Development and validation of a dementia screening tool for primary care in Taiwan: Brain Health Test.

OBJECTIVES: To develop a simple dementia screening tool to assist primary care physicians in identifying patients with cognitive impairment among subjects with memory complaints or at a high risk for dementia. DESIGN: The Brain Health Test (BHT) was developed by several experienced neurologists, psychiatrists, and clinical psychologists in the Taiwan Dementia Society. Validation of the BHT was conducted in the memory clinics of various levels of hospitals in Taiwan. PARTICIPANTS: All dementia patients at the memory clinics who met the inclusion criteria of age greater or equal to 50 years were enrolled. Besides the BHT, the Mini-Mental State Examination and Clinical Dementia Rating were used to evaluate the cognition state of the patients and the severity of dementia. RESULTS: The BHT includes two parts: a risk evaluation and a cognitive test (BHT-cog). Self or informants reports of memory decline or needing help from others to manage money or medications were significantly associated with cognitive impairment. Among the risk factors evaluated in the BHT, a total risk score greater or equal to 8 was defined as a high risk for dementia. The total score for the finalized BHT-cog was 16. When the cutoff value for the BHT-cog was set to 10 for differentiating dementia and a normal mental state, the sensitivity was 91.5%, the specificity was 87.3%, the positive predictive value was 94.8%, and the negative predictive value was 80.1% The area under the receiver operating characteristic curve between dementia and healthy subjects was 0.958 (95% CI = 0.941-0.975). CONCLUSIONS: The BHT is a simple tool that may be useful in primary care settings to identify high-risk patients to target for cognitive screening.

Diagnostic accuracy of Instrumental Activities of Daily Living for dementia in community-dwelling older adults.

BACKGROUND: many people living with dementia remain underdiagnosed and unrecognised. Screening strategies are important for early detection. OBJECTIVE: to examine whether the Lawton's Instrumental Activities of Daily Living (IADL) scale, compared with other cognitive screening tools-the Mini-Mental State Examination (MMSE), and the Ascertain Dementia 8-item Informant Questionnaire (AD8)-can identify older (≥ 65 years) adults with dementia. DESIGN: population-based cross-sectional observational study. SETTING: all 19 counties in Taiwan. PARTICIPANTS: community-dwelling older adults (n = 10,340; mean age 74.87 ± 6.03). METHODS: all participants underwent a structured in-person interview. Dementia was identified using National Institute on Aging-Alzheimer's Association core clinical criteria for all-cause dementia. Receiver operator characteristic curves were used to determine the discriminant abilities of the IADL scale, MMSE and AD8 to differentiate participants with and without dementia. RESULTS: we identified 917 (8.9%) participants with dementia, and 9,423 (91.1%) participants without. The discriminant abilities of the MMSE, AD8 and IADL scale (cutoff score: 6/7; area under curve = 0.925; sensitivity = 89%; specificity = 81%; positive likelihood ratio = 4.75; accuracy = 0.82) were comparable. Combining IADL with AD8 scores significantly improved overall accuracy: specificity = 93%; positive likelihood ratio = 11.74; accuracy = 0.92. CONCLUSIONS: our findings support using IADL scale to screen older community-dwelling residents for dementia: it has discriminant power comparable to that of the AD8 and MMSE. Combining the IADL and the AD8 improves specificity.

Comorbidity and dementia: A nationwide survey in Taiwan.

