One-Year Follow-up Pilot Study for Dementia Diagnosis in Elderly with Recall Score of 0 in Korean-version of Mini-Mental State Examination

BACKGROUND: The early stage of Alzheimer disease might show early memory impairment with normal general cognitive function. Our study aimed to investigate elderly with normal Korean version of mini-mental state examination (K-MMSE) score and recall score of 0 for 1 year. We predicted that the patients would show different characteristics and would progress more rapidly compared with normal controls. METHODS: This study was based on the data from complete enumeration survey of Mapo-gu Regional Center for Dementia in 2009. We divided all subjects into three groups: subjects with normal K-MMSE scores and recall score of 0 were group 1-1 (n=152), subjects with abnormal K-MMSE scores were group 1-2 (n=64) and subjects with normal K-MMSE scores and recall score of 1 to 3 were group 1-3 (n=941). We compared basic demographics and social characteristics among the three groups. After 1 year (2010), the subjects in group 1-1 (90 out of 152) underwent follow-up examinations for dementia diagnosis. They were also divided into three groups (2-1, 2-2, 2-3) according to K-MMSE and recall scores. RESULTS: Group 1-1 showed different baseline characteristics compared with normal controls. After 1 year, 25.5% (23 out of 90) of the group 2-1 were diagnosed as mild cognitive impairment (n=16) or dementia (n=7). CONCLUSION: Our study suggested that subjects with normal K-MMSE scores but recall score of 0 are not entirely "normal". Further detailed evaluation might be needed if memory impairment is suspicious although the K-MMSE scores are within normal range.

The Survey for Current State and Dognition of Activities of Daily Living in Dementia Patients- "Il-sang-ye-chan" Campaign

BACKGROUND: Disability of Activities of daily living (ADL) is the most important factor for care of dementia patients. So Korean Dementia Association has prepared the survey for current state and cognition of active daily living in Korean dementia patients. METHODS: A total of 100 subjects were interviewed. Structured open and closed questions about ADL for dementia were asked. They are main caregivers of dementia patients who working over 5hours per day. Assessments included age, sex, education level, economic status, severity of dementia patients, pattern of the care-giving, current state and cognition of ADL, and needs of the caregivers. RESULTS: The cognition of ADL was very low (51%) and this is correlated with economic status. Increasing of care-giving time is the most stressful for caregivers, they frequently suffered from disability of outgoing and personal hygiene. Dementia patient's ADL disability causes serious economic losses, need of the caregivers about guide lines or education program was very high. CONCLUSION: Considering these results, we should design more detailed study about dementia patient's ADL disability and prepare guide line or program for it.

A Comparison of the Prospective Memory among College Students, Normal Elderly, and Parkinson's Disease Patients

BACKGROUND: This study was conducted to examine the effects of normal aging and cerebral pathology on the prospective memory and the relationships between the prospective memory and frontal lobe functions. METHODS: The subjects were 30 college students, 30 normal elderly, and 30 Parkinson's disease patients. There was no significant difference in the mean age or education level between the normal elderly and Parkinson's disease patients. The Cambridge Prospective Memory Test and the Prospective and Retrospective Memory Questionnaire were administered to evaluate the prospective memory. The Seoul Verbal Learning Test and Rey Complex Figure Test were given to assess the verbal and visual episodic memories. The subjects also took the Sorting Test, the Korean-Color Word Stroop Test, and the Iowa Gambling Task to assess the frontal lobe functions. RESULTS: The results showed that the prospective memory declines with aging and pathological process. The normal elderly showed significantly lower scores on the time-based prospective memory than the event-based prospective memory, although the college students and Parkinson's disease patients did not show any differences between them. Many significant correlations were found between the prospective memory tests and frontal lobe tests in the normal elderly and Parkinson's disease patients, although only a few correlations were found in the college students. CONCLUSIONS: These quantitative and qualitative changes in the prospective memory by aging and frontal lobe dysfunction would support the de-differentiation hypothesis of aging.

