Age at onset and pattern of neuropsychological impairment in mild early-stage Alzheimer disease. A study of a community-based population.

OBJECTIVES: To examine the effects of age at onset on neuropsychological functioning in a group of patients with probable Alzheimer disease (AD) and, within this group, to scrutinize further those patients with mild early-onset disease as it was hypothesized that within this group specific patterns of cognitive impairment could be identified that correlated with neuropathological staging of the disease. DESIGN: Each patient underwent an extensive neuropsychological test battery to examine a wide range of cognitive processes to provide information to identify subtypes of dementia. SETTING: The Memory Clinic in the Department of Geriatric Medicine, Concord Hospital, Concord, New South Wales, Australia. PATIENTS: One hundred forty-five community-residing case patients with probable AD were studied; within this group, 51 case patients with mild AD and a Mini-Mental State Examination score greater than 19 were further examined; 36 similarly aged control patients who were part of a larger case-control study of AD in an urban population were also examined. A diagnosis of probable and possible AD was made if the case patient had evidence of memory impairment and met criteria according to the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association. OUTCOME MEASURES: Individual neuropsychological test scores were compared. The tests were then grouped into 7 cognitive domains. Patterns of early cognitive impairment were derived from these comparisons. RESULTS: With an earlier age at onset, significantly more impairment on tests of digit span and praxis was seen, while the duration of disease had no independent effect once the age at onset was fixed. Patients with mild early-onset dementia and a Mini-Mental State Examination score greater than 19 showed significant impairment in tests of attention, memory, frontal/executive functions, visuospatial ability, praxis, and visual agnosia compared with that shown by control patients. In this group, further analyses revealed that impairment in memory and frontal/ executive functions were the earliest signs of cognitive impairment. CONCLUSIONS: These data showed that when the duration of disease was adjusted for, case patients with an earlier age at onset of AD demonstrated significantly more impairment on tests of attention span and working memory (digit span), graphomotor function (copy loops), and apraxia than those with an older age at onset. Our findings support the view that the hippocampus and its connections are affected in the early stages of AD. The deficits in the frontal/executive functions also suggest that a disruption of cortical pathways to the frontal lobes and the pathological changes in this region occur early in the disease.

Are malnutrition and stress risk factors for accelerated cognitive decline? A prisoner of war study.

We set out to test the hypothesis that severe malnutrition and stress experienced by prisoners of war (POWs) are associated with cognitive deficits later in life. We assessed 101 former Australian POWs of the Japanese and 108 veteran control subjects using a battery of neuropsychological tests, a depression scale, a clinical examination for dementia, and CT. We divided the POWs into high weight loss (>35%) and low weight loss groups (<35%). We found no significant differences in cognitive performance between the POWs and control subjects or between high and low weight loss groups on any of the tests or in the prevalence of dementia. Scores on the depression scale showed that the former POWs had more depressive symptoms than the control subjects a decade previous, but the difference had diminished over time. This study does not support the hypothesis that malnutrition is a risk factor for accelerated cognitive decline nor the theory that severe stress can lead to hippocampal neuronal loss and cognitive deficits. Cognitive deficits in earlier studies of former POWs may have been associated with concurrent depression.

Is experience as a prisoner of war a risk factor for accelerated age-related illness and disability?

