020; 19:54-64. [PMID: 32602280 PMCID: PMC7326614 DOI: 10.12779/dnd.2020.19.2.54] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/11/2020] [Accepted: 05/17/2020] [Indexed: 12/03/2022] Open
Abstract
Neurobehavioral symptoms of dementia (NBSD) are very common and are significant symptoms of the illness, contributing most to caregiver burdens and often resulting in premature institutionalization of the person with dementia. The main symptoms of NBSD are anxiety, depression, delusions, and hallucinations. NBSD produce significant problems for both patients and caregivers. The pathophysiology of NBSD is determined by genetic, structural, or environmental factors. Therefore, treatment of NBSD requires continuous and organic cooperation between patients, caregivers, social environments, and doctors. Therefore, it is important for neurologists, who mainly view NBSD for dementia patients, to increase their understanding of these more comprehensive areas as well as the latest insights and treatments to help patients and caregivers.
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12
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Banning LCP, Ramakers IHGB, Deckers K, Verhey FRJ, Aalten P. Apolipoprotein E and affective symptoms in mild cognitive impairment and Alzheimer's disease dementia: A systematic review and meta-analysis. Neurosci Biobehav Rev 2018; 96:302-315. [PMID: 30513312 DOI: 10.1016/j.neubiorev.2018.11.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 10/24/2018] [Accepted: 11/30/2018] [Indexed: 01/17/2023]
Abstract
OBJECTIVE APOE status has been associated to affective symptoms in cognitively impaired subjects, with conflicting results. METHODS Databases CINAHL, Embase, PsychINFO and PubMed were searched for studies evaluating APOE genotype with affective symptoms in MCI and AD dementia. Symptoms were meta-analyzed separately and possible sources of heterogeneity were examined. RESULTS Fifty-three abstracts fulfilled the eligibility criteria. No association was found between the individual symptoms and APOE ε4 carriership or zygosity. For depression and anxiety, only pooled unadjusted estimates showed positive associations with between-study heterogeneity, which could be explained by variation in study design, setting and way of symptom assessment. CONCLUSIONS There is no evidence that APOE ε4 carriership or zygosity is associated with the presence of depression, anxiety, apathy, agitation, irritability or sleep disturbances in cognitively impaired subjects. Future research should shift its focus from this single polymorphism to a more integrated view of other biological factors.
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Affiliation(s)
- Leonie C P Banning
- Alzheimer Center Limburg, Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Inez H G B Ramakers
- Alzheimer Center Limburg, Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Kay Deckers
- Alzheimer Center Limburg, Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Frans R J Verhey
- Alzheimer Center Limburg, Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Pauline Aalten
- Alzheimer Center Limburg, Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands.
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13
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Ruthirakuhan M, Lanctôt KL, Di Scipio M, Ahmed M, Herrmann N. Biomarkers of agitation and aggression in Alzheimer's disease: A systematic review. Alzheimers Dement 2018; 14:1344-1376. [DOI: 10.1016/j.jalz.2018.04.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 04/12/2018] [Accepted: 04/26/2018] [Indexed: 01/24/2023]
Affiliation(s)
- Myuri Ruthirakuhan
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoTorontoONCanada
| | - Krista L. Lanctôt
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoTorontoONCanada
- Geriatric PsychiatrySunnybrook Health Sciences CentreTorontoONCanada
- Department of PsychiatryUniversity of TorontoTorontoONCanada
| | - Matteo Di Scipio
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
| | - Mehnaz Ahmed
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Department of Pharmacology and ToxicologyUniversity of TorontoTorontoONCanada
| | - Nathan Herrmann
- Hurvitz Brain Sciences ProgramSunnybrook Research InstituteTorontoONCanada
- Geriatric PsychiatrySunnybrook Health Sciences CentreTorontoONCanada
- Department of PsychiatryUniversity of TorontoTorontoONCanada
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14
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Kim J, Fischer CE, Schweizer TA, Munoz DG. Gender and Pathology-Specific Effect of Apolipoprotein E Genotype on Psychosis in Alzheimer's Disease. Curr Alzheimer Res 2018; 14:834-840. [PMID: 28219318 DOI: 10.2174/1567205014666170220150021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 02/10/2017] [Accepted: 02/20/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Symptoms of psychosis is one of the common clinical manifestations of Alzheimer's disease (AD). However, the pathophysiology behind psychosis is unknown. OBJECTIVE The aim of the present study was to explore the relationship between Apolipoprotein E (APOE) genotype, Lewy body pathology, and psychosis in AD. METHOD The data was obtained from the National Alzheimer's disease Coordinating Centre (NACC), using the Uniform Data Set and the Neuropathology Data Set. Subjects with frequent neuritic plaque on CERAD, and Braak Stage of V or VI, corresponding to high probability of AD based on the NIA-AA Regan criteria were included in the analysis. RESULTS Subjects with two copies of ε4 alleles were significantly more likely to develop psychosis, both delusions and/or hallucinations, during the course of their illness. This association was gender-specific, only reaching significance in females. Our findings further showed that presence of two copies of ε4 allele was positively associated with the formation of Lewy bodies. Only in females with Lewy bodies was the effect of two copies of ε4 allele significant, reaching an odd ratio of 4.5. CONCLUSION The APOE ε4 allele has a female-specific effect in inducing psychosis in AD through the formation of Lewy bodies.
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Affiliation(s)
- Julia Kim
- Keenan Research Centre for Biomedical Research, the Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Corinne E Fischer
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - Tom A Schweizer
- Institute of Medical Sciences, University of Toronto, Toronto, ON, M5S 1A8, Canada
| | - David G Munoz
- Department of Laboratory Medicine, Room 2-097 CC Wing, St. Michael's Hospital, 30 Bond Street. Toronto, Ontario, M5B 1W8, Canada
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15
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Qian W, Fischer CE, Schweizer TA, Munoz DG. Association Between Psychosis Phenotype and APOE Genotype on the Clinical Profiles of Alzheimer's Disease. Curr Alzheimer Res 2018; 15:187-194. [PMID: 28847281 PMCID: PMC6211852 DOI: 10.2174/1567205014666170829114346] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 07/07/2017] [Accepted: 08/29/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Psychosis is a common phenomenon in Alzheimer's disease (AD). The APOE ε4 allele is the strongest genetic risk factor for the development of AD, but its association with psychosis remains unclear. OBJECTIVE We investigated the associations between psychosis, subdivided into delusions and hallucinations, as well as APOE ε4 allele on cognitive and functional outcomes. Secondarily, we investigated the associations between APOE ε4, Lewy bodies, and psychosis. METHODS Data from the National Alzheimer's Coordinating Center (NACC) were used. Nine hundred patients with a confirmed diagnosis of AD based on the NIA-AA Reagan were included in the analysis. Global cognition was assessed using the Mini-Mental State Exam (MMSE) and functional status was assessed using the Functional Activities Questionnaire (FAQ). Psychosis status was determined using the Neuropsychiatric Inventory Questionnaire (NPI-Q). Factorial design was used to assess the effects of psychosis and APOE ε4, as well as their interaction. RESULTS Psychosis and the presence of APOE ε4 were both associated with lower MMSE scores, while only psychosis was associated with higher FAQ scores. Furthermore, patients with hallucinations had lower MMSE and higher FAQ scores than patients with only delusions. There was a significant interaction effect between psychosis and APOE ε4 on MMSE scores, with APOE ε4 negatively affecting patients with hallucinations-only psychosis. APOE ε4 was positively associated with the presence of Lewy body pathology, and both were found to be more prevalent in psychotic patients, with a stronger association with hallucinations. CONCLUSION Psychosis in AD was associated with greater cognitive and functional impairments. Patients with hallucinations-with or without delusions-conferred even greater deficits compared to patients with only delusions. The APOE ε4 allele was associated with worse cognition, especially for patients with hallucination-only psychosis. APOE ε4 may mediate cognitive impairment in the hallucinations phenotype through the development of Lewy bodies. Our findings support that subtypes of psychosis should be evaluated separately.