Activities of Daily Living and Dementia

Activities of daily living (ADL) refer to the ability to care for self and perform daily activities within an individual's place or in outdoor environments. ADL comprise two main categories: Basic or physical ADL and Instrumental ADL. The latter allows for the earlier detection of functional decline than the former. The cognitive changes in neurodegenerative dementias contribute to the impaired ability of the patients to take care of themselves. Activities of daily living is a major criterion for diagnosing dementia. Furthermore, it has recently been emphasized that some impairment of activities of daily living, particularly of complex instrumental functions, is already present even in mild cognitive impairment prodromal stage of dementia, although mild cognitive impairment is distinguished from dementia by the absence of significant deficit in activities of daily living. The impaired activities of daily living increase the rate of institutionalization of the patients with dementia to nursing home and inevitably bring about the changes in the qualities of life not only of the patients but their caregivers. One of the best ways to evaluate the degree of impairment in activities of daily living and the care burden is through standardized functional assessment tools according to the severity of dementia. These tools provide objective data, thereby allowing the clinicians to judge decline and improvement in the functional status and to plan individualized care. In this review, we will review the clinical significance of evaluating ADL, the assessment tools according to the severity of dementia, and therapeutic approaches to enhance the functional levels. We will also review the impact of the impaired ADL on the quality of life among the patients and their care providers.

Factors Associated with a Decline in Activities of Daily Living in Patients with Dementia at Geriatric Hospitals: A 6 Month Prospective Study

BACKGROUND: Decreased activities of daily living (ADL) in elderly people are related to decreased quality of life and death and are a clinically important issue. However, few studies have investigated the various characteristics and risk factors for a decline in ADL among elderly in-patients in geriatric hospitals in Korea. METHODS: In total, 163 elderly in-patients with dementia in three geriatric hospitals located in Incheon, Gwangju and Yongin, Korea were surveyed prospectively for associated factors of a decline in ADL after 6 months. RESULTS: On average, the subjects were 79.4+/-7.6 years old, and 67.5% were female. Approximately 63% had Alzheimer type dementia, 36.8% only attended primary school, 73.0% were widowed, and 38.7% had been admitted to hospitals for less than 1 year. The Korean version of the Mini Mental State Examination (K-MMSE) score was 14.1+/-6.5, and the clinical dementia rating was 1.9+/-0.9. In total, 8.6% were bed-ridden and 59.5% and 64.6% had never experienced fecal and urinary incontinence, respectively. Total ADL scores declined after 6 months follow-up, and significantly associated factors were low K-MMSE score, fecal incontinence, and co-existence of fecal and urinary incontinence. CONCLUSION: Low K-MMSE scores, fecal incontinence, and the co-existence of fecal and urinary incontinence were associated with ADL declines in elderly in-patients with dementia in long-term care hospitals located in three cities in Korea.

Encephalitis Lethargica With Catatonia

Encephalitis lethargica (EL) is an acute or subacute central nervous system (CNS) infectious disorder presenting with pharyngitis followed by sleep disorder, basal ganglia signs (particularly parkinsonism), and neuropsychiatric sequelae. We report a 67-year-old man who had hypersomnolence, oculogyric crisis, akinetic mutism, parkinsonism, and malignant catatonia, which represented the stereotypic movement disorder with additional features of hyperthermia. His symptoms dramatically improved after steroid pulse therapy, indicating that EL syndrome could be a postinfectious neurological autoimmune CNS disorder.

