Adherence to continuous positive airway pressure treatment in a cohort of elderly adults with newly diagnosed obstructive sleep apnea.

PURPOSE: To evaluate adherence to continuous positive airway pressure (CPAP) treatment in elderly patients newly diagnosed with obstructive sleep apnea syndrome (OSAS). METHODS: Consecutive patients ≥ 70 years attending one of the participating centers, requiring CPAP treatment and agreeing to participate, were included. Mean hours of CPAP during the first 5 months of treatment defined adherence as CPAP ≥ 4 h/day on 70% of nights over a 30-day period. RESULTS: From January 2014 to April 2019, 262 patients aged between 76.7 and 87.7 years (mean age, 82.6 years) were included and fully evaluated; 224 (85.5%) were adherent. Mean adherence time was 6.9 h in adherent patients, vs 2 h in non-adherent patients (p < 0.0001). Compared to non-adherent patients, adherent patients tended to have higher baseline AHI without reaching statistical significance (44.7 vs 39.5, p = 0.0913). They less frequently presented with dementia (3.7% vs 21.6%, p < 0.0001). The somnolence (ODSI and Epworth), nocturia, and depression (QD2A) scores of adherent patients improved significantly from baseline to the fifth month: ODSI decreased from 7 to 3.7 (p < 0.0001), Epworth from 8.7 to 6.2 (p < 0.0001), nocturia from 6.6 to 4.1 (p = 0.0015), and QD2A from 3.7 to 3 (p = 0.0025). Many more patients in the non-adherent group used nasal plugs than in the adherent group (14.7% vs 2.1%, p = 0.0006). CONCLUSION: The present real-world study showed the ability of newly diagnosed elderly adults (including the very old) to adhere to CPAP therapy and the benefit of 5 months' well-conducted CPAP treatment. REGISTRATION NUMBER: Not applicable.

Observation and Interview-based Diurnal Sleepiness Inventory for measurement of sleepiness in patients referred for narcolepsy or idiopathic hypersomnia.

STUDY OBJECTIVES: First, to determine whether the 3-item Observation and Interview-based Diurnal Sleepiness Inventory (ODSI) measures the degree of excessive daytime sleepiness in patients with suspected narcolepsy or idiopathic hypersomnia (IH). Second, to assess the correlation between the ODSI and the Epworth Sleepiness Scale (ESS) as well as objective polysomnographic measurements. Third, to test the accuracy of the ODSI to detect narcolepsy or IH (narcolepsy/IH) compared with the ESS. METHODS: A total of 181 patients complaining of excessive daytime sleepiness filled in the ESS and the ODSI and underwent measurements including actigraphy, full-night polysomnography, Multiple Sleep Latency Test, and 24-hour bedrest sleep recording. RESULTS: Narcolepsy or IH was diagnosed in 76 patients. The ODSI found excessive daytime sleepiness in 92.3% of all patients and in 98.7% of those diagnosed with narcolepsy/IH. In the whole population, the ODSI was significantly positively correlated with the ESS (R = .547; 95% confidence interval: .436, .642; P < .001) and weakly with 24-hour total sleep time on bedrest recording (R = .208; 95% confidence interval: .056, .350; P = .047) but not with the Multiple Sleep Latency Test. The ODSI offered a higher negative (92.9%) and positive (44.9%) predictive value to detect narcolepsy/IH than did the ESS (66.7% and 43.3%, respectively). In the IH group, the ODSI's third-item score (daily sleepiness duration) was significantly higher in patients with than without increased 24-hour total sleep time (P = .023). CONCLUSIONS: The ODSI is a brief, simple first-line questionnaire that explores both intensity and duration of daytime sleepiness and offers a high sensitivity to detect narcolepsy and IH.

Sleep Disturbances in MCI and AD: Neuroinflammation as a Possible Mediating Pathway.

