Fluctuating cognition in Dementia.pptx

1. Fluctuating Cognition In
Dementia

2. Cognitive fluctuations (CF) are defined
as spontaneous alterations in cognition,
attention and arousal.
Fluctuating cognition is a complex and
disabling symptom

3. Alzheimer dementia
◦20% of people with
Alzheimer dementia
(AD) (Kolbeinsson
and Jonsson, 1993,
Robertson et al.,
1998, Escand onet al.,
2010),

4. Vascular Dementia
35–50% of people
with vascular
dementia (VaD)
(Hachinski et al.,
1975,
Romanet al.,
1993)

5. Dementia in Parkinson's
◦29% of people with
Dementia in
Parkinson’s
◦(Ballard et al., 2002).

6. Dementia With Lewy Bodies
around 90% in
people diagnosed
with dementia with
Lewy bodies (DLB
(Byrne et al.,
1989,McKeith et al.,
2005).

7. Objectives: To examine the frequency, characteristics, and diagnostic utility of FC in dementia
using clinical, attentional, and EEG markers.
Method: A total of 155 subjects (61 with AD, 37 with DLB, 22 with vascular dementia[VaD], 35
elderly controls) received
◦ clinical evaluation for FC using a semi quantified measure applied by experienced
clinicians and
◦ 90-second cognitive choice reaction time (CRT) and vigilance reaction time (VIGRT)
trials.
◦ Forty subjects also received an evaluation of mean EEG frequency across 90
seconds.

8. Results showed
Patients with DLB had a greater prevalence and severity of FC than did patients with AD or VaD
rated using clinical, attentional, and EEG measures.
The 90-second cognitive and EEG trials demonstrated that FC occurs on a second-to-second
basis in patients with DLB.
Patients with VaD had a higher prevalence of FC than did those with AD, although the profile of FC
was different from that expressed by DLB cases.

18. Assessment Of Cognitive
Fluctuation In Dementia

19. Results: We identified only three psychometric measures, which have
been developed for the identification
and assessment of CF, and these have not been adequately tested as
yet for reliability and validity

20. The Mayo Fluctuations Composite Scale
Title/Authors/Journal Details of measurement Psychometric properties Assessment of
quality/utility
The Mayo Fluctuations
Composite Scale
(MFCS)
Ferman et al. (2004)
Neurology
62, 181 – 187.
A 19 item informant-
rated
questionnaire, mostly
with
dichotomous answer
frame
(n = 16 items) but also
with
three four-option
questions
exploring attention,
somnolence, daytime
sleep
and communication
Acceptable test–retest
reliability;
Positive predictive value
of 83% in
differentiating DLB from
AD. This
provided a calculated
sensitivity of
63% and specificity of
88% in
distinguishing DLB from
AD using a
cut-off score ≥3.
Moderate to high
quality of
predictive value of
four items** out of
the 19-item
questionnaire.

21. The four items identified in the MCFS by Ferman et al. (2004)
namely
(1) Drowsiness or lethargy all the time or several times a day;
(2) daytime sleep of 2 or more h (before 7 pm);
(3) staring into space for long periods; and
(4) times when the patient’s flow of ideas

22. The Clinician Assessment of Fluctuation
Title/Authors/Jou
rnal
Details of measurement Psychometric properties Assessment of
quality/utility
The Clinician
Assessment of
Fluctuation(CAF)
Walker et al.
(2000b).Br J
Psychiatry,
177,252 – 256.
A brief two-item, clinician
administered, informant
rated scale with
questions regarding
frequency and duration
of CF. Qualitative innature
exploring two domains:
frequency and duration
of fluctuations.
Good sensitivity (81%) and
specificity (92%) at distinguishing
DLB versus AD.
Sensitivity (81%)
and specificity (82%)DLB versus
VaD.
Sensitivity (64%) and
specificity (77%)VaD versuss AD.
Moderate quality,
although clinically
difficult to use as
responses are
highly subjective in nature
and no
clearly defined scoring
frame on
which to base clinical
diagnoses.

23. The Clinician Assessment of Fluctuation

25. The One Day Fluctuation Assessment Scale
Title/Authors/Journal Details of measurement Psychometric properties Assessment of
quality/utility
The One Day
Fluctuation
Assessment Scale
(ODFAS)
Walker et al. (2000b).
Br J Psychiatry, 177,
252 – 256.
A brief seven-item clinician
rated scale of fluctuating
cognition based on the
previous day, exploring:
fluctuation, drowsiness, falls,
attention, communication,
disorganised thinking, and
levels of consciousness.
sensitivity
(93%) and specificity (87%)
at distinguishing DLB from
AD and controls.
A 90% agreement rate
with the CAF was also
reported.
Moderate to high quality

28. Care givers of 13 patients with early probable DLB and 12 patients with early
probable AD
• Clinical Dementia Rating scale and Mini Mental Status Examination
• Unified Parkinson’s Disease Rating Scale (UPDRS22)—motor
examination,
• Brief Psychiatric Rating Scale (BPRS23), and
• Hospital Anxiety and Depression Scale (HADS
• Clinician Assessment of Fluctuation and the One Day Fluctuation
Assessment Scale,
• Descriptions of fluctuating cognition were recorded verbatim, analysed,
and rated.

