Atypical Presentations of Foix-Chavany-Marie Syndrome (FCMS) in Stroke.

Foix-Chavany-Marie syndrome (FCMS) presents with anarthria and bilateral (B/L) central facio-linguo-velo-pharyngo-masticatory paralysis with "autonomic voluntary dissociation." The most common cause of FCMS is cerebrovascular disease, while rarer causes include central nervous system infection, developmental disorders, epilepsy, and neurodegenerative disorders. Even though this syndrome is also referred to as (B/L) anterior operculum syndrome, patients with lesion in sites other than (B/L) opercular regions also can develop the syndrome. In this article we describe two such atypical cases. Case 1: A 66-year-old man with diabetes and hypertension who is a smoker had right-sided hemiplegia one year back developed the syndrome acutely two days before admission. CT brain showed left perisylvian infarct and right internal capsule anterior limb infarct. Case 2: A 48-year-old gentleman, who is a diabetic and hypertensive had right-sided hemiplegia one year back and developed the syndrome acutely two days before admission. CT brain showed (B/L) infarcts in the posterior limb of the internal capsule. Both patients had bifacial, lingual, and pharyngolaryngeal palsy thereby confirming the diagnosis of FCMS. None of them had the classical (B/L) opercular lesions on imaging and one patient did not even have a unilateral opercular lesion. Contrary to the common teaching, (B/L) opercular lesions are not always necessary to produce FCMS and can occur even without opercular lesions at all.

A case of vagal cephalgia as a manifestation of a lung neoplasm-A case report and review of literature.

Lung cancer can present with unilateral atypical facial pain, a rare symptom due to vagus nerve involvement or paraneoplastic syndrome. This manifestation is usually missed, delaying the diagnosis and prognosis. We discuss a case of a 45-year-old male who presented with right-sided hemifacial pain and with normal neurological investigations.

Utility of IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly) in Diagnosing Dementia in Malayalam Speaking Population.

Background: Among screening instruments used to diagnose dementia by interviewing the caregivers rather than the patients, Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is widely used. Objectives: To adapt and validate IQCODE in a Malayalam-speaking population and to study the utility of IQCODE in diagnosing dementia. Materials and Methods: Cross-sectional study conducted as a two-phase survey on individuals aged ≥55 years availing dementia care services at three tertiary care hospitals and a dementia clinic in Kerala, India. In the first phase, modifications were made in the questionnaire (IQCODE) in accordance with local social and cultural practices. The questionnaire was then translated to Malayalam and back-translated to English. In the second phase, this was administered to healthy elderly subjects and close caretakers of dementia patients. These patients underwent neuropsychology evaluation consisting of mini-mental state examination (MMSE) and Addenbrooke's cognition examination-Malayalam (ACE-M), and the statistical correlation between mean IQCODE scores and ACE-M scores was assessed using ANOVA test. Results: A total of 396 patients with dementia were included in the study. The mean age group was 72.54 ± 7.11 years. The mean IQCODE score was 3.93 ± 0.68, and the mean ACE-M score was 39.96 ± 23.41. It has a statistically significant correlation with the total score of MMSE and ACE-M scales, confirming its utility as a good screening instrument. Conclusion: The IQCODE could be adapted and translated to Malayalam without making any major changes in its content and has good acceptance among this cohort of hospital-based subjects.

Cognitive Impairment in Strategic Infarct Dementia: A Report of Three Cases.

Strokes involving specific areas regulating cognition and behavioral functions constitute strategic infarct vascular dementia. We present three patients with acute behavioral changes and cognitive impairment following a strategic infarct. Case 1 is of a 59-year-old male, a known patient of diabetes mellitus under treatment, who presented with acute onset of memory deficit along with difficulty in recognizing faces, and left hemispatial neglect. Case 2 is of a 62-year-old male, a smoker, who presented with acute onset of behavioral abnormalities, gait apraxia, and decreased word output. Case 3 is of a 64-year-old female, a known patient of type 2 diabetes mellitus and cerebrovascular accident with left hemiparesis, who presented with psychomotor withdrawal, depression, and cautious gait. One of the most prevalent forms of dementia in adults is vascular dementia, often caused by multiple small strokes, termed multi-infarct dementia. Strategic infarct dementia, on the other hand, is usually caused by a small, single cerebral infarct. The strategic brain regions specifically involved in post-stroke cognitive impairment requires detailed clinical examination along with radiological imaging for accurate localization. Thus the cognitive impact of ischemic strokes can be understood and predicted by clinicians with the help of maps of strategic brain regions associated with global and domain-specific cognitive functions.

