Functional Neuroimaging in Dementia

Dementia refers to a clinical syndrome of cognitive deterioration and difficulty in the performance of activities of daily living. The most common cause of dementia is Alzheimer’s disease (AD), followed by vascular dementia (VaD) at old age and frontotemporal dementia (FTD) at young onset. Most dementia subtypes show a gradual decline in clinical and cognitive symptomatology, which enables us to identify subjects in a prodromal stage of dementia, referred to as mild cognitive impairment (MCI). As functional neuroimaging techniques provide a means to investigate (early) alterations in brain functioning, these techniques can aid research regarding dementia subtypes and prodromal dementia stages. The focus of this thesis was twofold. In a first chapter I studied the effects of cerebral small vessel disease (CSVD) on brain functioning and structural connectivity in MCI using functional MRI and diffusion tensor imaging. CSVD is a fairly common condition in elderly, which affects the small vessels of the brain supplying the white matter and deeper grey matter regions, visible on MRI as white matter hyperintensities and lacunar infarcts. CSVD contributes to cognitive and clinical symptoms in MCI, but the underlying mechanisms are unclear. The presence of CSVD was found to have a large effect on microstructural white matter integrity throughout the brain. Important fiber tracts for brain network functioning were found to be affected mainly by CSVD in MCI, while the presence of atrophy caused by neurodegenerative conditions did not have a large effect. We found that the presence and extent of CSVD in MCI was furthermore related to decreased medial temporal lobe activation, a brain region important for memory functioning, and decreased deactivation within a region known to be highly involved in the default mode network. These multimodal neuroimaging findings suggest that CSVD affects the microstructure of the white matter, as well as neural functioning during cognitive performance. We postulate that the mechanism through which CSVD affects cognition, or contributes to cognitive deterioration in MCI is neural network interference, as a consequence of damaging the interconnecting fiber tracts. A second focus of this thesis was investigating brain functioning in FTD, AD and progressive supranuclear palsy, using single-photon emission computed tomography (SPECT). Early discrimination between these neurodegenerative conditions during life is hampered by the fact that clinical and cognitive symptomatology can overlap. The use of quantitative analysis of perfusion SPECT neuroimaging may aid addressing these issues. We identified the functional substrate of episodic memory fa

Qualitative Assessment of Verbal Fluency Performance in Frontotemporal Dementia

Background/Aims: Verbal fluency is impaired in patients with frontotemporal dementia (FTD) and primary progressive aphasia (PPA). This study explored qualitative differences in verbal fluency (clustering of words, switching between strategies) between FTD and PPA variants. Methods: Twenty-nine patients with behavioral variant FTD (bvFTD) and 50 with PPA (13 nonfluent/agrammatic, 14 semantic, and 23 logopenic) performed a semantic and letter fluency task. Clustering (number of multiword strings) and switching (number of transitions between clustered and nonclustered words) were recorded by two independent raters. Between-group differences, associations with memory, language, and executive functioning, and longitudinal change (subsample) in clustering and switching were examined. Results: Interrater reliability was high (median 0.98). PPA patients generated (a) smaller (number of) clusters on semantic and letter fluency than bvFTD patients (p < 0.05). Semantic variant patients used more switches than nonfluent/agrammatic or logopenic variant patients (p < 0.05). Clustering in semantic fluency was significantly associated with memory and language (range standardized regression coefficients 0.24-0.38). Switching in letter fluency was associated with executive functioning (0.32-0.35). Conclusion: Clustering and switching in verbal fluency differed between patients with subtypes of FTD and PPA. Qualitative aspects of verbal fluency provide additional information on verbal ability and executive control which can be used for clinically diagnostic purposes

Trajectories and Determinants of Quality of Life in Dementia with Lewy Bodies and Alzheimer's Disease

Background: Quality of Life (QoL) is an important outcome measure in dementia, particularly in the context of interventions. Research investigating longitudinal QoL in dementia with Lewy bodies (DLB) is currently lacking. Objective: To investigate determinants and trajectories of QoL in DLB compared to Alzheimer’s disease (AD) and controls. Methods: QoL was assessed annually in 138 individuals, using the EQ5D-utility-score (0–100) and the health-related Visual Analogue Scale (VAS, 0–100). Twenty-nine DLB patients (age 69 ± 6), 68 AD patients (age 70 ± 6), and 41 controls (age 70 ± 5) were selected from the Dutch Parelsnoer Institute-Neurodegenerative diseases and Amsterdam Dementia Cohort. We examined clinical work-up over time as determinants of QoL, including cognitive tests, neuropsychiatric inventory, Geriatric Depression Scale (GDS), and disability assessment of dementia (DAD). Results: Mixed models showed lower baseline VAS-scores in DLB compared to AD and controls (AD: ±SE = -7.6 ± 2.8, controls: ±SE = -7.9 ± 3.0, p < 0.05). An interaction between diagnosis and time since diagnosis indicated steeper decline on VAS-scores for AD patients compared to DLB patients (±SE = 2.9 ± 1.5, p < 0.1). EQ5D-utility-scores over time did not differ between groups. Higher GDS and lower DAD-scores were independently associated with lower QoL in dementia patients (GDS: VAS ±SE = -1.8 ± 0.3, EQ5D-utility ±SE = -3.7 ± 0.4; DAD: VAS = 0.1 ± 0.0, EQ5D-utility ±SE = 0.1 ± 0.1, p < 0.05). No associations between cognitive tests and QoL remained in the multivariate model. Conclusion: QoL is lower in DLB, while in AD QoL shows steepe

Correction to: Cognitive profiles discriminate between genetic variants of behavioral frontotemporal dementia

The original version of this article unfortunately contained a mistake. The presentation of Table 1 was incorrect. The original article has been corrected. The corrected Table 1 is given below. (Table presented.)

