Global Deterioration Scale Stage Research Articles

CSF Aβ40 Levels Do Not Correlate with the Clinical Manifestations of Alzheimer’s Disease

Introduction: Cerebrospinal fluid (CSF) biomarker quantification provides physicians with a reliable diagnosis of Alzheimer’s disease (AD). However, the relationship between their concentration and disease course has not been clearly elucidated. This work aimed to investigate the clinical and prognostic significance of Aβ₄₀ CSF levels. Methods: A retrospective cohort of 76 patients diagnosed with AD using a decreased Aβ₄₂/Aβ₄₀ ratio was subclassified into hyposecretors (Aβ₄₀ <7,755 pg/mL), normosecretors (Aβ₄₀ 7,755–16,715 pg/mL), and hypersecretors (Aβ₄₀ >16,715 pg/mL). Potential differences in AD phenotype, Montreal Cognitive Assessment (MoCA) scores, and Global Deterioration Scale (GDS) stages were assessed. Correlation tests for biomarker concentrations were also performed. Results: Participants were classified as hyposecretors (n = 22, median Aβ₄₀ 5,870.500 pg/mL, interquartile range [IQR] 1,431), normosecretors (n = 47, median Aβ₄₀ 10,817 pg/mL, IQR 3,622), and hypersecretors (n = 7, 19,767 pg/mL, IQR 3,088). The distribution of positive phosphorylated Tau (p-Tau) varied significantly between subgroups and was more common in the normo- and hypersecretor categories (p = 0.003). Aβ₄₀ and p-Tau concentrations correlated positively (ρ = 0.605, p < 0.001). No significant differences were found among subgroups regarding age, initial MoCA score, initial GDS stage, progression to the dementia stage, or changes in the MoCA score. Conclusion: In this study, we found no significant differences in clinical symptoms or disease progression in AD patients according to their CSF Aβ₄₀ concentration. Aβ₄₀ was positively correlated with p-Tau and total Tau concentrations, supporting their potential interaction in AD pathophysiology.

Two Year Outcomes, Cognitive and Behavioral Markers of Decline in Healthy, Cognitively Normal Older Persons with Global Deterioration Scale Stage 2 (Subjective Cognitive Decline with Impairment).

Little is known with respect to behavioral markers of subjective cognitive decline (SCD), a condition initially described in association with Global Deterioration Scale (GDS) stage 2. Two-year interval behavioral markers were investigated herein. Subjects from a published 7-year outcome study of GDS stage 2 subjects were selected. This study had demonstrated a hazard ratio of 4.5 for progression of GDS stage 2, in comparison with GDS stage 1 (no subjective or objective cognitive decline) subjects, after controlling for demographic and temporal variables. Because GDS 2 subjects have previously demonstrated impairment in comparison with healthy persons free of complaints, we herein suggest the terminology "SCD(I)" for these persons. 98 SCD(I) persons, 63 women and 35 men, mean baseline age, 67.12±8.75 years, with a mean educational background of 15.55±2.60 years, and mean baseline MMSE scores of 28.9±1.24 were followed for 2.13±0.30 years. Observed annual decline on the GDS was 6.701% per annum, very close to a 1986 published estimate. At follow up, the MMSE, and 7 of 8 psychometric tests did not decline significantly. Of 21 Hamilton Depression Scale items, 2 improved and the remainder were unchanged. Anxieties declined from multiple perspectives. The Brief Cognitive Rating Scale (BCRS) declined significantly (p < 0.001), with component declines in Remote memory (p < 0.01), and Functioning/self-care (p = 0.01). SCD(I) persons decline at an annual rate of approximately 6.7% /year from several recent studies. The BCRS assessments and the Digit Symbol Substitution Test can be sensitive measures for future studies of progression mitigation.