Mild cognitive impairment (MCI) and Alzheimer's disease (AD) affect a high proportion of the elderly population with an increasing prevalence. Sleep disturbances are frequent in those with MCI and AD. This review summarizes existing research on sleep disturbances and neuroinflammation in MCI and AD. Although strong evidence supports various pathways linking sleep and AD pathology, the temporal direction of this central relationship is not yet known. Improved understanding of sleep disturbance and neuroinflammation in MCI and AD may aid in the identification of targets for their prevention.

CPAP Adherence May Slow 1-Year Cognitive Decline in Older Adults with Mild Cognitive Impairment and Apnea.

BACKGROUND/OBJECTIVES: Obstructive sleep apnea (OSA) has been linked to an increased risk for Alzheimer's disease (AD), but little prospective evidence exists on the effects of OSA treatment in preclinical AD. The objective was to determine if continuous positive airway pressure (CPAP) treatment adherence, controlling for baseline differences, predicts cognitive and everyday function after 1 year in older adults with mild cognitive impairment (MCI) and to determine effect sizes for a larger trial. DESIGN: Quasi-experimental pilot clinical trial with CPAP adherence defined as CPAP use 4 hours or more per night over 1 year. SETTING: Sleep and geriatric clinics and community. PARTICIPANTS: Older adults, aged 55 to 89 years, with an apnea-hypopnea index of 10 or higher participated: (1) MCI, OSA, and CPAP adherent (MCI +CPAP), n = 29; and (2) MCI, OSA, CPAP nonadherent (MCI -CPAP), n = 25. INTERVENTION: CPAP. MEASUREMENTS: The primary cognitive outcome was memory (Hopkins Verbal Learning Test-Revised), and the secondary cognitive outcome was psychomotor/cognitive processing speed (Digit Symbol subtest from the Wechsler Adult Intelligence Scale Substitution Test). Secondary function and progression measures were the Everyday Cognition, Alzheimer's Disease Cooperative Study-Clinical Global Impression of Change Scale, and Clinical Dementia Rating. RESULTS: Statistically significant improvements in psychomotor/cognitive processing speed in the MCI +CPAP group vs the MCI -CPAP group were observed at 1 year after adjustment for age, race, and marital status (parameter estimate = 1.68; standard error = 0.47; 95% confidence interval = 0.73-2.62), with a 6-month effect size (ES) of 0.46 and a 1-year ES of 1.25. There were small to moderate ESs for memory (ES 0.20, 6 mo), attention (ES 0.25, 1 y), daytime sleepiness (ES 0.33, 6 mo and ES 0.22, 1 y), and everyday function (ES 0.50, 6 mo) favoring the MCI +CPAP group vs the MCI -CPAP group. CONCLUSION: Controlling for baseline differences, 1 year of CPAP adherence in MCI +OSA significantly improved cognition, compared with a nonadherent control group, and may slow the trajectory of cognitive decline. TRIAL REGISTRATION NUMBER: Memories; NCT01482351; https://clinicaltrials.gov/ct2/show/NCT01482351?cond=MCI+and+OSA&rank=1 J Am Geriatr Soc 67:558-564, 2019.

Chronic Medical Conditions and Sleep in the Older Adult.

Demographic changes in developed countries are leading to an aging population with a high prevalence of chronic medical conditions, disability, and sleep disorders. Evidence suggests that medical conditions and comorbid sleep disorders interact. This article aims to review frequently encountered medical conditions and examine their consequences on sleep in the older adult, and to review the possible impact of sleep disturbances on these common medical conditions. These medical conditions include pain, falls, cancer, and chronic heart failure. Strategies to improve sleep disturbances in older patients with comorbid medical conditions are provided according to available data and clinical experience.

Observation and Interview-based Diurnal Sleepiness Inventory for measurement of sleepiness in older adults.