BACKGROUND: Comorbid medical diseases are highly prevalent in the geriatric population, imposing hardship on healthcare services for demented individuals. Dementia also complicates clinical care for other co-existing medical conditions. This study investigated the comorbidities associated with dementia in the elderly population aged 65 years and over in Taiwan. METHODS: We conducted a nationwide, population-based, cross-sectional survey; participants were selected by computerized random sampling from all 19 Taiwan counties between December 2011 and March 2013. After exclusion of incomplete or erroneous data, 8,456 subjects were enrolled. Of them, 6,183 were cognitively normal (control group), 1,576 had mild cognitive impairment (MCI), and 697 had dementia. We collected information about types of comorbidities (i.e., vascular risk factors, lung diseases, liver diseases, gastrointestinal diseases, and cancers), Charlson comorbidity index score, and demographic variables to compare subjects with normal cognition, MCI, and dementia. RESULTS: Regardless of the cognitive condition, over 60% of the individuals in each group had at least one comorbid disease. The proportion of subjects possessing at least three comorbidities was higher in those with cognitive impairment (MCI 20.9%, dementia 27.3%) than in control group (15%). Hypertension and diabetes mellitus were the most common comorbidities. The mean number of comorbidities and Charlson comorbidity index score were greater in MCI and dementia groups than in control group. Logistic regression demonstrated that the comorbidities significantly associated with MCI and dementia were cerebrovascular disease (OR 3.35, CI 2.62-4.28), cirrhosis (OR 3.29, CI 1.29-8.41), asthma (OR 1.56, CI 1.07-2.27), and diabetes mellitus (OR 1.24, CI 1.07-1.44). CONCLUSION: Multiple medical comorbid diseases are common in older adults, especially in those with cognitive impairment. Cerebrovascular disease, cirrhosis, asthma, and diabetes mellitus are important contributors to cognitive deterioration in the elderly. Efforts to lower cumulative medical burden in the geriatric population may benefit cognitive function.

Effectiveness of different memory training programs on improving hyperphagic behaviors of residents with dementia: a longitudinal single-blind study.

BACKGROUND: Hyperphagia increases eating-associated risks for people with dementia and distress for caregivers. The purpose of this study was to compare the long-term effectiveness of spaced retrieval (SR) training and SR training combined with Montessori activities (SR + M) for improving hyperphagic behaviors of special care unit residents with dementia. METHODS: The study enrolled patients with dementia suffering from hyperphagia resident in eight institutions and used a cluster-randomized single-blind design, with 46 participants in the SR group, 49 in the SR + M group, and 45 participants in the control group. For these three groups, trained research assistants collected baseline data on hyperphagic behavior, pica, changes in eating habits, short meal frequency, and distress to caregivers. The SR and SR + M groups underwent memory training over a 6-week training period (30 sessions), and a generalized estimating equation was used to compare data of all the three groups of subjects obtained immediately after the training period and at follow-ups 1 month, 3 months, and 6 months later. RESULTS: Results showed that the hyperphagic and pica behaviors of both the SR and SR + M groups were significantly improved (P<0.001) and that the effect lasted for 3 months after training. The improvement of fast eating was significantly superior in the SR + M group than in the SR group. The improvement in distress to caregivers in both intervention groups lasted only until the posttest. Improvement in changes in eating habits of the two groups was not significantly different from that of the control group. CONCLUSION: SR and SR + M training programs can improve hyperphagic behavior of patients with dementia. The SR + M training program is particularly beneficial for the improvement of rapid eating. Caregivers can choose a suitable memory training program according to the eating problems of their residents.

Marital Status, Lifestyle and Dementia: A Nationwide Survey in Taiwan.

BACKGROUND: Evidence of an association between lifestyle and marital status and risk of dementia is limited in Asia. METHODS: In this nationwide population-based cross-sectional survey, participants were selected by computerized random sampling from all 19 counties in Taiwan. A total of 10432 residents were assessed by a door-to-door in-person survey, among whom 7035 were normal and 929 were diagnosed with dementia using the criteria recommended by National Institute on Aging-Alzheimer's Association. Premorbid lifestyle habits and demographic data including marital status were compared between normal subjects and participants with dementia. RESULTS: After adjustment for age, gender, education, body mass index, smoking, drinking, marital status, sleep habits, exercise, social engagement and co-morbidities including hypertension, diabetes and cerebrovascular diseases, an increased risk for dementia was found in people with widow or widower status (OR 1.42, 95% CI 1.15-1.77) and people who used to take a nap in the afternoon (OR 1.33, 95% CI 1.02-1.72). Decreased risk was found in people with the habit of regular exercise (OR 0.12, 95% CI 0.09-0.16), adequate night sleep (OR 0.55, 95% CI 0.39-0.76) and regular social engagement (OR 0.53, 95% CI 0.36-0.77). CONCLUSIONS: Our results provide preliminary evidence of possible risk-reduction effects for dementia, including regular exercise even in modest amounts, social engagement and adequate night sleep, whereas people with the widow/widower status or who used to take an afternoon nap might have increased risk of dementia.

