Dissociation of neuropathology from severity of dementia in late-onset Alzheimer disease

BACKGROUND

Little is known about Alzheimer disease at advanced ages, although its incidence continues to increase at least through the ninth decade of life.

OBJECTIVE

To examine the effects of age on the relationship between clinical dementia severity and neuropathologic hallmarks in a large sample spanning the full age range.

METHODS

The authors assessed 81 subjects during life for dementia severity, and examined their brains. They analyzed plaque and tangle burden, as well as the activities of the cholinergic marker enzymes acetylcholinesterase (AChE) and choline acetyltransferase (ChAT), in relation to age at death and the clinical severity of dementia.

RESULTS

Dementia severity was strongly related to plaque and tangle burden in relatively young patients (aged < 75 years), but this correlation diminished with age and disappeared in the ninth decade of life. Among the oldest patients studied, there was no difference in plaque and tangle load between the mild and severe dementia cases. This interaction (p < 0.0001 for plaque density) was not observed for the cholinergic markers ChAT and AChE.

CONCLUSION

The nature or expression of Alzheimer disease may be different in severely demented older patients, who have equal cholinergic deficits but significantly lower plaque and tangle burden. If confirmed in a prospective study, these findings have diagnostic and therapeutic implications.

The relationship between apolipoprotein E, dementia, and vascular illness

The purpose of this study was to concurrently assess the relationship of Apolipoprotein E (APOE) with both dementias and vascular illnesses in the very old. Nine hundred and fifty nine subjects (mean age 85 years) in a long-term care facility were genotyped and cognitively tested with the Mini Mental State Exam. All subjects were studied for the relationship of APOE with atherosclerotic heart disease, hypertension, or stroke without concomitant dementia. Four hundred fifty individuals met criteria for inclusion into one of the following groups: Alzheimer's disease (n = 318), vascular dementia (n = 49), or not demented controls (n = 83) and were investigated for the relationship between APOE and these diagnostic categories. APOE epsilon4 was not associated with atherosclerotic heart disease, hypertension, or stroke without concomitant dementia. The APOE epsilon3 allele was more common in men with atherosclerotic heart disease. In contrast, the APOE epsilon4 allele was more common in patients with Alzheimer's disease (22%) and vascular dementia (26%) than in not demented controls (7%). APOE epsilon4 is associated with dementias in the very old, whereas its relationship with either peripheral or central nervous system vascular disease without dementia is not as robust.

Adult Kawasaki disease. Report of two cases treated with intravenous gamma globulin

There are 36 reports in the English-language literature of Kawasaki disease in adults. We present two additional cases, in one of which retinal vasculitis developed, a previously unreported complication antemortem. We report the first use of intravenous gamma globulin in the United States for treatment of adult-onset Kawasaki disease and review the pertinent literature.

Pulmonary embolism in the nursing home population: high frequency at autopsy in female residents

Pathological and clinical findings of all consecutive autopsies performed at The Jewish Home and Hospital for Aged from 4/1/85 to 12/31/86 were reviewed to determine the frequency and clinical significance of pulmonary embolism as a cause of death in the nursing home. The autopsies were performed by a single pathologist and a diagnosis of pulmonary embolism (PE) was based on microscopic confirmation of macroscopic findings. All charts during this time period were reviewed for classic signs and symptoms of PE, presence of risk factors associated with PE, ambulatory status and rapidity of death. The autopsy rate during this period was 25.6%. Of 41 autopsies reviewed (31 females and 10 males) 14 cases of pulmonary embolism were found representing a prevalence of 34.1%. All occurred in females. Pulmonary infarction was present in four cases. Massive PE (interrupting blood flow to both lungs) and major PE (interrupting flow to one entire lung) made up 11 of the cases (26.8% of all autopsies). Classic symptoms were not more frequent premortem in those with PE than those without PE. The presence of risk factors, or rapid death, or bedbound state did not predict the presence of PE. In none of the cases was the diagnosis established premortem. Elderly female residents of chronic care facilities appear to be at special risk of death from pulmonary embolism. Clinical findings are not of a diagnostic nature.

Cystometric evaluation of bladder dysfunction in elderly diabetic patients

To select the appropriate treatment for an elderly patient with urinary incontinence, the cause of the incontinence needs to be determined. In diabetic patients who are incontinent, the underlying problem has been described in the past as urinary retention secondary to autonomic neuropathy. In cystometric studies conducted on 23 elderly diabetic nursing home patients (mean age, 80 years; 19 women, 4 men), who presented with symptoms of urinary dysfunction, involuntary contractions were demonstrated in 61% of the subjects. Thirteen percent of the patients had normal voluntary contractions of the bladder, 17% had voluntary contractions of a low magnitude, and 9% had no contractions at all. The majority (76%) of the subjects presenting with urinary incontinence had involuntary bladder contractions, while all of the subjects presenting with urinary retention had either voluntary contractions of a low magnitude or no contractions. It cannot be assumed that all elderly diabetic patients presenting with urinary symptoms have poorly contracting bladders (diabetic bladder). Urodynamic studies can be helpful when choosing therapy for the elderly diabetic patient with urinary dysfunction.

Multinodular keratoacanthoma

Multinodular keratoacanthoma is characterized by multiple keratoacanthoma nodules at the periphery of a progressively expanding tumor and central scar formation. This recognizable variant of keratoacanthoma does not spontaneously resolve, is associated with significant tissue destruction, and mandates early aggressive therapy.