MoCA in five Indian languages: A brief screening tool to diagnose dementia and MCI in a linguistically diverse setting.

INTRODUCTION AND OBJECTIVES: Early dementia diagnosis in low and middle-income countries (LMIC) is challenging due to limited availability of brief, culturally appropriate, and psychometrically validated tests. Montreal Cognitive Assessment (MoCA) is one of the most widely used cognitive screening tests in primary and secondary care globally. In the current study, we adapted and validated MoCA in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam) and determined the optimal cut-off points that correspond to screening for clinical diagnosis of dementia and MCI. METHODS: A systematic process of adaptation and modifications of MoCA was fulfilled. A total of 446 participants: 214 controls, 102 dementia, and 130 MCI were recruited across six centers. RESULTS: Across five languages, the area under the curve for diagnosis of dementia varied from 0.89 to 0.98 and MCI varied from 0.73 to 0.96. The sensitivity, specificity and optimum cut-off scores were established separately for five Indian languages. CONCLUSIONS: The Indian adapted MoCA is standardized and validated in five Indian languages for early diagnosis of dementia and MCI in a linguistically and culturally diverse population.

Picture-naming test for a linguistically diverse population with cognitive impairment and dementia.

BACKGROUND: Picture-naming tests (PNTs) evaluate linguistic impairment in dementia due to semantic memory impairment, impaired lexical retrieval or perceptual deficits. They also assess the decline in naming impairment at various stages of dementia and mild cognitive impairment (MCI) that occurs due to progressive cognitive impairment. With the increasing numbers of people with dementia globally, it is necessary to have validated naming tests and norms that are culturally and linguistically appropriate. AIMS: In this cross-sectional study we harmonized a set of 30 images applicable to the Indian context across five languages and investigated the picture-naming performance in patients with MCI and dementia. METHODS & PROCEDURES: A multidisciplinary expert group formed by the Indian Council of Medical Research (ICMR) collaborated towards developing and adapting a picture naming test (PNT) known as the ICMR-PNT in five Indian languages: Hindi, Bengali, Telugu, Kannada and Malayalam. Based on cross-cultural adaptation guidelines and item-wise factor analysis and correlations established separately across five languages, the final version of the ICMR-PNT test was developed. A total of 368 controls, 123 dementia and 128 MCI patients were recruited for the study. Psychometric properties of the adapted version of the ICMR-PNT were examined, and sensitivity and specificity were examined. OUTCOMES & RESULTS: The ICMR-PNT scores in all languages combined were higher in controls compared with patients with dementia and MCI (F2, 615 = 139.85; p < 0.001). Furthermore, PNT scores for MCI was higher in comparison with patients with dementia in all languages combined (p < 0.001). The area under the curve across the five languages ranged from 0.81 to 1.00 for detecting dementia. There was a negative correlation between Clinical Dementia Rating (CDR) and ICMR-PNT scores and a positive correlation between Addenbrooke's Cognitive Examination-III (ACE-III) and ICMR-PNT scores in control and patient groups. CONCLUSIONS & IMPLICATIONS: The ICMR-PNT was developed by following cross-cultural adaptation guidelines and establishing correlations using item-wise factor analysis across five languages. This adapted PNT was found to be a reliable tool when assessing naming abilities effectively in mild to moderate dementia in a linguistically diverse context. WHAT THIS PAPER ADDS: What is already known on this subject Picture-naming evaluates language impairment linked to naming difficulties due to semantic memory, lexical retrieval or perceptual disturbances. As a result, picture naming tests (PNTs) play an important role in the diagnosis of dementia. In a heterogeneous population such as India, there is a need for a common PNT that can be used across the wide range of languages. What this study adds to existing knowledge PNTs such as the Boston Naming Test (BNT) were developed for the educated, mostly English-speaking, Western populations and are not appropriate for use in an Indian context. To overcome this challenge, a PNT was harmonized in five Indian languages (Hindi, Bengali, Telugu, Kannada and Malayalam) and we report the patterns of naming difficulty in patients with MCI and dementia. The ICMR-PNT demonstrated good diagnostic accuracy when distinguishing patients with mild to moderate dementia from cognitively normal individuals. What are the potential or actual clinical implications of this work? With the growing number of persons suffering from Alzheimer's disease and other forms of dementia around the world, its critical to have culturally and linguistically relevant naming tests and diagnosis. This validated ICMR-PNT can be used widely as a clinical tool to diagnose dementia and harmonize research efforts across diverse populations.