A nationwide survey of mild cognitive impairment and dementia, including very mild dementia, in Taiwan.

An increasing population of dementia patients produces substantial societal impacts. We assessed the prevalence of mild cognitive impairment (MCI) and all-cause dementia, including very mild dementia (VMD), in Taiwan. In a nationwide population-based cross-sectional survey, participants were selected by computerized random sampling from all 19 Taiwan counties and were enrolled between December 2011 and March 2013. Cases were identified through in-person interviews based on the National Institute on Aging-Alzheimer's Association clinical criteria. Demographic data and histories involving mental status and function in daily living were collected. The principal objective assessments were the Taiwanese Mental Status Examination and Clinical Dementia Rating. In all, 10,432 people aged 65 years or older (mean age 76.2 ± 6.7, 52.3% women) were interviewed. The age-adjusted prevalence of all-cause dementia was 8.04% (95% CI 7.47-8.61), including a 3.25% (95% CI 2.89-3.61) prevalence of VMD; that of MCI was 18.76% (95% CI 17.91-19.61). Women had a higher prevalence than men of both all-cause dementia (9.71% vs. 6.36%) and MCI (21.63% vs. 15.57%). MCI affects a considerable portion of the population aged 65 and above in Taiwan. The inclusion of VMD yields dementia prevalence rates higher than those previously reported from Taiwan. Old age, female gender, and a low educational level are significant associated factors.

Culture qualitatively but not quantitatively influences performance in the Boston naming test in a chinese-speaking population.

BACKGROUND/AIMS: The Boston Naming Test (BNT) is the most frequently administered confrontational naming test, but the cultural background of the patients may influence their performance in the BNT. The aim of this study was to identify differences in performance in the BNT between a Chinese population in Taiwan, Chinese populations in other areas and a Caucasian population. METHODS: A total of 264 native, Chinese-speaking, cognitively normal elders aged >60 years were enrolled in our study and conducted the 30-item Chinese version of the BNT. Another 10 BNT studies were categorized, analyzed and compared with the present study. RESULTS: Higher education was associated with higher scores, whereas age and gender had no effect on performance in the BNT. The score of the Chinese-speaking population was equivalent to the English-speaking population. A disparity in difficulties with items was not only apparent between the Taiwanese and Caucasian populations, but also between the Chinese-speaking populations in the different geographic areas. CONCLUSION: For the most part, the impact of culture on performance in the BNT may not be quantitative but qualitative. Attention should be paid to a potential effect of culture on difficulties with items when administering the BNT to non-English-speaking populations. Understanding differences in performance in the BNT in distinct cultural settings improves the clinical application of the BNT.

Confrontation naming errors in Alzheimer's disease.

BACKGROUND/AIMS: Impairment in visual interpretation, semantic conception, or word retrieval may contribute to the naming errors identified in the Boston Naming Test (BNT). We investigated the possible cognitive mechanism of the naming difficulty in Alzheimer's disease (AD) by analyzing the error patterns presented in the BNT. METHODS: The Chinese version of the 30-item BNT (BNT-30) was performed on 115 normal control (NC) subjects and 104 mild-to-moderate AD patients. Accurate rates after semantic and phonemic cues were analyzed. The frequencies of 7 types of error patterns in the AD patients and the NC subjects were compared. RESULTS: The accurate rate after semantic cues was significantly lower in the AD than in the NC groups, but phonemic cues were more helpful than semantic cues to achieve accurate naming in both groups. The AD patients made more errors in all error patterns. Particularly, the frequency of nonresponse errors (n = 806) in the AD group significantly exceeded that in the NC group (n = 382). However, the distribution of the error patterns did not differ between the two groups. CONCLUSION: Naming difficulties in AD might be attributed to progressive semantic knowledge degradation. The AD and the NC groups differ quantitatively but not qualitatively in the error patterns in confrontation naming.