Cerebellar Hypoperfusion during Transient Global Amnesia: An MRI and Oculographic Study

BACKGROUND AND PURPOSE: Transient global amnesia (TGA) is characterized by sudden anterograde and retrograde amnesia lasting for up to 24 hours. Diffusion-weighted magnetic resonance imaging (DWI) in cases of TGA and ischemia demonstrates a high frequency of high signal intensities restricted to the hippocampus, and this has been proposed as an etiology of TGA. The aims of this study were to characterize the DWI and single-photon-emission computed tomography (SPECT) findings during the acute and recovered phases of TGA and to correlate the findings with oculomotor abnormalities. METHODS: Five consecutive patients with a clinical diagnosis of TGA underwent DWI and SPECT of the brain within 24 hours after symptom onset and again 3 days later. Eye movements were also recorded using three-dimensional video-oculography. RESULTS: In all patients, DWI disclosed small punctuate (1-3 mm), high-signal lesions in the lateral portion of the hippocampus. The initial SPECT also revealed hypoperfusion in the cerebellar vermis, which had recovered by the follow-up examination. Three patients showed saccadic hypermetria or impaired smooth pursuit only during the acute phase. CONCLUSIONS: Our patients with TGA showed cerebellar vermian hypoperfusion in addition to ischemic insults to the lateral hippocampus. The oculomotor abnormalities observed in our patients support the occurrence of cerebellar dysfunction during the TGA attack.

Clinical Course of Small Vessel Dementia Patients According to Cholinesterase Inhibitor Treatment

BACKGROUND: Small vessel dementia (SVD) is the most frequent cause of vascular dementia and is regarded a distinct clinical entity. However, the data on the natural course of SVD and drug trials specifically aiming SVD have been sparse. The aim of this study was to answer the following three questions: 1) How does SVD progress? 2) Does cholinesterase inhibitor therapy improves cognitive symptoms and daily activity of life (ADL) in SVD? 3) Is there any clinical difference among the subtypes of SVD? METHODS: According to cholinesterase inhibitor medications, patients with SVD were retrospectively analyzed using Hyoja Dementia registry. In this study, effects of treatment were assessed by comparing the scores of Korea version Mini-Mental State Examination (MMSE), Clinical Dementia Rating scale (CDR), Functional Independence Measure (FIM) at the base line with those at endpoints. RESULTS: After 12 months, the mean MMSE, CDR, FIM scores improved significantly in the cholinesterase inhibitor treatment group, compared with that in no-treatment group. In no-treatment group, annual decline of MMSE was 2.7, compared with 0.3 increment in the treatment group. White matter type of SVD showed worst prognosis compared with other types. CONCLUSIONS: This study suggests that SVD has more benign clinical course than previously reported, and cholinesterase inhibitor improves cognitive and ADL functions in SVD. Among the subtypes of SVD, the white matter type may have poor prognosis.

Associated Conditions and Clinical Significance of Awake Bruxism

BACKGROUND: Awakebruxism is defined as an oral parafunctional activity that includes clenching and grinding of teeth during wakefulness. Confirming the possible related anatomy and the clinical significance of awake bruxism in Yong-in Hyoja Geriatric Hospital is the aim of this study. METHODS: We analyzed the medical records of 503 patients who were admitted in hospital from April to June 2005. After the recognition of bruxism, the clinical, brain imaging studies and statistical parametric mapping(SPM) of Brain SPECT were done. RESULTS: (1) In each disease group, 5 among 125 Alzheimer's disease(AD) patients(4.0%, 5/125), 3 among 11 frontotemporal dementia(FTD) patients(27.3%; 3/11), 7 among 230 stroke patients(including two patients related with citalopram, 3.0%; 7/230), 1 among 45 Parkinson's disease patients(2.2%; 1/45), and 4 hydrocephalus patient(23.5%; 4/ 17) had bruxism. (2) Even though awake bruxism occurred in early stage after stroke onset, it occurred in late stage after AD and FTD onset. This occurred in far advanced stage of AD, while it occurred in moderately advanced stage of FTD and stroke. (3) SPM analysis in AD and FTD patients with awake bruxism revealed significant hypoperfusion in frontotemporal and other subcortical structures. CONCLUSIONS: This study suggests that awake bruxism is encountered in various diseases in geriatric hospital. It is closely related frontotemporal lobe dysfunction in degenerative dementia like FTD and AD. Therefore it can be regarded as one of marker of frontal or related subcortical neurological sign in degenerative dementia.

