Glen R. Finney

Artwork before and after onset of progressive nonfluent aphasia

ObjectiveCompare changes in art quality before and after the onset of progressive nonfluent aphasia (PA). BackgroundSome patients with left frontotemporal lobar degeneration (FTLD), particularly PA start painting and improve in art despite their disease. There is only 1 case reported of FTLD where the person was an artist before onset. MethodsDigital images of 7 paintings were obtained. Three paintings were from 6 years before onset of PA, 1 was from year of onset, and 3 were from 5 years after. Seven college-educated raters without art backgrounds, 5 men and 2 women, used a 1 to 5 point scale to rate 4 qualities of the paintings: representation, esthetics, novelty, and closure. The subjects had not previously viewed these paintings. One art expert also rated the paintings on these 4 qualities. ResultsQuality ratings did not differ for 3 qualities, but novelty decreased over time. The art expert rated all qualities stable over time. ConclusionsArtistic ability in this previously trained artist with PA did not improve. Instead, the novelty of her work decreased. FTLD may not improve artistic skills in those who already possess them and there can be a decrease in one quality strongly related to creativity—novelty.

Lewy body dementia and creativity: case report.

BACKGROUND We studied a visual artist with Lewy body dementia (LBD) to learn how this disease influenced his paintings during the course of the disease. METHODS Study 1 evaluated two paintings of the same subject matter, one that the patient painted before his illness and the other after the onset of this disease. Study 2 evaluated a collection of his paintings from the time before he was ill (1994) until the time he stopped painting when he was suffering with LBD (2002). To learn how the onset and progression of LBD affected his paintings we had judges score the following qualities: aesthetic-beauty, closure completeness, evocative impact, novelty, technique and representational quality. RESULTS In Study 1 we found that the representational ratings for the picture he painted when he had LBD was significantly lower than the picture he painted before he developed LBD. In Study 2, we found that all the artistic qualities measures temporally declined except novelty. We also found that the paintings that were judges as having the highest quality representations were significantly more novel than those that had poorer representations. In addition, we conducted a forward stepwise regression analysis using quality measures as predictor of year. This analysis revealed that only representational quality significantly predicted painting year. CONCLUSIONS Our results suggest that as LBD progresses, except for novelty there is a gradual degradation of the ability to visually express artistic subject matter. It possible that the preserved ability to paint novel picture is related to relative preservation of frontal lobe function, but the degradation of other artistic qualities might be related to deterioration of the parietal lobes which either impairs the brains iconic representations or the knowledge needed to portray these representations.

Auditory Responsive Naming versus Visual Confrontation Naming in Dementia

Dysnomia is typically assessed during neuropsychological evaluation through visual confrontation naming. Responsive naming to description, however, has been shown to have a more distributed representation in both fMRI and cortical stimulation studies. While naming deficits are common in dementia, the relative sensitivity of visual confrontation versus auditory responsive naming has not been directly investigated. The current study compared visual confrontation naming and auditory responsive naming in a dementia sample of mixed etiologies to examine patterns of performance across these naming tasks. A total of 50 patients with dementia of various etiologies were administered visual confrontation naming and auditory responsive naming tasks using stimuli that were matched in overall word frequency. Patients performed significantly worse on auditory responsive naming than visual confrontation naming. Additionally, patients with mixed Alzheimers disease/vascular dementia performed more poorly on auditory responsive naming than did patients with probable Alzheimers disease, although no group differences were seen on the visual confrontation naming task. Auditory responsive naming correlated with a larger number of neuropsychological tests of executive function than did visual confrontation naming. Auditory responsive naming appears to be more sensitive to effects of increased of lesion burden compared to visual confrontation naming. We believe that this reflects more widespread topographical distribution of auditory naming sites within the temporal lobe, but may also reflect the contributions of working memory and cognitive flexibility to performance.

Normal pressure hydrocephalus.