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Affiliation(s)
- Winnie Qian
- Keenan Research Centre for Biomedical Research, The Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Corinne E. Fischer
- Keenan Research Centre for Biomedical Research, The Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Faculty of Medicine, Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Tom A. Schweizer
- Keenan Research Centre for Biomedical Research, The Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
- Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, University of Toronto, ON, Canada
- Division of Neurosurgery, St. Michael’s Hospital, Toronto, ON, Canada
| | - David G. Munoz
- Keenan Research Centre for Biomedical Research, The Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Division of Pathology, St. Michael’s Hospital, Toronto, ON, Canada
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16
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Kolanowski A, Boltz M, Galik E, Gitlin LN, Kales HC, Resnick B, Van Haitsma KS, Knehans A, Sutterlin JE, Sefcik JS, Liu W, Petrovsky DV, Massimo L, Gilmore-Bykovskyi A, MacAndrew M, Brewster G, Nalls V, Jao YL, Duffort N, Scerpella D. Determinants of behavioral and psychological symptoms of dementia: A scoping review of the evidence. Nurs Outlook 2017; 65:515-529. [PMID: 28826872 DOI: 10.1016/j.outlook.2017.06.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/20/2017] [Accepted: 06/06/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Behavioral and psychological symptoms of dementia (BPSD) are prevalent in people with neurodegenerative diseases. PURPOSE In this scoping review the Kales, Gitlin and Lykestos framework is used to answer the question: What high quality evidence exists for the patient, caregiver and environmental determinants of five specific BPSD: aggression, agitation, apathy, depression and psychosis? METHOD An a priori review protocol was developed; 692 of 6013 articles retrieved in the search were deemed eligible for review. Gough's Weight of Evidence Framework and the Cochrane Collaboration's tool for assessing risk of bias were used. The findings from 56 high quality/low bias articles are summarized. DISCUSSION Each symptom had its own set of determinants, but many were common across several symptoms: neurodegeneration, type of dementia, severity of cognitive impairments, and declining functional abilities, and to a lesser extent, caregiver burden and communication. CONCLUSION Research and policy implications are relevant to the National Plan to Address Alzheimer's Disease.
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Affiliation(s)
| | - Marie Boltz
- College of Nursing, Penn State, University Park, PA
| | | | - Laura N Gitlin
- Department of Community-Public Health, Center for Innovative Care in Aging, Johns Hopkins School of Nursing, Baltimore, MD; Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD
| | - Helen C Kales
- The Program for Positive Aging, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, Ann Arbor, MI
| | | | - Kimberly S Van Haitsma
- Program for Person Centered Living Systems of Care, College of Nursing, The Pennsylvania State University, University Park, PA; Polisher Research Institute, Madlyn & Leonard Abramson Center for Jewish Life, North Wales, PA
| | - Amy Knehans
- Penn State College of Medicine, Harrell Health Sciences Library, Research & Learning Commons, Hershey, PA
| | | | | | - Wen Liu
- College of Nursing, The University of Iowa, Iowa City, IA
| | | | | | | | - Margaret MacAndrew
- Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - Glenna Brewster
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, School of Nursing, University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Danny Scerpella
- Center for Innovative Care in Aging, Johns Hopkins School of Nursing, Johns Hopkins University, Baltimore, MD
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Upregulation of Mineralocorticoid Receptor in the Hypothalamus Associated with a High Anxiety-like Level in Apolipoprotein E4 Transgenic Mice. Behav Genet 2017; 47:416-424. [DOI: 10.1007/s10519-017-9843-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 03/01/2017] [Indexed: 12/12/2022]
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18
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Oliveira FFD, Chen ES, Smith MC, Bertolucci PH. Associations of cerebrovascular metabolism genotypes with neuropsychiatric symptoms and age at onset of Alzheimer's disease dementia. ACTA ACUST UNITED AC 2017; 39:95-103. [PMID: 28099631 PMCID: PMC7111454 DOI: 10.1590/1516-4446-2016-1991] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 07/05/2016] [Indexed: 12/03/2022]
Abstract
Objective: To study associations of cerebrovascular metabolism genotypes and haplotypes with age at Alzheimer’s disease dementia (AD) onset and with neuropsychiatric symptoms according to each dementia stage. Methods: Consecutive outpatients with late-onset AD were assessed for age at dementia onset and Neuropsychiatric Inventory scores according to Clinical Dementia Rating scores, apolipoprotein E gene (APOE) haplotypes, angiotensin-converting enzyme gene (ACE) variants rs1800764 and rs4291, low-density lipoprotein cholesterol receptor gene (LDLR) variants rs11669576 and rs5930, cholesteryl ester transfer protein gene (CETP) variants I422V and TaqIB, and liver X receptor beta gene (NR1H2) polymorphism rs2695121. Results: Considering 201 patients, only APOE-ɛ4 carriers had earlier dementia onset in multiple correlations, as well as less apathy, more delusions, and more aberrant motor behavior. Both ACE polymorphisms were associated with less intense frontally mediated behaviors. Regarding LDLR variants, carriers of the A allele of rs11669576 had less anxiety and more aberrant motor behavior, whereas carriers of the A allele of rs5930 had less delusions, less anxiety, more apathy, and more irritability. CETP variants that included G alleles of I422V and TaqIB were mostly associated with less intense frontally mediated behaviors, while severely impaired carriers of the T allele of rs2695121 had more anxiety and more aberrant motor behavior. Conclusion: Though only APOE haplotypes affected AD onset, cerebrovascular metabolism genotypes were associated with differences in several neuropsychiatric manifestations of AD.
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Affiliation(s)
- Fabricio F de Oliveira
- Departamento de Neurologia e Neurocirurgia, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
| | - Elizabeth S Chen
- Departamento de Morfologia e Genética, EPM, UNIFESP, São Paulo, SP, Brazil
| | - Marilia C Smith
- Departamento de Morfologia e Genética, EPM, UNIFESP, São Paulo, SP, Brazil
| | - Paulo H Bertolucci
- Departamento de Neurologia e Neurocirurgia, Escola Paulista de Medicina (EPM), Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil
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Stern Y, Gu Y, Cosentino S, Azar M, Lawless S, Tatarina O. The Predictors study: Development and baseline characteristics of the Predictors 3 cohort. Alzheimers Dement 2017; 13:20-27. [PMID: 27219818 PMCID: PMC5118195 DOI: 10.1016/j.jalz.2016.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/18/2016] [Accepted: 04/09/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The Predictors study was designed to predict the length of time to major disease outcomes in Alzheimer's disease (AD) patients. Here, we describe the development of a new, Predictors 3, cohort. METHODS Patients with prevalent or incident AD and individuals at-risk for developing AD were selected from the North Manhattan community and followed annually with instruments comparable to those used in the original two Predictors cohorts. RESULTS The original Predictors cohorts were clinic based and racially/ethnically homogenous (94% white, 6% black; 3% Hispanic). In contrast, the 274 elders in this cohort are community-based and ethnically diverse (39% white, 40% black, 21% other; 78% Hispanic). Confirming previous observations, psychotic features were associated with poorer function and mental status and extrapyramidal signs with poorer function. DISCUSSION This new cohort will allow us to test observations made in our original clinic-based cohorts in patients that may be more representative of the general community.