Choosing anesthesia options for cataract surgery in patients with dementia

Background and Aims:Not all patients with dementia are the same, and Global Deterioration Scale (GDS) helps in staging dementia. Ophthalmologists usually prefer general anesthesia (GA) for cataract surgery in patients with dementia. We evaluated the impact of “Choosing Wisely” initiative on anesthesia options for cataract surgery in patients with dementia undergoing cataract surgery.Material and Methods:A retrospective review of electronic perioperative database was performed over a 4-year period of patients with a specific diagnosis of dementia undergoing cataract surgery, after the introduction of the “Choosing Wisely” based on preoperative GDS assessment. Preferred method by the listing ophthalmologist, changes in anesthesia modality based on GDS, and the occurrence of intraoperative events were analyzed.Results:One hundred and thirty-six patients with dementia underwent cataract surgery over a 4-year period. The mean patient age was 78 years, 73.5% female, and 55% ASA physical status III. GA was administered for GDS stage 6–7, and regional anesthesia (RA) for GDS stages 1–5. Surgery was uneventful under RA in 64% of the patients (87 out of 136), and 2% (3 patients) originally deemed suitable for RA were converted to GA.Conclusions:The authors found a reduced requirement for GA when “Choosing Wisely’ initiative was used based on the GDS stage.

Discriminative validity of an abbreviated Semantic Verbal Fluency Test.

ABSTRACT.Semantic verbal fluency (SVF) is one of the most widely used tests for cognitive assessment due to its diagnostic utility (DU).Objective:our objective is to evaluate the DU to detect cognitive impairment (CI) of a short version of the SVF applied in 30 seconds (SVF1-30).Methods:a prospective sample of consecutive patients evaluated in a Neurology Unit between December 2016 and December 2017 were assessed with the Global Deterioration Scale (GDS), 30-second and 60-second SVF tests (animals), and the Fototest, which includes a fluency task of people’s names. The DU for CI was evaluated by the area under the ROC curve and effect size (“d” Cohen).Results:the study included 1012 patients (256 with CI, 395 with dementia). SVF1-30 shows a good correlation with GDS stage. The DU of SVF1-30 is identical to that of the classical version, applied in 60 seconds, (SVFtotal) for CI (0.89 ± 0.01; p > 0.50), and shows no significant difference for dementia (0.85 ± 0.01 vs. 0.86 ± 0.01, p > 0.15).Discussion:the DU of SVF1-30 is similar to that of the SVFtotal, allowing a reduction in examination time with no loss of discriminative capacity.

Behavioral and psychological symptoms in dementia in Hong Kong Chinese

Behavioral and psychological symptoms of dementia (BPSD) constitute an integral component of cognitive impairment including, vascular dementia. They could contribute significantly not to caregiver stress but also to escalating healthcare costs. Method: 100 consecutive patients attending a Memory Clinic, located in a district hospital in Hong Kong diagnosed to have vascular dementia were reviewed. The National Institute of Neurological Disorders and Stroke Association Internationale pour la Recherche et I’Enseignement en Neurosciences (NINDS-AIREN) criteria were used to establish the diagnosis of vascular dementia. The Global Deterioration Scale (GDS) was used to stage the severity of the disease. The assessment of BPSD was based on collateral clinical history, patients’ subjective experiences and objective behavior. Neuropsychiatric Inventorywas adopted as the assessment tool. Results: 62% were GDS stage and 38% stage 5. About 91% of stage 5 patients had BPSD and 8% in stage 4 patients. The prevalence of BPSD was about 40%. Amongst these, the pattern of various domains reviewed: individual behaviors include delusion (20%), hallucination (12%), depression (42%), apathy (21%), anxiety (16%), elation (12%), disinhibition (8%), aggression (11%), irritability (13%), aberrant motor behavior (11%), sleep and nighttime behavioral disorders (26%) and eating disorders (19%). Conclusion: BPSD are frequent in vascular dementia of mild-to-moderate severity.Like other types of dementia, correct identification and evaluation of these symptoms is a crucial component of the clinical approach to vascular dementia.

