Ronald F. Zec

The effects of estrogen replacement therapy on neuropsychological functioning in postmenopausal women with and without dementia: a critical and theoretical review.

We review 42 studies examining the effects of estrogen replacement therapy (ERT) on memory and cognition in nondemented postmenopausal women. Although there are an appreciable number of nonsignificant findings, the number of significant findings favoring ERT users considerably outnumbers the rare findings of better performance in controls. Experimental studies demonstrate a consistent beneficial effect on verbal memory, but these are short-term studies of the more acute effects of ERT. The observational studies suggest that there may be a long-lasting effect of continued ERT on cognitive functioning, but these studies need to be interpreted with caution because of the lack of random assignment and a possible “healthy user bias.” We also summarize findings from studies on the effects of ERT on Alzheimers disease (AD). ERT is associated with a decreased risk for dementia, but there is little evidence for a positive effect on cognition in women with AD. Definitive answers to questions about the long-term effects of ERT on cognitive aging and risk of developing AD should be provided by 3 ongoing clinical trials.

A Cross-Sectional Study of the Effects of Age, Education, and Gender on the Boston Naming Test

The effects of age, education, and gender on visual confrontation naming using the 60-item Boston Naming Test (BNT) were studied in 1111 “normal” elderly (ages 50–101) and 61 younger adults (ages 20–49). Significantly poorer mean BNT scores and increasing variability (measured in standard deviations) were found with successively older age groups and with lower educational levels even after stratification on the demographic variables. There was a non-significant trend for males to score slightly higher than females. Age declines on the BNT were considerably greater for this cross-sectional data than for the longitudinal data we previously reported.

The neuropsychology of aging.

There are three general categories of causes of the cognitive decline associated with aging: disuse, disease, and aging per se. People tend to use certain skills or abilities less with age and, thus, those skills decline due to the disuse. Physical illnesses tend to increase with age, which will tend to compromise cognitive functioning. Further, there are actual neurobiological changes with age that will contribute to deterioration of cognitive abilities. Variability of performance between different individuals within an age group increases with age due to each of these three major contributing factors to age decline. The best defense against age-related cognitive deterioration is practice. Practice tends to mitigate the effects of aging by not allowing disuse to occur. In addition, practice can overcompensate for age effects by building a larger reserve capacity to offset any real neurobiological effects of age. Practice can also lead to compensatory strategies in which alternative way of maintaining performance levels are found.

A Comparison of Phonemic, Semantic, and Alternating Word Fluency in Parkinson's Disease

Abstract Word fluency in 45 medicated non-demented Parkinson’s disease (PD) patients and 45 normal control subjects was studied with a Phonemic Word Fluency (PWF) task using the letters F, A, and S, a Semantic Word Fluency (SWF) task using the categories animals, boys’ names, and states, and an Alternating Word Fluency (AWF) task requiring the person to alternate between colors and occupations, animals and states, and words beginning with C and P. The number of words generated did not differ for trials with F, A, S, or states, but PD patients generated significantly fewer animal names and boys’ names. PD patients also generated significantly fewer words on each of the three AWF trials. The PD patients scored 21% lower than the normal control group on the total AWF score, but only 10% lower for the PWF and SWF scores. The greater impairment on the AWF task which requires the use of internal attentional control to rapidly shift mental set can be considered a type of executive functioning deficit. This is consistent with the growing literature suggesting frontal systems dysfunction in PD and with the view that dopaminergic treatment only incompletely restores functioning in the frontostriatal system.

Normative Data Stratified for Age, Education, and Gender on the Boston Naming Test

Stratified normative data for age, education, and gender are provided for the 60-item Boston Naming Test (BNT) on 1026 older participants ages 50–95 years using overlapping age ranges. Tables are presented that convert BNT raw scores to scaled scores and percentiles. Mild dementia cases were eliminated using a comprehensive cognitive battery. In a companion paper we found significantly poorer mean BNT scores and increasing variability with successively older age groups and decreasing educational levels indicating the need for demographically stratified normative data when determining an individuals degree of impairment. These norms should be clinically useful when assessing suspected dementia cases.