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Affiliation(s)
- Yaakov Stern
- Cognitive Neuroscience Division, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | - Yian Gu
- Cognitive Neuroscience Division, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Stephanie Cosentino
- Cognitive Neuroscience Division, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Martina Azar
- Cognitive Neuroscience Division, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Siobhan Lawless
- Cognitive Neuroscience Division, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Oksana Tatarina
- Cognitive Neuroscience Division, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
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van der Linde RM, Dening T, Stephan BCM, Prina AM, Evans E, Brayne C. Longitudinal course of behavioural and psychological symptoms of dementia: systematic review. Br J Psychiatry 2016; 209:366-377. [PMID: 27491532 PMCID: PMC5100633 DOI: 10.1192/bjp.bp.114.148403] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 02/27/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND More information about the pattern of behavioural and psychological symptoms of dementia (BPSD) in the course of dementia is needed to inform patients and clinicians and to design future interventions. AIMS To determine the persistence and incidence of BPSD and their relation to cognitive function, in individuals with dementia or in cohorts investigated for dementia onset. METHOD A systematic literature review analysed the baseline prevalence, persistence and incidence of 11 symptoms. The review was conducted according to established guidelines with the exception that we could not exclude the possibilities of bias in the studies examined. RESULTS The 59 included studies showed considerable heterogeneity in their objectives and methods. The symptoms hyperactivity and apathy showed high persistence and incidence; depression and anxiety low or moderate persistence and moderate incidence; and psychotic symptoms low persistence with moderate or low incidence. CONCLUSIONS Despite heterogeneity across studies in terms of setting, focus and length of follow-up, there were clinically relevant differences in the longitudinal courses of different BPSD. Apathy was the only symptom with high baseline prevalence, persistence and incidence during the course of dementia.
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Affiliation(s)
- Rianne M. van der Linde
- Correspondence: R. van der Linde, Department of Public Health and Primary Care, Herchel Smith Building, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK.
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Quaranta D, Vita MG, Bizzarro A, Masullo C, Piccininni C, Gainotti G, Marra C. Cognitive and behavioral determinants of psychotic symptoms in Alzheimer's disease. Dement Geriatr Cogn Disord 2015; 39:194-206. [PMID: 25572669 DOI: 10.1159/000369161] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 10/16/2014] [Indexed: 11/19/2022] Open
Abstract
AIMS To investigate the relationship between psychotic symptoms and cognitive impairment in Alzheimer's disease (AD). METHODS A total of 108 subjects affected by AD were subdivided into subjects without delusions (ND), subjects with paranoid delusions (PD), subjects with delusional misidentifications (DM), subjects with both DM and PD (DM+PD), subjects with visual hallucinations (v-HALL), and subjects without visual hallucinations (N-HALL). RESULTS PD and ND subjects performed similarly on neuropsychological tests, while DM patients performed significantly worse than PD and ND patients. v-HALL patients performed worse than N-HALL patients on memory, visuospatial, and executive functions. As for behavioral features, DM and v-HALL subjects reported higher scores on the abnormal motor behavior subscale of the neuropsychiatric inventory (NPI); PD subjects reported higher scores on the disinhibition subscale of the NPI. The severity of PD was predicted by the severity of disinhibition (B = 0.514; p = 0.016) but not by neuropsychological performances. The severity of DM was predicted by age (B = 0.099; p = 0.048) and MMSE (B = -0.233; p = 0.001). The severity of v-HALL was predicted by age (B = 0.052; p = 0.037) and scores on an immediate visual memory task (B = -0.135; p = 0.007). CONCLUSIONS The occurrence of PD may require the relative sparing of cognitive functions and be favored by frontal lobe dysfunction, while DM is associated with the overall level of cognitive impairment. Finally, v-HALL are associated with the impairment of visuospatial abilities.
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Affiliation(s)
- Davide Quaranta
- Research Center for Neuropsychology, Institute of Neurology, Catholic University, Rome, Italy
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Woodward MC. Pharmacological Treatment of Challenging Neuropsychiatric Symptoms of Dementia. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2005.tb00348.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Pink A, Stokin GB, Bartley MM, Roberts RO, Sochor O, Machulda MM, Krell-Roesch J, Knopman DS, Acosta JI, Christianson TJ, Pankratz VS, Mielke MM, Petersen RC, Geda YE. Neuropsychiatric symptoms, APOE ε4, and the risk of incident dementia: a population-based study. Neurology 2015; 84:935-43. [PMID: 25653291 DOI: 10.1212/wnl.0000000000001307] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the population-based interaction between a biological variable (APOE ε4), neuropsychiatric symptoms, and the risk of incident dementia among subjects with prevalent mild cognitive impairment (MCI). METHODS We prospectively followed 332 participants with prevalent MCI (aged 70 years and older) enrolled in the Mayo Clinic Study of Aging for a median of 3 years. The diagnoses of MCI and dementia were made by an expert consensus panel based on published criteria, after reviewing neurologic, cognitive, and other pertinent data. Neuropsychiatric symptoms were determined at baseline using the Neuropsychiatric Inventory Questionnaire. We used Cox proportional hazards models, with age as a time scale, to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). Models were adjusted for sex, education, and medical comorbidity. RESULTS Baseline agitation, nighttime behaviors, depression, and apathy significantly increased the risk of incident dementia. We observed additive interactions between APOE ε4 and depression (joint effect HR = 2.21; 95% CI = 1.24-3.91; test for additive interaction, p < 0.001); and between APOE ε4 and apathy (joint effect HR = 1.93; 95% CI = 0.93-3.98; test for additive interaction, p = 0.031). Anxiety, irritability, and appetite/eating were not associated with increased risk of incident dementia. CONCLUSIONS Among prevalent MCI cases, baseline agitation, nighttime behaviors, depression, and apathy elevated the risk of incident dementia. There was a synergistic interaction between depression or apathy and APOE ε4 in further elevating the risk of incident dementia.
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Affiliation(s)
- Anna Pink
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Gorazd B Stokin
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Mairead M Bartley
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Rosebud O Roberts
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Ondrej Sochor
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Mary M Machulda
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Janina Krell-Roesch
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - David S Knopman
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Jazmin I Acosta
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Teresa J Christianson
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - V Shane Pankratz
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Michelle M Mielke
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Ronald C Petersen
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria
| | - Yonas E Geda
- From Mayo Clinic Translational Neuroscience and Aging Program (A.P., J.K.-R., J.I.A., Y.E.G.), and Departments of Psychiatry & Psychology (Y.E.G.) and Neurology (Y.E.G.), Mayo Clinic, Scottsdale, AZ; Departments of Neurology (M.M.B., D.S.K., R.C.P.) and Psychiatry & Psychology (M.M. Machulda), Divisions of Epidemiology (R.O.R., M.M. Mielke, R.C.P., Y.E.G.) and Biomedical Statistics and Informatics (T.J.C., V.S.P.), Department of Health Sciences Research, Mayo Clinic, Rochester, MN; International Clinical Research Center (A.P., G.B.S., O.S., J.K.-R., Y.E.G.), Brno, Czech Republic; and Paracelsus Medical University (A.P.), Salzburg, Austria.