29. In addition to the standard assessment of the presence, frequency and severity of FC on each of the
scales, care giver descriptions of FC were also recorded verbatim to document qualitative
characteristics of FC in each patient group.
Both items of the Clinician Assessment of Fluctuation, and question two of the One Day Fluctuation
Assessment Scale
 ‘‘Does the patient ever have spontaneous impaired alertness and concentration,—that is appear
drowsy but awake, look dazed, not be aware of what is going on around?’’
‘‘Has the level of confusion experienced by the patient tended to vary a lot recently from day to day
or week to week?’
‘‘Has the patient had a period (or periods) today when he or she seemed to be confused and
muddled and then a period (or periods) when he or she seemed to be improved and functioning
better? Give examples of the worst and best period of function.’’

30. Results

31. QUANTITATIVE ASSESSMENT OF FC IN DLB AND AD
Clinician Assessment of
Fluctuation Scale
• clinically significant FC (score>5)
• 77% of patients with DLB
• none of the patients with AD
• group difference in terms of
standard quantitative scores was
significant, t (23)=5.04, p,0.01

32. Qualitative characterization of FC in DLB and AD
Clinician Assessment of Fluctuation Scale
DLB care givers described
Lapse in the stream of awareness or attention (‘‘he detaches, he’s off with the pixies’’; ‘‘she has
temporary lapses and can’t focus properly’’).
Descriptions of blank staring during which the patient appeared to disengage from the ongoing flow of
activity or conversation,
-whereas AD care givers did not describe this
phenomenon.
Rather, AD care givers described
Periods of ‘‘confusion’’ characterised, for example, by repetitiveness in conversation or forgetfulness in
relation to a recent event or a plan of action.
In general, descriptions of FC in the AD group often related to task or situational demands ‘‘he gets
confused when he is under pressure, like when he lost his bank book and got really muddled’’).
 ‘‘Does the patient ever have spontaneous impaired alertness and concentration,—that is
appear drowsy but awake, look dazed, not be aware of what is going on around?’’
‘‘Has the level of confusion experienced by the patient tended to vary a lot recently from day to
day or week to week?’

33. FC in the DLB group appeared to be unrelated to demands on
memory function, and occurred spontaneously in the absence of a
situational explanation.
Patients lost the ability to engage in meaningful cognitive or physical activity
(‘‘he kind of drifts off and doesn’t concentrate or respond’’; ‘‘he seems vague, he looks
around and doesn’t know what he is doing’’).
Episodic confusion in DLB often took on a confabulatory or fleeting delusional quality
(‘‘one day she is telling me she has been to New York, the next day she is lucid’’; ‘‘some
days she thinks there are extra people staying for dinner’’).
Relatively short lived alterations in cognitive and functional abilities were also used to
describe FC by the DLB care givers
◦ (‘‘he’s spasmodic’’, ‘‘most days he’s in and out’’, ‘‘she has temporary lapses’’)

34. In the AD group it was more often the case that
Actions or thoughts were deflected onto another task or
question as a result of memory failure
◦ (‘‘she forgets what she was going to do, then starts something else’’).
When episodes of ‘‘confusion’’ occurred in AD, care
givers provided typical examples of forgetting
◦ (‘‘he will ask the same question 10 times in an hour’’).
more persisting, enduring quality to the ‘fluctuations’,
often in the form of ‘‘good days’’ and ‘‘bad days’’.

35. One Day Fluctuation Assessment Scale (77%) of DLB and 67% of AD caregivers responded ‘‘yes’’
to this item. Examples given echoed the qualitative
differences described above.

36. Take away points
FC in DLB
◦ an interruption in the flow of awareness or attention.
◦ frequently associated with transient episodes of confusion and an inability to
engage in meaningful cognitive activity, followed by reversion to a near normal
level of function.
◦ These episodes occurred spontaneously, in the absence of a situational
explanation, suggesting that they were internally driven.
Fluctuations in AD
◦ diminished capacity to cope with the cognitive demands of the immediate
environment
◦ ‘‘fluctuation’’ is elicited by situations in which an underlying cognitive impairment
manifests itself, typically as repetitiveness in conversation, forgetfulness in
relation to a recent task or event, or other behavioural consequences of poor
memory.
FC in DLB was often transient, while FC by AD a more enduring state shift (good
days/bad days,somnolent/alert).

37. Measurement of
fluctuation in cognition

39. Dementia cognitive fluctuation scale
Description Utility Limitations
Dementia cognitive
fluctuation scale
(DCFS) Lee et al.
(2014)
Informant-based 17-
item test across four
domains (confusion,
sleep, daytime
alertness,
communication) derived
from above
scales. Each item
scored to a 5-point
scale.
Discriminative items
between dementia
subtypes consistent
with MFCS.
Reasonable
discrimination between
dementias
of these items
(sensitivity =
79–80%, specificity =
74–79%). Good
test-retest and inter-
rater reliability.
Lengthy to administer.
Captures various
clinical features of DLB
and so similar
to MFCS,
discriminability may not
relate
to nature of fluctuations
themselves.