Normal Pressure Hydrocephalus first became recognized as a treatable, reversible disorder in the 1960s. The classic triad of magnetic apraxia, urinary incontinence, and dementia remain relevant into the 21(st) century as being the basis for symptomatic diagnosis and predicting potential benefit from ventriculoperitoneal shunting, though they have been greatly augmented by the addition of modern neuroimaging, particularly MRI. Modern criteria recognize a wider range of diagnostic criteria, and new positive and negative prognostic indicators for treatment benefit have been discovered, though the mainstay remains initial drainage of a large volume of cerebrospinal fluid and monitoring for clinical improvement. Even with our advances in understanding both primary and secondary normal pressure hydrocephalus, diagnosis, management, and counseling remain challenging in this disorder.

Improving clinical cognitive testing: Report of the AAN Behavioral Neurology Section Workgroup

Objective: To evaluate the evidence basis of single-domain cognitive tests frequently used by behavioral neurologists in an effort to improve the quality of clinical cognitive assessment. Methods: Behavioral Neurology Section members of the American Academy of Neurology were surveyed about how they conduct clinical cognitive testing, with a particular focus on the Neurobehavioral Status Exam (NBSE). In contrast to general screening cognitive tests, an NBSE consists of tests of individual cognitive domains (e.g., memory or language) that provide a more comprehensive diagnostic assessment. Workgroups for each of 5 cognitive domains (attention, executive function, memory, language, and spatial cognition) conducted evidence-based reviews of frequently used tests. Reviews focused on suitability for office-based clinical practice, including test administration time, accessibility of normative data, disease populations studied, and availability in the public domain. Results: Demographic and clinical practice data were obtained from 200 respondents who reported using a wide range of cognitive tests. Based on survey data and ancillary information, between 5 and 15 tests in each cognitive domain were reviewed. Within each domain, several tests are highlighted as being well-suited for an NBSE. Conclusions: We identified frequently used single-domain cognitive tests that are suitable for an NBSE to help make informed choices about clinical cognitive assessment. Some frequently used tests have limited normative data or have not been well-studied in common neurologic disorders. Utilizing standardized cognitive tests, particularly those with normative data based on the individuals age and educational level, can enhance the rigor and utility of clinical cognitive assessment.

Acute lorazepam effects on neurocognitive performance

A double-blind, placebo-controlled, crossover design was employed to determine whether acute lorazepam (2 mg orally) cognitive side effects would emerge in a differential age-dependent fashion in 15 young (mean age=22 years) and 12 older (mean age=64 years) subjects. Acute use of lorazepam is frequently the initial treatment choice for convulsive status epilepticus or repetitive seizure clusters. Cognitive assessment was performed during drug and placebo conditions using a computerized battery of cognitive tests. With the exception of performance on the reasoning composite score, significant drug effects were present on all primary cognitive domain measures. However, the only significant drug-by-age interaction effect was seen for dual-task performance. The relationship between test performance and plasma lorazepam concentrations was generally modest and non-significant, suggesting that individual differences in pharmacokinetics are not a major factor contributing to the emergence of cognitive side effects. Despite robust lorazepam effects on multiple measures of neurocognitive function, differential age effects are largely restricted to dual-task performance. These results indicate that with the exception of dual-task performance, older individuals in the age range of this study do not appear to be at increased risk for the emergence of cognitive side effects following a single 2-mg dose of lorazepam.

Lorazepam effects on Word Memory Test performance: a randomized, double-blind, placebo-controlled, crossover trial.

The Word Memory Test (WMT) is a common measure of symptom validity. To investigate the effects of acute benzodiazepines on WMT scores, oral lorazepam 2 mg (LOR) and placebo were administered 1 week apart in a randomized, double-blind, placebo-controlled, crossover study. A total of 28 participants completed the study and were administered the WMT during each drug condition. Within-participant comparisons of LOR vs placebo revealed significant LOR effects for Immediate Recognition (p = .007) and Consistency (p = .019), but not Delayed Recognition (p = .085). Significant LOR effects were present for Reaction Time Measures (Immediate Recognition RT, p = .013; Delayed Recognition RT, p = .001; Multiple Choice RT, p = .011) and Delayed Memory scores (Multiple Choice, p = .007; Paired Associates, p = .029; Free Recall, p = .001). A pattern similar to crossover results was detected for LOR vs placebo between-group differences for initial test assessment scores. When examined using publisher recommended cut scores for the principal WMT measures, there were six participants failing the WMT during initial LOR testing; all six subsequently performed in the normal range upon retesting with placebo. One participant failed WMT during placebo and obtained passing scores during LOR. These data indicate that multiple WMT measures may be affected by acute LOR dosing, and provide additional evidence that potential latent variables and their effects on both SVT performance and cognitive function should be part of the clinical decision-making process.