Neuropsychology of schizophrenia according to Kraepelin: Disorders of volition and executive functioning

Emil Kraepelin was the first to identify schizophrenia as a distinct disease in 1896. The purpose of this paper is to rediscover and reexamine the neuropsychology of schizophrenia according to Kraepelin. Kraepelin thought that the “dementia” of dementia praecox was primarily a disorder of volition, rather than one of intellect. “Volition” or “will” referred to the ability to make conscious decisions and to carry them out. By quoting relevant passages in his classic textbook,Dementia Praecox and Paraphrenia, the case is made that Kraepelins detailed description of volitional deficits in patients with dementia praecox clearly documents impairments in executive functioning in schizophrenic patients during the preneuroleptic era. To a large extent, these deficits may be responsible for the “dementia” of dementia praecox and the “chronicity” of chronic schizophrenia. If this hypothesis is correct, the long-range prognosis of patients with schizophrenia may be considerably improved by treatment programs designed to facilitate executive functioning.

Electrocortical mapping, MRI, and neuropsychological measures: Evidence of Alzheimer's disease in the presence of vascular lesions

We report here a case study of a 76-year-old woman with a high school education, whose presenting psychiatric symptomatology indicated dementia of unknown etiology. Neuropsychological test results were consistent with AD, but diagnosis was complicated by an MRI showing a large right hemisphere cortical infarct and scattered subcortical changes leading to a diagnosis of possible AD. Electrocortical mapping showed the right hemisphere infarct, and gave independent evidence suggestive of AD in the relatively intact left hemisphere. This case demonstrates the utility of multidimensional assessment as an aid to differential diagnosis.

Psychometric Strengths and Weaknesses of the Alzheimer Disease Assessment Scale in Clinical Testing: Recommendations for Improvements

The Alzheimer Disease Assessment Scale (ADAS) is a brief screening test that measures a variety of cognitive functions that are typically impaired in patients with Alzheimer dementia (AD) and provides an index of overall severity of dementia. The ADAS is sensitive to the progressive decline in functioning over time in patients with dementia of the Alzheimer type (DAT) (Rosen et al., 1984) and is being used with increasing frequency as an efficacy measure in drug therapy studies.

The Executive Board System

Traumatic brain injuries often result in frontal lobe damage, in addition to diffuse damage, from the impact of the frontal lobes against the protruding frontal bones (Levin, Benton, & Grossman, 1982). Frontal lobe damage produces behavioral, emotional, and cognitive problems, especially impaired executive functioning (Lezak, 1983; Sohlberg & Mateer, 1989). Memory and attentional deficits are also very common long-term sequelae after traumatic brain injuries due to diffuse brain damage that affects both the medial temporal lobe structures and the brain stem. Although impairments in executive functions (e.g., planning, self-monitoring, self-correction) largely determine the extent of psychosocial and vocational recovery following head injury, rehabilitation efforts have been minimal (Sohlberg & Mateer, 1989).

P-138: An autopsy-confirmed case study of the conversion from normal cognition to amnestic MCI to AD

Background: The conversion from Mild Cognitive Impairment (MCI) to dementia has received considerable research attention, whereas the transition from normal cognition to MCI and dementia in an autopsy-confirmed case of Alzheimer disease (AD) has not been studied in detail. Objective: We studied the conversion from normal memory and cognition to MCI of the amnestic type to early dementia with annual assessments over 10 years using a comprehensive neuropsychological test battery in a neuropathologically-confirmed case of AD. Methods: The woman was 74 years old at the first evaluation and was 84 years old at the time of her last assessment. She was a retired high school teacher with 18 years of education. An annual half-day cognitive assessment was administered to the patient including tests of mental status, attention, new learning and memory, language, visuospatial functioning, and problem solving ability. Results: The patient scored well within normal limits on all memory and cognitive test measures using age norms at her first evaluation (age 74). A gradual progressive decline over ten years on measures of new declarative learning and memory, especially on word-list learning tests, was found resulting in severe memory impairment at age 78. Only later did measurable decline on the non-memory cognitive measures emerge. Neuropathological findings at autopsy revealed Alzheimer-type changes that indicated a high likelihood, by NIA-Reagan criteria, that the dementia was due to Alzheimer disease. There was moderate CERAD plaque grade and Braak and Braak tangle stage V. There was a heavy NFT and NP burden in the hippocampus, entorhinal cortex, perirhinal cortex, and amygdala, a moderate number in the inferior temporal gyrus with less Alzheimer pathology burden in the frontal, parietal, and occipital cortices and the superior temporal gyrus. Conclusions: Progressive memory decline in an autopsy-confirmed case of AD occurred gradually over 7-8 years before there is detectable nonmemory cognitive deficits emerged on a comprehensive neuropsychological battery of tests. This case is likely representative of many, but not all, cases of AD.