Faculty Bibliography

The hippocampal formations of 13 subjects with severe Alzheimer disease [AD; Global Deterioration Scale (GDS) stage 7] and of 5 age-matched subjects without symptoms of dementia were reconstructed from serial sections. Functional assessment staging (FAST) was used at the time of demise to assess 9 patients at stages 7a-c (incipient averbal and nonambulatory) and 4 patients at stages 7e-f (immobile). The duration of the disease from FAST stage 5 until demise ranged from 2 to 8 years in the first of these subgroups, and from 10 to 13 years in the second. The volumes of the entire hippocampal formation and of the cornu ammonis, its sectors and layers, the dentate gyrus, the subicular complex, and the entorhinal cortex were calculated. Hippocampal formation volume decreased by 36% in the incipient averbal and nonambulatory patients and by 60% in the severely functionally impaired immobile patients, in comparison with controls. In the final substages of AD, immobile patients exhibited significant atrophy, in comparison with controls, in the cornu ammonis and all of its sectors and layers except CA4, the subicular complex and all of its parts, and the entorhinal cortex (p < 0.05). Within the AD patient group, significant correlations were noted between both the magnitude of functional severity and the duration of AD and the volumes of most hippocampal formation subdivisions studied. For the cornu ammonis, subicular complex, and entorhinal cortex, volumetric loss correlations with FAST stage 7 ordinally enumerated substages were r = -0.71, -0.79, and -0.62, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

OBJECTIVE: To investigate the prevalence of contractures in patients with Alzheimer's disease and to assess possible associations between contractures and cognitive and functional decline in Alzheimer's disease. DESIGN: Case series. SETTING: Subjects from an outpatient, university-based, dementia research center, followed, when necessary, into residential home and nursing home settings. PATIENTS: A consecutive sample of 161 patients (48 men, 113 women; mean age 75.3 +/- 8.6 years) with a clinical diagnosis of probable Alzheimer's disease and with deficits in basic activities of daily living or more severe functional impairment. MAIN OUTCOME MEASURES: For cognition, the Mini-Mental State Examination (MMSE); for functioning, the Functional Assessment Staging Scale (FAST); contracture is defined as a decrease of 50% or more of the normal passive range of motion of the joint. RESULTS: Prevalence of contractures was correlated highly with degree of functional impairment (r = .70, P < .001). More than three quarters of patients who had lost the ability to walk manifested contractures; however, contractures were found in fewer than 11% of all ambulatory patients examined. When present, contractures involved more than one extremity in 97% of cases and involved all four extremities in more than two-thirds of patients. CONCLUSION: Joint contractures are very common in the severe stages of Alzheimer's disease. More than a quarter of a million institutionalized residents in US nursing homes are likely to be afflicted by this potentially painful and disfiguring condition. Possible pathophysiology and contributing factors and possible means of intervention for this major source of disability are discussed

Objective: The purpose of the study was to develop a standardized instrument, the Behavior Rating Scale for Dementia, for rating psychopathology in patients with probable Alzheimer's disease and to conduct a multicenter pilot study of this instrument. Method: The rating scale was developed collaboratively on the basis of clinical experience and existing instruments. Items were scaled according to frequency of psychopathology and were administered to an informant who was familiar with the subject. The scale was administered in a standardized manner by trained examiners who had met predetermined certification standards. The study group consisted of 303 subjects with probable Alzheimer's disease who had undergone standardized clinical evaluations by the Consortium to Establish a Registry for Alzheimer's Disease. Results: Subjects had an average of 15 problems rated as present in the preceding month. Wide variability in the nature of disturbances was found, with a number of items rated as present since the illness began but not in the east month. Interrater agreement was high. Factor analysis suggested eight preliminary factors that mapped onto clinically relevant domains: depressive features, psychotic features, defective self-regulation, irritability/agitation, vegetative features, apathy, aggression, and affective lability. Conclusions: The Behavior Rating Scale for Dementia provides a standardized, reliable measure that can be administered to caregivers of demented subjects. On the basis of the present study, the scale has been revised slightly. After additional studies in progress, the Behavior Rating Scale for Dementia will be available for general use in assessing a wide range of psychopathology in dementia.

OBJECTIVE: Traditional mental status and psychometric assessments bottom out in the late stages of Alzheimer disease (AD). A method adapted from cognitive testing in infants, the Ordinal Scales of Psychological Development was modified (M-OSPD) and applied to a severely demented population. The concurrent validity of this method was tested in comparison with Functional Assessment Staging (FAST). Internal consistency as a measure for reliability was also determined. DESIGN: Cross sectional study. SETTING: Subjects were generally evaluated in their residence, usually a nursing home or a private home. PATIENTS: Severely cognitively impaired subjects who fulfilled criteria for probable AD were studied. MEASUREMENTS: Evaluation consisted of clinical global, mental status, functional, and cognitive assessments including the Global Deterioration Scale (GDS) and the Mini-Mental State Examination (MMSE). RESULTS: Seventy patients were evaluated. Traditional mental status assessments (eg, the MMSE) manifested virtually uniform bottom scores in all GDS stage 7 subjects (n = 46), and GDS stage 6 subjects had MMSE scores within one standard deviation unit of zero. In contrast, the M-OSPD scale continued to show results in the last stages of the disease. The Spearman correlation coefficient between the M-OSPD total score and the 11 FAST substages represented in this sample was -0.77 (P < 0.001). CONCLUSIONS: The results indicate that patients who are functionally more impaired also show continuing increments in cognitive loss. These cognitive and functional assessments for measuring the magnitude of deterioration in AD can be applied to the estimated half-million nursing home residents presently labeled 'untestable' with the goal of optimization of care and residual capacities

We report on the quantitative analysis of the EEG (QEEG), using the Neurometric method, in large samples of normal elderly; normal subjectively impaired elderly; patients with mild cognitive impairment; patients presenting with a continuum of primary cognitive deterioration from mild to moderately severe as measured by the Global Deterioration Scale (GDS), compatible with dementia of the Alzheimer's type (DAT). Neurometric QEEG measures were found to be a sensitive index of degree of cognitive impairment, especially reflected in increased absolute and relative power in the theta band, with delta increasing in later stages of deterioration. While these abnormalities were widespread, neither localized or lateralized, MANOVA's for GDS and relative power in theta reached highest significance in a bilateral temporo-parietal arc. A possible relationship between hippocampal dysfunction, cognitive deterioration, and theta abnormalities is discussed in relation to these findings. The results suggest that Neurometric QEEG features are sensitive to the earliest presence of subjective cognitive dysfunction and might be useful in the initial evaluation of patients with suspected dementia, as well as in estimating the degree of cognitive deterioration in DAT patients