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Donati A, Studer J, Petrillo S, Pocnet C, Popp J, Rossier J, von Gunten A. The evolution of personality in patients with mild cognitive impairment. Dement Geriatr Cogn Disord 2014; 36:329-39. [PMID: 24022337 DOI: 10.1159/000353895] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2013] [Indexed: 11/19/2022] Open
Abstract
AIMS To describe personality traits and their changes in mild cognitive impairment (MCI) and control subjects. METHODS Sixty-three MCI and 90 control subjects were asked to describe their current personality traits by the Structured Interview for the Five-Factor Model (SIFFM). For each subject, a close relative retrospectively assessed these descriptions both as to the previous and current personality traits, using the Revised NEO Personality Inventory, Form R (NEO-PI-R). RESULTS Self-assessed MCI subjects reported significantly lower scores in the openness dimension than control subjects [F(1, 150) = 9.84, p = 0.002, ηp(2) = 0.06]. In current observer ratings, MCI subjects had higher scores on neuroticism [F(1, 137) = 7.55, p = 0.007, ηp(2) = 0.05] and lower ones on extraversion [F(1, 137) = 6.40, p = 0.013, ηp(2) = 0.04], openness [F(1, 137) = 9.93, p = 0.002, ηp(2) = 0.07], agreeableness [F(1, 137) = 10.18, p = 0.002, ηp(2) = 0.07] and conscientiousness [F(1, 137) = 25.96, p < 0.001, ηp(2) = 0.16]. Previous personality traits discriminated the groups as previous openness [odds ratio (OR) = 0.97, 95% confidence interval (CI) = 0.95-0.99, p = 0.014] and conscientiousness (OR = 0.96, 95% CI 0.94-0.98, p = 0.001) were negatively related to MCI group membership. In MCI subjects, conscientiousness [F(1, 137) = 19.20, p < 0.001, ηp(2) = 0.12] and extraversion [F(1, 137) = 22.27, p < 0.001, ηp(2) = 0.14] decreased between previous and current evaluations and neuroticism increased [F(1, 137) = 22.23, p < 0.001, ηp(2) = 0.14], whereas no significant change was found in control subjects. CONCLUSIONS MCI subjects undergo significant personality changes. Thus, personality assessment may aid the early detection of dementia.
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Affiliation(s)
- A Donati
- Service of Old Age Psychiatry, Department of Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
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Ford AH. Neuropsychiatric aspects of dementia. Maturitas 2014; 79:209-15. [PMID: 24794580 DOI: 10.1016/j.maturitas.2014.04.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 03/28/2014] [Accepted: 04/01/2014] [Indexed: 11/15/2022]
Abstract
Dementia affects approximately 6.5% of people over the age of 65. Whilst cognitive impairment is central to the dementia concept, neuropsychiatric symptoms are invariably present at some stage of the illness. Neuropsychiatric symptoms result in a number of negative outcomes for the individual and their caregivers and are associated with higher rates of institutionalization and mortality. A number of factors have been associated with neuropsychiatric symptoms including neurobiological changes, dementia type, and illness severity and duration. Specific patient, caregiver and environmental factors are also important. Neuropsychiatric symptoms can be broadly divided into four clusters: psychotic symptoms, mood/affective symptoms, apathy, and agitation/aggression. Neuropsychiatric symptoms tend to persist over time although differing symptom profiles exist at various stages of the illness. Assessment should take into account the presenting symptoms together with an appreciation of the myriad of likely underlying causes for the symptoms. A structured assessment/rating tool can be helpful. Management should focus on non-pharmacological measures initially with pharmacological approaches reserved for more troubling symptoms. Pharmacological approaches should target specific symptoms although the evidence-base for pharmacological management is quite modest. Any medication trial should include an adequate appreciation of the risk-benefit profile in individual patients and discussion of these with both the individual and their caregiver.
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Affiliation(s)
- Andrew H Ford
- Western Australian Centre for Health & Ageing (M573), Centre for Medical Research, University of Western Australia, 35 Stirling Highway, Crawley, Perth, WA 6009, Australia.
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Tsuno N, Homma A. What is the association between depression and Alzheimer’s disease? Expert Rev Neurother 2014; 9:1667-76. [DOI: 10.1586/ern.09.106] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Zahodne LB, Devanand DP, Stern Y. Coupled cognitive and functional change in Alzheimer's disease and the influence of depressive symptoms. J Alzheimers Dis 2013; 34:851-60. [PMID: 23302654 DOI: 10.3233/jad-121921] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In Alzheimer's disease (AD), cognition and function are only moderately correlated in cross-sectional studies, and studies of their longitudinal association are less common. One potential non-cognitive contributor to function is depression, which has been associated with poorer clinical outcomes. The current study investigated longitudinal associations between functional abilities, cognitive status, and depressive symptoms in AD. 517 patients diagnosed with probable AD and enrolled in The Multicenter Study of Predictors of Disease Course in Alzheimer's Disease were included. Patients were followed at 6-month intervals over 5.5 years. Longitudinal changes in the Blessed Dementia Rating Scale, modified Mini-Mental State Exam, and the depression subscale of the Columbia University Scale for Psychopathology in AD were examined in a multivariate latent growth curve model that controlled for gender, age, education, and recruitment site. Results showed that cognition and function worsened over the study period, whereas depressive symptoms were largely stable. Rates of change in cognition and function were correlated across participants and coupled within participants, indicating that they travel together over time. Worse initial cognitive status was associated with faster subsequent functional decline, and vice versa. Higher level of depressive symptoms was associated with worse initial functioning and faster subsequent cognitive and functional decline. These findings highlight the importance of both cognitive and psychiatric assessment for functional prognosis. Targeting both cognitive and depressive symptoms in the clinical treatment of AD may have incremental benefit on functional abilities.
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Affiliation(s)
- Laura B Zahodne
- Cognitive Neuroscience Division, Department of Neurology and Taub Institute for Research on Alzheimer's Disease and The Aging Brain, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA
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Miloyan BH, Razani J, Larco A, Avila J, Chung J. Aspects of Attention Predict Real-World Task Performance in Alzheimer's Disease. APPLIED NEUROPSYCHOLOGY-ADULT 2013; 20:203-210. [PMID: 23406263 DOI: 10.1080/09084282.2012.685133] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
More research is needed to examine the relationship between specific neuropsychological functions and observation-based daily activity tests in patients with Alzheimer's disease (AD). Fifty-six patients with AD were administered tests of attention and processing speed and an observation-based activities-of-daily-living (ADL) task. Complex short-term attention capacity best predicted real-world task performance, accounting for several domains of ADL functioning. These results suggest that complex attention requiring working-memory systems, but not simple attention or processing speed, account for moderate portions of variability in daily task performance. These results may aid in understanding the attentional processes required for performing daily activities and can be useful to health care professionals in treatment planning.
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Affiliation(s)
- Beyon H Miloyan
- a Department of Psychology , California State University , Northridge , California
| | - Jill Razani
- a Department of Psychology , California State University , Northridge , California
| | - Andrea Larco
- a Department of Psychology , California State University , Northridge , California
| | - Justina Avila
- a Department of Psychology , California State University , Northridge , California
| | - Julia Chung
- b Department of Psychiatry , Harbor-UCLA Medical Center , Torrance , California
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Cognitive decline and dementia risk in older adults with psychotic symptoms: a prospective cohort study. Am J Geriatr Psychiatry 2013; 21:119-28. [PMID: 23343485 DOI: 10.1016/j.jagp.2012.10.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2011] [Revised: 03/07/2012] [Accepted: 04/23/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To study the temporal association between psychotic symptoms with cognitive decline and incident dementia. DESIGN Population-based prospective cohort study. SETTING General population in England and Wales. PARTICIPANTS A subsample of 2,025 participants of the Medical Research Council Cognitive Function and Ageing Study, representing a study sample of 11,916 nondemented adults age 65 years or older. MEASUREMENTS Baseline presence of psychotic symptoms was assessed with the Geriatric Mental State. Cognitive decline (Cambridge Cognitive Examination) and incident dementia (Automated Geriatric Examination for Computer Assisted Taxonomy diagnosis) were evaluated at 2, 6, and 10 years from baseline. RESULTS A total of 330 participants reported baseline symptoms of paranoid delusions, misidentification, or hallucinations, estimated to represent 13.4% of the older general population without dementia. Psychotic symptoms were cross-sectionally associated with worse cognitive functioning, and individuals with psychotic symptoms displayed more rapid cognitive decline from baseline to a 6-year follow-up, especially in nonmemory functions, than people without such symptoms. They further carried an increased overall risk of later dementia (odds ratio = 2.76, 95% confidence interval = 1.75-4.36). The risk increment was observed independently of baseline cognition, depression, anxiety, and vascular risk factors, increased with increasing numbers of psychotic symptoms, and was highest in people age 65-74 years. CONCLUSIONS Older adults with psychotic symptoms are vulnerable to develop dementia and might be a promising target for indicated prevention strategies. Their neuropsychological functioning should be evaluated on a regular basis.