Antipsychotic drug prescription rates among Dutch nursing homes: the influence of patient characteristics and the dementia special care unit

Objectives: To assess the differences in antipsychotic drug prescription rates in residents with dementia in dementia special care units (SCUs) of Dutch nursing homes, considering the differences in patient characteristics.Method: As part of the Waalbed-II study, the data on antipsychotic drug use in 290 patients were collected and the Global Deterioration Scale (GDS) stage, type of dementia and behaviour (Cohen-Mansfield Agitation Inventory (CMAI)) were measured in 14 SCUs in nine nursing homes. A multilevel logistic regression model was used to assess the difference in antipsychotic drug prescription rates between dementia SCUs adjusted for age, gender, GDS stage, type of dementia and CMAI factor scores.Results: Two hundred and ninety residents met the inclusion criteria. Thirty-two per cent were prescribed an antipsychotic drug. Antipsychotic drugs were more often prescribed in patients with physically aggressive and non-aggressive behaviour and in patients with mixed dementia (vascular/Alzheimer's) than in patients with other types of dementia. Antipsychotic drug prescriptions significantly differed among the dementia SCUs. The odds of antipsychotic drug use for patients in the SCU with the highest prevalence of drug use were 2.76 (95% confidence interval (CI) 1.14–6.69) times as high as for the SCU with the lowest prevalence of drug use, taking the patient characteristics into account.Conclusion: Antipsychotic drug use in nursing home residents with dementia is not only predicted by the type of dementia and patient behaviour, but it is independently associated with the dementia SCU at which the patient resides. This result indicates that antipsychotic drugs are not only prescribed for their clinical indications (agitation/aggression) but are associated with environmental factors that may reflect a specific nursing home prescribing culture.

Severity of Dementia, Anosognosia, and Depression in Relation to the Quality of Life of Patients with Alzheimer Disease: Discrepancies Between Patients and Caregivers

To investigate the factors associated with discrepancies between patient and caregiver reports of the quality of life of patients (QoLp) with Alzheimer disease. Cross-sectional analytic study of 141 patients and their caregivers. The instruments used were the Quality of Life in AD, the Global Deterioration Scale (GDS), the Geriatric Depression Scale, and the Anosognosia Questionnaire-Dementia. Differences were analyzed according to GDS stage. A linear regression analysis was conducted using the difference between the absolute QoLp scores of patients and caregivers. A cluster analysis involving patient variables was then performed. The discrepancy between patient and caregiver QoLp ratings increased in line with GDS stages (χ(2) (2)= 8.7, p= 0.013). In the regression model (F [7,133]= 16.6, p<0.001; R(2)=0.477), discrepancies in QoLp reports were associated with greater anosognosia, less depression, and a better cognitive status in patients and with female gender among caregivers. The cluster analysis showed that patients with the lowest ratings of QoLp had a better cognitive status, more depression, and less anosognosia. Conversely, the highest ratings were given by patients with a poorer cognitive status, less depression, and greater anosognosia. The factors associated with greater discrepancies between patient and caregiver ratings of QoLp were severity of dementia, anosognosia, depression, and cognitive status in patients and female gender in caregivers. In patients with advanced dementia, greater anosognosia leads to more positive ratings in QoLp and complementary observations are required.

Intervention Strategies for Individuals With Early Alzheimer's Disease and COPD

An elderly individual's ability to generate a functional cough is compromised by the loss of expiratory muscle strength (sarcopenia) and reduced elastic recoil of the lungs, resulting in reduced expiratory flow rates and velocity and a decreased intrathoracic airway pressure increasing the risk for aspiration and pneumonia. The addition of COPD and Alzheimer's disease to the individual's comorbidities limit a successful respiratory therapy program and the speech-language pathologist's interventions. The following activities promote expiratory muscle strength building and endurance for individuals diagnosed on the Global Deterioration Scale Stage 3 through early Stage 6. The respiratory therapist and attending physician should provide baselines and benchmarks for the speech-language pathologist throughout the individual's treatment. The activities listed here need to be a component of a multidisciplinary intervention that includes upper extremity exercise and walking for strength building and endurance.