INTRODUCTION: There is no established reference standard for subjective measures of sleepiness in older adults. METHODS: This study compares the Observation and Interview-based Diurnal Sleepiness Inventory (ODSI) with two existing instruments for measurement of sleepiness and daily functioning, the Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ). RESULTS: A total of 125 study participants were included in this study and were administered the ODSI, ESS and FOSQ; subjects had a mean age of 70.9 ± 5.27 years, mean Apnea-Hypopnea Index of 31.9 ± 27.9 events/hour and normal cognitive functioning (Mini-Mental State Examination score > 24). The ODSI showed a significant association with the ESS (Spearman's ρ: 0.67, P < 0.001) and with the FOSQ (Spearman's ρ: -0.52, P < 0.001). The ODSI 1 item (assessing sleepiness in active situations) was borderline significantly correlated with the ESS (ß = 0.14; 95% confidence interval [CI], -0.01 to 0.29; P = 0.069). ODSI 2 item (sleepiness in passive situations) was correlated with the ESS (ß = 1.65; 95% CI, 1.32 to 1.98; P < 0.001). Both ODSI 1 (ß = -0.15; 95% CI, -0.24 to -0.07; P < 0.001) and ODSI 2 (ß = -0.35; 95% CI, -0.55 to 0.16; P < 0.001) were significantly correlated with the FOSQ. CONCLUSION: The ODSI is a suitable measure of sleepiness and is appropriate for usage in clinical care in older adults.

Principles of practice parameters for the treatment of sleep disordered breathing in the elderly and frail elderly: the consensus of the International Geriatric Sleep Medicine Task Force.

Sleep disordered breathing (SDB) is a leading cause of morbidity worldwide. Its prevalence increases with age. Due to the demographic changes in industrial societies, pulmonologists and sleep physicians are confronted with a rapidly growing number of elderly SDB patients. For many physicians, it remains unclear how current guidelines for SDB management apply to elderly and frail elderly patients. The goal of this consensus statement is to provide guidance based on published evidence for SDB treatment in this specific patient group.Clinicians and researchers with expertise in geriatric sleep medicine representing several countries were invited to participate in a task force. A literature search of PubMed from the past 12 years and a systematic review of evidence of studies deemed relevant was performed.Recommendations for treatment management of elderly and frail elderly SDB patients based on published evidence were formulated via discussion and consensus.In the last 12 years, there have been surprisingly few studies examining treatment of SDB in older adults and even fewer in frail older adults. Studies that have been conducted on the management of SDB in the older patient population were rarely stratified for age. Studies in SDB treatment that did include age stratification mainly focused on middle-aged and younger patient groups. Based on the evidence that is available, this consensus statement highlights the treatment forms that can be recommended for elderly SDB patients and encourages treatment of SDB in this large patient group.

A Three-Item Instrument for Measuring Daytime Sleepiness: The Observation and Interview Based Diurnal Sleepiness Inventory (ODSI).

STUDY OBJECTIVES: We aimed to develop a new three-item assessment tool for daytime sleepiness in older adults, the Observation and interview-based Diurnal Sleepiness Inventory (ODSI) and determine its validity, internal consistency, test-retest reliability, and optimal cutoff score. METHODS: A total of 133 elderly subjects including 73 patients with obstructive sleep apnea (OSA) (mean age, 79 y) and 60 controls (mean age, 80 y) were consecutively enrolled and answered all questionnaires. The ODSI questionnaire was validated using the Epworth Sleepiness Scale considered as a gold standard. Reliability, validity, and cut-points were tested. RESULTS: The ODSI has acceptable validity, internal consistency, and test-retest reliability properties. The ODSI has internal consistency and a reliability coefficient (Pearson rho) of 0.70 for its three items, which suggests strong reliability. The estimated sensitivity and specificity were 0.842 with 95% confidence interval [0.624; 0.945] and 0.851 [0.761; 0.911], respectively. The consistency of summated scale scores during test and retest sessions was high (r = 0.970, 95% bootstrap confidence interval [0.898; 0.991]). Receiver operating characteristic analysis suggests that a cut-point of 6 is effective for identifying older adults with excessive levels of daytime sleepiness. CONCLUSIONS: The ODSI is a brief, valid, easy-to-administer three-item assessment that can screen for excessive daytime sleepiness among elderly patients with OSA.

