Michael H. Rosenbloom

The functional neuroanatomy of decision-making.

Decision-making is a complex executive function that draws on past experience, present goals, and anticipation of outcome, and which is influenced by prevailing and predicted emotional tone and cultural context. Functional imaging investigations and focal lesion studies identify the orbitofrontal, anterior cingulate, and dorsolateral prefrontal cortices as critical to decision-making. The authors review the connections of these prefrontal regions with the neocortex, limbic system, basal ganglia, and cerebellum, highlight current ideas regarding the cognitive processes of decision-making that these networks subserve, and present a novel integrated neuroanatomical model for decision-making. Finally, clinical relevance of this circuitry is illustrated through a discussion of frontotemporal dementia, traumatic brain injury, and sociopathy.

The sixth vital sign project: Is cognitive screening in the elderly population clinically effective?

Corsi Block Tapping test 4.15 (.37) 4.9 (.83) 0.001* Visuo Spatial Supra Span 7.46 (7.1) 10.08 (2.67) 0.210 VOSP – screening 17 (2.98) 18.84 (1.34) 0.048* VOSP – object 1 15.65 (4.04) 19 (1.22) 0.008* VOSP – object 2 15.41 (4.37) 21.23 (4.81) 0.002* VOSP – object 3 12.12 (3.99) 17.31 (1.49) 0.001* VOSP – object 4 13.12 (2.52) 11.31 (2.06) 0.044* VOSP – space 5 9.59 (.71) 9.85 (.37) 0.247 VOSP – space 6 18.29 (1.93) 19.46 (.78) 0.050* VOSP – space 7 7.82 (2.61) 9.38 (.87) 0.048* VOSP – space 8 7.88 (2.23) 8.69 (1.49) 0.269 Clock Drawing Test – a 11.55 (2.99) 13.35 (1.1) 0.038* Clock Drawing Test – b 9.5 (3.23) 11.78 (.69) 0.014* Clock Drawing Test – c1 9.55 (1.23) 10.21 (.42) 0.063 Clock Drawing Test – c2 9.2 (1.47) 10.21 (.42) 0.018* Clock Drawing Test – c3 9.75 (1.01) 10.21 (.42) 0.119

AMYLOID PET IMAGING IN A COMMUNITY NEUROLOGY PRACTICE: FEASIBILITY AND CLINICAL OUTCOMES

cases than controls (rate ratio (RR) 1.48; 95% confidence interval (CI) 1.46, 1.50). There was a significant time effect in all models ranging from a decreasing effect for ancillary services to a large, increasing effect for long-term care services. HCU among cases was higher in long-term care settings (RR 5.13; 95% CI 4.87, 5.41) followed by inpatient care settings (RR 2.0; 95% CI 1.95, 2.03) compared to controls. Increased disease-specific HCU among cases was observed for Parkinson’s disease (RR 9.0; 95% CI 7.89, 10.37), psychiatric disease (RR 4.56; 95% CI 4.30, 4.85), chronic liver disease (RR 3.89; 95% CI 3.43, 4.41), and stroke (RR 2.71; 95% CI 2.56, 2.86). Conclusions: HCU is significantly elevated among individuals with ADRD prior to diagnosis. HCU by comorbid condition may be equally, if not more informative than health care setting alone in understanding early indicators of ADRD. Increased HCU for certain comorbidities could reflect potential disease mismanagement due to early stages of ADRD.

AMYLOID PET IMAGING AND NEUROPSYCHOLOGICAL PHENOTYPES IN ALZHEIMER’S AND NON-ALZHEIMER’S DEMENTIAS

Test re-test reliability was adequate for learning trials, LDFR & d’ (r1⁄4.67 to .73; p<.05). Analysis revealed significant inter-correlations between learning and memory scores (r1⁄4.33 to .93), components of WAOMT and odour identification (r1⁄4.15 to .21), verbal episodic memory (r 1⁄4.17 to .26) and visual episodic memory (r 1⁄4 .16 to .27). Females performed better than males on Trial 3 F(1,113) 1⁄4 4.49, p1⁄4 .4 and recognition hits F(1,113)1⁄4 6.24, p1⁄4 .14, controlling for MoCA scores. Performance decreased with age (r 1⁄4 -.13 to -.20). Conclusions:Relationships were found between conceptually similar constructs of verbal and visual episodic memory and odour identification. Performance was found to decrease with age, and females demonstrated an advantage overall males in learning trial 3 and recognition hits. The WAOMT presents a reliable, valid and simple test of odour episodic memory. Future research implications include examining the longitudinal relationship between OEM and cognitive decline.