The effect of music therapy compared with general recreational activities in reducing agitation in people with dementia: a randomised controlled trial

This study aimed to compare the effects of music therapy with general recreational day activities in reducing agitation in people with dementia, residing in nursing home facilities. In a randomised controlled design, residents with dementia (n = 94) were allocated to either music therapy or recreational activities. Both music therapy and general activities were offered twice weekly for 4 months. Changes in agitation were measured with a modified Cohen-Mansfield Agitation Inventory (CMAI) at four intervals on each intervention day. A mixed model analysis was used to evaluate the effectiveness of music therapy, compared with general activities, on CMAI scores at 4 h after the intervention, controlled for CMAI scores at 1 h before the session and session number. Data were analysed for 77 residents (43 randomised to music therapy and 34 to general activities). In both groups, the intervention resulted in a decrease in agitated behaviours from 1 h before to 4 h after each session. This decrease was somewhat greater in the music therapy group than in the general activities group, but this difference was statistically not significant (F = 2.885, p = 0.090) and disappeared completely after adjustment for Global Deterioration Scale stage (F = 1.500; p = 0.222). Both music therapy and recreational activities lead to a short-term decrease in agitation, but there was no additional beneficial effect of music therapy over general activities. More research is required to provide insight in the effects of music therapy in reducing agitation in demented older people.

Understanding Dementia Prevalence Among Centenarians

The goals of this article are to (a) establish the concurrent and clinical validity of the Global Deterioration scale in assessing cognitive functions and stages of dementia among centenarians, (b) identify the prevalence of all-cause dementia in representative samples of centenarians, and (c) demonstrate how variations in sample demographic characteristics could significantly affect estimates of dementia prevalence. A quarter of the 244 centenarians in a population-based sample had no objective evidence of memory deficits. Another quarter showed signs of transient confusion, and about half showed classical behavioral signs of dementia with about 15% in each of Global Deterioration scale stages 4-6 and about 5% in the most severe stage 7. Variations in age, gender, race, residence status, and education of the study sample as well as criteria used for dementia rating were found to affect prevalence.

Development of Global Deterioration Scale Staging Algorithm

The Global Deterioration Scale (GDS) is a useful tool for staging dementia; each stage is described by spe-cific characteristics. However, one should not rely on the presence or absence of a single symptom in determining the stage. There is a need for a systematic computerized program to enable untrained doctors to easily assess dementia. This study aimed to generate an algorithm to help stage dementia.

P02-231 - Cognitive complaints are associated to multi-morbidity in an old population with good cognitive functioning

IntroductionThe role of cognitive complaints has recently received increasing attention in dementia research.AimTo investigate whether the subjective perception of cognitive deficits is related to multi-morbidity in an old Italian cohort.MethodsThe study population(N = 6,825) included persons who did not receive a diagnosis of dementia(DSM-IIIR criteria), were not cognitively impaired and scored &lt; 4 at the Global Deterioration Scale(GDS). On GDS stage one, Individuals with GDS score equal to one do not report memory problems and no deficits are detected during the interview. In subjects with GDS score = 2, a very mild cognitive decline is appreciable. On GDS score = 3,deficiencies begin to be noted. The examining physicians diagnosed the somatic disorders according to the International Classification Disease version 10 (ICD-10). Mental health was clinically assessed by the examining physicians with semi-structured questions. A multimorbidity index was created based on the number of co-occurring chronic disorders. Binary logistic regression analyses were used to estimate multiadjusted Odds ratio (aOR) and 95% Confidence Intervals (CI).ResultsAccording to GDS, 28.4% (N = 1,940) of participants reported some degree of perceived cognitive decline. Cognitive complaints were associated with increasing age, low education, and multimorbidity. Stroke (aOR,95%CI 1.6;1.3–1.9),diabetes(aOR,95%CI 1.4;1.1–1.7),depressive(aOR,95%CI 2.2;1.8–2.7) and anxiety symptoms(aOR, 95%CI 1.5;1.3–1.8) were significantly associated with perceived cognitive decline. When performances at MMSE were taken into account, cardiovascular(aOR,95%CI 2.3;1.3–4.1) and respiratory diseases(aOR,95%CI 1.9;1.0–3.6) were associated with self-perceived cognitive decline in absence of observable cognitive deficits.ConclusionsCognitive complaints have many somatic correlates and some of them may account for the discrepancy between perceived cognitive decline and cognitive assessment.

