Janet Grace

Factor Analysis of the Frontal Systems Behavior Scale (FrSBe)

The Frontal Systems Behavior Scale (FrSBe), formerly called the Frontal Lobe Personality Scale (FLOPS), is a brief behavior rating scale with demonstrated validity for the assessment of behavior disturbances associated with damage to the frontal-subcortical brain circuits. The authors report an exploratory principal factor analysis of the FrSBe–Family Version in a sample including 324 neurological patients and research participants, of which about 63% were diagnosed with neurodegenerative diseases (Huntingtons, Parkinsons, and Alzheimers diseases). The three-factor solution accounted for a modest level of variance (41%) and confirmed a factor structure consistent with the three subscales proposed on the theoretical basis of the frontal systems. Most items (83%) from the FrSBe subscales of Apathy, Disinhibition, and Executive Dysfunction loaded saliently on three corresponding factors. The FrSBe factor structure supports its utility for assessing both the severity of the three frontal syndromes in aggregate and separately.

Apathy and Executive Dysfunction in Mild Cognitive Impairment and Alzheimer Disease

OBJECTIVE The authors assessed and contrasted frontally mediated behavior changes in patients diagnosed with Mild Cognitive Impairment (MCI) and Alzheimer disease (AD). Apathy, executive dysfunction, and disinhibition are common in AD, but these behaviors have not been studied in MCI. METHODS Participants were patients diagnosed with AD (n=25) or MCI (n=20). Current behavior and behavior before the onset of cognitive impairment was rated by knowledgeable informants on the Frontal Systems Behavior Scale (FrSBe). RESULTS Apathy and executive dysfunction exhibited the greatest increase in both MCI and AD, and both increased significantly over baseline scores. No significant differences in behavior change were found between the two groups. Behavior change was moderately correlated with a measure of dementia severity, indicating that greater disease severity was associated with more abnormal behavior. CONCLUSION Changes in frontally-mediated behaviors are common in very early and mild stages of cognitive impairment, even before functional decline in daily living is evident. These behaviors deserve more study in MCI because they may have implications for prognosis, treatment adherence, family distress, and patient quality of life.

Neuropsychological deficits associated with driving performance in Parkinson's and Alzheimer's disease

Neuropsychological and motor deficits in Parkinsons disease that may contribute to driving impairment were examined in a cohort study comparing patients with Parkinsons disease (PD) to patients with Alzheimers disease (AD) and to healthy elderly controls. Nondemented individuals with Parkinsons disease [Hoehn & Yahr (H&Y) stage I-III], patients with Alzheimers disease [Clinical Demetia Rating scale (CDR) range 0-1], and elderly controls, who were actively driving, completed a neuropsychological battery and a standardized road test administered by a professional driving instructor. On-road driving ability was rated on number of driving errors and a global rating of safe, marginal, or unsafe. Overall, Alzheimers patients were more impaired drivers than Parkinsons patients. Parkinsons patients distinguished themselves from other drivers by a head-turning deficiency. Drivers with neuropsychological impairment were more likely to be unsafe drivers in both disease groups compared to controls. Compared to controls, unsafe drivers with Alzheimers disease were impaired across all neuropsychological measures except finger tapping. Driving performance in Parkinsons patients was related to disease severity (H&Y), neuropsychological measures [Rey Osterreith Complex Figure (ROCF), Trails B, Hopkins Verbal List Learning Test (HVLT)-delay], and specific motor symptoms (axial rigidity, postural instability), but not to the Unified Parkinson Disease Rating Scale (UPDRS) motor score. Multifactorial measures (ROCF, Trails B) were useful in distinguishing safe from unsafe drivers in both patient groups.

A review of rating scales for measuring behavior change due to frontal systems damage

Objective:To perform a critical review of scales designed to measure frontal behavior change. Background:Changes in cognition due to frontal disease or damage have been well described, but noncognitive changes in behavior are often more deleterious functionally for frontal patients. Method:The review concentrates on five behavior rating scales: the Behavior Rating Inventory of Executive Functions (BRIEF), the Dysexecutive Questionnaire (DEX), the Frontal Behavior Inventory (FBI), the Frontal Systems Behavior Scale (FrSBe), the Iowa Rating Scales of Personality Change (IRSPC), and the Neuropsychiatric Inventory (NPI). Other scales purporting to measure specific aspects of frontal functioning, but having less research support, are described briefly. Results and Conclusions:The BRIEF and FrSBe have good reliability and large-scale norms. No norms are available for the other scales. The FrSBe and IRSPC have been shown to be valid in discriminating frontal from nonfrontal lesioned patients, but this has not been shown in the other scales. The FBI and NPI require trained raters, whereas the FrSBe, IRSPC, and BRIEF are administered to patients and/or family informants directly. The NPI and FBI are sensitive to certain changes in behavior attributed to frontal systems disruption but have been used primarily in dementia.

Development and initial validation of a screening tool for Parkinson disease surgical candidates.

As there is currently no standardized assessment tool for evaluating Parkinson disease (PD) patients for deep brain stimulation (DBS), the authors developed the Florida Surgical Questionnaire for Parkinson Disease (FLASQ-PD). Part I of the study was a retrospective analysis of 174 patients presenting for a surgical screening. Part II was a multicenter study to assess the correlation of FLASQ-PD scores. The results of this study suggest that the FLASQ-PD may be a useful triage tool for screening PD patients for DBS surgery.