Callosal degeneration topographically correlated with cognitive function in amnestic mild cognitive impairment and Alzheimer's disease dementia.

Degeneration of the corpus callosum (CC) is evident in the pathogenesis of Alzheimer's disease (AD). However, the correlation of microstructural damage in the CC on the cognitive performance of patients with amnestic mild cognitive impairment (aMCI) and AD dementia is undetermined. We enrolled 26 normal controls, 24 patients with AD dementia, and 40 single-domain aMCI patients with at least grade 1 hippocampal atrophy and isolated memory impairment. Diffusion tensor imaging (DTI) with fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (DA), and radial diffusivity (DR) were measured. The entire CC was parcellated based on fiber trajectories to specific cortical Brodmann areas using a probabilistic tractography method. The relationship between the DTI measures in the subregions of the CC and cognitive performance was examined. Although the callosal degeneration in the patients with aMCI was less extended than in the patients with AD dementia, degeneration was already exhibited in several subregions of the CC at the aMCI stage. Scores of various neuropsychological tests were correlated to the severity of microstructural changes in the subregional CC connecting to functionally corresponding cortical regions. Our results confirm that CC degeneration is noticeable as early as the aMCI stage of AD and the disconnection of the CC subregional fibers to the corresponding Brodmann areas has an apparent impact on the related cognitive performance.

Patterns of executive dysfunction in amnestic mild cognitive impairment.

BACKGROUND: Executive dysfunction is not uncommon in patients with amnestic mild cognitive impairment (aMCI). This study aimed to investigate the applicability of executive function tests (EFTs) in aMCI as an aid in establishing the diagnosis of multi-domain MCI. METHODS: One hundred and twenty (120) aMCI patients, 126 Alzheimer's disease (AD) patients, and 100 normal controls were enrolled. The EFTs evaluated included the trail making test, digit backward span, Stroop color-word test, and design fluency and category fluency tests. RESULTS: Of the aMCI participants, 66% exhibited impairment in at least one EFT. Among the five selected EFTs, the category fluency test was the most discriminative in detecting executive dysfunction between patients with aMCI (standardized ß = 0.264) or AD (standardized ß = 0.361) with the controls, followed by the Stroop test. The performance of aMCI patients with two or more impaired EFTs was significantly different from those of controls but not from those of AD patients. CONCLUSION: In the clinical setting, aMCI patients who fail in two or more EFTs may represent a unique population with multi-domain MCI that require close follow-up.

Multiple diffusivities define white matter degeneration in amnestic mild cognitive impairment and Alzheimer's disease.

Different diffusivity measurements in diffusion-tensor imaging (DTI) could be helpful for detecting the distinct mechanisms of white matter degeneration in Alzheimer's disease (AD). However, few studies have explored the changes of white matter in amnestic mild cognitive impairment (aMCI) and AD by whole-brain voxel-wise analyses of all diffusivity indices. The association between grey matter atrophy and white matter damage measured by distinct diffusivities is still uncertain. Structural magnetic resonance imaging and DTI with four diffusivity indices, comprising fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity, were performed in 30 normal controls, 26 mild AD patients, and 40 aMCI patients with isolated memory impairment. T1 voxel-based morphometry and DTI tract-based spatial statistics were applied to compare the grey and white matter changes in the 3 groups. In contrast to the lack of significant white matter change presenting in aMCI patients, extended white matter degeneration over entire cerebral networks was exhibited in mild AD patients. Both axonal degradation and demyelination contributed to the white matter degeneration in AD; nevertheless, demyelination essentially involved the frontal portion of cerebral networks. Axonal degradation and demyelination over the temporal region were associated with the contiguous grey matter atrophy. However, only the severity of demyelination over the frontal region was correlated with the degree of atrophy over adjacent frontal grey matter. Our results suggest that different mechanisms of white matter damage demonstrate discrete regional distribution in AD. Demyelination may independently correlate with contiguous grey matter over the frontal region.

[Cognitive Abilities Screening Instrument, Chinese Version 2.0 (CASI C-2.0): administration and clinical application].

