Study of Alzheimer's Dementia Patients with Parkinsonian Features

Abstract

This paper presents a study to test the hypothesis that a parkinsonian subtype of Alzheimer's disease exists. Twenty-one patients with dementia of the Alzheimer's type (DAT) and coexistent parkinsonian features were matched to 21 DAT control patients without parkinsonian signs. All subjects were drawn from 136 patients with DAT evaluated between 1980 and 1982. Items from a standardized clinical evaluation at the time of diagnosis, from continuous yearly follow-ups, and neuropathologic examination were compared to determine if qualitative differences exist between the two groups. Those with parkinsonian features had significantly shorter duration of symptoms prior to presentation, a trend toward more reports of decreased self-care, and more primitive reflexes on physical examination. While the total Folstein Mini-Mental State Exam (MMSE) scores at presentation were not significantly different, the cases showed greater impairment in language and registration subitems. During follow-up, no differences were observed in performance on MMSE and Dementia Rating Scale scores. Survival curves showed a trend toward poorer survival in the cases. Neuropathologic data were obtained on seven patients with both DAT and parkinsonian features and showed three cases with Alzheimer's disease (AD) alone and four with AD and Parkinson's disease. Four of the DAT control patients were examined neuropathologically, and all had AD without evidence of Parkinson's disease. The results provide preliminary evidence that Alzheimer's patients with parkinsonian signs are a subtype characterized by distinct neurologic signs and a more rapid course.

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References

1. Ditter SM , Mirra SS . Neuropathologic and clinical features of Parkinson's disease in Alzheimer's patients. Neurology 1987; 37:754–760.

2. Leverenz J , Sumi SM . Parkinson's disease in patients with Alzheimer's disease. Arch Neurol 1986; 43:662–664.

3. Chui HC , Teng EL , Henderson V , Moy A. Clinical subtypes of dementia of the Alzheimer type. Neurology 1985; 35:1544–1550.

4. Molsa PK , Martila RJ , Rinne UK . Extrapyramidal signs in Alzheimer's disease. Neurology 1984; 34:1114–1116.

5. Mayeux R , Stern Y , Spanton S. Heterogeneity in dementia of the Alzheimer type: evidence of subgroups. Neurology 1985; 35:453–461.

6. Bondareff W , Mountjoy CQ , Roth M , et al. Age and histopathologic heterogeneity in Alzheimer's disease. Evidence for subtypes. Arch Gen Psychiatry 1987; 44:412–417.

7. Roth M. Evidence on the possible heterogeneity of Alzheimer's disease and its bearing on future inquiries into etiology and treatment. In: Butler R , Beam A , Eds. The aging process; therapeutic implications. New York: Raven Press, 1985: 251.

8. Yates CM , Simpson J , Gordon A , et al. Catecholamines and cholinergic enzymes in presenile and senile Alzheimer type dementia and Down's syndrome. Brain Res 1983; 280:119–126.

9. Rossor MN , Iversen LL , Reynolds GP , et al. Neurochemical characteristics of early and late onset types of Alzheimer's disease. Br Med J 1984; 288:961–964.

10.

10. St. George-Hyslop PH , Tanzi RE , Polinsky RJ , et al. The genetic defect causing familial Alzheimer's disease maps on chromosome 21. Science 1987; 235:885–890.

11.

11. Breitner JC , Folstein MR . Familial Alzheimer's dementia: a prevalent disorder with specific clinical features. Psychol Med 1984; 14:63–80.

12.

12. Breitner JC , Folstein MF , Murphy EA . Familial aggregation in Alzheimer dementia I: a model for the age dependent expression of an autosomal dominant gene. J Psychiatr Res 1986; 20:31–43.

13.

13. Funkenstein HH , Albert MS , Cook NR , et al. Extrapyramidal signs and other neurologic findings in clinically diagnosed Alzheimer's disease. A community-based study. Arch Neurol 1993; 50:51–56.

14.

14. Forstl H , Burns A , Luthert P , et al. The Lewy body variant of Alzheimer's disease clinical and pathological findings. Br J Psychiatry 1993; 162:385–392.

15.

15. Morris JC , Drazner M , Fuling K , Grant EA . Clinical and pathological aspects of Parkinsonism in Alzheimer's disease. Arch Neurol 1989; 46:651–657.

16.

