1、Barry Reisberg, M. D.,Professor of Psychiatry Director, Fisher Alzheimers Disease Program Clinical Director, Aging & Dementia Research Center Director, Clinical Core, NYU Alzheimers Disease Center New York University School of Medicine,Agenda,3:00 PM Introduction to Workshop Barry Reisberg, M.D.3:05
2、 PM Cognitive dynamics: how variability in brain Kenneth Rockwood M.D., FRCPC, FRCP function influences the risk of cognitive decline3:35 PM Current Knowledge of Methodologies for Barry Reisberg, M.D. Clinical Trials in Pre-MCI Persons with Subjective Cognitive Impairment (SCI)4:25 PM Discussion of
3、Current Knowledge and Joel Sadavoy M.D., FRCPC Methodologies4:35 PM Discussion of Clinical Instrumentation for Barry Reisberg, M.D. Subject Selection and Assessment4:55 PM Subject Interview Workshop Faculty and Participants5:25 PM Final Discussion Joel Sadavoy M.D., FRCPC,GLOBAL DETERIORATION SCALE
4、(GDS),(Choose the most appropriate global stage based upon cognition and function, and CHECK ONLY ONE.) 1. No subjective complaints of memory deficit. No memory deficit evident on clinical interview. 2. Subjective complaints of memory deficit, most frequently in following areas:(a) forgetting where
5、one has placed familiar objects;(b) forgetting names one formerly knew well. No objective evidence of memory deficit on clinical interview. No objective deficit in employment or social situations. Appropriate concern with respect to symptomatology. 3. Earliest clear-cut deficits.Manifestations in mo
6、re than one of the following areas: (a) patient may have gotten lost when traveling to an unfamiliar location. (b) co-workers become aware of patients relatively poor performance. (c) word and/or name finding deficit become evident to intimates. (d) patient may read a passage or book and retain rela
7、tively little material. (e) patient may demonstrate decreased facility remembering names upon introduction to new people. (f) patient may have lost or misplaced an object of value. (g) concentration deficit may be evident on clinical testing. Objective evidence of memory deficit obtained only with a
8、n intensive interview. Decreased performance in demanding employment and social settings. Denial begins to become manifest in patient. Mild to moderate anxiety frequently accompanies symptoms.4. Clear-cut deficit on careful clinical interview. Deficit manifest in following areas: (a) decreased knowl
9、edge of current and recent events. (b) may exhibit some deficit in memory of ones personal history. (c) concentration deficit elicited on serial subtractions. (d) decreased ability to travel, handle finances, etc. Frequently no deficit in following areas: (a) orientation to time and place. (b) recog
10、nition of familiar persons and faces. (c) ability to travel to familiar locations. Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening of affect and withdrawal from challenging situations.,GLOBAL DETERIORATION SCALE (GDS),5. Patient can no longer survive without some
11、 assistance. Patient is unable during interview to recall a major relevant aspect of their current life, e.g.: (a) their address or telephone number of many years. (b) the names of close members of their family (such as grandchildren). (c) the name of the high school or college from which they gradu
12、ated. Frequently some disorientation to time (date, day of the week, season, etc.) or to place. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their
13、own names and generally know their spouses and childrens names. They require no assistance with toileting or eating, but may have difficulty choosing the proper clothing to wear.6. May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaw
14、are of all recent events and experiences in their lives. Retain some knowledge of their surroundings; the year, the season, etc. May have difficulty counting by 1s from 10, both backward and sometimes forward. Will require some assistance with activities of daily living: (a) may become incontinent.