Validation of ICMR Neurocognitive Toolbox for Dementia in the Linguistically Diverse Context of India.

Objectives: The growing prevalence of dementia, especially in low- and middle-income countries (LMICs), has raised the need for a unified cognitive screening tool that can aid its early detection. The linguistically and educationally diverse population in India contributes to challenges in diagnosis. The present study aimed to assess the validity and diagnostic accuracy of the Indian Council of Medical Research-Neurocognitive Toolbox (ICMR-NCTB), a comprehensive neuropsychological test battery adapted in five languages, for the diagnosis of dementia. Methods: A multidisciplinary group of experts developed the ICMR-NCTB based on reviewing the existing tools and incorporation of culturally appropriate modifications. The finalized tests of the major cognitive domains of attention, executive functions, memory, language, and visuospatial skills were then adapted and translated into five Indian languages: Hindi, Bengali, Telugu, Kannada, and Malayalam. Three hundred fifty-four participants were recruited, including 222 controls and 132 dementia patients. The sensitivity and specificity of the adapted tests were established for the diagnosis of dementia. Results: A significant difference in the mean (median) performance scores between healthy controls and patients with dementia was observed on all tests of ICMR-NCTB. The area under the curve for majority of the tests included in the ICMR-NCTB ranged from 0.73 to 1.00, and the sensitivity and specificity of the ICMR-NCTB tests ranged from 70 to 100% and 70.7 to 100%, respectively, to identify dementia across all five languages. Conclusions: The ICMR-NCTB is a valid instrument to diagnose dementia across five Indian languages, with good diagnostic accuracy. The toolbox was effective in overcoming the challenge of linguistic diversity. The study has wide implications to address the problem of a high disease burden and low diagnostic rate of dementia in LMICs like India.

Idiopathic Normal Pressure Hydrocephalus Presenting as Psychosis.

BACKGROUND: Normal pressure hydrocephalus (NPH) is a syndrome characterized by gait disturbance, dementia, urinary incontinence, and dilation of ventricular system with normal opening cerebrospinal fluid pressure. Idiopathic NPH (i NPH) presenting as psychosis is uncommon. OBJECTIVES: The objective of this study is to describe idiopathic NPH presenting as Psychosis. SUBJECTS AND METHODS: Patients availing dementia care service from three tertiary care hospitals, across Kerala, with a diagnosis of psychosis were evaluated. RESULTS: Three patients with NPH, diagnosed as per the consensus criteria, presenting as psychosis are described. Patient 1: Fifty-five-year-old lady with psychosis was found to have iNPH. She gave history of psychosis relieved with successful shunting of the hydrocephalus. She developed recurrence of psychosis each time the hydrocephalus recurred due to shunt malfunction and was relieved with correction of hydrocephalus with shunting. Patient 2 was a 67-year-old gentleman with long history of pyschosis with paranoid ideas. Five years after onset of illness, he developed gait apraxia, and a CT scan done showed normal pressure hydrocephalus. Patient 3 had bipolar illness since age of 60 years of age. He also developed gait apraxia 5 years into the illness and was diagnosed as having iNPH following imaging. CONCLUSIONS: All the patients had psychosis much before other features of iNPH developed. One of the patient's psychosis was temporally associated with onset and offset of hydrocephalus, thereby strongly supporting the causative nature of iNPH. iNPH though rare can be one of the causes for late onset secondary psychosis.

Bilingualism and Its Implications for Neuropsychological Evaluation.

OBJECTIVE: In the background of a large population of bilinguals globally, the study aimed to develop standards of neuropsychological testing in the context of bilingualism. Because bilingualism is known to affect cognitive processes, bilinguals and monolinguals were compared on their performance on cognitive tests, to investigate the possibility of the need for separate normative data for the two groups. METHOD: A comprehensive neuropsychological test battery, standardized across five Indian languages: the Indian Council of Medical Research-Neuro Cognitive Tool Box (ICMR-NCTB) was administered to 530 participants (267 monolingual and 263 bilinguals matched for age and education). A systematic method of testing cognition in bilinguals was developed; to identify the appropriate language for testing, ensure language proficiency of examiner, and to interpret the bilingual responses. Additionally, the performance of bilinguals on the ICMR-NCTB was compared with monolinguals. RESULTS: Cognitive testing in the bilingual context was performed in the most proficient language of the participants, by examiners well versed with the language. Results from the language-based tests suggested that the frequent occurrence of borrowed- and language-mixed words required consideration while scoring. The reported bilingual effect on cognitive processes did not reflect as differences in the performance between bilinguals and monolinguals. CONCLUSIONS: Observations from the study provide robust recommendations for neuropsychological testing in the context of bilingualism. Results indicate that separate normative data may not be required for bilinguals and monolinguals. The study will be relevant and provide a reference framework to address similar issues in the large population of bilinguals in other societies.