16. Zetusky WJ , Jankovic J , Priozzolo FJ . The heterogeneity of Parkinson's disease: clinical and prognostic implications. Neurology 1985; 35:522–526.

17.

17. Mortimer JA , Pirozzolo FJ , Hansch EC , Webster DD . Relationship of motor symptoms to intellectual deficits in Parkinson's disease. Neurology 1982; 32:133–137.

18.

18. Larson EB , Reifler BV , Featherstone HJ , English DR . Dementia in elderly outpatients: a prospective study. Ann Intern Med 1984; 100:417–423.

19.

19. Larson EB , Reifler BV , Sumi SM , et al. Diagnostic evaluation of 200 elderly outpatients with suspected dementia. J Gerontol 1985; 40:536–543.

20.

20. Folstein MF , Folstein S , McHugh S. “Minimental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198.

21.

21. Blessed G , Tomlinson BE , Roth M. The association between quantitative measures of dementia and senile change in the cerebral gray matter of elderly subjects. Br J Psychiatry 1968; 114:797–811.

22.

22. Khachaturian ZS . Diagnosis of Alzheimer's disease. Arch Neurol 1985; 42: 1097.

23.

23. Tyrell PJ , Rossor MN . Extrapyramidal signs in dementia of Alzheimer's type. Lancet 1989; 2:920. Letter.

24.

24. Klawans H , Tanner C. Movement disorders in the elderly. In: Albert M , ed. Clinical neurology of aging. New York: Oxford, 1987: 387.

25.

25. Jellinger K. Neuropathological substrates of Alzheimer's disease and Parkinson's disease. J Neural Trans Suppl 1987; 24:109–129.

26.

26. Jorm AF . Subtypes of Alzheimer's dementia: a conceptual analysis and critical review. Psychol Med 1985; 15:543–553.

27.

27. Laird NM , Ware JH . Random effects for longitudinal data. Biometrics 1982; 38:963–974.

28.

28. Huber SJ , Shuttleworth EC , Paulson GW , et al. Cortical vs subcortical dementia. Neuropsychological differences. Arch Neurol 1986; 43:392–394.

29.

29. Albert M. Subcortical dementia in Alzheimer's disease. In: Katzman R , Terry R , Bick K , Eds. Senile dementia and related disorders. New York: Raven Press, 1978: 173–180.

30.

30. Hansen L , Salmon D , Galasko D , et al. The Lewy body variant of Alzheimer's disease: a clinical and pathologic entity. Neurology 1990; 40:1–8.

31.

31. Dickson DW , Davies P , Mayeux R , et al. Diffuse Lewy body disease* Neuropathological and biochemical studies of six patients. Acta Neuropathol 1987; 75:8–15.

32.

32. Byrne EJ , Lennox G , Lowe J , Godwin-Austen RB . Diffuse Lewy body disease: clinical features in 15 cases. J Neurol Neurosurg Psychiatry 1989; 52:709–717.

33.

33. Lennox G , Lowe J , Landon M , et al. Diffuse Lewy body disease: correlative neuropathology using anti-ubiquitin immunocytochemistry. J Neurol Neurosurg Psychiatry 1989; 52:1236–1247.

34.

34. Gibb WR , Mountjoy CQ , Mann DM , Lees AJ . A pathological study of the association between Lewy body disease and Alzheimer's disease. J Neurol Neurosurg Psychiatry 1989; 52:701–708.

35.

35. Gibb WR , Esiri MM , Lees AJ . Clinical and pathological features of diffuse cortical Lewy body disease (Lewy body dementia). Brain 1985; 110:1131–1153.

36.

36. Burkhardt CR , Filley CM , Kleinschmidt-DeMasters BK , et al. Diffuse Lewy body disease and progressive dementia. Neurology 1988; 38:1520–1528.

37.

37. Crystal HA , Dickson DW , Lizardi JE , et al. Antemortem diagnosis of diffuse Lewy body disease. Neurology 1990; 40: 1523–1528.

38.

38. Kosaka K , Tsuchiya K , Yoshimura M. Lewy body disease with and without dementia: a clinicopathological study of 35 cases. Clin Neuropathol 1988; 7:299–305.

39.

39. McKeith IG , Perry RH , Fairbairn AF , et al. Operational criteria for senile dementia of Lewy body type (SDLT). Psychol Med 1992; 22:911–922.