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Association of serotonin and dopamine gene pathways with behavioral subphenotypes in dementia. Neurobiol Aging 2012; 33:791-803. [DOI: 10.1016/j.neurobiolaging.2010.06.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 06/10/2010] [Accepted: 06/16/2010] [Indexed: 11/22/2022]
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Proitsi P, Powell JF. Missense substitutions associated with behavioural disturbances in Alzheimer's disease (AD). Brain Res Bull 2012; 88:394-405. [PMID: 22414959 DOI: 10.1016/j.brainresbull.2012.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 02/03/2012] [Accepted: 02/24/2012] [Indexed: 11/18/2022]
Abstract
Behavioural and psychological symptoms in dementia, or BPSD, occur in the majority of Alzheimer's disease (AD) patients. They are associated with considerable patient morbidity and greater care-giver stress. There is some evidence suggesting that BPSD have a genetic component and a large number of studies have examined the association of candidate genes with these symptoms. This review provides a comprehensive summary of all the published studies investigating the association of candidate gene missense substitutions with BPSD. Missense substitutions could potentially alter protein function or render the protein non-functional, resulting in phenotypic consequences. More than 80 studies investigating the association of 8 missense substitutions in 7 genes with BPSD were identified. However, results of these studies are contradictory and do not provide firm support for these associations. Larger studies and more systematic approaches will delineate the association of missense substitutions with behavioural symptoms in AD.
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Affiliation(s)
- Petroula Proitsi
- King's College London, Institute of Psychiatry, Department of Neuroscience, De Crespigny Park, London SE5 8AF, UK.
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Panza F, Frisardi V, Seripa D, D'Onofrio G, Santamato A, Masullo C, Logroscino G, Solfrizzi V, Pilotto A. Apolipoprotein E genotypes and neuropsychiatric symptoms and syndromes in late-onset Alzheimer's disease. Ageing Res Rev 2012; 11:87-103. [PMID: 21763789 DOI: 10.1016/j.arr.2011.06.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Revised: 05/29/2011] [Accepted: 06/30/2011] [Indexed: 12/31/2022]
Abstract
Neuropsychiatric symptoms (NPS) in dementia, previously denominated as behavioural and psychological symptoms of dementia, are often more distressing, impairing, and costly than cognitive symptoms, representing a major health burden for older adults. These symptoms are common features of Alzheimer's disease (AD), and are one of the major risk factors for institutionalization. There is a high prevalence of neuropsychiatric disturbances in patients with AD, including depression, anxiety, apathy, psychosis, aggression, and agitation. At present, the role of the apolipoprotein E (APOE) genotypes in the development of NPS or neuropsychiatric syndromes/endophenotypes in AD patients is unclear. In this article, we summarized the findings of the studies of NPS and neuropsychiatric syndromes in AD in relation to APOE genotypes, with special attention to the possible underlying mechanisms. While some studies failed to find a significant association between the APOE polymorphism and NPS in late-onset AD, other studies reported a significant association between the APOE ɛ4 allele and an increase in agitation/aggression, hallucinations, delusions, and late-life depression or anxiety. However, current cumulative evidence coming from the few existing longitudinal studies shows no association of APOE genotypes with NPS as a whole in AD. Some negative studies that focused on the distribution of APOE genotypes between AD patients with or without NPS further emphasized the importance of sub-grouping NPS in distinct neuropsychiatric syndromes. Explanations for the variable findings in the existing studies included differences in patient populations, differences in the assessment of neuropsychiatric symptomatology, possible lack of statistical power to detect associations in the negative studies, and small sample sizes generating false positives that cannot be consistently replicated. Finally, many reviewed studies were cross-sectional, whereas it would be of paramount importance to evaluate the risk for incident NPS in relation to the APOE genotype in prospectively followed cohorts of AD patients. In fact, identifying predisposing genetic risk factors may allow us to understand the pathophysiological features of neuropsychiatric syndromes or symptoms in AD, so optimizing possible therapeutic options.
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Affiliation(s)
- Francesco Panza
- Geriatric Unit & Gerontology-Geriatrics Research Laboratory, Department of Medical Sciences, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy.
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Woods DL, Phillips LR, Martin JL. Biological Basis for Sleep Disturbance and Behavioral Symptoms in Dementia: A Biobehavioral Model. Res Gerontol Nurs 2011; 4:281-93. [DOI: 10.3928/19404921-20110302-01] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 10/26/2010] [Indexed: 11/20/2022]
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D'Onofrio G, Panza F, Seripa D, Sancarlo D, Paris F, Cascavilla L, Urbano M, Gravina C, Fontana A, Solfrizzi V, Pellegrini F, Pilotto A. The APOE polymorphism in Alzheimer's disease patients with neuropsychiatric symptoms and syndromes. Int J Geriatr Psychiatry 2011; 26:1062-70. [PMID: 21905100 DOI: 10.1002/gps.2644] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 09/03/2010] [Indexed: 11/07/2022]
Abstract
BACKGROUND Neuropsychiatric symptoms (NPS) are a common feature of Alzheimer's disease (AD), resulting in particular AD endophenotypes. The common AD genetic risk factor apolipoprotein E (APOE) has been suggested underlying these AD endophenotypes. METHODS APOE genotyping, a comprehensive geriatric assessment (CGA), and Neuropsychiatric Inventory were performed on 322 consecutive older patients. Patients were divided into three groups: AD with NPS (N = 93), AD without NPS (N = 108), and, as a control group, patients with no cognitive impairment (NoCI: N = 121). Patients with NPS were further sub-divided in four groups according to the European Alzheimer's Disease Consortium (EADC) classification of neuropsychiatric syndromes in AD: hyperactive, psychotic, affective, and apathetic. RESULTS AD patients with NPS showed a significantly higher grade of cognitive impairment, more severity stage of dementia, more disability in the activities of daily living (ADL), and the instrumental ADL than AD patients without NPS. As expected, an higher frequency of APOE ε3/ε4 genotype was observed in patients with AD, both with and without NPS, than patients with NoCI. No difference in the distribution of APOE genotypes was found between AD patients with vs. without NPS. However, in AD patients APOE ε4-carriers, there was an increased risk of affective [odds ratio (OR): 2.34, 95% confidence interval (CI): 1.19-4.58) and apathetic (OR: 2.24,95%CI: 1.19-4.22) syndromes. CONCLUSIONS These findings did not suggest a significant association between APOE polymorphism and presence of NPS in AD patients. In AD patients with NPS, however, APOE ε4-carrier status was associated with an increased risk of affective and apathetic syndromes.