A Screening Tool to Detect Stroke Aphasia: Adaptation of Frenchay Aphasia Screening Test (FAST) to the Indian Context.

BACKGROUND: Aphasia is a common consequence of stroke. To optimize recovery, it becomes critical as there are early identification and treatment of language deficits. The rising burden of stroke aphasia and lack of screening tools in the Indian context necessitates the need for a screening tool. OBJECTIVE: We aimed to adapt and validate the Frenchay Aphasia Screening Test (FAST) to the Indian context in two widely spoken Indian languages, Telugu and Kannada, for the literate and illiterate population. METHODS: A systematic process of adaptation and culturally appropriate modifications of the original FAST were done in 116 healthy controls and 115 patients. The validity of the adapted test was established. RESULTS: The optimum cut-off values for detecting aphasia in our sample ranged from 25 to 25.5 (literate) and 13.5 to 15.5 (illiterate) with high sensitivity and specificity. There was also a significant correlation between aphasia scores for adapted FAST and the Western Aphasia Battery (WAB), establishing good convergent validity. DISCUSSION: Results of the adaptation and validation of two Indian versions of FAST, suggest that it is an easy-to-use screening measure for detecting stroke-related language disabilities. The psychometric properties of the Indian version of FAST met the standardised requirements for adaptation and validation. CONCLUSIONS: The Indian version of FAST was found to be a reliable and valid bedside screening tool for aphasia in stroke patients. We aim that this study will facilitate the use of the test across other Indian languages and a large clinical population in the future.

Validation of Indian Council of Medical Research Neurocognitive Tool Box in Diagnosis of Mild Cognitive Impairment in India: Lessons from a Harmonization Process in a Linguistically Diverse Society.

BACKGROUND/AIMS: In a linguistically diverse country such as India, challenges remain with regard to diagnosis of early cognitive decline among the elderly, with no prior attempts made to simultaneously validate a comprehensive battery of tests across domains in multiple languages. This study aimed to determine the utility of the Indian Council of Medical Research-Neurocognitive Tool Box (ICMR-NCTB) in the diagnosis of mild cognitive impairment (MCI) and its vascular subtype (VaMCI) in 5 Indian languages. METHODS: Literate subjects from 5 centers across the country were recruited using a uniform process, and all subjects were classified based on clinical evaluations and a gold standard test protocol into normal cognition, MCI, and VaMCI. Following adaptation and harmonization of the ICMR-NCTB across 5 different Indian languages into a composite Z score, its test performance against standards, including sensitivity and specificity of the instrument as well as of its subcomponents in diagnosis of MCI, was evaluated in age and education unmatched and matched groups. RESULTS: Variability in sensitivity-specificity estimates was noted between languages when a total of 991 controls and 205 patients with MCI (157 MCI and 48 VaMCI) were compared due to a significant impact of age, education, and language. Data from a total of 506 controls, 144 patients with MCI, and 46 patients with VaMCI who were age- and education-matched were compared. Post hoc analysis after correction for multiple comparisons revealed better performance in controls relative to all-cause MCI. An optimum composite Z-score of -0.541 achieved a sensitivity of 81.1% and a specificity of 88.8% for diagnosis of all-cause MCI, with a high specificity for diagnosis of VaMCI. Using combinations of multiple-domain 2 test subcomponents retained a sensitivity and specificity of >80% for diagnosis of MCI. CONCLUSIONS: The ICMR-NCTB is a "first of its kind" approach at harmonizing neuropsychological tests across 5 Indian languages for the diagnosis of MCI due to vascular and other etiologies. Utilizing multiple-domain subcomponents also retains the validity of this instrument, making it a valuable tool in MCI research in multilingual settings.

Standardising Dementia Diagnosis Across Linguistic and Educational Diversity: Study Design of the Indian Council of Medical Research-Neurocognitive Tool Box (ICMR-NCTB).

