Annamma George

Effects of Age, Education and Gender on Verbal Fluency

The objective was to study the effects of age, education and gender on verbal fluency in cognitively unimpaired, older individuals. The methods used were as follows: cognitively unimpaired elderly (55-84 years) subjects (n = 153), were administered category (animal) (CF) and letter (/pa/) (LF) fluency tasks, in their native language of Malayalam. Results and conclusions were (1) Level of education, but not age or gender, significantly influence LF. (2) Level of education (directly) and in the elderly subjects, age (inversely) affect CF. (3) Age, but not education, has a differential effect on the tasks of verbal fluency, influencing CF more than LF.

Mini Mental State Examination and the Addenbrooke's Cognitive Examination: Effect of education and norms for a multicultural population

OBJECTIVE To derive population norms on the Malayalam adaptation of Addenbrookes Cognitive Examination (M-ACE) and the inclusive Malayalam mini mental state examination (M-MMSE). MATERIALS AND METHODS Education-stratified norms were obtained on randomly selected cognitively unimpaired community elders (n = 519). RESULTS Valid data on norms was available on 488 subjects (age 68.5 +/- 7.1 and education 7.9 +/- 5.4). Education and age, but not gender had a significant effect on both M-ACE and M-MMSE. When compared to the effect of age, the effect of education was sevenfold more on the M-ACE and ninefold more on the M-MMSE. The mean composite score on the M-ACE (and the M-MMSE) was 42.8 +/- 9.8 (14.9 +/- 3.1) for those with 0 (n = 72), 55.9 +/- 12.5 (19.7 +/- 4.1) with 1-4 (n = 96), 62.6 +/- 11.4 (21.9 +/- 3.7) with 5-8 (n = 81), 77 +/- 10.2 (25.7 +/- 2.4) with 9-12 (n = 136) and 83.4 +/- 7.2 (26.7 +/- 1.6) with > 12 (n = 103) years of formal education. CONCLUSIONS Education has the most potent effect on performance on both M-ACE and M-MMSE in the Indian cohort. Education-stratified scores on the M-ACE and the M-MMSE, will provide a more appropriate means of establishing the cognitive status of patients. It is also our feeling that these cut-off scores will be useful across India.

Instrumental activities of daily living scale for dementia screening in elderly people

OBJECTIVE To develop and validate an Instrumental Activities of Daily Living Scale for elderly people (IADL-E) to use in conjunction with cognitive screening tests for dementia in an educationally and socioculturally heterogeneous population. METHOD Eleven IADL items were selected and weighted for major factors causing heterogeneity in the population--gender, education, social (rural/urban) setting and age. Each item was rated for its applicability (yes/no), degree of disability (scored from 0 to 2) and causative impairment (cognitive and/or physical). From this a composite index of cognitive (CDI) or physical (PDI) disability was derived. Validation was performed retrospectively on 240 subjects: 135 without and 105 with dementia by DSM-IV. RESULTS The IADL-E had a high internal consistency (alpha = 0.95). The area under the receiver operating characteristic (ROC) curve was 0.97 (CI = 0.94-0.99). A cutoff score of 16 on CDI provided a sensitivity of 0.91, specificity 0.99 and positive predictive value 0.76 (at 5% base rate). IADL-E correlated highly with clinical (DSM-IV, kappa = 0.89), functional (CDR, 0.82) and cognitive (Mini-mental Status Examination, MMSE, 0.74) diagnoses. It showed good responsiveness, with the change on CDI over a median of 23 months correlating significantly with that on MMSE (coefficient = -0.382, CI = -0.667 to -0.098; p=0.009). Individual items had good interrater and test-retest reliability. CONCLUSIONS The IADL-E is a reliable, sensitive and responsive scale of functional abilities useful in dementia screening in a socioculturally heterogeneous population.

Dementia in Kerala, South India: prevalence and influence of age, education and gender

Data on the prevalence of dementia in India with a large and aging population is scant. We studied prevalence of AD and dementia in Kerala, South India, and effects of age, education and gender on it.

Incidence of Alzheimer's disease in India: A 10 years follow-up study

OBJECTIVE To determine overall and age-specific incidence rates of Alzheimers disease (AD) in a southern Indian province, Kerala. MATERIALS AND METHODS A 10-year (2001-2011) prospective epidemiologic study of community residing subjects aged ≥55 years at enrollment. The catchment area included four urban and semi-urban regions of Trivandrum city in Kerala, India, was selected to provide a range of demographic and socioeconomic representation. Cognitive and functional ability screening were done at baseline and 24-month follow-up assessments. Consensus diagnostic procedures were done using the Diagnostic and Statistical Manual of Mental Disorders, 4 th edition (DSM-IV), and the National Institute of Neurological and Communicative Disorders and Stroke - Alzheimers Disease and Related Disorders Association (NINDS-ADRDA) criteria for the diagnosis of dementia and AD. RESULTS Among the 1066 eligible participants who were cognitively normal at baseline, 104 developed dementia (98 with AD) over a follow-up period of 8.1 years. The incidence rates per 1000 person-years for AD was 11.67 (95% CI: 10.9-12.4) for those aged ≥55 years and higher for those aged ≥65 years (15.54, 95% CI: 14.6-16.5). In those aged ≥65 years, the world age standardized incidence rate was 21.61 per 100,000, and standardized against the age distribution for the year 2000 U.S. Census, the age-adjusted incidence rate was 9.19 (95% CI: 9.03-9.35) per 1000 person-years. Incidence rate of AD increased significantly and proportionately with increasing age. CONCLUSION These are the first AD incidence rates to be reported from southern India. The incidence rates appear to be much higher than that reported from rural north India, comparable with that reported from China, and marginally lower than that reported from the western world.

