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Insidious Onset Gradual Decline

By Ernest Sanchez,2014-11-25 09:26
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Insidious Onset Gradual Decline

    (E)Table 1. Key findings from the initial evaluation of the very mildly impaired patients who were inaccurately diagnosed with Alzheimer’s Disease

     or one of its variants. The initial clinical diagnosis (DX) and the final diagnosis are also shown.

     Insidious Onset/ Pertinent History Neurological Examination Hachinski Neuroimaging Depression Clinical DX Final DX (Clinical

    Gradual Decline Score (DIS) or Autopsy)

    (Rosen)

     Autopsy

    Diagnosis

    Patient # 1 Yes None Extrapyramidal Features 2 MRI: Generalized No Probable LBV Dementia with

    Atrophy and Deep Argyrophilic Grains

    White Matter Changes

    Patient # 2 Yes None Extrapyramidal Features 2 CT: Volume Loss No Probable LBV Progressive

    Limitation of Vertical Gaze Supranuclear Palsy

    Abnormal Coordination

    Gait Disorder

    Lower Motor Neuron Weakness

    Patient # 3 Yes None Extrapyramidal Features 2 CT: Normal Yes Probable LBV Vascular Dementia

    Limitation of Vertical Gaze (2 yrs. Before

    Abnormal Coordination ADRC Evaluation)

    Gait Disorder

Other Clinical

    Diagnosis

    Patient # 4 Yes Seizure Disorder, Normal 0 CT and MRI: Normal Yes Possible AD Traumatic Dementia

    Two Motor Vehicle

    Accidents with Loss

    of Consciousness

(E)Table 1 (Continued)

     Insidious Onset/ Pertinent History Neurological Examination Hachinski Neuroimaging Depression Clinical DX Final DX (Clinical

    Gradual Decline Score (DIS) or Autopsy)

    (Rosen)

     Other Clinical

    Diagnosis

    (Continued)

    Patient # 5 Yes Family History of Normal 0 None No Possible AD Familial

    Striato-Nigral Striato-Nigral

    Degeneration Degeneration

    Patient # 6 Yes None Normal 0 CT: Generalized No Probable AD Amnestic Disorder

    Atrophy

    Patient # 7 Yes Alcohol Abuse Extrapyramidal Features 5 MRI: Generalized No Probable AD Probable Progressive

    Hypothyroidism Limitation of Vertical Gaze Atrophy Supranuclear Palsy

    Abnormal Coordination

    Gait Disorder

Normal

    Patient # 8 Yes None Normal 0 CT: Small Left Yes Possible AD Normal

    Fronto-Parietal

    Hyperintensity (Poss.

    Meningioma)

    Patient # 9 Yes Cardiovascular Normal 0 CT: Normal No Probable AD Normal

    Disease

    Patient # 10 Yes None Normal 2 CT: Generalized No Probable AD Normal

    Atrophy (Later Treated)

    Patient # 11 Yes None Extrapyramidal Features 1 None No Probable AD Normal

    Patient # 12 Yes Hypothyroidism Normal 1 None No Possible AD Normal

    (E)Table 2. The mean score achieved by the normal control (NC) subjects and very mildly impaired

    patients with Alzheimer’s Disease (AD) on the neuropsychological test measures at the initial

    evaluation. Standard deviations are shown in parentheses.

     Neuropsychological Test NC Subjects AD Patients

    (n=98) (n=98)

     Global Mental Status

     Dementia Rating Scale (Max.=144; n=74) 137.7 (5.7) 120.0 (9.6)

     Attention

     WAIS-R Digit Span Subtest (Max.=19; n=93) 10.0 (2.7) 8.4 (2.0)

    (Scale Score)

     Memory

     BSRT-Trial 6 Total (Max.=10; n=75) 8.1 (1.7) 4.5 (1.4)

     BSRT-Trial 6 LTM (Max.=10; n=75) 7.0 (2.6) 1.8 (1.6)

     CVLT-Trials 1-5 (T-score) (Avg.=100; n=23) 46.7 (13.3) 22.1 (11.0)

     CVLT-Short Delay (z-score; n=20) -0.4 (1.4) -2.6 (1.0)

     CVLT-Long Delay (z-score; n=20) -0.4 (1.3) -2.7 (0.9)

     Visual Reproduction Test (Max.=21; n=82) 12.0 (4.1) 6.5 (3.4)

    (Immediate)

     Visual Reproduction Test (Max.=21; n=82) 8.9 (4.1) 1.6 (2.5)

    (Delay)

     Logical Memory Test (Max.=50; n=27) 24.6 (6.9) 11.1 (5.8)

    (Immediate)

     Logical Memory Test (Max.=50; n=27) 18.0 (7.5) 3.6 (4.7)

    (Delay)

     Language

     Boston Naming Test (Max.=30; n=95) 27.5 (2.3) 22.5 (5.2)

     Letter Fluency Test (FAS) (n=95) 40.8 (12.1) 28.0 (11.3)

