New Diagnostic Criteria and Treatment for Dementia with Lewy Bodies

Dementia with Lewy bodies (DLB) is the second most common cause of neurodegenerative dementia. The Dementia with Lewy Bodies Consortium has revised DLB consensus diagnostic criteria. We reviewed recent (fourth) clinical diagnosis criteria and treatment options. The revised DLB clinical criteria included clinical features and updated diagnostic biomarkers. Compared with third criteria, they removed suggestive features and reassigned rapid eye movement sleep behavior disorder (RBD) in core clini-cal features with fluctuating cognition, recurrent visual hallucination, and parkinsonism. They classified biomarkers into two groups, indicative and supportive biomarkers, according to diagnostic specificity and evidence quality. Indicative biomarkers in-cluded reduced dopamine transporter uptake in basal ganglia demonstrated by single-photon emission CT or positron emission tomography, low uptake 123 Iodine- metaiodobenzylguanidine myocardial scintigraphy, and RBD in polysomnography. In treatment of DLB, cholinesterase inhibitor can improve cognitive function and activities of daily living. Neuroleptics should use with caution due to sensitivity in DLB.

Review of Court-Ordered Treatment in New York State / 신경정신의학

In recent decades, laws for involuntary treatment have evolved in ways that protect human rights as well as public safety. Globally, many nations have legislation for psychiatric patients that provide procedural advocacy during their involuntary treatment while a court or another independent organization reviews its lawfulness. In contrast, people with severe mental illness in Korea risk encountering human rights violations and loss of timely treatment, because their involuntary admissions are primarily initiated by family members and civil doctors and not by courts or government. The Mental Health Promotion and Welfare Act, revised in 2016, does not address this fundamental weakness, instead restricting involuntary admission criteria and bypassing the implementation of any procedural assistance programs. Subsequently untreated patients lead to clinical aggravation and even serious felony offenses. This paper introduces New York State’s court-ordered treatment system via the Mental Hygiene Law as a model for the revision of Korean legislation. The findings show that involuntary admissions in New York State are initiated by many parties as well as familial relatives and may be held up to 60 days without any court order.However, patients are assigned legal counsel for the ability to request for a court hearing at any time during their admission. The Assisted Outpatient Program is another legal intervention that requires a person with a mental illness that would likely result in serious harm to self or others to receive supervised outpatient treatment. We argue that the New York State model can be implemented effectively in Korea considering its current medical and judicial status.

Review of Court-Ordered Treatment in New York State / 신경정신의학

In recent decades, laws for involuntary treatment have evolved in ways that protect human rights as well as public safety. Globally, many nations have legislation for psychiatric patients that provide procedural advocacy during their involuntary treatment while a court or another independent organization reviews its lawfulness. In contrast, people with severe mental illness in Korea risk encountering human rights violations and loss of timely treatment, because their involuntary admissions are primarily initiated by family members and civil doctors and not by courts or government. The Mental Health Promotion and Welfare Act, revised in 2016, does not address this fundamental weakness, instead restricting involuntary admission criteria and bypassing the implementation of any procedural assistance programs. Subsequently untreated patients lead to clinical aggravation and even serious felony offenses. This paper introduces New York State’s court-ordered treatment system via the Mental Hygiene Law as a model for the revision of Korean legislation. The findings show that involuntary admissions in New York State are initiated by many parties as well as familial relatives and may be held up to 60 days without any court order.However, patients are assigned legal counsel for the ability to request for a court hearing at any time during their admission. The Assisted Outpatient Program is another legal intervention that requires a person with a mental illness that would likely result in serious harm to self or others to receive supervised outpatient treatment. We argue that the New York State model can be implemented effectively in Korea considering its current medical and judicial status.

Normative Data for the Logical Memory Subtest of the Wechsler Memory Scale-IV in Middle-Aged and Elderly Korean People

OBJECTIVE: The purpose of this study is to identify the demographic variables that are affecting performances on the Logical Memory (LM) subtest included in the Korean version of the Wechsler Memory Scale (WMS)-IV and to provide normative data on the LM subtest for the middle-age and elderly Korean people.METHODS: The participants were 435 non-demented adults aging from 50 to 90 and with the educational level ranging from 0 to 21 years.RESULTS: Age and education were found to be significantly associated with performance on the LM subtest, while gender effect was not statistically significant. Therefore, we stratified the norm blocks by age and education. Age was divided into three groups: 50–59, 60–74, and 75–90 years. Education was stratified into three groups: 0–8 years, 9–12 years, and 13 years or more.CONCLUSION: The normative data provided in the current study are expected to be useful in clinical and research settings to detect or define subtle changes in episodic memory in Korean adults and elderly, and can also be used for cross-cultural comparison of verbal episodic memory performance among elderly populations using different languages.