Two Cases of Citalopram Induced Awake Bruxism / 대한정신약물학회지

Bruxism has been defined as an oral parafunctional activity characterized by clenching, bracing, gnashing and grinding of teeth while asleep and or awake. While bruxism has been associated with a number of neurological diseases, it has been mostly highlighted following drug medication. We report 2 female patients of awake bruxism after citalopram medication. The bruxism in these patients was completely or significantly improved after cessation of citalopram. We discuss the pathophyisological mechanism of bruxsm associated with selective serotonin reuptake inhibitors (SSRIs). These cases highlight that bruxism can occur in response to citalopram, as do in other SSRIs.

The Change of K-MMSE Following Donepezil Medication in Patients with Alzheimer's Disease and Small Vessel Dementia, and the Characteristics of Alzheimer's Disease with Meaningful K-MMSE Change

OBJECTIVES: Donepezil is a widely used drug for the treatment of patients with Alzheimer's disease(AD). The aim of the present study was to clarify the efficacy and the characteristics of responders to donepezil. METHODS: Patients with probable AD(n=80 ; 75.7 years) and small vessel dementia(SVD)(n=18 ; 77.8 years) who received donepezil were retrospectively analyzed using Alzheimer's registry, and three questions were asked: 1) Does donepezil therapy improves cognitive symptoms in patients with dementia? 2) If donepezil improves cognitive symptoms, which items of the K-MMSE are improved? 3) What are the characteristics of responder to donepezil medication? RESULTS: 1) After donepezil medication, cognitive function measured by the K-MMSE was significantly improved in both types of dementia(AD and SVD), However, statistical differences were not found between these groups. 2) In a clinical trial of donepezil, the patients performed better than before mediation on K-MMSE items assessing orientation, recall, construction, concentration, calculation. 3) In AD, the K-MMSE score before medication was closely related with response of donepezil. CONCLUSION: This study suggests that donepezil improves various cognitive functions in both types of dementia, and the responsive group had significantly lower K-MMSE scores than the non-responsive group before medication.

A Case of Rapidly Progressive Dementia caused by Idiopathic Hypereosinophilic Syndrome

Hypereosinophilic syndrome is a rare disease, characterized by hypereosinophilia of the blood and by the presence of varying internal symptoms and neurological signs. We report a 70-year-old woman who was admitted with rapidly progressive cognitive dysfunction, which had begun 10 months earlier. On admission, she had hypereosinophilia with elevated IgE. Following steroid therapy, there was rapid improvement of dementia. Considering the possibility of irreversibility at delayed intervention, the early diagnosis and treatment of dementia due to hypereosinophilic syndrome cannot be overemphasized.

Practice Guidelines for the Manegement of Alzheimer's Disease

No abstract available.

EEG Coherence in Alzheimer's Disease

BACKGROUND: EEG coherence can be used to evaluate the functional cortical connections and to get information about the synchronization of the regional cortical activity. We studied EEG coherence in patients affected by clinically probable Alzheimer's disease (AD) in order to quantify the modifications in the cortico-cortical or cortico-subcortical connections. METHODS: The EEGs were recorded in 62 AD patients and in 30 normal age-matched subjects from 16 electrodes with linked-ears reference. Spectral parameters and coherence were calculated by a multichannel autoregressive model using 20 artifact-free 2-sec epoch in normal controls and AD patients. RESULTS: In AD patients, alpha coherence in frontal field and theta, alpha interhemispheric coherence was significantly decreased, whereas alpha, beta coherence in posterior field was significantly increased. Some electrodes in the anterior field showed significant negative correlation with MMSE, whereas other electrodes in the posterior field showed significant positive correlation with MMSE. CONCLUSIONS: This study suggests that coherence is a useful tool for understanding electrophysiologic change of AD and for correlating with the severity of cognitive dysfunction. And these coherence changes can be interpreted as the effects of neuronal loss and neocortical disconnection.