Ageing and trajectories of depressive symptoms in community-dwelling men and women.

OBJECTIVE: The aim of this study was to investigate age-related patterns of depressive symptoms in older men and women and to identify their determinants. METHODS: The Center for Epidemiological Studies Depression Scale was used to prospectively assess depressive symptoms in 1059 men and 1531 women, enrolled in a French representative population-based cohort (PAQUID study) and followed over a period of 20 years. Using a group-based trajectory method with an accelerated longitudinal design, we modelled the course of depressive symptoms between 65 and 104 years of age and examined associations between trajectory patterns and baseline socio-demographic and health variables. RESULTS: In men, we identified three rising trajectories: 'never depressed' including 65% of the sample, 'emerging depression' (28%) and 'increasing depression' (7%). Compared with the membership of the never-depressed trajectory, that of the two higher trajectories was significantly associated with a history of depression and dyspnoea. In women, we identified two slightly rising trajectories (never depressed, 56%, and 'rising subclinical', 33%) and one stable high trajectory ('persistent depression', 11%). Membership of the two higher trajectories was significantly associated with the use of benzodiazepine, polymedication and dyspnoea. A history of nondepressive psychiatric disorder was a risk factor for membership of the persistent-depression group, whereas being widowed seemed to be a protective factor for membership of this group. CONCLUSION: High-risk groups for later-life depression should be targeted differently in older men and women in order to implement appropriate interventions to prevent chronicity and disability.

Limits of the Epworth Sleepiness Scale in older adults.

PURPOSE: Excessive daytime sleepiness (EDS) in older adults is associated with obstructive sleep apnea, falls, reduced quality of life, and mortality. The Epworth Sleepiness Scale (ESS) is widely used to assess sleepiness. However, EDS assessment with the ESS may not be accurate in older adults. We aimed to (1) describe the responsiveness of nondemented older subjects to the ESS and (2) compare the self-report ESS scores to those of close relatives (CR) proxy and identify factors influencing any discrepancies between them. METHODS: This is a cross-sectional observational study including 104 independently living nondemented older subjects with daytime sleepiness complaints and 104 nondemented CRs. Cognitive tests (Mini-Mental State Examination) and the ESS were completed separately by subjects and CRs to assess the subject's daytime sleepiness. RESULTS: Almost 60 % of subjects and CRs were not able to answer at least one question on the ESS. Despite the fact that all subjects complained of EDS, only 24 % of them had an abnormal ESS score (>10). Subjects rated their sleepiness lower (7.10 ± 4.31) than their CR proxy did (9.70 ± 5.14) (p < 0.0001). In multivariate analysis, an increase in age and a decrease in cognitive status of the subjects appeared related to the difference in ESS between subject and CR. CONCLUSIONS: The majority of older adults were not able to answer all of the ESS items. The ESS may underestimate sleepiness severity in older subjects. Despite EDS complaints in all subjects, only one quarter of them had a pathological ESS score.

Occult nighttime hypertension in daytime normotensive older patients with obstructive sleep apnea.