The Relationship between Emotional Labor and Job Stress among Hospital Workers

BACKGROUND: We divided hospital workers into two groups according to whether one was an interpersonal service worker (ISW) or was not (non-ISW). We then explored differences between these groups in job stress and emotional labor type and investigated the mediating factors influencing their relationships. METHODS: Our participants included both ISW (n = 353) and non-ISW (n = 71) hospital workers. We administered the Korean Standard Occupational Stress Scale Short Form to measure job stress and the Emotional Labor Scale to indicate both emotional labor type and characteristics. We also administered the Beck Depression Inventory-II to indicate the mediating factors of depressive symptoms, the Beck Anxiety Inventory to indicate the mediating factors of anxiety, and the State Anger Subscale of the State-Trait Anger Expression inventory to indicate the mediating factors of anger. RESULTS: The ISW group showed more severe job stress than the non-ISW group over a significantly longer duration, with greater intensity, and with higher level of surface acting. The ISW group showed a significant positive correlation between surface acting and job stress and no significant correlation between deep acting and job stress. Parallel mediation analysis showed that for ISWs surface acting was directly related to increased job stress, indirectly related to depression, and unrelated to anxiety and anger. CONCLUSION: The ISW group displayed more surface acting and job stress in its emotional labor than the non-ISW group. In the ISW group, surface acting during emotional labor was positively correlated with job stress. Depression partially mediated their relationship.

Effectiveness of group cognitive behavioral therapy with mindfulness in end-stage renal disease hemodialysis patients

BACKGROUND: Many patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD) experience depression. Depression influences patient quality of life (QOL), dialysis compliance, and medical comorbidity. We developed and applied a group cognitive behavioral therapy (CBT) program including mindfulness meditation for ESRD patients undergoing HD, and measured changes in QOL, mood, anxiety, perceived stress, and biochemical markers. METHODS: We conducted group CBT over a 12-week period with seven ESRD patients undergoing HD and suffering from depression. QOL, mood, anxiety, and perceived stress were measured at baseline and at weeks 8 and 12 using the World Health Organization Quality of Life scale, abbreviated version (WHOQOL-BREF), the Beck Depression Inventory II (BDI-II), the Hamilton Rating Scale for Depression (HAM-D), the Beck Anxiety Inventory (BAI), and the Perceived Stress Scale (PSS). Biochemical markers were measured at baseline and after 12 weeks. The Temperament and Character Inventory was performed to assess patient characteristics before starting group CBT. RESULTS: The seven patients showed significant improvement in QOL, mood, anxiety, and perceived stress after 12 weeks of group CBT. WHOQOL-BREF and the self-rating scales, BDI-II and BAI, showed continuous improvement across the 12-week period. HAM-D scores showed significant improvement by week 8; PSS showed significant improvement after week 8. Serum creatinine levels also improved significantly following the 12 week period. CONCLUSION: In this pilot study, a CBT program which included mindfulness meditation enhanced overall mental health and biochemical marker levels in ESRD patients undergoing HD.

Clinical Dementia Rating Orientation Score as an Excellent Predictor of the Progression to Alzheimer's Disease in Mild Cognitive Impairment

OBJECTIVE: This study aimed to examine the usefulness of each subscale score of the Clinical Dementia Rating (CDR) for predicting Alzheimer's disease (AD) dementia progression in amnestic mild cognitive impairment (MCI) elderly subjects. METHODS: Fifty-nine elderly MCI individuals were recruited from a university dementia and memory disorder clinic. Standardized clinical and neuropsychological tests were performed both at baseline and at the time of 2 years follow-up. Logistic regression analyses were conducted to examine the ability of various clinical measures or their combinations to predict progression to AD dementia in MCI individuals. RESULTS: MCIp individuals showed significantly higher CDR Orientation subscale and CDR sum-of-boxes (SOB) score than MCInp ones, while there were no significant differences in other CDR subscale scores between the two. MCIp individuals also showed marginally higher MMSE scores than MCInp ones. A series of logistic regression analyses demonstrated that the model including CDR Orientation subscale had better AD dementia prediction accuracy than either the model with either MMSE or CDR-SOB. CONCLUSION: Our findings suggest that CDR Orientation subscale score, a simple and easily available clinical measure, could provide very useful information to predict AD dementia progression in amnestic MCI individuals in real clinical settings.