Síntomas psicológicos y conductuales en deterioro cognitivo leve y enfermedad de Alzheimer

Introduction To describe the neuropsychiatric symptoms (NPS) in elderly patients with either mild cognitive impairment (MCI) or Alzheimer's disease (AD) and their relevance in the differential diagnosis between the two entities. Material and methods A total of 179 subjects, aged more than 64 years old, with either MCI ( n=90) or AD ( n=89) and Global Deterioration Scale stage 4-5 were studied. NPS were assessed using the Neuropsychiatric Inventory scale. We identified the prevalence of the symptoms in each group and determined the risk conferred by each symptom to the differential diagnosis between the two entities. Results Sixty-seven patients with MCI (74.4%) and 82 with AD (92.1%) showed at least one NPS ( p<0.01), the most prevalent being depression and apathy in both groups. The mean number of NPS was 2.1 in MCI and 3.2 in AD. NPS were more frequent in patients with more white matter ischemic lesions (WMIL) ( p<0.05). The presence of at least one NPS increased the risk of being diagnosed with AD rather than MCI (odds ratio [OR] 3.6: 95% confidence interval [CI] 1.4–5.7; p<0.01) adjusted by age, sex, Mini-Mental State Examination and WMIL. The NPS independently associated with a diagnosis of AD were delusions (OR 4.9; 95% CI 1.3–18.6; p<0.05), apathy (OR 2.5; 95% CI 1.3–4.7 p<0.01), disinhibition (OR 3.1; 95% CI 1.5–6.4; p<0.01) and aberrant motor behavior (OR 6.3; 95% CI 1.7–23.4; p<0.01). Conclusions NPS are frequent in elderly individuals with MCI and mild-moderate AD and may help to differentiate between these two entities.

Prevalence and correlates of psychotropic drug use in Dutch nursing-home patients with dementia

Neuropsychiatric symptoms in dementia patients are common and are often treated with psychotropic drugs. The aim of this study was to determine the prevalence and correlates of psychotropic drug use in Dutch nursing home patients with dementia. Psychotropic drug use of 1322 patients on 59 dementia special care units (SCUs) in 25 nursing homes was registered. Drugs were categorized according to the Anatomical Therapeutical Chemical classification (ATC). The influence of age, gender, dementia stage measured by the Global Deterioration Scale (GDS), and type of neuropsychiatric symptoms on psychotropic drug use was analyzed using binomial logistic regression analysis. 63% of the patients used at least one psychotropic drug. Psychotropics in general and antipsychotics in particular were most frequently prescribed in GDS stage 6, and in patients aged between 65 and 75 years. Psychotropics in general were positively associated with depression, night-time behavior and agitation. Antipsychotic drug use was positively associated with psychosis, agitation and night-time behavior and was negatively associated with apathy. Anxiolytics were associated with age, psychosis, agitation and night-time behavior. Antidepressants were most frequently prescribed in GDS stage 6 and associated with female gender, agitation and depression. Sedatives were only associated with night-time behavior. Nursing home patients with dementia have a high prevalence of psychotropic drug use. In particular, the association with neuropsychiatric symptoms raises questions of efficacy of these drugs and the risk of chronic use.

Predictors of neuropsychiatric symptoms in nursing home patients: influence of gender and dementia severity

The aim of the study was to assess the influence of dementia severity and gender on neuropsychiatric symptoms in demented nursing home patients. Neuropsychiatric symptoms were assessed in a large sample of 1319 Dutch nursing home patients using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory-Nursing Home version (NPI-NH). The influence of gender and severity of cognitive decline, assessed with the Global Deterioration Scale (GDS), was investigated using logistic regression analysis and subsequently corrected for possible confounders, such as age, duration of institutionalization and psychoactive medication use. While physically aggressive behaviour was more common in patients with very severe cognitive deterioration (GDS stage 7), disinhibition, irritability, physically non-aggressive and verbally agitated behaviour were more common in patients in GDS stage 5 or 6. Physically aggressive behaviour was more common in men, whereas female patients demonstrated more verbally agitated behaviour. With respect to other neuropsychiatric symptoms, delusions and depression were also more common in patients in GDS stage 5 and 6, while prevalences of anxiety and apathy further increased in severely demented patients (GDS stage 7). Apathy was more prevalent in male patients, while depression and anxiety were more common in females. In nursing home patients, neuropsychiatric symptoms were associated with the severity of dementia, with most symptoms occurring in patients showing (moderately) severe cognitive decline. Only physical aggression, anxiety and apathy were more common in patients with very severe cognitive decline. Dementia severity and gender were important predictors of neuropsychiatric symptoms in this patient cohort.