OBJECTIVES: While the burden of dementia is increasing in low- and middle-income countries, there is a low rate of diagnosis and paucity of research in these regions. A major challenge to study dementia is the limited availability of standardised diagnostic tools for use in populations with linguistic and educational diversity. The objectives of the study were to develop a standardised and comprehensive neurocognitive test battery to diagnose dementia and mild cognitive impairment (MCI) due to varied etiologies, across different languages and educational levels in India, to facilitate research efforts in diverse settings. METHODS: A multidisciplinary expert group formed by Indian Council of Medical Research (ICMR) collaborated towards adapting and validating a neurocognitive test battery, that is, the ICMR Neurocognitive Tool Box (ICMR-NCTB) in five Indian languages (Hindi, Bengali, Telugu, Kannada, and Malayalam), for illiterates and literates, to standardise diagnosis of dementia and MCI in India. RESULTS: Following a review of existing international and national efforts at standardising dementia diagnosis, the ICMR-NCTB was developed and adapted to the Indian setting of sociolinguistic diversity. The battery consisted of tests of cognition, behaviour, and functional activities. A uniform protocol for diagnosis of normal cognition, MCI, and dementia due to neurodegenerative diseases and stroke was followed in six centres. A systematic plan for validating the ICMR-NCTB and establishing cut-off values in a diverse multicentric cohort was developed. CONCLUSIONS: A key outcome was the development of a comprehensive diagnostic tool for diagnosis of dementia and MCI due to varied etiologies, in the diverse socio-demographic setting of India.

Author Correction: Global diversity and biogeography of bacterial communities in wastewater treatment plants.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Alexia without Agraphia-report of Five Cases and Review of Literature.

Alexia without agraphia (also called pure alexia or word blindness) was the first of the disconnection syndromes to be described. It results from the loss of visual input to the language area without involvement of the language area. The most common cause is occlusion of the left posterior cerebral artery with involvement of left occipital cortex and the splenium of corpus callosum. However, it can also be caused by any lesion affecting the splenium of corpus callosum disrupting the white matter tracts from the left visual cortex to the angular gyrus. We hereby describe five cases of alexia without agraphia, of which three are due to involvement of the left occipital cortex and splenium, and two are due to involvement of the splenium of corpus callosum alone.

Global diversity and biogeography of bacterial communities in wastewater treatment plants.

Microorganisms in wastewater treatment plants (WWTPs) are essential for water purification to protect public and environmental health. However, the diversity of microorganisms and the factors that control it are poorly understood. Using a systematic global-sampling effort, we analysed the 16S ribosomal RNA gene sequences from ~1,200 activated sludge samples taken from 269 WWTPs in 23 countries on 6 continents. Our analyses revealed that the global activated sludge bacterial communities contain ~1 billion bacterial phylotypes with a Poisson lognormal diversity distribution. Despite this high diversity, activated sludge has a small, global core bacterial community (n = 28 operational taxonomic units) that is strongly linked to activated sludge performance. Meta-analyses with global datasets associate the activated sludge microbiomes most closely to freshwater populations. In contrast to macroorganism diversity, activated sludge bacterial communities show no latitudinal gradient. Furthermore, their spatial turnover is scale-dependent and appears to be largely driven by stochastic processes (dispersal and drift), although deterministic factors (temperature and organic input) are also important. Our findings enhance our mechanistic understanding of the global diversity and biogeography of activated sludge bacterial communities within a theoretical ecology framework and have important implications for microbial ecology and wastewater treatment processes.

A new scoring system and norms for, and the performance of cognitively-unimpaired older adults on the cube copying test.

BACKGROUND: Cube copying test is often used as screening test for dementia. However, there is a paucity of an effectively scoring system, and very little is known about how healthy older adults perform on this test. In this study, we present a modified scoring system for the wire-cube copying, evaluate the performance of cognitively unimpaired elderly individuals, and generate norms on community-dwelling older adults. MATERIALS AND METHODS: The task consisted of copying a three-dimensional printed cube (i.e., wire-cube) of size 2.5 cm3. The scoring system devised by Maeshma et al. was modified and used. The target population consisted of cognitively normal individuals aged ≥65 years living in a predefined geographical area. RESULTS: In this study, there were 511 participants (62% females) aged 69 ± 7.2 years. Of the 295 figures available, 51 were rejected. Among the candidates with acceptable cubes, 182 (74.5%) had ≥9 years of education. Of the 51 rejected cubes, 37 (72.5%) participants had <9 years of education. Education was found to be significantly correlated with composite score (P < 0.001) whereas age and sex had no correlation. The total score as well as subgroup scores of the cubes were correlating well with Mini-mental state examination (MMSE) as well as Addenbrooke's Cognitive Examination (ACE) composite scores (P < 0.0001). CONCLUSION: Good correlation was found between composite scores and subscores with most of the ACE parameters. The test can be used as a rapid screening test for dementia in view of its good correlation with ACE composite scores and subscores; it also has the advantage of being independent of culture and language.