OBJECTIVES: To assess nighttime blood pressure (BP), the dipping phenomenon and the relationships between nighttime BP, and polysomnography parameters in older patients with obstructive sleep apnea (OSA) who have been identified by their primary care physician as being normotensive during the daytime. DESIGN: Cross-sectional study. SETTING: University hospital-based geriatric sleep center. PARTICIPANTS: Daytime normotensive, community-dwelling older adults, consecutively referred by their primary care physicians for suspicion of OSA. MEASUREMENTS: Overnight polysomnography and 24-hour ambulatory blood pressure measurement (ABPM). Daytime hypertension defined as systolic BP ≥135 mm Hg and/or diastolic BP ≥85 mm Hg. Nighttime hypertension defined as systolic BP ≥120 mm Hg and/or diastolic BP ≥70 mm Hg. Dipper pattern characterized by nighttime fall of mean BP ≥10%. RESULTS: Forty-five participants (30 OSA; 15 non-OSA) completed the study (76.9 ± 6.2 years old). ABPM indicated clinically significant nighttime systolic (132.5 ± 16.0) and diastolic (72.6 ± 9.4) hypertension in patients with OSA previously classified as daytime normotensives and found only a mild degree of nighttime systolic hypertension (123.7 ± 16.1) in patients without OSA (P = .105). A significant nondipping phenomenon was found in patients with OSA (-0.5 ± 7.4 vs 5.4 ± 6.4; P = .016). Nighttime mean BP (r = 0.301; P = .049) and dipping status (r = -0.478; P = .001) were correlated with apnea-hypopnea index. A significant correlation was found between systolic BP (r = 0.321; P = .035), diastolic BP (r = 0.373; P = .013), mean BP (r = 0.359; P = .018), and hypoxia (sleep time spend with SaO2 <90%). CONCLUSION: Daytime normotensive older adults with OSA are at high risk for having occult nighttime hypertension. Thus, 24-hour ABPM may be appropriate for older patients with OSA whose clinical blood pressure does not display any daytime elevation.

Perceived effectiveness of diverse sleep treatments in older adults.

OBJECTIVES: To describe the different methods that older adults use to treat sleep problems and the perceived effectiveness of these methods. DESIGN: Cross-sectional study of treatment patterns for sleep disorders using a mailed questionnaire that gathered information concerning sleep history, demographics, and treatment choices. SETTING: Community. PARTICIPANTS: Community-based sample of adults aged 65 and older, of whom 242 responded (67% response rate). MEASUREMENTS: Standardized questionnaires to assess sleep parameters (Pittsburgh Sleep Quality Index), demographic information, and sleep treatment options. RESULTS: Study participants engaged in a variety of treatment regimens to improve their sleep, with the average number of treatments attempted being 4.8±2.9. The most commonly used interventions were watching television or listening to the radio (66.4%) and reading (56.2%). The most commonly used pharmacotherapy was pain medication (40.1%). Prescription sleeping pills had the greatest self-reported effectiveness. Approximately half of all study participants who used alcohol or over-the-counter sleep aids had not discussed their sleep problems with their doctor. CONCLUSION: Older adults frequently choose treatments for their sleep problems that can potentially worsen their sleep symptoms. Many patients have not spoken to their healthcare provider about their treatment choices. These findings highlight the importance of discussing sleep habits and self-treatment choices, as well as treating sleep disorders, in older adults.

Brain perfusion SPECT with an automated quantitative tool can identify prodromal Alzheimer's disease among patients with mild cognitive impairment.

OBJECTIVE: To improve diagnosis of early Alzheimer's disease (AD), i.e., prodromal AD, by an automated quantitative tool combining brain perfusion single-photon emission computed tomography (SPECT) images and memory tests scores in order to be applied in clinical practice. PATIENTS AND METHODS: In this prospective, longitudinal, multi-centric study, a baseline (99m)Tc-ECD perfusion SPECT was performed in 83 patients with memory complaint and mild cognitive impairment (MCI). After a 3-year follow-up, 11 patients progressed to Alzheimer's disease (MCI-AD group), and 72 patients remained stable (MCI-S group), including 1 patient who developed mild vascular cognitive impairment. After comparison between the MCI-S and MCI-AD groups with a voxel-based approach, region masks were extracted from the statistically significant clusters and used alone or in combination with Free and Cued Selective Reminding Test (FCSRT) scores for the subject's categorization using linear discriminant analysis. Results were validated using the leave-one-out cross-validation method. RESULTS: Right parietal and hippocampal perfusion was significantly (p<0.05, corrected) decreased in the MCI-AD group as compared to the MCI-S group. The patients' classification in the MCI group using the mean activity in right and left parietal cortex and hippocampus yielded a sensitivity, specificity, and accuracy of 82%, 90%, and 89%, respectively. Combination of SPECT results and FCSRT free recall scores increased specificity to 93%. CONCLUSION: The combination of an automated quantitative tool for brain perfusion SPECT images and memory test scores was able to distinguish, in a group of amnestic MCI, patients at an early stage of AD from patients with stable MCI.