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Affiliation(s)
- Grazia D'Onofrio
- Geriatrics Unit and Gerontology-Geriatric Research Laboratory, Department of Medical Sciences, IRCCS 'Casa Sollievo della Sofferenza', San Giovanni Rotondo, FG, Italy
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Ismail Z, Nguyen MQ, Fischer CE, Schweizer TA, Mulsant BH, Mamo D. Neurobiology of delusions in Alzheimer's disease. Curr Psychiatry Rep 2011; 13:211-8. [PMID: 21404128 DOI: 10.1007/s11920-011-0195-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Alzheimer's disease (AD) is associated with cognitive and functional impairment as well as neuropsychiatric sequelae, including psychotic symptoms such as delusions and hallucinations. Strong evidence supports the need to study delusions separate from hallucinations. Integrating the epidemiology, clinical correlates, and neuropathological and genetic literature for delusions in AD allows us to speculate on etiology and mechanisms. Plaque and tangle deposition in individuals with susceptible alleles of serotonergic, muscarinic, nicotinic, or Apoε4 genes appears to result in disruption of cortical circuitry, culminating in delusions. While delusions in AD correspond to a phenotype distinct from AD without delusions, subtypes of delusions may also define further distinct clinical entities. Persecutory delusions may occur earlier in the illness and have a more significant genetic component than misidentification delusions, which are associated with increased cognitive impairment and advanced dementia. Clearly distinguishing between these two syndromes is essential to making progress in the area of delusions in AD.
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Affiliation(s)
- Zahinoor Ismail
- Centre for Addiction and Mental Health, Geriatric Mental Health Program, University of Toronto, 1001 Queen Street W., Toronto, Ontario, Canada.
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Abstract
OBJECTIVES To examine the association between physical activity (PA) and Alzheimer disease (AD) course. BACKGROUND PA has been related to lower risk for AD. Whether PA is associated with subsequent AD course has not been investigated. METHODS In a population-based study of individuals aged 65 years and older in New York who were prospectively followed up with standard neurologic and neuropsychological evaluations (every ~1.5 years), 357 participants i) were nondemented at baseline and ii) were diagnosed with AD during follow-up (incident AD). PA (sum of participation in a variety of physical activities, weighted by the type of activity [light, moderate, and severe]) obtained 2.4 (standard deviation [SD], 1.9) years before incidence was the main predictor of mortality in Cox models and of cognitive decline in generalized estimating equation models that were adjusted for age, gender, ethnicity, education, comorbidities, and duration between PA evaluation and dementia onset. RESULTS One hundred fifty incident AD cases (54%) died during the course of 5.2 (SD, 4.4) years of follow-up. When compared with incident AD cases who were physically inactive, those with some PA had lower mortality risk, whereas incident AD participants with much PA had an even lower risk. Additional adjustments for apolipoprotein genotype, smoking, comorbidity index, and cognitive performance did not change the associations. PA did not affect rates of cognitive or functional decline. CONCLUSION Exercise may affect not only risk for AD but also subsequent disease duration: more PA is associated with prolonged survival in AD.
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Panza F, Seripa D, D'Onofrio G, Frisardi V, Solfrizzi V, Mecocci P, Pilotto A. Neuropsychiatric Symptoms, Endophenotypes, and Syndromes in Late-Onset Alzheimer's Disease: Focus on APOE Gene. Int J Alzheimers Dis 2011; 2011:721457. [PMID: 21559196 PMCID: PMC3090058 DOI: 10.4061/2011/721457] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 02/11/2011] [Accepted: 02/11/2011] [Indexed: 01/31/2023] Open
Abstract
Neuropsychiatric symptoms, previously denominated as behavioural and psychological symptoms of dementia, are common features of Alzheimer's disease (AD) and are one of the major risk factors for institutionalization. At present, the role of the apolipoprotein E (APOE) gene in the development of neuropsychiatric symptoms in AD patients is unclear. In this paper, we summarized the findings of the studies of neuropsychiatric symptoms and neuropsychiatric syndromes/endophenotypes in AD in relation to APOE genotypes, with special attention to the possible underlying mechanisms. While some studies failed to find a significant association between APOE and neuropsychiatric symptoms in late-onset AD, other studies reported a significant association between the APOE ε4 allele and an increase in agitation/aggression, hallucinations, delusions, and late-life depression or anxiety. Furthermore, some negative studies that focused on the distribution of APOE genotypes between AD patients with or without neuropsychiatric symptoms further emphasized the importance of subgrouping neuropsychiatric symptoms in distinct neuropsychiatric syndromes. Explanations for the variable findings in the existing studies included differences in patient populations, differences in the assessment of neuropsychiatric symptomatology, and possible lack of statistical power to detect associations in the negative studies.
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Affiliation(s)
- Francesco Panza
- Geriatric Unit and Gerontology-Geriatrics Research Laboratory, Department of Medical Sciences, IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, 71013 Foggia, Italy
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Flirski M, Sobow T, Kloszewska I. Behavioural genetics of Alzheimer's disease: a comprehensive review. Arch Med Sci 2011; 7:195-210. [PMID: 22291757 PMCID: PMC3258720 DOI: 10.5114/aoms.2011.22068] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 07/12/2010] [Accepted: 08/24/2010] [Indexed: 12/16/2022] Open
Abstract
Behavioural and psychological symptoms of dementia (BPSD) are present in the course of the illness in up to 90% of patients with Alzheimer's disease (AD). They are the main source of caregiver burden and one of the major factors contributing to early institutionalization. The involvement of a genetic component in BPSD aetiology seems beyond controversy, though the exact significance of particular polymorphisms is uncertain in the majority of cases. Multiple genes have been assessed for their putative influence on BPSD risk. In this paper we review the behavioural genetics of AD, particularly the importance, with respect to BPSD risk, of genes coding for apolipoprotein E and proteins involved in the process of neurotransmission: serotonin receptors, serotonin transporter, COMT, MAO-A, tryptophan hydroxylase and dopamine receptors. A general conclusion is the striking inconsistency of the findings, unsurprising in the field of psychiatric genetics. The potential reasons for such discrepancy are exhaustively discussed.
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Affiliation(s)
- Marcin Flirski
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, Poland
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van der Flier WM, Pijnenburg YA, Fox NC, Scheltens P. Early-onset versus late-onset Alzheimer's disease: the case of the missing APOE ɛ4 allele. Lancet Neurol 2010; 10:280-8. [PMID: 21185234 DOI: 10.1016/s1474-4422(10)70306-9] [Citation(s) in RCA: 224] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Some patients with early-onset Alzheimer's disease (AD) present with a distinct phenotype. Typically, the first and most salient characteristic of AD is episodic memory impairment. A few patients, however, present with focal cortical, non-memory symptoms, such as difficulties with language, visuospatial, or executive functions. These presentations are associated with specific patterns of atrophy and frequently with a young age at onset. Age is not, however, the only determinant of phenotype; underlying factors, especially genetic factors, seem also to affect phenotype and predispose patients to younger or older age at onset. Importantly, patients with atypical early-onset disease seldom carry the APOE ɛ4 allele, which is the most important risk factor for lowering the age of onset in patients with AD. Additionally, theAPOE ɛ4 genotype seems to predispose patients to vulnerability in the medial temporal areas, which leads to memory loss. Conversely, patients negative for the APOE ɛ4 allele and with early-onset AD are more likely to be predisposed to vulnerability of cerebral networks beyond the medial temporal lobes. Other factors are probably involved in determining the pattern of atrophy, but these are currently unknown.