Abstract- The Cognitive Abilities Screening Instrument (CASI) has been commonly used in dementia research and clinical practice to evaluate a subject's cognitive abilities and to follow-up possible progression of dementia. It has a detailed manual for test administration and scoring in order to minimize testing errors. The Chinese version of CASI (CASI C-2.0) has been used in many clinical and epidemiological studies in Taiwan. Since cognitive abilities are influenced by education, and there are high rates of illiterate or low education individuals among the elderly in Taiwan, the normative data of CASI, including its total score and its cognitive domain scores, should be divided into different education ranges. In clinical practice, the cut-off scores in differentiating between dementia and normal are suggested to be: 49/50 for Education year = 0; 67/68 for Education years = 1-5; and 79/80 for Education years more than 6.

Learning and error patterns in the Chinese Verbal Learning Test in subjects with mild cognitive impairment and normal elderly.

PURPOSE: The discrimination between normal elderly (NC) and those with mild cognitive impairment (MCI) is of clinical relevance since the conversion from MCI to Alzheimer dementia (AD) is high. METHODS: This study enrolled 216 amnestic MCI patients and 103 NC from our memory clinics and assessed whether the learning curve, recall and cued scores, as well as error patterns from the Chinese Version Verbal Learning Test (CVVLT) helped to distinguish between these two groups. RESULTS: Our results revealed that subjects with MCI had a lower rate of acquisition and deceleration of learning in the learning curve. The MCI group also showed a lower retention rate and recall scores as compared with the NC group. Further, the error patterns offered discrimination values between the two groups in total number of perseverations, intrusion in the cued recall, as well as prototypic and unrelated errors in recognition. An inverse correlation was seen between memory scores and error patterns. CONCLUSION: This study suggests that by combining the learning and error patterns from the verbal memory test, patients with MCI can be better differentiated from normal elderly.

Functional disability profiles in amnestic mild cognitive impairment.

BACKGROUND/AIMS: Instrumental activities of daily living (IADL) can be impaired in mild cognitive impairment (MCI), and the severity of functional disability predicts Alzheimer's disease (AD) in amnestic MCI (aMCI). This study investigated the functional profiles of aMCI in a Chinese population. METHODS: The Disability Assessment for Dementia scores of 56 subjects with single-domain aMCI (sd-aMCI) and 94 with multiple-domain aMCI (md-aMCI) were compared with normal controls (n = 64) and mild AD patients (n = 102). RESULTS: Both the sd-aMCI (2.5 ± 2.5) and md-aMCI (3.7 ± 3.5) groups had more impaired IADL items than the controls (0.7 ± 1.7). Their IADL scores were intermediate, between the control and AD groups. sd-aMCI subjects presented deficits in 7 IADL items involving the 'meal preparation', 'telephoning', 'finance', 'medications', 'housework', and 'leisure' subscales. md-aMCI subjects presented deficits in 14 IADL items involving all subscales of daily activities. The Mini-Mental State Examination and Modified Trail-Making Test Part B scores were the major neuropsychological correlates of IADL performance in aMCI. CONCLUSION: IADL can be impaired in both sd-aMCI and md-aMCI. Including the functional ability assessment in the evaluation of aMCI may help clinicians to provide appropriate suggestions to maintain daily functioning.

More severe white matter changes in the elderly with jugular venous reflux.