Pain tolerance and obstructive sleep apnea in the elderly.

OBJECTIVE: Patients with painful conditions often suffer from sleep disturbances. However, changes in sleep pattern per se could also influence pain tolerance. Untreated obstructive sleep apnea (OSA) causes major disturbances in sleep pattern. The aim of this study was to assess whether continuous positive airway pressure (CPAP) treatment in elderly patients with OSA would result in improved pain tolerance. DESIGN: Randomized, double-blind crossover study. SETTING: Geriatric sleep center based in Antoine Charial University Hospital (Lyon, France). PARTICIPANTS: A total of 13 consecutive OSA patients aged 70 and older randomly assigned CPAP treatment (lowCPAP versus highCPAP). Eleven patients completed the study. MEASUREMENTS: Overnight sleep recording, electrical pain tolerance assessment, and visual analog scale for sleep quality were performed. RESULTS: Both low- and highCPAP treatment significantly improved respiratory parameters. However, compared with baseline, the electrical pain tolerance score was significantly enhanced (analgesic effect) only under highCPAP treatment (21.2 ± 10.9 versus 28.4 ± 16.0; P = .03). CONCLUSION: The treatment of OSA with CPAP would have an analgesic effect. This would represent a unique outcome attributed to CPAP treatment. Given the high prevalence of both OSA and chronic pain conditions in the elderly; our findings could hold many implications for very large segments of the elderly population.

[Obstructive sleep apnea and cognitive impairment in the elderly]. / Syndrome d'apnées obstructives du sommeil et troubles cognitifs chez les sujets âgés.

Obstructive Sleep Apnea Syndrome (OSAS) is characterized by repeated episodes of upper airway obstruction during sleep that result in intermittent hypoxemia and arousal. The prevalence of OSAS increases with aging, occurring in up to 25% of older adults and up to 48% in patients with Alzheimer's disease. OSAS causes hypoxia, fragmented sleep, daytime sleepiness, cognitive dysfunction, functional decline, and brain damage resulting from reduced cerebral blood flow, ischemic brain lesions, microvascular reactivity, white matter lesions, and grey matter loss. OSAS is considered as an independent risk factor for hypertension, stroke and mortality. The treatment of choice for OSAS is continuous positive airway pressure (CPAP). OSAS-related cognitive dysfunction has been shown in a variety of domains including attention, executive functioning, motor efficiency, working memory, and long-term episodic memory. Proposed mechanisms include hypoxemia, sleep fragmentation and inflammatory process, but it remains unclear which mechanisms underlie the relationship between OSAS and disturbances in the different cognitive domains. Recent studies suggest that OSAS may exacerbate cognitive functioning in dementia and that CPAP therapy can be applied to these patients and improve cognitive functioning.

Falling-asleep-related injured falls in the elderly.

OBJECTIVES: To describe the clinical features and therapeutic response to continuous positive airway pressure (CPAP) in elderly obstructive sleep apnea syndrome (OSAS) patients with sleepiness and falling-asleep-related injured falls. PATIENTS AND METHODS: In 2 geriatric units, 4 consecutive OSAS patients with falling-asleep-related injured falls were diagnosed. They were treated with CPAP and followed for 9 to 24 months. RESULTS: Mean age at initial observation was 82 years. All patients shared the following characteristics: self-reported daytime sleepiness, falling-asleep-related injured falls, recurrent fall history, medical comorbid conditions, PSG confirmed OSAS, and successful treatment with CPAP. They declared resolution of sleepiness and attention without any further fall under CPAP therapy. CONCLUSION: A causal relationship exists between OSAS and falling-asleep-related injured falls in the elderly. Treatment of OSAS with CPAP can improve attention, daytime vigilance, and consequently gait and balance control and prevent falls in these patients.

Observation-based nocturnal sleep inventory: screening tool for sleep apnea in elderly people.