Clinical Implication of "Closing-in" in Patients with Dementia

BACKGROUND: "Closing-in" phenomenon is defined as a tendency to close in the model while copying tasks. This unique phenomenon is one of the constructional apraxia often observed in dementia, especially in Alzheimer's disease (AD). The aim of this study is to investigate the usefulness of "closing-in" in the differential diagnosis of AD and subcortical vascular dementia, and to clarify what the associated factors to this phenomenon are. METHODS: Based on copying data of alternating square and triangle in younger control, we operationally defined "closing-in". "Closing-in" in copied figure was classified into three types: overlap, adherent and near types. With this criteria, we analyzed the incidence of "closing-in" in younger control (N=30), elderly control (N=22), AD (N=64), and subcortical vascular dementia (N=31). RESULTS: Compared with subcortical vascular dementia, AD patients had a significantly higher occurrence of "closing-in" phenomenon. Among "closing-in" type, overlap and adherent type was exclusively occurred in AD. A discriminant analysis, calculated by combining results obtained by AD, showed that symptom onsets with age. Korean Mini-Mental State Examination, Clinical Dementia Rating Scale, Rey-Osterrieth Complex Figure Test were significantly correlated with "closing-in". In EEG mapping, though AD patients with apraxia had significantly lower alpha spectra power in all fields, there is no statistical difference between patients with closing-in and those without. CONCLUSIONS: This study suggests that "closing-in" phenomenon was a phase- and AD-specific useful tool for differential diagnosis with subcortical vascular dementia. Moreover, overlap and adherent subtypes of "closing-in" was highly specific in AD, so further clinical study may be promising.

Pharmacological Treatments of Behavioral Symptoms in Dementia

Behavioral symptoms are well-recognized concomitants of the progression of dementia. These symptoms include agitation, aggression, anxiety, depression, disinhibition, delusions, hallucination, and sleep disturbance. Because these symptoms are a major source of impaired quality of life for patients and their caregivers, appropriate pharmacological management of them may reduce the burden of caregivers and postpone institutionalization. Furthermore, behavioral symptoms may be more amenable to pharmacological intervention than cognitive symptoms. For that reason, detailed evaluation and appropriate treatment are the mainstay in the management of dementia patients. In this article, we reviewed symptomatology and psychopharmacology for behavioral symptoms of dementia.

Differences of Spectral EEG Analysis and Prognosis Following Single Hemispheric Infarction and Hemorrhage in Striatocapsular Area

BACKGROUND: Vascular dementia is common cause of dementia, second to the dementia of Alzheimer desease. However in Asia and many developing countries, the incidence of vascular dementia exceeds that of Alzheimer's disease. Though many stroke-related factors related the nature of vascular injury, e.g. infarction and hemorrhage, have not assessed yet. Clarifying the difference of electroencephalograpy and clinical prognosis between infarction and hemorrhage, the aim of this study was to elucidate the role of nature of vascular injury. METHODS: to reduce confounding factors, the study population was restricted to the patients of single hemispheric striatocapsular infarction and hemorrhage saving cortex. On admission, we checked the KMMSE and FIM scores and using quantified EEG, we analyzed occipital peak frequency and the relative background alpha, theta and delta spectra power taken from 16 derivations by averaging twenty-2 -sec epoch in infarction, hemorrhage patients and elderly controls. After 6 months follow up, we compare the MMSE, FIM score between infarction and hemorrhage group. RESULTS: 1) Compared with infarction group, hemorrhage groups had a significantly bilateral lower occipital peak freqauency and background bilateral alpha spectra power. 2) In hemorrhage group, there is lower tendency in K-MMSE after 6 month follow up compared to infarction group. CONCLUSION: This study suggests that hemorrhage show more bilateral electrophysiological dysfunction than infarction group and possible grave prognosis for vascular dementia compared to infarction group.