Neuropsychiatric Manifestations of Cognitively Advanced Idiopathic Normal Pressure Hydrocephalus.

BACKGROUND: Neuropsychiatric manifestations of patients with idiopathic normal pressure hydrocephalus (iNPH) have not been studied in a systematic way. AIM: To study the spectrum of neuropsychiatric abnormalities in patients with iNPH. PATIENT SELECTION AND EVALUATION: Patients attending 3 different tertiary care centers during three consecutive time periods spanning from 2010 to 2015 were analyzed for neuropsychiatric manifestations. Patients diagnosed as having probable or possible iNPH as per the consensus criteria were included in the study. Neuropsychiatric manifestations were captured by a comprehensive inventory (Cambridge Behavioral Inventory, CBI). RESULTS: The CBI score was available for 41 patients. The mean Mini-Mental State Examination score was 15.37 (SD 7.2) and the Addenbrooke's Cognitive Examination score was 34.95 (SD 19.67), thereby indicating cognitively advanced iNPH. All patients had impairment in one or more items on the CBI. The mean score was 55.46 (SD 27) out of 180, thereby indicating a mild degree of impairment. Among the subscores, impairment with motivation was the most observed abnormality followed by memory impairment. When the CBI total score and subscores were compared, all of them (except motivation) were higher for Alzheimer's disease; however, none was statistically significant. Even though the motivation score was higher for iNPH, the difference did not reach statistical significance. CONCLUSIONS: It can be concluded that neurobehavioral abnormalities are common in patients with cognitively advanced normal pressure hydrocephalus. However, the intensity of involvement appeared less when compared to Alzheimer's disease. Apathy appears to be the most common impairment.

Cognition in advanced normal pressure hydrocephalus: A pilot study from South India.

BACKGROUND: Literature on cognition in normal pressure hydrocephalus (NPH) is sparse and more so on cognition in advanced NPH. OBJECTIVE: To study the cognitive profile in a hospital-based cohort of cognitively-advanced NPH. SETTINGS AND DESIGN: This was a prospective cross-sectional study. The patients included those availing dementia care service from three different tertiary care centres during a period of 5 years from 2010 to 2014. Patients were considered to have cognitively-advanced NPH if the Addenbrooke's Cognitive Examination(ACE) score was 50 or less. In addition to ACE, the patients underwent a battery of other neuropsychologic tests including the digit forward test, Trail A and Trail B, Rey auditory verbal learning test, Cambridge behaviour inventory, hospital anxiety and depression scale, informant questionnaire for cognitive decline in the elderly, and scale for activities of daily living. Data analysis was done using the Statistical Package for the Social Sciences. RESULTS: Dementia was confirmed in 326 cases, 193 (59.2%) with NPH, 77 (23.6%) with Alzheimer's disease (AD), 29 (8.9%) with frontotemporal dementia (FTD), and 27 (8.3%) with vascular dementia based on the commonly used criteria. Detailed neuropsychologic assessment could be done in 23 patients with NPH and 15 patients with AD. The mean age was 72.06 ± 9.62 years. Thirteen (56.5%) of the patients were males, and the mean duration of education was for 7.74 ± 3.21 years; the mean duration of illness was for 2.73 ± 2.72 years. The mean mini-mental state examination score was 11.6 ± 5.2 and the mean ACE score was 27.26 ± 1.3. The most severely impaired factor was memory (mean score 6.7 ± 4; percentage of maximum score [PMS] 19.41 ± 11.58) and the least affected was language (mean score 15.56 ± 8.25; PMS 37.06 ± 19.63. No significant difference was seen between ACE total score or subscores when the 15 advanced AD patients were compared. DISCUSSION: The cognitive profile of NPH at an advanced stage was similar to that seen in advanced AD. CONCLUSION: As advanced NPH shows cognition similar to cortical dementia, the pathologic correlate in NPH may not be hydrocephalus alone.