OBJECTIVES: To measure the ability of the Observation-based Nocturnal Sleep Inventory (ONSI) to detect the presence or absence of sleep apnea syndrome (SAS) in older adults. DESIGN: Cross-sectional blinded study. SETTING: University hospital-based geriatric sleep center. PARTICIPANTS: All participants aged 70 and older were referred by physicians for suspicion of SAS. MEASUREMENTS: ONSI performed by nurses; overnight polysomnography. SAS was defined as an apnea-hypopnea index of 15 events or more per hour of sleep. RESULTS: A total of 121 consecutive patients were evaluated for study participation. Six were excluded because of technical difficulties with polysomnography or too-frequent awakenings related to medical conditions. One hundred eleven patients completed the validation process. Polysomnography identified 68 patients as having SAS and 43 patients as not having SAS. The nurse-administered ONSI demonstrated good levels of sensitivity (90%), specificity (81%), positive predictive value (88%), and negative predictive value (83%) in screening older adults for SAS. CONCLUSION: The ONSI is the first valid SAS screening tool proposed for older persons in hospitals and nursing homes. This study demonstrates that the ONSI provides accurate information; is a simple, easy-to-use bed-side tool; and is highly sensitive and specific in screening SAS when compared with overnight polysomnography results.

Mobility decline of unknown origin in mild cognitive impairment: an MRI-based clinical study of the pathogenesis.

Mobility dysfunction of unknown origin predicts dementia in the elderly and is associated with periventricular leukoaraiosis (LA), another predictor of dementia of still controversial pathogenesis, in the elderly with mild cognitive impairment (MCI). Thus, this study examined which gait and balance parameters best correlate with periventricular LA to better understand the pathogenesis of mobility decline in MCI. High resolution MRI and detailed mobility assessment were performed in 61 subjects (72 years+/-5) with MCI. Cognitive assessment included Free and Cued Selective Reminding Test (FCSRT) and the Trail Making test part B (TMB). Mobility assessment included reports of falls in the previous 6-month period, the walking while talking test, the timed "up and go test" (TUG), measurement of fast gait speed, the standing test and the one-leg standing test. There was an association between marked periventricular LA and slow postural changes, slow gait (TUG and gait speed), altered balance (standing test and one-leg standing test), altered walking while talking test. But after adjusting for age and ventriculomegaly on a logistic multiple regression model, performance on the TUG test was the only clinical predictor of periventricular LA (>10 s, P=0.002). Poorer TUG performances were more frequent with vascular than Alzheimer's disease-like profiles on the FCSRT and TMB tests (P=0.01). In conclusion, the clinical profile of patients demonstrating a main MR brain correlate of mobility dysfunction supports a main pathomechanism of subtle vascular extrapyramidal dysfunction in MCI.

Classifying late-onset dementia with MRI: is arteriosclerotic brain degeneration the most common cause of Alzheimer's syndrome?

Our aim was to use early magnetic resonance imaging (MRI) to investigate the causes of cognitive decline in elderly people with mild cognitive impairment (MCI). Baseline structural and flow quantification MR sequences, and clinical and neuropsychological follow-up for at least two years, were performed on 62 elderly subjects with MCI. Of these subjects, 17 progressed to dementia, and 15 of these progressed to dementia of the Alzheimer type (DAT). Conversion to clinically diagnosed DAT was related to six distinct MR profiles, including one profile suggesting severe AD (20% of these converters) and five profiles suggesting severe cerebrovascular dysfunction. Two profiles suggested arteriosclerotic brain degeneration, one profile suggested severe venous windkessel dysfunction, and two suggested marked cerebral hypoperfusion associated with very low craniospinal compliance or marked brain atrophy. As compared with vascular MR type converters, AD MR type converters showed high executive and mobility predementia performances. Severe whole anteromesial temporal atrophy and predominantly left brain atrophy on visual MR analysis was only observed in AD MR type converters. In conclusion, these observations enhance the pathogenic complexity of the Alzheimer syndrome, and suggest that the role of arteriosclerotic brain degeneration in late life dementia is underestimated.