The effect of hippocampal function, volume and connectivity on posterior cingulate cortex functioning during episodic memory fMRI in mild cognitive impairment

Objectives: Diminished function of the posterior cingulate cortex (PCC) is a typical finding in early Alzheimer’s disease (AD). It is hypothesized that in early stage AD, PCC functioning relates to or reflects hippocampal dysfunction or atrophy. The aim of this study was to examine the relationship between hippocampus function, volume and structural connectivity, and PCC activation during an episodic memory task-related fMRI study in mild cognitive impairment (MCI). Method: MCI patients (n = 27) underwent episodic memory task-related fMRI, 3D-T1w MRI, 2D T2-FLAIR MRI and diffusion tensor imaging. Stepwise linear regression analysis was performed to examine the relationship between PCC activation and hippocampal activation, hippocampal volume and diffusion measures within the cingulum along the hippocampus. Results: We found a significant relationship between PCC and hippocampus activation during successful episodic memory encoding and correct recognition in MCI patients. We found no relationship between the PCC and structural hippocampal predictors. Conclusions: Our results indicate a relationship between PCC and hippocampus activation during episodic memory engagement in MCI. This may suggest that during episodic memory, functional network deterioration is the most important predictor of PCC functioning in MCI. Key Points: • PCC functioning during episodic memory relates to hippocampal functioning in MCI. • PCC functioning during episodic memory does not relate to hippocampal structure in MCI. • Functional network changes are an important predictor of PCC functioning in MCI

Correction to: Cognitive profiles discriminate between genetic variants of behavioral frontotemporal dementia

The original version of this article unfortunately contained a mistake. The presentation of Table 1 was incorrect. The original article has been corrected. The corrected Table 1 is given below. (Table presented.)

Cognitive profiles discriminate between genetic variants of behavioral frontotemporal dementia

Introduction: Trials to test disease-modifying treatments for frontotemporal dementia are eagerly awaited and sensitive instruments to assess potential treatment effects are increasingly urgent, yet lacking thus far. We aimed to identify gene-specific instruments assessing clinical onset and disease progression by comparing cognitive functioning between bvFTD patients across genetic mutations. Methods: We examined differences in 7 cognitive domains between bvFTD patients with GRN (n = 20), MAPT (n = 29) or C9orf72 (n = 31) mutations, and non-carriers (n = 24), and describe

Longitudinal cognitive biomarkers predicting symptom onset in presymptomatic frontotemporal dementia

Introduction: We performed 4-year follow-up neuropsychological assessment to investigate cognitive decline and the prognostic abilities from presymptomatic to symptomatic familial frontotemporal dementia (FTD). Methods: Presymptomatic MAPT (n = 15) and GRN mutation carriers (n = 31), and healthy controls (n = 39) underwent neuropsychological assessment every 2 years. Eight mutation carriers (5 MAPT, 3 GRN) became symptomatic. We investigated cognitive decline with multilevel regression modeling; the prognostic performance was assessed with ROC analyses and stepwise logistic regression. Results: MAPT converters declined on language, attention, executive function, social cognition, and memory, and GRN converters declined on attention and executive function (p < 0.05). Cognitive decline in ScreeLing phonology (p = 0.046) and letter fluency (p = 0.046) were predictive for conversion to non-fluent variant PPA, and decline on categorical fluency (p = 0.025) for an underlying MAPT mutation. Discussion: Using longitudinal neuropsychological assessment, we detected a mutation-specific pattern of cognitive decline, potentially suggesting prognostic value of neuropsychological trajectories in conversion to symptomatic FTD

Gray and white matter changes in presymptomatic genetic frontotemporal dementia: a longitudinal MRI study

In genetic frontotemporal dementia, cross-sectional studies have identified profiles of presymptomatic neuroanatomical loss for C9orf72 repeat expansion, MAPT, and GRN mutations. In th

Assessment of Visual Association Memory in Low-Educated, Non-Western Immigrants with the Modified Visual Association Test

Background: Neuropsychological tests are influenced by culture, language, level of education, and literacy, but there are few cognitive tests of which the applicability in ethnic minority populations has been studied. Objectives: The aim of this study was to assess the reliability and validity of the Visual Association Test (VAT), a test of visual association memory, in a non-Western, low-educated memory clinic population. Additionally, a modified version of the VAT using colored photographs instead of line drawings was studied (mVAT). Method: Both the original VAT and the mVAT were administered to non-Western immigrants (n = 73) from 2 multicultural memory clinics in Rotterdam, The Netherlands, and a control sample of non-demented Turkish elderly (n = 14) with low education levels (32 and 29% illiterate, respectively). Results: Both the VAT and the mVAT were able to discriminate persons with and without dementia (area under the curve: VAT, 0.77-0.88; mVAT, 0.85-0.95). The mVAT had more homogeneous item difficulty levels than the VAT. Administration of parallel versions of the VAT and the mVAT within the same person revealed higher scores on the mVAT (Z = -3.35, p = 0.001). Conclusions: The mVAT is a reliable and valid measure of memory in non-Western immigrants. Clinicians and researchers should be aware that the memory performance of immigrants may be systematically underestimated when using tests with black-and-white line drawings, such as the original VAT