James L. Mack

The basis of visual constructional disability in patients with unilateral cerebral lesions.

Patients with left and right unilateral hemispheric lesions were compared on the Form Assembly Task, a visual construction task requiring perceptual but not executive, motor, or verbal skills. Right lesioned patients were inferior to lefts and normals in both degree and frequency of impairment. Performances on the assembly task and two visual discrimination tasks were correlated among right but not left lesioned patients. Left lesioned patients took significantly longer to achieve maximum level of performance than either rights or normals. Neither sex nor duration of lesion affected Form Assembly performance. Results were consistent with the hypothesis that visual perceptual deficits underlie constructional difficulties among right but not left lesioned patients.

Auditory Comprehension in Aphasia

Publisher Summary This chapter discusses the disturbances of auditory comprehension in aphasia. The comprehension of aphasics has been studied less than their expressions because the analysis of comprehension must be based on the observation of overt responses; it is thus confounded by output deficits. The chapter also discusses the early contributions to the study of comprehension deficits in aphasia and reviews various techniques that have been developed for the assessment of comprehension, including single tests and large test batteries. Aphasia is defined as the loss of language ability that is secondary to cerebral damage and that causes a disorder of translation of thoughts into words and words into thoughts. Within this broad definition, aphasic syndromes may be divided into two types: those with nonfluent and those with fluent output. About 20% of all patients with aphasia have Brocas aphasia. The diagnosis of this form of aphasia is based on the observation of reduced verbal output in both speech and writing.

Behavior Rating Scale for Dementia: Development of Test Scales and Presentation of Data for 555 Individuals with Alzheimer's Disease

We studied 555 Alzheimers disease patients on the Behavior Rating Scale for Dementia (BRSD), which uses infor mant interviews to measure behavioral pathology in demented patients. For the 45 items, ratings of present ranged from 5% to 66% of the subjects, with 39 rated present in at least 10%. Twenty-nine items were significantly corre lated with dementia severity. The mean number of items present per subject was 13.5; only two subjects had none rated present. Factor analysis identified six factors common to mildly and moderately demented subjects. Six sub scales were developed: Depressive Symptoms, Inertia, Vegetative Symptoms, Irritability/Aggression, Behavioral Dysregulation, and Psychotic Symptoms. Interitem consistency was high for three subscales (αs from .75 to .80) and moderate for three (αs from .48 to .56). Four subscale scores and total scores were significantly but weakly cor related with dementia severity. Detailed results and test instructions are presented in the BRSD manual, available from The Consortium to Establish a Registry for Alzheimers Disease. (J Geriatr Psychiatry Neurol 1999; 12:211-223).

Assessment of functional ability in Alzheimer disease: a review and a preliminary report on the Cleveland Scale for Activities of Daily Living.

SummaryAssessment of activities of daily living (ADL) in Alzheimer disease (AD) is critical in establishing the diagnosis, monitoring disease progression, evaluating the efficacy of treatment interventions, and determining the need for health and social services. The proper method to measure ADL depends on the purposes to which the scale is to be put. Existing ADL scales differ as to the type of behaviors assessed, the nature of the observations made, and the manner in which the observations are quantified. These scales were not specifically designed to evaluate changes in the nature and extent of the broad spectrum of functional difficulties seen in individuals with AD. We describe the Cleveland Scale for Activities of Daily Living (CSADL), an informant-based instrument designed to expand upon the capacity of existing physical and instrumental ADL scales by assessing both premorbid and current component acts (e.g., initiation versus implementation) of daily living functions.

Executive functions and Alzheimer's disease: problems and prospects

The term executive functioning refers to mental activity that is involved in the planning, initiation, and regulation of behavior (Lezak, 1982, 1983). It is considered the central organizing function of the brain that results in systematic, goal-directed activity. Executive functions are called into play in non-routine situations, where automatic or reflexive behaviors are not adequate to solve the problem at hand. As described by Luria (1973), in carrying out mental activities,

Quality of life in dementia: State of the art-report of the international working group for harmonization of dementia drug guidelines and the Alzheimer's society satellite meeting