Commentary on “A roadmap for the prevention of dementia II: Leon Thal Symposium 2008.” Subjective cognitive impairment as an antecedent of Alzheimer's dementia: Policy import

Commentary on “A roadmap for the prevention of dementia II: Leon Thal Symposium 2008.” Subjective cognitive impairment as an antecedent of Alzheimer's dementia: Policy import

Reporting Dementia on the Death Certificates of Nursing Home Residents Dying With End-Stage Dementia

To the Editor: In 2004, the National Center for Health Statistics (NCHS) ranked Alzheimer disease as the fifth leading cause of death among US residents older than 65 years, an increase from prior years.1 NCHS data are derived from death certificates. Retrospective studies of patients who died at various stages of dementia suggest this condition is under-reported on death certificates.2,3 We prospectively observed a cohort of nursing home residents who had been diagnosed with end-stage dementia to describe which conditions were documented on their death certificates. Methods. Data were collected between 2003 and 2007 from the Choices, Attitudes, and Strategies for Care of Advanced Dementia at the End-of-Life study, a prospective study of 323 residents of 22 Boston-area nursing homes with advanced dementia, each followed up for up to 18 months.4 Eligibility criteria included age older than 60 years and advanced dementia (based on physician documentation of dementia in chart and Global Deterioration Scale stage 7 determined by a nurse).5 The Hebrew SeniorLife institutional review board approved this study. Written consent was provided by participants’ health care proxies. Descriptive data included age, sex, race (reported by proxies using predefined categories), dementia type (Alzheimer, vascular, or other, from medical records), nursing home length of stay, living in a dementia special care unit, location of death, and functional status at study entry (from nurses; Bedford Alzheimer Nursing Severity Subscale6). Descriptive variables, including race, were ascertained to allow for comparability with other samples. Massachusetts death certificates, obtained for all participants who died during follow-up, have 3 sections. In part 1, line A requests the “immediate cause of death.” Lines B through D request the “sequence of conditions resulting in the immediate cause of death.” Part 2 asks for “other significant conditions contributing to death” (no limit on number). Two research assistants who were unaware of the study aims independently abstracted causes of death verbatim from the death certificates. Conditions were categorized into predefined clinically relevant groups and quantified using proportions. Exact binomial 95% confidence intervals (CIs) were calculated using SAS version 9.1 (SAS Institute, Cary, North Carolina). Results. Of the 323 participants, 165 died during follow-up (Table 1). Among all decedents, dementia documentation on their death certificates was none, 37.0% (95% CI, 29.6%–44.8%); listed in part 1 line A, 15.8% (95% CI, 10.6%–22.2%); listed in part 1 lines B–D, 35.2% (95% CI, 27.9%–43.0%); and listed in part 2, 16.4% (95% CI, 11.2%–22.9%) (Table 2). Seven participants had dementia listed in parts 1 and 2. Among the 114 decedents with a premortem diagnosis of Alzheimer disease, documentation of dementia anywhere on their death certificates was none, 33.3% (95% CI, 24.8%–42.8%); Alzheimer disease, 27.2% (95% CI, 19.3%–36.8%); “dementia” without further specification, 37.7% (95% CI, 28.8%–47.3%); and vascular dementia, 0.9% (95% CI, 0.2%–4.8%). Table 1 Characteristics of Nursing Home Decedents With Advanced Dementia (N = 165) Table 2 Causes of Death of Decedents With Advanced Dementia in Nursing Homes, Recorded According to Location on Death Certificates (N = 165) Comment. In this study, dementia, and specifically Alzheimer disease, was underreported on death certificates, raising concerns about the accuracy of mortality statistics based on these documents. Despite the terminal stage of dementia in our cohort, dementia was not recorded on 37% of death certificates. The absence of Alzheimer disease on three-quarters of death certificates of decedents with this premortem diagnosis is a particular problem because among the causes of dementia, NCHS ranks only Alzheimer disease among its leading causes of death. This study is limited in that 94% of the cohort died in nursing homes where dementia is more likely to be reported on death certificates compared with hospitals.2 There may be some inaccuracies in the clinical dementia subtypes obtained from the chart. The findings may not be generalizable outside Boston; however, the study sample and nursing homes are comparable with those in the rest of the United States.4 An appreciation that patients die from and with dementia is necessary to inform end-of-life decision making. Underestimation of the burden of dementia as a major fatal illness may hamper planning of health services needed for persons dying with this condition.