Subclinical hyperthyroidism and hyperkinetic behavior in children

The authors report three children who exhibited developmental learning disabilities (DLDs) associated with behavioral disturbances, such as attention deficit, hyperactivity, and autistic features. The thyroid function tests performed as a part of routine endocrinologic evaluation of children with DLDs revealed a hormonal profile consistent with hyperthyroidism. These children had no systemic signs of hyperthyroidism. Treatment with neomercazole resulted in good control of their hyperkinetic behavior and subsequent improvement in language function attributable to an increased attention span, thereby facilitating speech therapy. Although routine screening of all children with DLDs for thyroid dysfunction may not be cost-effective, selective screening of children with familial attention-deficit hyperactivity disorder and those with attention-deficit and hyperactivity in association with DLDs and pervasive developmental disorders appears to be justified.

Extent of initial injury determines language lateralization in mesial temporal lobe epilepsy with hippocampal sclerosis (MTLE-HS)

Purpose:  To assess the prevalence and attributes of atypical language lateralization (ALL) in patients with left mesial temporal lobe epilepsy associated with hippocampal sclerosis (MTLE‐HS).

Primary progressive aphasia: A comparative study of progressive nonfluent aphasia and semantic dementia

Primary progressive aphasia (PPA), a degenerative disorder, is often misdiagnosed as Alzheimers disease. Its subtypes, semantic dementia (SD), and progressive nonfluent aphasia (PNFA), are often difficult to differentiate from each other. Our objective was to highlight the differences in the language profiles of patients with SD and PNFA. To bring out these differences, we report two patients with PPA, one with SD and the other with PNFA. They were administered the Western aphasia battery (WAB) and a semantic battery, which assesses semantic memory. The profiles of language impairment on the WAB indicated that the patient with PNFA had syntactic errors in expressive speech but relatively preserved semantics and comprehension, whereas the patient with SD had preserved syntax but made semantic errors in expressive speech, and had impaired comprehension. There were differences in their performance on the semantic battery too. The patient with SD made relatively less errors on confrontation naming, although on the pointing task he failed to point to those line drawings, which he was unable to name on confrontation. In contrast, the finding of the PNFA patient was the reverse of this. Supplementing conventional neuropsychological tests with formal tests for assessment of language functions is useful in the early diagnosis of PPA. The performance of PPA patients on a detailed assessment of language that includes use of formal tests such as the semantic battery helps to differentiate PNFA from SD.

Community-based naming agreement, familiarity, image agreement and visual complexity ratings among adult Indians

The validity of Snodgrass and Vanderwart pictures and their norms derived on a western population on naming, familiarity, imageability and visual-complexity, is not established on a population with cultural background different from the west. We developed, therefore, a set of culturally appropriate pictures for and derived norms on Indians. Line-drawings of 103 concepts (67 from Snodgrass and Vanderwart, 36 new) from 10 semantic-categories were normed on 200 community-based older subjects. Only 31% of the Snodgrass and Vanderwart items showed a concept-agreement on the Indians comparable to western norms. Naming, familiarity and image-agreement mutually correlated but not with visual-complexity. Low-education and rural-residence tended to reduced concept-agreement. The output of this study will be of use in national and cross-national studies.

Profiles of language impairment in progressive nonfluent aphasia

Objective: To study language in noncaucasian patients with progressive nonfluent aphasia (PNA). To determine differences in the language impairment in PNA patients with and without early onset behavioral changes. Materials and Methods: Based on clinical evaluation, six PNA patients were divided into those with ( EB , n =2) and without ( NB , n =4) early onset (i.e., within 24 months from onset) behavioural symptoms of frontotemporal dementia (FTD). NB was sub-grouped as Moderate (language plus subtle cognitive dysfunction; n =2) and Mild (isolated language dysfunction; n =2). Language on the western aphasia battery (WAB) of NB was compared with that of EB and of the three groups were compared with that of controls. Clinical follow-up ranged between 24 and 60 months from onset. Results: Three categories were matched for the disease duration. Compared to controls, significantly (P <0.05) lower scores were seen for all three groups on WAB fluency, repetition and writing; for the Moderate and EB on reading, naming and comprehension; and for the EB alone on information content. Information content and comprehension were significantly lower for the EB when compared to the NB. Over comparable periods, the aphasia quotient of patients in EB declined by more than 30 points and in the Moderate by 3 points. Conclusions: PNA frequently shows behavioral features suggestive of FTD early in the course of the illness. Poor information content on WAB differentiates patients with early behavioral dysfunction from those without. The extent of language impairment is a function of the disease stage rather than of disease duration, suggesting thereby that the initial 2 years of relatively isolated language disorder criteria, while useful, may exclude some patients with PNA.