Computerized Maze Navigation and On-Road Performance by Drivers With Dementia

This study examined the ability of computerized maze test performance to predict the road test performance of cognitively impaired and normal older drivers. The authors examined 133 older drivers, including 65 with probable Alzheimer disease, 23 with possible Alzheimer disease, and 45 control subjects without cognitive impairment. Subjects completed 5 computerized maze tasks employing a touch screen and pointer as well as a battery of standard neuropsychological tests. Parameters measured for mazes included errors, planning time, drawing time, and total time. Within 2 weeks, subjects were examined by a professional driving instructor on a standardized road test modeled after the Washington University Road Test. Road test total score was significantly correlated with total time across the 5 mazes. This maze score was significant for both Alzheimer disease subjects and control subjects. One maze in particular, requiring less than 2 minutes to complete, was highly correlated with driving performance. For the standard neuropsychological tests, highest correlations were seen with Trail Making A (TrailsA) and the Hopkins Verbal Learning Tests Trial 1 (HVLT1). Multiple regression models for road test score using stepwise subtraction of maze and neuropsychological test variables revealed significant independent contributions for total maze time, HVLT1, and TrailsA for the entire group; total maze time and HVLT1 for Alzheimer disease subjects; and TrailsA for normal subjects. As a visual analog of driving, a brief computerized test of maze navigation time compares well to standard neuropsychological tests of psychomotor speed, scanning, attention, and working memory as a predictor of driving performance by persons with early Alzheimer disease and normal elders. Measurement of maze task performance appears to be useful in the assessment of older drivers at risk for hazardous driving.

Insight and cognitive impairment: effects on quality-of-life reports from mild cognitive impairment and Alzheimer's disease patients.

This study follows previous work to determine the effect of patient insight and cognitive impairment on the reliability and validity of self-reported quality of life (QOL) from patients diagnosed with Alzheimers disease (AD) and mild cognitive impairment (MCI). AD and MCI patients (N = 68) and their caregivers participated. Patients with impaired insight provided QOL ratings that were less reliable than those provided by patients with better insight. Patient-caregiver agreement for QOL reports was used as an index of validity. Neither better insight nor lesser cognitive impairment suggested better agreement. Thus, even when patient insight is intact, patient reports are unlikely to agree with caregiver reports. Patient and caregiver reports about patient QOL may represent 2 unique, yet potentially valid, perspectives.

Executive and emotional dysfunction in Machado-Joseph disease.

Machado‐Joseph disease (MJD) is an autosomal dominant spinocerebellar ataxia. Few studies have examined the neuropsychological and neurobehavioral profiles of patients with MJD. In this study, six individuals with MJD were given a battery of neuropsychological tests. Relative impairments on timed verbal attention tasks and verbal fluency (Stroop, Oral Symbol Digit Modalities, and Controlled Oral Word Association Test) were found. Other executive impairments also were seen on the Wisconsin Card Sorting Test, independent of motor dysfunction severity. Moderate‐ to severe levels of depressive symptoms were endorsed by four of the six patients, and caregivers observed increased apathy in the patients. Impaired executive and emotional functioning in MJD does not appear to be related to ataxia severity. These patients did not meet the criteria for dementia. General cognitive abilities, language, list learning, story recall, and untimed tasks of attention were within normal limits. Impaired executive abilities and emotional functioning in MJD patients is consistent with disruption of frontal‐subcortical systems.

Validity of informant reports about AD and MCI patients' memory.

Efficient, valid, and economical methods are needed to measure memory in elderly patients who are participants in clinical trials for the prevention or treatment of dementia. Data provided by knowledgeable informants are an ideal means of assessment, but factors that may limit the validity of informant-report data are not known. This study investigated the living status, relationship type, and educational history of informants and determined the impact of these factors on the validity of informant-report data about patients (N = 62) diagnosed with Alzheimer disease or mild cognitive impairment. Validity of informant-reported memory was indicated by the correlation between the reports and patients’ performance on a neuropsychological memory test. Results indicated that informants who lived with patients provided more accurate reports of the patients’ memory than informants who did not live with the patient. Spouses were more accurate than other relationship types, although relationship type was confounded with living status. Patient education and neuropsychiatric symptoms were not significantly associated with informant accuracy. Results of this study will aid in selecting informants who can provide the most accurate data about memory disorder patients and will aid in the development of protocols for clinical trials for dementia prevention and treatment.

A double-blind comparison of galantamine hydrobromide ER and placebo in Parkinson disease

Objective: To study the efficacy and safety of galantamine hydrobromide ER for the enhancement of cognition in non-demented Parkinson’s patients (PD). Methods: Sixty-nine non-demented PD participants were randomised in a double-blind, placebo-controlled study of galantamine or placebo. Galantamine was administered over 16 weeks (8 mg/day for 4 weeks, a therapeutic dose of 16 mg/day for 6 weeks and a maximum dose of 24 mg/day for 6 weeks). Outcome measures were neuropsychological (attention, verbal fluency, executive, memory, visuospatial), behavioural (Frontal Systems Behavior Scale, Neuropsychiatric Inventory-Questionnaire, PDQ-39) and motor (Unified Parkinson’s Disease Rating Scale motor scale). Results: 26 individuals on active medication and 28 individuals on placebo were included in the outcome analyses. No significant differences were found between the active and placebo groups on cognitive, behavioural or motor outcome measures. Most common adverse events were gastrointestinal and self-reported worsening of PD symptoms. Conclusions: Contrary to our hypotheses, galantamine treatment did not improve attention/executive, memory or visuospatial performance in non-demented PD patients. Further, there was a high, statistically significant drop-out rate in the treatment group due to gastrointestinal side effects and self-reported worsening of PD symptoms. Treatment with galantamine did not enhance self-perception of mental sharpness or quality of life. No negative behavioural change such as hallucinations or apathy was found with treatment.