OBJECTIVE: To determine whether the experience of internment as a Prisoner of War (POW) during World War II was associated with a higher prevalence of chronic disease and diminished functional performance in later life. DESIGN: A retrospective and prospective cohort design. SETTING: Concord Repatriation General Hospital, Sydney, Australia. PARTICIPANTS: A random sample of 101 Australian, male, ex-prisoners of the Japanese and a comparison group of 107 non-POW combatants from the same theatre of war. MEASUREMENTS: Outcome variables were self-perceived health status, hospital admissions and length of stay, number of prescription medications used, number of somatic symptoms reported, number and types of medical diagnoses, a neurology of aging clinical examination, and the Instrumental Activities of Daily Living (IADL) and Physical Self Maintenance Scales (PSMS). RESULTS: Prisoners of War reported more somatic symptoms (mean 7.2 vs 5.4, P = .002) than non-POWs, had more diagnoses (mean 9.4 vs 7.7 P < .001), and used a greater number of different medications (mean 4.5 vs 3.4, P = .001). There were no differences in hospital admissions or length of stay. Among 15 broad categories of diagnosis, differences were confined to gastrointestinal disorders (POWs 63% vs non-POWs 49%, P = .032), musculoskeletal disorders (POWs 76% vs non-POWs 60%, P = .011), and cognitive disorders (excluding head injury, dementia, and stroke) (POWs 31% vs non-POWs 15%, P = .006). Of the 36 signs in the neurology of aging examination, POWs had a significantly higher proportion of seven extrapyramidal signs and six signs relating to ataxia. POWs were more likely to be impaired on the IADL scale than were non-POWs (33% vs 17%, P = .012) but not significantly more likely to be impaired on the PSMS. CONCLUSIONS: There were few differences between POWs and controls, and those differences were relatively small. Our findings do not support a major role for a catastrophic life stress in the development of chronic illness and disability in later life. However it is possible that the POW experience played a part in premature, abnormal, or unsuccessful aging in some individuals.

Alcohol consumption and cognitive performance in a random sample of Australian soldiers who served in the Second World War.

OBJECTIVE: To examine the association between the average daily alcohol intake of older men in 1982 and cognitive performance and brain atrophy nine years later. SUBJECTS: Random sample of 209 Australian men living in the community who were veterans of the second world war. Their mean age in 1982 was 64.3 years. MAIN OUTCOME MEASURES: 18 standard neuropsychological tests measuring a range of intellectual functions. Cortical, sylvian, and vermian atrophy on computed tomography. RESULTS: Compared with Australian men of the same age in previous studies these men had sustained a high rate of alcohol consumption into old age. However, there was no significant correlation, linear or non-linear, between alcohol consumption in 1982 and results in any of the neuropsychological tests in 1991; neither was alcohol consumption associated with brain atrophy on computed tomography. CONCLUSION: No evidence was found that apparently persistent lifelong consumption of alcohol was related to the cognitive functioning of these men in old age.

Declining prevalence of psychiatric disorder in older former prisoners of war.

The aim of this study was to examine change in the prevalence of psychiatric disorders over a decade late in the lives of ex-prisoners of war (POWs) and nonprisoner veterans of World War II. In 1982-83 we drew a random sample of POWs and non-POWs living in Sydney, Australia. They were interviewed by a psychiatrist at that time and again 9 years later. They also completed self-rating anxiety and depression scales. Anxiety disorders were the most prevalent and declined by half from 32.7% at the first interview to 16.8% 9 years later (p < .001) whereas the prevalence of depressive disorders fell by two-thirds from 26.9% to 8.7% (p < .001). In POWs the prevalence of both anxiety and depression declined more markedly than in non-POWs. Consistent changes also occurred in scores on the self-rating anxiety and depression scales. The psychological impact of these POWs' tragic wartime experience had at last begun to dim after nearly 50 years.

Prisoner of war experience: effects on wives.

The aim of this study was to compare the wives of Australian soldiers who had been imprisoned during World War II (POWs) with a control group of non-POWs' wives and also to compare the POWs and non-POWs themselves in respect to several psychological and family life characteristics on which differences might be expected to arise from the long-term effects of imprisonment. A random sample of 145 of these veterans and their wives completed several self-administered mood and family life scales, an inventory of somatic symptoms, questions about the impact of the war on the veteran in the postwar decades, and several social background questions. The POWs themselves were more depressed and reported more somatic symptoms and a greater postwar impact of the war than the non-POWs. However, these differences were not accompanied by concomitant differences among their wives. There was some evidence of an influence of the POW's mood on his wife's mood in significant correlations between husbands' and wives' depression and anxiety scale scores in POW couples alone. Otherwise, there was very little indication that the POW experience had any long-term effect on the marriage relationship as measured by the variables included in this study.