Korean Brain Aging Study for the Early Diagnosis and Prediction of Alzheimer's Disease: Methodology and Baseline Sample Characteristics

OBJECTIVE: The Korean Brain Aging Study for the Early Diagnosis and Prediction of Alzheimer's disease (KBASE) aimed to recruit 650 individuals, aged from 20 to 90 years, to search for new biomarkers of Alzheimer's disease (AD) and to investigate how multi-faceted lifetime experiences and bodily changes contribute to the brain changes or brain pathologies related to the AD process. METHODS: All participants received comprehensive clinical and neuropsychological evaluations, multi-modal brain imaging, including magnetic resonance imaging, magnetic resonance angiography, [11C]Pittsburgh compound B-positron emission tomography (PET), and [18F]fluorodeoxyglucose-PET, blood and genetic marker analyses at baseline, and a subset of participants underwent actigraph monitoring and completed a sleep diary. Participants are to be followed annually with clinical and neuropsychological assessments, and biannually with the full KBASE assessment, including neuroimaging and laboratory tests. RESULTS: As of March 2017, in total, 758 individuals had volunteered for this study. Among them, in total, 591 participants–291 cognitively normal (CN) old-aged individuals, 74 CN young- and middle-aged individuals, 139 individuals with mild cognitive impairment (MCI), and 87 individuals with AD dementia (ADD)–were enrolled at baseline, after excluding 162 individuals. A subset of participants (n=275) underwent actigraph monitoring. CONCLUSION: The KBASE cohort is a prospective, longitudinal cohort study that recruited participants with a wide age range and a wide distribution of cognitive status (CN, MCI, and ADD) and it has several strengths in its design and methodologies. Details of the recruitment, study methodology, and baseline sample characteristics are described in this paper.

Association of Changes in Mood Status and Psychosocial Well-Being with Depression During Interferon-Based Treatment for Hepatitis C

OBJECTIVE: The aims of this prospective study were to investigate temporal changes in mood status and distress level, as well as the development of depression, during pegylated interferon (PEG-IFN)-based treatment of patients with chronic hepatitis C (CHC). We also explored whether baseline demographic, psychiatric, and personality traits predicted the evolution of depression. METHODS: CHC patients without depression were screened with laboratory tests; psychiatric interviews; and evaluations of mood symptoms, level of distress, and personality traits. A total of 67 treatment-naïve patients with CHC were consecutively treated with PEG-IFN-α-2a plus ribavirin for 48 (genotype 1, n=29) or 24 (genotype 2, n=38) weeks. Patients were followed prospectively every 4 weeks during the treatment period. RESULTS: Seven patients (10.4%) were diagnosed with major depressive disorder (MDD), and eight (11.9%) developed subsyndromal depression. Times to onset of MDD and subsyndromal depression were 6.67±5.01 and 11.11±5.58 weeks, respectively, after initiation of treatment. Patients who developed MDD had significantly increased fatigue and anxiety and poor psychological well-being during the course of treatment. Pretreatment subthreshold mood symptoms were a significant predictor of depression. CONCLUSION: An early psychiatric assessment may be helpful in improving psychological well-being in those with CHC, leading to adherence to PEG-IFN-based treatment.

Screening Ability of Subjective Memory Complaints, Informant-Reports for Cognitive Decline, and Their Combination in Memory Clinic Setting

OBJECTIVE: This study aimed to compare the accuracy of subjective memory complaints, informant-reports for cognitive declines, and their combination for screening cognitive disorders in memory clinic setting. METHODS: One-hundred thirtytwo cognitively normal (CN), 136 mild cognitive impairment (MCI), and 546 dementia who visited the memory clinic in the Seoul National University Hospital underwent standardized clinical evaluation and comprehensive neuropsychological assessment. The Subjective Memory Complaints Questionnaire (SMCQ) and the Seoul Informant Report Questionnaire for Dementia (SIRQD) were used to assess subjective memory complaints and informant-reports for cognitive declines, respectively. RESULTS: Both SMCQ and SIRQD showed significant screening ability for MCI, dementia, and overall cognitive disorder (CDall: MCI plus dementia) (screening accuracy: 60.1–94.6%). The combination of SMCQ and SIRQD (SMCQ+SIRQD) was found to have significantly better screening accuracy compared to SMCQ alone for any cognitive disorders. SMCQ+SIRQD also significantly improved screening accuracy of SIRQD alone for MCI and CDall, but not for dementia. CONCLUSION: Our findings suggest that the combined information of both subjective memory complaints and informant-reports for cognitive declines can improve MCI screening by each individual information, while such combination appears not better than informant-reports in regard of dementia screening.