OBJECTIVE: The etiology of age-related white matter changes is unclear. Cerebral white matter changes on magnetic resonance imaging (MRI) and progressive dementia have been reported in patients with dural arteriovenous fistulas of the sigmoid sinus. The frequency of jugular venous reflux, which mimics a dural arteriovenous fistula, significantly increases with age. We investigated whether jugular venous reflux was associated with the severity of age-related white matter changes in 97 persons (aged 55-90 years, mean [standard deviation]: 75.77 [8.19] years; 55 men) from a medical center memory clinic. METHODS: MRI (1.5T) and the semiquantitative Scheltens scale were used to investigate the severity of white matter changes. Subjects were classified into 3 groups (no, mild, and severe jugular venous reflux) by duplex ultrasonography. RESULTS: Subjects with severe jugular venous reflux had more severe age-related white matter changes in occipital subcortical, thalamus, pontine, and summed infratentorial regions compared with subjects with no jugular venous reflux (all corrected p < 0.0166), especially subjects aged ≥75 years (corrected p < 0.0166 in occipital subcortical; corrected p < 0.0001 in pontine and summed infratentorial regions). In subjects ≥75 years, we further noted that the whole brain age-related white matter changes rating scores were higher in the severe jugular venous reflux group than the no and mild jugular venous reflux groups (corrected p < 0.0166). INTERPRETATION: People with severe jugular venous reflux exhibit more severe age-related white matter changes, especially in caudal brain regions. We also demonstrate age-dependent jugular venous reflux effects on the severity of age-related white matter changes. These findings may provide new clues into the pathophysiology of age-related white matter changes.

APOE ε4 increases the risk of progression from amnestic mild cognitive impairment to Alzheimer's disease among ethnic Chinese in Taiwan.

OBJECTIVE: To evaluate the effect of the apolipoprotein E (APOE) ε4 in the progression from mild cognitive impairment (MCI) to Alzheimer's disease (AD) in ethnic Chinese people in Taiwan. METHODS: Subjects older than 60 years with normal cognition, MCI or AD were enrolled from the memory clinic from 2000 to 2008. Normal ageing and MCI subjects were evaluated with clinical and neuropsychological examinations annually, and their APOE genotypes were determined. RESULTS: A total of 326 normal ageing subjects, 304 amnestic MCI and 537 AD patients were recruited at baseline. The frequencies of APOE ε4 were 22.1% in normal ageing, 26.6% in MCI and 40.8% in AD patients. During the follow-up period (42.5±18.5 months), there were 227 MCI patients, and 248 normal ageing subjects received one or more annual follow-up evaluation. The ε4+carriers had a higher annual conversion rate than did the ε4-negative subjects either in the MCI (15.9% vs 9.0%) or in the normal ageing subjects (2.2% vs 0.7%). The mean survival time before progression to AD was 57.0 months for the MCI ε4+carriers, 85.9 months for MCI ε4-negative patients, 86.2 months for normal ageing e4+carriers and 120.8 months for normal ageing ε4-negative subjects. The adjusted hazard ratio of APOE ε4 for developing AD was 2.0 (95% CI 1.2 to 3.2) in MCI and 5.3 (95% CI 1.2 to 24.1) in normal ageing. CONCLUSION: APOE ε4 increased the risk of developing AD both in amnestic MCI and in normal ageing in a clinic-recruited ethnic Chinese population.

Validating the Chinese version of the Verbal Learning Test for screening Alzheimer's disease.

Episodic memory tasks are one of the most sensitive tools to discriminate Alzheimer's disease (AD). This study aimed to validate a shorter version verbal memory test that will efficiently assess Chinese elderly with memory complaints. One hundred and eighty-five elderly with normal cognition (NC) and 217 AD patients were evaluated. Each participant received the Chinese Version Verbal Learning Test (CVVLT) consisting of 9 two-character nouns with 4 learning trials, 2 delayed recalls in 30 seconds and 10 minutes, and a word recognition test. In the NC elderly, age and sex had significant effects on recall scores in CVVLT, while education level showed an inverse correlation with 3 different patterns of errors made during the learning, recall, and recognition trials. AD patients had lower scores across all recall tests. In those with lower educational level, NC elderly had higher perseveration errors than AD patients. The cutoff value between the AD and NC groups in the 10-minute recall was 4/5 for those aged >75 years and 5/6 for those aged <75 years. This study has good validity in discriminating AD participants and the data here can help in diagnosing AD and mild cognitive impairment using the CVVLT.

Accelerated hippocampal atrophy rates in stable and progressive amnestic mild cognitive impairment.