Mild cognitive impairment and subjective cognitive impairment

Mild cognitive impairment and subjective cognitive impairment

IC-P2-154: Patterns of regional change over time in the syndromic variants of frontotemporal dementia and Alzheimer's disease

All patients underwent a neuropsychological examination and behavioral assessment by means of a battery of scales. Staging of dementia severity was assessed by means of the Global Deterioration Scale (GDS). Based on GDS scores, patients were recategorized in three subgroups according to dementia severity: mild (GDS stages 2 and 3, n 62), moderate (GDS stages 4 and 5, n 252) and severe (GDS stages 6 and 7, n 245) dementia. Frontal lobe symptoms were assessed by means of the Middelheim Frontality Score (MFS). Results: In FTD patients, no significant difference in MFS total score between FTD patients belonging to the mild and severe dementia stages was found (p 0.828, n 28). In both AD and DLB groups, the MFS total score increased significantly when disease progressed as demonstrated by significantly higher MFS total scores in severe dementia stages compared to mild stages (AD: p 0.001, n 254; DLB: p 0.001, n 25). Comparing the evolution of the MFS total scores in function of disease progression between FTD and AD patients, significantly higher MFS total scores were achieved in FTD patients, irrespective of dementia severity (p 0.001 for mild, moderate and severe dementia subgroups). At no stage of disease severity, significant differences in MFS total scores comparing DLB and AD groups were achieved. The MFS items ‘disinhibition’ and ‘aspontaneity’ were present in a significantly higher proportion of severely affected DLB patients compared to severely affected AD patients (p 0.005 and p 0.009 respectively). Conclusions: In FTD, mean MFS scores were high at dementia onset and remain as such during the disease evolution. Compared to AD, FTD patients displayed significantly more frontal lobe symptoms, allowing discrimination between both diseases, especially in the earliest disease stages. With disease progression, AD and DLB patients gradually displayed more frontal lobe symptoms.

Mild cognitive impairment (MCI): a historical perspective

Descriptions of dementia can be traced to antiquity. Prichard (1837) described four dementia stages and Kral (1962) described a "benign senescent forgetfulness" condition. The American Psychiatric Association's DSM-III (1980) identified an early dementia stage. In 1982, the Clinical Dementia Rating (CDR) and the Global Deterioration Scale (GDS) were published, which identified dementia antecedents. The CDR 0.5 "questionable dementia" stage encompasses both mild dementia and earlier antecedents. GDS stage 3 described a predementia condition termed "mild cognitive decline" or, alternatively, beginning in 1988, "mild cognitive impairment" (MCI). This GDS stage 3 MCI condition is differentiated from both a preceding GDS stage 2, "subjective cognitive impairment" (SCI) stage and a subsequent GDS 4 stage of mild dementia.GDS stage 3 MCI has been well characterized. For example, specific clinical concomitants, mental status and psychological assessment score ranges, behavioral and emotional changes, neuroimaging concomitants, neurological reflex changes, electrophysiological changes, motor and coordination changes, and changes in activities, accompanying GDS stage 3 MCI have been described.Petersen and associates proposed a definition of MCI in 2001 which has been widely used (hereafter referred to as "Petersen's MCI"). Important differences between GDS stage 3 MCI and Petersen's MCI are that, because of denial, GDS stage 3 MCI does not require memory complaints. Also, GDS stage 3 MCI recognizes the occurrence of executive level functional deficits, which Petersen's MCI did not. Nevertheless, longitudinal and other studies indicate essential compatibility between GDS stage 3 MCI and Petersen's MCI duration and outcomes.