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Affiliation(s)
- Wiesje M van der Flier
- Alzheimer Centre, Department of Neurology, VU University Medical Centre, Amsterdam, The Netherlands
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Takeda M, Martínez R, Kudo T, Tanaka T, Okochi M, Tagami S, Morihara T, Hashimoto R, Cacabelos R. Apolipoprotein E and central nervous system disorders: reviews of clinical findings. Psychiatry Clin Neurosci 2010; 64:592-607. [PMID: 21105952 DOI: 10.1111/j.1440-1819.2010.02148.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Dementia is a major health problem in developed countries with over 25 million people affected worldwide and probably over 75 million people at risk during the next 20 years. Alzheimer's disease (AD) is the most frequent cause of dementia (50-70%), followed by vascular dementia (30-40%), and mixed dementia (15-20%). AD pathogenesis is still to be elucidated but it is believed to be the complex interaction between genetic and environmental factors in later life. Three causative genes for familial AD have been identified: amyloid precursor protein, presenilin-1, and presenilin-2. There are 150 genes involved with increased neuronal vulnerability to premature death in the AD brain. Among these susceptibility genes, the apolipoprotein E (ApoE) gene is the most prevalent as a risk for AD pathogenic process in which complex interactions between genetic and environmental factors are involved, leading to a cascade of pathogenic events converging in final pathways to premature neuronal death. Some of these mechanisms are common to several neurodegenerative disorders that differ depending upon the genes affected and the involvement of environmental conditions. ApoE is a key lipoprotein in lipid and cholesterol metabolism and it is also the major risk gene for AD and many other central nervous system disorders. The pathogenic role of ApoE-4 is still to be clarified; however, diverse evidence suggests that ApoE may play pleiotropic functions in dementia and central nervous system disorders.
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Affiliation(s)
- Masatoshi Takeda
- Department of Psychiatry, Osaka University Graduate School of Medicine, Osaka, Japan.
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Laks J, Engelhardt E. Peculiarities of geriatric psychiatry: a focus on aging and depression. CNS Neurosci Ther 2010; 16:374-9. [PMID: 20875046 DOI: 10.1111/j.1755-5949.2010.00196.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
There is a debate on whether Geriatric Psychiatry stands for itself as a discrete specialty or whether it is an extension of clinical Geriatrics, Neurology, and Psychiatry. This review aims to outline some recent data and possible approaches to define peculiarities of Geriatric Psychiatry, focusing on certain characteristics that define the aging brain. Geriatric depression is discussed taking into consideration some data from translational research. The brain aging process is not uniform. Frontal areas show marked impairment in inhibiting irrelevant information in working memory as they age, and the recruitment of these areas occur differently than in young subjects. Executive functions also change in normal elderly. Geriatric depression is a general definition of a multidimensional disorder with multiple risk factors. Dysexecutive syndrome is considered as a key to the neuropsychology of geriatric depression, correlated with functional impairment in late life. Late-onset depression has a higher load of comordibity, of cerebrovascular disease, and of some genetic factors that may be different from early onset depression. Also, there are at least four clusters of treatment outcomes that are common in geriatric depression, which mirror the neuropsychological and clinical profiles. Research and practice in Geriatric Psychiatry should focus on the interaction of various dimensions and risk factors rather than on attempting to find a single cause to the disorders. Some answers may be found in comorbidity issues, in white matter lesions, which are more common in the elderly, and in genetic factors that impact on the aging process.
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Affiliation(s)
- Jerson Laks
- Institute of Psychiatry of the Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.
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DeMichele-Sweet MA, Sweet RA. Genetics of psychosis in Alzheimer's disease: a review. J Alzheimers Dis 2010; 19:761-80. [PMID: 20157235 DOI: 10.3233/jad-2010-1274] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In and of itself, late-onset Alzheimer's disease (AD) can be a devastating illness. However, a sub-group of AD patients develop psychosis as the disease progresses. These patients have an added burden of greater cognitive impairment, higher rates of institutionalization, and higher mortality than AD patients without psychosis. While the etiopathogenesis such as psychosis in AD (AD+P) is not known, mounting evidence accrued over the past ten years indicates that AD+P represents a distinct phenotype with a genetic basis. Elucidating the genetic mechanism of AD+P is crucial if better pharmaceutical treatments are to be developed for these patients. The goal of this review is to summarize what is currently known regarding the genetic basis of psychosis in AD. Specific attention is given to familial aggregation and heritability, linkage to chromosomal loci, and associations of candidate genes of APOE and the monoamine neurotransmitter system.
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Premorbid personality traits are associated with post-stroke behavioral and psychological symptoms: a three-month follow-up study in Perth, Western Australia. Int Psychogeriatr 2009; 21:1063-71. [PMID: 19586564 DOI: 10.1017/s1041610209990457] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Previous research has found an association between post-stroke depressive symptoms and premorbid personality. This study sought to investigate further the relationship between premorbid personality and a number of common post-stroke behavioral and psychological symptoms in a three-month follow-up study. METHODS This prospective study was conducted between May 2003 and January 2005 in a Perth metropolitan teaching hospital. The pre-stroke personality of stroke survivors was assessed by interviewing a close family member (informant) within four weeks of the index stroke using the NEO Personality Inventory-Revised. Three months after the stroke, patients were followed up and assessed with the Cambridge Cognitive examination and Hospital Anxiety and Depression Scale, and their informants completed the Neuropsychiatric Inventory-carer distress version (NPI) and instrumental activities of daily living scale. RESULTS Depressive symptoms were the most commonly reported post-stroke symptom (45.1%). Spearman's correlations showed that high neuroticism was positively correlated with NPI total scores (rho = 0.37, p = 0.007), NPI total distress scores (rho = 0.47, p = 0.001), and specifically with agitation and irritability NPI composite scores. Agreeableness was inversely correlated with agitation (rho = -0.40, p = 0.004) and irritability (rho = -0.37, p = 0.007) composite scores. CONCLUSIONS Premorbid personality traits of high neuroticism and low agreeableness are associated with the presence of post-stroke agitation, irritability, and carer distress. This knowledge may contribute to the development of strategies designed to identify patients and families who require more intense supervision and support during post-stroke rehabilitation.
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Scarmeas N, Honig LS, Choi H, Cantero J, Brandt J, Blacker D, Albert M, Amatniek JC, Marder K, Bell K, Hauser WA, Stern Y. Seizures in Alzheimer disease: who, when, and how common? ACTA ACUST UNITED AC 2009; 66:992-7. [PMID: 19667221 DOI: 10.1001/archneurol.2009.130] [Citation(s) in RCA: 201] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Transient symptoms in Alzheimer disease (AD) are frequent and include seizures, syncope, and episodes of inattention or confusion. The incidence of seizures in AD and predictors of which patients with AD might be more predisposed to them is based primarily on retrospective studies and is not well established. OBJECTIVE To determine the incidence and predictors of new-onset unprovoked seizures. DESIGN Prospective cohort study. SETTING Three academic centers. Patients Four hundred fifty-three patients with probable AD observed prospectively from mild disease stages since 1992. Main Outcome Measure Informant interviews every 6 months included questions about whether the patient had a seizure (convulsion, fainting, or "funny" spell) and whether diagnosis or treatment for epilepsy or seizure was made. Two epileptologists independently retrospectively reviewed all available medical records for 52 patients with positive responses to either of these questions, and using a specific checklist form, events were diagnosed as to whether they were unprovoked seizures (intrarater concordance, kappa = 0.67). Diagnosis of unprovoked seizures constituted the event in survival analyses. Potential predictors included sex, age, race/ethnicity, educational achievement, duration of illness, baseline cognition and function, depression, medical comorbidities, and time-dependent use of cholinesterase inhibitors and neuroleptic agents, apolipoprotein E genotype, and previous electroencephalographic findings. RESULTS Over the course of 3518 visit-assessments (per patient: mean, 7.8; maximum, 27), 7 patients (1.5%) developed seizures. Younger age was associated with higher risk (hazard ratio, 1.23; 95% confidence interval, 1.08-1.41; P = .003 for each additional year of age) of seizure incidence. No other predictor was significant. The overall incidence of seizures was low (418 per 100 000 person-years of observation) although significantly higher than expected for idiopathic unprovoked seizures in similar age ranges of the general population (hazard ratio, 8.06; 95% confidence interval, 3.23-16.61). CONCLUSIONS Unprovoked seizures are uncommon in AD, but they do occur more frequently than in the general population. Younger age is a risk factor for seizures in AD.