Study on Cognitive Reserve in Korea Using Korean Version of Cognitive Reserve Index Questionnaire / 신경정신의학

OBJECTIVES: To evaluate cognitive reserve in Korea using Korean version of Cognitive Reserve Index questionnaire (K-CRIq) and to investigate the effects of gender and age on cognitive reserve. METHODS: Three hundred and fifty-eight healthy subjects aged 25–85 years old in one community participated in the study. K-CRIq was developed and administered to all subjects to assess the effects of gender and age on cognitive reserve. Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were administered to subjects over 65 years old to test concurrent validity. RESULTS: Age and gender as well as their interaction significantly affected Cognitive Reserve Index (CRI) score. Men had higher cognitive reserve than women over 45 years old, but at younger ages there was no gender difference in cognitive reserve. CRI score and sub-scores were strongly associated with the MMSE and MoCA. CONCLUSION: The results indicate that the gender effect on cognitive reserve is disappearing in the young generation in Korea. Scores in neuropsychological tests are predicted well by the CRI score.

Comparison of Regional Gray Matter Atrophy, White Matter Alteration, and Glucose Metabolism as a Predictor of the Conversion to Alzheimer's Disease in Mild Cognitive Impairment

We compared the predictive ability of the various neuroimaging tools and determined the most cost-effective, non-invasive Alzheimer's disease (AD) prediction model in mild cognitive impairment (MCI) individuals. Thirty-two MCI subjects were evaluated at baseline with [18F]-fluorodeoxyglucose positron emission tomography (FDG-PET), MRI, diffusion tensor imaging (DTI), and neuropsychological tests, and then followed up for 2 yr. After a follow up period, 12 MCI subjects converted to AD (MCIc) and 20 did not (MCInc). Of the voxel-based statistical comparisons of baseline neuroimaging data, the MCIc showed reduced cerebral glucose metabolism (CMgl) in the temporo-parietal, posterior cingulate, precuneus, and frontal regions, and gray matter (GM) density in multiple cortical areas including the frontal, temporal and parietal regions compared to the MCInc, whereas regional fractional anisotropy derived from DTI were not significantly different between the two groups. The MCIc also had lower Mini-Mental State Examination (MMSE) score than the MCInc. Through a series of model selection steps, the MMSE combined with CMgl model was selected as a final model (classification accuracy 93.8%). In conclusion, the combination of MMSE with regional CMgl measurement based on FDG-PET is probably the most efficient, non-invasive method to predict AD in MCI individuals after a two-year follow-up period.

A Normative Study of the Digit Span in an Educationally Diverse Elderly Population

OBJECTIVE: The purpose of this study was to explore the effect of demographic variables on Digit Span test (DS) performance in an educationally diverse elderly population and to provide normative information. METHODS: The DS was administered to 784 community-dwelling volunteers aged 60-90 years with an educational history of from zero to 25 years of full-time education. People with serious neurological, medical and psychiatric disorders (including dementia) were excluded. RESULTS: Age, education and gender were found to be significantly associated with performance on the DS. Based on the results obtained, DS norms were stratified by age (2 strata), education (3 strata), and gender (2 strata). CONCLUSION: Our results on DS performance suggest that both attention and working memory are influenced by age, education and gender. The present study provides reasonably comprehensive normative information on the DS for an educationally diverse elderly population.

Improvement of Screening Accuracy of Mini-Mental State Examination for Mild Cognitive Impairment and Non-Alzheimer's Disease Dementia by Supplementation of Verbal Fluency Performance

OBJECTIVE: This study aimed to investigate whether the supplementation of Verbal Fluency: Animal category test (VF) performance can improve the screening ability of Mini-Mental State Examination (MMSE) for mild cognitive impairment (MCI), dementia and their major subtypes. METHODS: Six hundred fifty-five cognitively normal (CN), 366 MCI [282 amnestic MCI (aMCI); 84 non-amnestic MCI (naMCI)] and 494 dementia [346 Alzheimer's disease (AD); and 148 non-Alzheimer's disease dementia (NAD)] individuals living in the community were included (all aged 50 years and older) in the study. RESULTS: The VF-supplemented MMSE (MMSE+VF) score had a significantly better screening ability for MCI, dementia and overall cognitive impairment (MCI plus dementia) than the MMSE raw score alone. MMSE+VF showed a significantly better ability than MMSE for both MCI subtypes, i.e., aMCI and naMCI. In the case of dementia subtypes, MMSE+VF was better than the MMSE alone for NAD screening, but not for AD screening. CONCLUSION: The results support the usefulness of VF-supplementation to improve the screening performance of MMSE for MCI and NAD.