Status of neurology medical school education Results of 2005 and 2012 clerkship director survey

Objective: To survey all US medical school clerkship directors (CDs) in neurology and to compare results from a similar survey in 2005. Methods: A survey was developed by a work group of the American Academy of Neurology Undergraduate Education Subcommittee, and sent to all neurology CDs listed in the American Academy of Neurology database. Comparisons were made to a similar 2005 survey. Results: Survey response rate was 73%. Neurology was required in 93% of responding schools. Duration of clerkships was 4 weeks in 74% and 3 weeks in 11%. Clerkships were taken in the third year in 56%, third or fourth year in 19%, and fourth year in 12%. Clerkship duration in 2012 was slightly shorter than in 2005 (fewer clerkships of ≥4 weeks, p = 0.125), but more clerkships have moved into the third year (fewer neurology clerkships during the fourth year, p = 0.051). Simulation training in lumbar punctures was available at 44% of schools, but only 2% of students attempted lumbar punctures on patients. CDs averaged 20% protected time, but reported that they needed at least 32%. Secretarial full-time equivalent was 0.50 or less in 71% of clerkships. Eighty-five percent of CDs were “very satisfied” or “somewhat satisfied,” but more than half experienced “burnout” and 35% had considered relinquishing their role. Conclusion: Trends in neurology undergraduate education since 2005 include shorter clerkships, migration into the third year, and increasing use of technology. CDs are generally satisfied, but report stressors, including inadequate protected time and departmental support.

Ipsilesional Attentional-Approach Neglect or Crossover Effect*

Patients with ipsilateral neglect (IN) bisect lines toward contralesional space. It has been posited that IN might be induced by an attempt at compensation, as part of the crossover effect, where patients with an ipsilesional bias when bisecting long lines, cross over and develop a contralesional bias on short lines or as a release of an approach (grasp) behavior that might be attentional or intentional. To test these alternative hypotheses we had a patient with IN from a right medial frontal lesion bisect lines that contained no cue, a left-sided cue, a right-sided cue, and bilateral cues. If this patient had ipsilateral neglect (IN) because of a crossover effect or compensation, right-sided cues should have influenced bisection more than left-sided cues. We, however, found that only left-sided cues induced a significant change (left-sided deviation) providing support for the attentional-approach (grasp) hypothesis. Further support of this contralesional attentional grasp hypothesis comes from the observation that this patient also had ipsilesional extinction to simultaneous stimuli.

The relationship between semantic knowledge and conceptual apraxia in Alzheimer disease.

Background:Conceptual apraxia (CA), a feature of Alzheimer disease (AD), can be detected by asking participants to identify the correct tool to act on an object. Assessment can be based on either learned associations (a tool selection test) or the mechanical properties that the tool needs to alter the target object (an alternative tool selection test). Objectives:We wanted to determine whether knowledge of semantic taxonomic relations (intrinsic properties shared by items) correlated with performance on tests for CA in people with AD or amnestic mild cognitive impairment (aMCI). Methods:We tested 10 participants with AD, 12 with aMCI, and 18 healthy older adults for CA using an alternative tool selection test, a tool selection test, and a test of taxonomic relations. Results:The aMCI group did not differ from the control group on the CA tests. The patients with AD were impaired on all tests except tool selection; their performance on the alternative tool selection test correlated significantly with their performance on the taxonomic relations test. Conclusions:The correlation between performances on the alternative tool selection test and the taxonomic relations test in AD suggests a common pathophysiologic substrate, either impairment in accessing conceptual-semantic representations or a degradation of these representations.