PREVALENCE OF NEUROPSYCHIATRIC AND MOTOR SYMPTOMS IN PRODROMAL DEMENTIA WITH LEWY BODIES

Background:When a disease-modifying therapy for Alzheimer’s disease (AD) becomes available, many researchers and industry leaders believe that the U.S. health care system will lack the capacity to provide patients with access to treatment within a reasonable timeframe. Access to care begins with effective identification of those patients appropriate for disease-modifying treatment. Risk stratification capacity can be expanded by employing validated cognitive self-assessments in the home setting, enabling patients to bring screening data to their health care professionals. Utilizing cognitive self-assessment screens as a first step toward effective risk stratification has potential to identify older adults who would benefit from a disease-modifying treatment. However, few self-assessments have been validated that are sensitive to mild cognitive impairment (MCI) or early AD. Methods:We conducted a national online survey of geriatric health care professionals on the potential use of selfassessment cognitive screening for MCI and AD to address these future health care needs. Next, we developed a rapid self-assessment screen (myMemCheck) designed for older adults who have concerns about their cognitive function. The psychometric properties of this instrument were investigated in two separate Maryland, USA nursing home and assisted living samples (Study 1, N 1⁄4 63; Study 2, N 1⁄4 200). Results: The instrument evidenced adequate reliability and strong construct validity across both studies. Receiver operating characteristic analysis yielded an optimal cut score for identifying older adults with MCI or early AD. Conclusions:We discuss implications of using a reliable and valid self-assessment for determining whether a comprehensive test or evaluation for MCI or AD is indicated. Wider detection of MCI and AD by accurate at-home cognitive self-assessments could reduce the screening burden on primary care physicians.

OUTCOMES FROM ROUTINE COGNITIVE SCREENING IN A HEALTH CARE SYSTEM

Background:Mild Cognitive Impairment (MCI) is widely considered a phase of transition between normality and dementia. Most of the studies of conversion from MCI to dementia has focused on amnestic MCI (aMCI) that is considered a preclinical phase of Alzheimer Disease (AD). An important goal would be to identify the neuropsychological tools that better predict conversion from MCI to dementia. Methods:Fifty-five aMCI subjects of the Treviso Dementia (TREDEM) Registry, were considered. They underwent a neuropsychological assessment in the first visit and at follow-up. Cox proportional-hazard regression models were created to measure the association between the dependent variable (dementia’s diagnosis or MCI status maintainance) and indipendent variables (neuropsychological test scores at baseline). Results: The sample (28 women and 27 men; mean age 76,82 6 5,88 ys; education 7,62 6 3,99 ys) was observed for an average time of 2,17 6 1,25 ys. ACox backward stepwise regression showed that Rey Auditiory Verbal Learning Test, Delayed Recall (RAVLT-DR) (p1⁄4.041) and Semantic Verbal Fluency (SVF) (p1⁄4.031) appear to be able to predict conversion to dementia. Age and education were significant, respectively as risk (Exp B1⁄41,116) and protective (Exp B1⁄40,81) factors. Conclusions:RAVLT-DR and SVF would appear as proper tools to predict the conversion from aMCI to Dementia.

Outcomes from routine cognitive screening in a general neurology clinic

MiDD was 9.90% in NCD, 16.89% in MCI, and 19.51% in ADD. The frequency of NIMH-dAD was 26.23%, 33.56%, and 40.24%, respectively. While the frequency of MaDD did not show any significant difference among cognitive subgroups, those of MiDD and NIMH-dAD, i.e., relatively milder depression syndromes, had significant group difference with gradual increase from NCD to ADD. Conclusions: The current findings obtained from a large number of cognitively diverse elderly individuals who visited a memory clinic indicated that mild depressive conditions are highly prevalent in general and more common in individuals with poorer cognitive condition, while the frequency of severe depressive disorder like MaDD is not related to cognitive status.

D2-4: Failure on Cognitive Screening Predicts Increased Healthcare Utilization

Background/Aims Most physicians fail to diagnose dementia until the moderate-severe stages. Cognitive screening for dementia in the asymptomatic population is not routinely performed due to the absence of evidence showing improved health outcomes. HealthPartners has piloted the use of the Mini-Cog as a standardized screening tool for cognitive function in patients aged 65 and older in order to assess the impact of undetected cognitive impairment on chronic disease management and healthcare utilization. Methods Patients screened within specialty or primary care clinics were identified. Data from the 18 months prior to screening was collected from the electronic medical record and included the Mini-cog score (scored 0–5, fail is less than 4), demographics, presence of diagnosis for four chronic diseases (diabetes, hypertension, hyperlipidemia, heart disease), measures of chronic disease management (HbA1c, blood pressure, lipid panel, INR levels), and measures of healthcare utilization. Data analysis consisted of Poisson regression and normal mixed effects regression. Results The Mini-Cog was administered in 753 patients (average 77 yr, 58% female) and 33% failed screening. No significant differences in chronic disease management were identified in the 18 months prior to screening between the patients that passed and failed. However, patients failing the MiniCog had a significantly higher incidence rate of hospitalizations (24%), emergency room visits (58%), appointment no shows (76%), cancelled visits (23%), and phone encounters (11%). In a sub-analysis, patients failing screening in specialty care (193 of 554) had a higher incidence rate of appointment no shows (82%), but no difference in hospitalizations. In contrast, patients failing screening in primary care (56 of 199) showed a more profound effect on crisis driven care (a 134% and 411% increase in hospitalization and emergency room visit rates, respectively compared to those passing), but no difference in appointment no shows. Conclusions Standardized cognitive screening in older adults has the potential to not only diagnosis dementia at its earliest stages, but also to identify at-risk individuals with higher healthcare utilization. The next step is to examine post-screen data for any changes in chronic disease management or healthcare utilization.

Localizing the Muse

The functional anatomy that underlies the creativity of a Salvador Dali or an Andy Warhol painting has remained a neurologic mystery. Seeley and colleagues present the case of Anne Adams, who experienced a gain in creative function in the setting of a nonfluent progressive aphasia. A lifelong scientist, Adams developed a late affinity for painting some 10 years before the diagnosis of her illness. Her creative …