Prevalence and Associated Factors of Depression in Mild Cognitive Impairment

OBJECTIVE: The aims of this study were to investigate the prevalence of co-morbid depression and related factors of depression in mild cognitive impairment (MCI) patients. METHODS: Nine hundred and six MCI individuals were included in this study. Depression was defined as major and minor depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV). Depression-related demographic and clinical factors were also explored through multivariate logistic regression analysis. RESULTS: In MCI patients, the prevalence of depression as defined according to the DSM-IV diagnostic criteria was 1.8% for major depressive disorder, 11.4% for minor depressive disorder, and overall 13.2% for both. Multivariate logistic regression showed that increased prevalence of overall depression was associated with female gender and non-amnestic subtype of MCI. CONCLUSION: Our findings based on a large number of MCI subjects who visited memory clinic indicated that more than ten percent of MCI patients have comorbid depression. In addition, female and non-amnestic subtype of MCI patients seems to be more vulnerable to depression.

Improvement of Dementia Screening Accuracy of Mini-Mental State Examination by Education-Adjustment and Supplementation of Frontal Assessment Battery Performance

This study aimed to investigate whether the demographic variable-adjustment and supplementation of Frontal Assessment Battery (FAB) score can improve the screening ability of Mini-Mental State Examination (MMSE) for dementia and its subtypes. Five hundred forty-one non-demented comparison (NC) and 474 dementia (320 Alzheimer's disease [AD]; 139 non-Alzheimer's disease dementia [NAD]; and 15 mixed AD-NAD dementia) individuals living in the community were included. Education-adjusted MMSE (MMSE-edu) score showed significantly better screening accuracy for overall dementia, AD, and NAD than MMSE raw score. FAB-supplemented MMSE (MMSE-FAB) score had significantly better screening ability for NAD, but not for overall dementia and AD, than MMSE raw score alone. Additional supplementation of FAB to MMSE-edu further increased the ability for overall dementia or NAD screening, but not for AD screening. Further education adjustment of MMSE-FAB also improved its ability for overall dementia, AD, and NAD screening. These results strongly support the usefulness of education-adjustment and supplementation of frontal function assessment to improve screening performance of MMSE for dementia and its subtypes, NAD in particular.

New Diagnostic Criteria for Alzheimer's Disease : NIA-AA Diagnostic Guidelines

NINCDS-ADRDA and DSM-III clinical diagnostic criteria for Alzheimer's disease (AD) were established in early 1980s, Since then, there has been unprecedented growth of scientific knowledge and techniques including reliable biomarkers for AD pathologies as well as information about non-AD dementia, various AD phenotypes, and insufficient diagnostic accuracy of the current AD criteria, The need to test early intervention was also much elevated. All these changes recently urged to revise the current AD clinical diagnostic criteria. Against these backgrounds, the National Institute of Aging and the Alzheimer's Association (NIA-AA)-sponsored expert workgroups proposed new diagnostic guidelines for AD in 2011, which consists of three separate parts : 1) the diagnosis of dementia due to Alzheimer's disease ; 2) the diagnosis of mild cognitive impairment due to Alzheimer's disease ; 3) toward defining the preclinical stage of Alzheimer's disease. This article aimed to briefly introduce the NIA-AA guidelines and their influence on clinical researches and practice on AD.

The Incidence and Related Factors of Delirium in Elderly Patients with Hip Fracture after Surgery

BACKGROUND: The purpose of this study is to investigate the incidence and associated factors of postoperative delirium in elderly patients with hip fracture. METHODS: We interviewed 90 patients with hip fracture with the aim of identifying underlying diseases and laboratory data. Cognitive function was measured with Mini Mental Status Exam-K (MMSE-K) before surgery. RESULTS: Delirium developed in 20 patients (22.2%). History of dementia (p=0.041) and mean score of MMSE-K (p<0.001) were significantly related to the incidence of delirium. An MMSE-K score less than 20 was an independent risk factor for postoperative delirium in patients with hip fracture. CONCLUSION: Cognitive impairment was a risk factor of postoperative delirium. MMSE-K is expected to be a simple indicator for predicting postoperative delirium in older patients with hip fracture.