     Category Fluency Test (n=95) 46.8 (8.8) 25.7 (8.5)

    (Animals, Fruits, Vegetables)

     WAIS-R Vocabulary Subtest (Max.=19; n=92) 12.2 (2.8) 10.2 (2.7)

    (Scale Score)

(E)Table 2 (Continued)

     Neuropsychological Test NC Subjects AD Patients

    (n=98) (n=98)

     Executive Functions

     Modified WCST- Categories (Max.=6; n=90) 5.3 (1.3) 3.2 (1.8)

     Modified WCST-(n=90) 2.0 (5.1) 10.2 (12.2)

    Perseverations

     Trail Making Test-Part A (Max.=150; n=93) 48.5 (20.8) 85.0 (56.7)

     Trail Making Test-Part B (Max.=300; n=87) 103.1 (47.5) 213.0 (75.4)

     WAIS-R Similarities Subtest (Max.=19; n=76) 10.8 (2.3) 8.0 (2.8)

    (Scale Score)

     WAIS-R Digit-Symbol (Max.=19; n=89) 6.9 (1.8) 4.1 (1.7)

    Substitution Test

    (Scale Score)

     WAIS-R Arithmetic Subtest (Max.=19; n=76) 10.9 (3.2) 7.3 (2.3)

    (Scale Score)

     Constructional and

    Visuospatial Ability

     WISC-R Block Design (Max.=62; n=94) 41.8 (10.4) 23.2 (14.1)

    Subtest

    (Raw Score)

     Clock Drawing Test-(Max.=3; n=95) 2.7 (0.6) 2.2 (0.8)

    Command

     Clock Drawing Test-Copy (Max.=3; n=95) 2.9 (0.3) 2.6 (0.7)

     Copy-a-Cube Test (Max.=13; n=89) 12.0 (1.2) 10.5 (2.9)

     Visual Reproduction Test (Max.=21; n=82) 17.4 (2.4) 15.8 (3.6)

    (Copy)

WAIS-R=Wechsler Adult Intelligence Scale-Revised; BSRT=Buschke Selective Reminding Test;

    CVLT=California Verbal Learning Test; WCST=Wisconsin Card Sorting Test; WISC-R=Wechsler

    Intelligence Scale for Children-Revised; Max.=Maximum score; n=the number of matched pairs of

    normal control subjects and patients with Alzheimer disease that completed the test.

(E)Figure Legends:

    (E)Figure 1. Receiver Operating Characteristic (ROC) curves comparing sensitivity and specificity for the accurate diagnosis of Alzheimer’s disease (AD) achieved with the Dementia Rating Scale, the Long-Delay Free Recall measure from the California Verbal Learning Test (CVLT), the Delayed Recall measure from the Logical Memory Test, and the Delayed Recall measure from the Visual Reproduction Test. The maximally effective cutpoint for each test is also shown.

    (E)Figure 2. Receiver Operating Characteristic (ROC) curves comparing sensitivity and specificity for the accurate diagnosis of Alzheimer’s disease (AD) achieved with the Trial 1-5 Learning

    measure from the California Verbal Learning Test (CVLT), the Category Fluency Test, Part B of the Trail-Making Test, and the Block Design Test. The maximally effective cutpoint for each test is also shown.

100100

    9090

    8080

    7070

    6060

    100100

    5050

    Cutpoint: < -1.5Cutpoint: < 133

    9090

    4040

     Sensitivity = 98% Sensitivity = 96%8080CVLT Long-Delay Free Recall (Z-Score)Dementia Rating Scale

    3030Specificity = 88%Specificity = 92%7070

    2020

    6060

    1010Sensitivity (%)Sensitivity (%)

    5050

    00

    010203040506070809010001020304050607080901004040

    Visual Reproduction Test: Delayed RecallLogical Memory Test: Delayed Recall

    3030

    2020

    1010Sensitivity (%)Sensitivity (%)

    00

    01020304050607080901000102030405060708090100

    Specificity (%)Specificity (%)

    Cutpoint: < 4Cutpoint: < 10

    Sensitivity = 87%Sensitivity = 87%

    Specificity (%)Specificity (%)

    Specificity = 86%Specificity = 89%

    100100

    9090

    8080

    7070

    6060

    100100

    5050

    Cutpoint: < 389090Cutpoint: < 36

    4040

    8080Sensitivity = 96% Sensitivity = 95%

    Specificity = 88%Specificity = 89%Category Fluency TestCVLT Trials 1-5 (T-Score)3030

    7070

    2020

    6060

    1010Sensitivity (%)Sensitivity (%)5050

    Cutpoint: < 34Cutpoint: > 130

    00

    010203040506070809010001020304050607080901004040

    Sensitivity = 78%Sensitivity = 85%

    Trail-Making Test: Part BSpecificity = 79%Block Design Test (WISC-R)3030Specificity = 83%2020

    1010Sensitivity (%)Sensitivity (%)

    00

    01020304050607080901000102030405060708090100

    Specificity (%)Specificity (%)

    Specificity (%)Specificity (%)

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