Studies suggest that smaller hippocampal volume predicts Alzheimer's disease (AD) in mild cognitive impairment (MCI). However, few studies have demonstrated decline rates in cognition and hippocampal volume in MCI subjects with stable clinical presentation. Furthermore, the effects of apolipoprotein E (ApoE) on the change rates of medial temporal structures and cognition in MCI are rarely investigated. Fifty-eight subjects with amnestic MCI and 20 normal aging elderly controls received annual neuropsychological and magnetic resonance imaging (MRI) assessments. Annual decline rates in neuropsychological test scores, hippocampal and amygdalar volumes were calculated. ApoE genotypes were examined. Nineteen (32.7%) MCI subjects converted to AD during an average 22.5-month follow-up period. The annual hippocampal atrophy rate was correlated with a decline in memory test scores. The presence of the ApoE varepsilon4 allele did not affect the change rates in neuropsychological test scores and medial temporal structures volume. Compared to subjects with stable MCI (MCI-S) and normal aging, progressive MCI (MCI-P) had the highest annual decline rates in cognition and hippocampal volume. Logistic regression analysis showed that higher annual decline rates in hippocampal volume and global cognitive test scores were associated with conversion to AD. Furthermore, although MCI-S subjects had little cognitive decline, their hippocampal atrophy rates were higher than those of normal aging controls. Therefore, accelerated hippocampal atrophy rates may be an early and important presentation in MCI subjects.

Sensitivity and specificity of the Clock Drawing Test, incorporating Rouleau scoring system, as a screening instrument for questionable and mild dementia: scale development.

OBJECTIVE: The objective of this study was to validate the Rouleau scoring system for the Clock Drawing Test (CDT) in northern Taiwan, a non-English speaking area, to increase its generalization by detecting subjects with questionable dementia (QD) from normal controls (NC) and subjects with mild dementia (AD). The system consists of two parts: a 10-point scoring and error types. A cross-sectional design was used. One hundred and sixteen subjects were recruited from a memory disorder clinic (n=40 NC; n=34 QD; n=42 AD). Reliability and validity were estimated, the predictive accuracy was calculated using the receiver operating characteristic (ROC) curve analysis, and the error types were counted. RESULTS: The results indicated that most of the error types committed were conceptual deficiencies and graphic difficulties; more errors were found in the command condition (CDT-command) than in the copy condition (CDT-copy); 15% of the subjects drew smaller clock circles in CDT-command, which did not relate to any other errors. No small clock was found in CDT-copy because a pre-dawn circle was provided. The inter-rater reliability of the Rouleau scoring system was .87 and .83 for the CDT-command and -copy, respectively, while the discriminate accuracy of the scoring system was relatively low in detecting QD vs. NC, QD vs. AD, but somewhat better in distinguishing AD vs. NC groups for the areas under the ROC curves was equal to .72 for the CDT-command, and .73 for the CDT-copy. Visuospatial construction and executive functioning explained the largest score variance of the CDT in both conditions, while depressive symptoms were not significantly associated with the CDT performance. CONCLUSION: The CDT using the Rouleau scoring system has been validated in mild AD subjects in Taiwan; however, to screen for QD sufferers, alternative scoring systems emphasizing hands or combining CDT with different neuropsychological tests such as the Clinical Abilities Screening Instrument are recommended.

Survival of ethnic Chinese with Alzheimer's disease: a 5-year longitudinal study in Taiwan.

Survival time and mortality risk factors in patients with Alzheimer's disease (AD) have been documented in Western countries, but comparable information on the ethnic Chinese is scarce. We consecutively recruited 159 AD patients and 145 control subjects from the Memory Clinic of Taipei Veterans General Hospital. After admission to the study, each subject received clinical, neuropsychological, and psychiatric evaluation and apolipoprotein E genotyping. Survival status was followed for 5 years. Forty-six AD patients (28.9%) and 3 control subjects (2.1%) died during the 5-year follow-up period. The mean survival time for AD patients was 4.48 years (SD = 0.1 years) after the time of enrollment. Among individuals with AD, those with severe disease, older patients, and those experiencing hallucinations were at greater risk for increased mortality. As expected, AD shortened life expectancy in these patients. The factors found to correlate with a shorter life span may suggest effective health care strategies for AD patients.