On November 19, 2000, the International Working Group for Harmonization of Dementia Drug Guidelines and the Alzheimer’s Society (U.K.) hosted the satellite meeting on the theme “Advances in Quality of Life in Dementia.” This meeting immediately preceded the first International Quality Research in Dementia Conference. The objectives of the satellite meeting were to bring together leading quality of life (QOL) researchers in plenary sessions and small-group workshops to present the latest thinking on measuring QOL and to allow a discussion of ways of conceptualizing and harmonizing the measurement of QOL. Essentially all contributors to the meeting viewed QOL as a concept that has both subjective and objective aspects and can vary from one individual to the next. Everyone also stressed the QOL is ultimately subjective, in that it involves a person’s sense that one’s life meets one’s expectations. Translating that concept into an instrument for evaluating QOL, however, generates a host of questions, and much of the discussion in the meeting concerned such questions. Sube Bannerjee directly addressed the question of why we wish to measure QOL in dementia. Dementia affects a great number of people and has a great impact. Moreover, it is a complex disorder compared with many health problems, in that its progression is nonlinear and it has multiple causes. Finally, interventions dealing with dementia are diverse, acting at multiple levels with multiple outcomes; QOL can provide a common language for evaluating the effects of these interventions. QOL has become a very important political issue insofar as it can be used to justify health care costs directed toward ameliorating the effects of dementia. The extreme ends of the continuum of dementia may require increasing attention. Mary Sano suggested that as our society becomes increasingly complex, even cognitive impairments too mild to warrant a diagnosis of dementia could be disabling and constricting and thus affect QOL. Another participant said that severely demented patients who are difficult to evaluate require the most environmental intervention yet receive less attention than less impaired patients. One of the primary issues discussed was the advisability of a QOL scale specific to dementia. A generic QOL scale offers ease of use and comparability across diseases. The speakers and participants in the conference, however, felt strongly that the effects of dementia require a disease-specific scale. Bannerjee pointed out, however, that the use of a disease-specific scale makes it difficult to compare the QOL impact of dementia with that of other diseases, and several speakers emphasized the appeal of a generic scale to policy makers. With a diseasespecific scale we may find it difficult to make a case for greater investment in treating dementia. Evaluating QOL in a purely subjective fashion poses many problems. Lynne Comer reported that the Newcastle group has done extensive work in interviewing AD patients to identify specific components that enhance or detract from their QOL, and Peter Whitehouse described the QOLAS, a scale based on Kelly’s Repertory Grid technique that allows an individual to select some of the variables relevant to measuring his or her QOL. Using such an individualized approach, however, can be timeSee Appendix for meeting speakers. Alzheimer Disease and Associated Disorders Vol. 15, No. 2, pp. 69–71

A longitudinal study of behavioral pathology across five levels of dementia severity in Alzheimer's disease: The CERAD behavior rating scale for dementia

As part of the Alzheimers Disease Cooperative Study (ADCS) Instrument Development Project, the CERAD Behavior Rating Scale for Dementia (BRSD) was examined for its sensitivity to degree of cognitive impairment, its test-retest reliability, and its sensitivity to longitudinal change. Sixty-four normal elderly participants and 261 patients with AD stratified into severity groups based on Mini-Mental State Exam (MMSE) scores were rated on the BRSD at baseline and 12-month follow-up visits. A subset of subjects was evaluated at a 1-month follow-up visit. Baseline BRSD Total Score discriminated the normal group from each AD group, and mean Total Score significantly increased with increasing dementia severity. Test-retest reliability between baseline and 1-month Total Scores was satisfactory for all AD groups. Longitudinal change was evaluated by 12-month change scores, which were significant in only the normal and in one AD group. From the results, we argue that the value of behavioral pathology assessment in clinical trials would be enhanced if additive scores were based on groups of correlated items rather than on a broad array of behaviors, some of which may increase and others may decrease in frequency as AD progresses.

CONCEPTUAL DEFICITS AND AGING: THE CATEGORY TEST

Category Test performance of 41 bright aged normals was compared with the performance of 40 young normals and a group of 43 patients with suspected neurological dysfunction. The aged normals were not only as deficient as the neurologic patients but showed a similar pattern of deficits on Category subtests. The extreme difficulty experienced by aged normals and patients on Subtests III and IV was explained as a function of task complexity rather than of conceptual difficulty. Further investigation of the relationship between the relative difficulty of conceptual principles and task complexity in a variety of impaired groups was suggested.

Criteria for progressive modification of neurobehavioral batteries

Six specific issues affecting the progressive modification of neurobehavioral test batteries used in field studies of populations exposed to neurotoxicants are discussed and test review recommendations are provided addressing each issue. The issues include: (a) general test review standards, (b) comprehensive assessment, (c) tailored batteries, (d) incorporation of new tests and techniques, (e) personnel and mechanisms for review, and (f) development of a battery assessing peripheral nervous system function.

Performance of subjects with probable Alzheimer disease and normal elderly controls on the Gollin Incomplete Pictures Test.

Our study was designed to evaluate perceptual ability measured by the Gollin Incomplete Pictures Test (in which subjects identify fragmented pictures of common objects) in Alzheimer Disease. We developed a standardized procedure for administering Gollins test and compared the performance of 58 Alzheimer patients and 37 elderly controls on the Gollin, two design copying tests, the Mini-Mental State Examination, a verbal version of the Knox Cubes test, a recognition memory test, and a verbal fluency test. Alzheimer patients performed significantly more poorly than controls on all tests. Factor analysis demonstrated a visual perceptual factor, with loadings on the Gollin test and design copying and three other factors representing primary memory, secondary memory, and language Results indicate the Gollin test measures visual perceptual ability, but the precise nature of the task requires further study. Identification of fragmented pictures appears a practical and potentially useful measure for evaluating at least some aspects of visual perception in patients with generalized cognitive impairment.