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Affiliation(s)
- Nikolaos Scarmeas
- Department of Neurology, Columbia University Medical Center, 622 W 168 St, PH Bldg, 19th Floor, New York, NY 10032, USA.
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Apolipoprotein epsilon4 status is associated with behavioral symptoms in nursing home residents with dementia. Int Psychogeriatr 2009; 21:722-8. [PMID: 19470200 DOI: 10.1017/s1041610209009235] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND While the relationship of apolipoprotein E (APOE) to behavioral symptoms of dementia (BSD) has been studied in community-dwelling persons with AD, it has received limited attention within the nursing home (NH) population. The aim of this study was to examine the association between APOE genotype and BSD in NH residents using direct observation. METHODS Thirty-six participants, aged 71-102 years, were compared using a non-randomized two-group design with continuous measures. APOE genotype was obtained by buccal swab. BSD, including restlessness, escape restraint, tapping and banging, searching and wandering, pacing and walking, and vocalization, were measured using the Modified Agitated Behavior Rating Scale. Participants were observed every 20 minutes for 12 hours per day for five days. Each participant's mean behavior scores were compared according to the presence or absence of the APOE epsilon4 allele. RESULTS Resident characteristics included a mean MMSE of 10.44 indicating moderate to severe dementia and a mean of 3.44 medical co-morbidities. Fifty-six percent of the participants had one epsilon4 allele. A significant difference was found between APOE epsilon4+/4- and mean behavioral scores (F(1,31)) = 4.40, p = 0.04). Restlessness was significantly inversely correlated with MMSE (r = -0.367, p = 0.03), but not APOE genotype. There was no significant correlation between proxy reporting and direct observation (r = 0.257, p = 0.13). CONCLUSION Findings indicate that the presence of the APOE epsilon4+ genotype increases the risk for BSD in NH residents with dementia. Direct observation proved a more accurate estimate of BSD than proxy report.
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Neuropsychiatric symptoms and the APOE genotype in Alzheimer’s disease. Neurol Sci 2009; 30:367-73. [DOI: 10.1007/s10072-009-0116-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Accepted: 06/25/2009] [Indexed: 11/26/2022]
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IDE Gene Polymorphism Influences on BPSD in Mild Dementia of Alzheimer's Type. Curr Gerontol Geriatr Res 2008:858759. [PMID: 19415148 PMCID: PMC2671997 DOI: 10.1155/2008/858759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 07/14/2008] [Accepted: 10/03/2008] [Indexed: 11/18/2022] Open
Abstract
Insulin degrading enzyme (IDE) degrades amyloid beta (Abeta), which may inhibit the accumulation of Abeta in a brain affected with dementia of Alzheimer's type (DAT). A decrease in the activity of IDE results in changes in glucose utilization in the brain, which could affect the cognitive and psychiatric symptoms of DAT. We investigated a possible association of IDE gene polymorphism and the behavioral and psychological symptoms of dementia (BPSD) in mild DAT. The genotyping for IDE and apolipoprotein E (ApoE) was determined in 207 patients with mild DAT and 215 controls. The occurrence of BPSD was demonstrated using the Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD). IDE gene polymorphism is unlikely to play a substantial role in conferring susceptibility to DAT, but it may be involved in the development of affective disturbance through the course of mild DAT, regardless of the presence of an ApoE epsilon4 allele. The present data could be the result of a small sample size. Further investigations using larger samples are thus required to clarify the correlation between IDE gene polymorphism, susceptibility to DAT, and emergence of BPSD.
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Irie F, Masaki KH, Petrovitch H, Abbott RD, Ross GW, Taaffe DR, Launer LJ, White LR. Apolipoprotein E epsilon4 allele genotype and the effect of depressive symptoms on the risk of dementia in men: the Honolulu-Asia Aging Study. ACTA ACUST UNITED AC 2008; 65:906-12. [PMID: 18678795 DOI: 10.1001/archpsyc.65.8.906] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT The apolipoprotein E epsilon4 (APOE epsilon4) allele is a genetic risk factor for Alzheimer disease. Recently, depression has also become recognized as a risk factor for dementia. However, the possible effect of the APOE genotype on the association between depression and dementia is unexamined. OBJECTIVE To examine the independent and combined effects of depression and APOE epsilon4 on the risk of dementia and its subtypes. DESIGN The Honolulu-Asia Aging Study, a population-based prospective cohort study of Japanese American men. SETTINGS AND PARTICIPANTS Depressive symptoms and presence of the APOE epsilon4 allele were assessed between March 1991 and October 1993 in 1932 cognitively healthy men aged 71 to 90 years. Incident cases of dementia were diagnosed during approximately 6 years of follow-up based on neurologic assessment at 2 repeated examinations (April 1994-April 1996 and October 1997-February 1999). MAIN OUTCOME MEASURES Overall dementia, Alzheimer disease, and vascular dementia. RESULTS The interaction of depression and APOE epsilon4 was statistically significant in the analytical models. Compared with men with neither APOE epsilon4 nor depression, the risk of dementia in nondepressed men with APOE epsilon4 was not significant (hazard ratio, 1.1; 95% confidence interval [CI], 0.6-1.8); however, depressed men without APOE epsilon4 had a 1.6-fold greater risk (95% CI, 0.8-3.0), whereas depressed men with APOE epsilon4 had a 7.1-fold greater risk (95% CI, 3.0-16.7) of dementia. For subtypes, we found similar increased risks of Alzheimer disease. CONCLUSIONS The APOE epsilon4 status modifies the association between depressive symptoms and dementia in elderly men. Because individuals with depressive symptoms and the APOE epsilon4 allele had a markedly increased risk of dementia, one might be especially watchful for early signs of dementia in the older person with depression who is also positive for the APOE epsilon4 allele. Because this cohort includes only men, further investigation in women is required.
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Affiliation(s)
- Fumiko Irie
- Pacific Health Research Institute, Honolulu, Hawaii, USA.
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Abstract
Dementia of the Alzheimer type is a progressive, fatal neurodegenerative condition characterized by deterioration in cognition and memory, progressive impairment in the ability to carry out activities of daily living, and a number of neuropsychiatric symptoms. This narrative review summarizes the literature regarding descriptive epidemiology, clinical course, and characteristic neuropathological changes of dementia of the Alzheimer type. Although there are no definitive imaging or laboratory tests, except for brain biopsy, for diagnosis, brief screening instruments and neuropsychiatric test batteries used to assess the disease are discussed. Insufficient evidence exists for the use of biomarkers in clinical practice for diagnosis or disease management, but promising discoveries are summarized. Optimal treatment requires both nonpharmacological and pharmacological interventions, yet none have been shown to modify the disease's clinical course. This review describes the current available options and summarizes promising new avenues for treatment. Issues related to the care of persons with dementia of the Alzheimer type, including caregiver burden, long-term care, and the proliferation of dementia special care units, are discussed. Although advances have been made, more research is needed to address the gaps in our understanding of the disease.
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Affiliation(s)
- Jessica J Jalbert
- Department of Community Health - Epidemiology, Warren Alpert School of Medicine at Brown University, 121 South Main, Box G, Providence, RI 02912, USA.
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