The Factors Associated with Typical Pattern of Brain SPECT in Alzheimer's Disease / 신경정신의학

OBJECTIVES: During the past few years, the development of functional brain imaging techniques has allowed to describe brain impairment in cognitive disorders. Among them, based on the observation of bilateral parietotemporal hypoperfusion in Alzheimer's disease(AD), single photon emission computed tomography(SPECT) is advocated by some as powerful diagnostic tool in the evaluation of demented patients. The aim of this study is to investigate the usefulness of SPECT in the diagnosis of AD and to clarify the associated factors of parietotemporal hypoperfusion, the typical SPECT pattern of Alzheimer's disease(AD). METHODS: We reviewed the SPECT scans of 26 patients fulfilling NINCDS-ADRDA criteria for probable AD, 14 with typical pattern of SPECT and 12 with atypical pattern of SPECT. Dementia severity was assessed by the Mini-Mental State Examination. Image interpretation was done visually by the consensus opinion of 2 experienced nuclear medicine physicians who were blind to clinical information. To estimate the association of typical pattern of SPECT with other variables of interest, discriminant function analysis was done. RESULTS: Though the overall diagnostic sensitivity of SPECT in AD was 53.8%, it was 76.9%, in early-onset AD patients. Typical pattern of SPECT was more frequent in the patients with early onset of the symptoms. Duration of symptoms, duration of education, sex, severity of disease was not associated with this SPECT pattern. CONCLUSION: These findings may be useful in the clinical setting and point to heterogeneity of AD according to age at onset.

Neuropsychological Differentiation between Alzheimer's Disease and Vascular Dementia

BACKGROUND: Neuropsychological Differentiation between Alzheimer's disease and vascular dementia has been controversial. The aim of this study was to detect neuropsychological differences between Alzheimer's disease (AD) and vascular dementia (VD). METHODS: Twenty one patients who met the criteria for probable AD according to the National Institute of Neurological Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) and 22 patients who met criteria for probable VD according to the National Institute of Neurological Disorders and Stroke and the Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN), were included in this study. These two dementia groups were matched for age, sex, education, Mini-Mental State Examination score, and severities of dementia. All patients underwent the Seoul Neuropsychological Screening Battery (SNSB). RESULTS: Patients with VD showed greater deficits in verbal fluency (P<.05) than AD patients. However, AD patients, compared with VD patients, showed greater deficits in verbal memory functions including the 3 words recall task. Otherwise, no significant between-group differences were found in task results. CONCLUSIONS: Neuropsychologically, patients with VD differ from patients with AD only in a few cognitive domains. (J Korean Neurol Assoc 19(2):143~148, 2001)

Neuropsychological Differentiation between Alzheimer's Disease and Vascular Dementia

BACKGROUND: Neuropsychological Differentiation between Alzheimer's disease and vascular dementia has been controversial. The aim of this study was to detect neuropsychological differences between Alzheimer's disease (AD) and vascular dementia (VD). METHODS: Twenty one patients who met the criteria for probable AD according to the National Institute of Neurological Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) and 22 patients who met criteria for probable VD according to the National Institute of Neurological Disorders and Stroke and the Association Internationale pour la Recherche et l'Enseignement en Neurosciences (NINDS-AIREN), were included in this study. These two dementia groups were matched for age, sex, education, Mini-Mental State Examination score, and severities of dementia. All patients underwent the Seoul Neuropsychological Screening Battery (SNSB). RESULTS: Patients with VD showed greater deficits in verbal fluency (P<.05) than AD patients. However, AD patients, compared with VD patients, showed greater deficits in verbal memory functions including the 3 words recall task. Otherwise, no significant between-group differences were found in task results. CONCLUSIONS: Neuropsychologically, patients with VD differ from patients with AD only in a few cognitive domains. (J Korean Neurol Assoc 19(2):143~148, 2001)