15、(b) will require travel assistance but occasionally will be able to travel to familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment.Personality and emotional ch
16、anges occur. These are quite variable and include: (a) delusional behavior, e.g., patients may accuse their spouse of being an imposter; may talk to imaginary figures in the environment, or to their own reflection in the mirror. (b) obsessive symptoms, e.g., person may continually repeat simple clea
17、ning activities. (c) anxiety symptoms, agitation, and even previously non-existent violent behavior may occur. (d) cognitive abulia, e.g., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action.7. All verbal abilities are lost over the c
18、ourse of this stage. Early in this stage words and phrases are spoken but speech is very circumscribed. Later there is no serviceable speech at all - only unintelligible utterances with rare emergence of seemingly forgotten words and phrases. Incontinent; requires assistance toileting and feeding. B
19、asic psychomotor skills (e.g. ability to walk) are lost with the progression of this stage. The brain appears to no longer be able to tell the body what to do. Generalized rigidity and developmental neurologic reflexes are frequently present. Reisberg, B., Ferris, S.H., de Leon, M.J., et al., The gl
20、obal deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 1982, 139:1136-1139. 1983 Barry Reisberg, M.D. All rights reserved.,GLOBAL DETERIORATION SCALE (GDS) Stage 1,1. No subjective complaints of memory deficit. No memory deficit evident on clinical
21、interview.,GLOBAL DETERIORATION SCALE (GDS) Stage 2,2. Subjective complaints of memory deficit, most frequently in following areas:(a) forgetting where one has placed familiar objects;(b) forgetting names one formerly knew well.No objective evidence of memory deficit on clinical interview.No objecti
22、ve deficit in employment or social situations. Appropriate concern with respect to symptomatology.,GLOBAL DETERIORATION SCALE (GDS) Stage 3,3. Earliest clear-cut deficits.Manifestations in more than one of the following areas: (a) patient may have gotten lost when traveling to an unfamiliar location
23、. (b) co-workers become aware of patients relatively poor performance. (c) word and/or name finding deficit become evident to intimates. (d) patient may read a passage or book and retain relatively little material. (e) patient may demonstrate decreased facility remembering names upon introduction to
24、 new people. (f) patient may have lost or misplaced an object of value. (g) concentration deficit may be evident on clinical testing.Objective evidence of memory deficit obtained only with an intensive interview. Decreased performance in demanding employment and social settings. Denial begins to bec
25、ome manifest in patient. Mild to moderate anxiety frequently accompanies symptoms.,Abridged Global Deterioration Scale,Copyright 2008 Barry Reisberg, M.D. All rights reserved. Abridged version published in Canadian Medical Association Journal, 2008; 179 (12); p. 1281. Modified from Reisberg, B., Fer
26、ris, S.H., de Leon, M.J, et al. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry, 1982; 139: 1136-1139.,Stage 1 No subjective memory deficit (no cognitive impairment); no problems with activities of daily living Stage 2 Subjective memory complaints (sub
27、jective cognitive impairment): Complaints of being forgetful, such as complaints of trouble with recall of names, complaints of misplacing objects Stage 3 Earliest clear deficits (mild cognitive impairment): Difficulties often noted at work; may have gotten lost; may have misplaced a valuable object
28、 Stage 4 Clear deficits on clinical examination (moderate cognitive impairment): Decreased knowledge of personal and/or current events; often trouble with travel and finances Stage 5 Can no longer survive independently in the community without some assistance (moderately severe cognitive impairment)
29、: Difficulty with recall of some important personal details (e.g., address, names of one or more important schools attended); may require cuing for activities of daily living Stage 6 Largely unable to verbalize recent events in their life (severe cognitive impairment): May forget name of spouse; inc
30、ontinence develops as this stage progresses; requires increasing assistance with activities of daily living; increased behavioral problems (e.g., agitation, delusions)Stage 7 Few intelligible words or no verbal abilities (very severe cognitive impairment): Loses the ability to walk as this stage evo
31、lves,Stage 1: NCI. No Thinking (Cognitive) Impairment. No self evident decline in memory or thinking abilities; no thinking related problems with daily activities or work. Stage 2: SCI. Subjective (Self Evident) Cognitive (Thinking) Impairment. Personal belief that thinking abilities have declined i
32、n comparison with the persons abilities five or ten year previously. Persons may notice that they are forgetful, such as of having trouble with recall of names, and/or of misplacing objects. Stage 3: MCI. Mild Cognitive (Thinking) Impairment. Earliest noticeable problems with memory and, or thinking
33、 abilities. For example, problems or difficulties with thinking abilities and performance may be noted at work; the person may have gotten lost; the person may have misplaced a valuable object. Sometimes other people notice that the person repeats things that the person has already said. Also, anxie
34、ty may be evident. Stage 4: Mild Dementia. Clear deficits on a doctors or other professionals examination of thinking abilities. Decreased knowledge of personal and/or current events. For example, the person may have gone away on a recent trip, perhaps to visit relatives, and the person may have com
35、pletely forgotten where they went. Often difficulties with managing personal funds or shopping correctly, or with independent travel or with meal preparation. Frequently, the person may become more withdrawn or less active in a variety of ways. For example, rather than preparing the holiday meal, th
36、e person may say “Im just not up to it this year”, or “Im getting old”, or “Im getting tired, or “Im just not the person I used to be.” Generally, persons at this stage can still manage independently in the community, although the difficulties mentioned may be evident. Stage 5: Moderate Dementia. Ca
37、n no longer survive independently in the community without some assistance. Difficulty with recall of some important personal details (for example, the persons correct address; the names of one or more important schools attended in childhood, adolescence, and early adulthood); may require cuing for
38、activities for daily living. Characteristically, persons at this stage have difficulties selecting appropriate clothing to wear for the day, considering the days events, weather conditions, etc. Therefore, the spouse or other assistant will begin to counsel regarding choice of clothing. Also, person
39、s at this stage can still generally put on their clothing and shower (bathe) without assistance. Stage 6: Moderately Severe Dementia. Largely unable to describe recent events in their life (severe thinking problems): When asked, has little or no idea of their current address, the current weather con
40、ditions, etc. May forget the name of their spouse. When asked, may or may not be able to state their former job, their mothers name, their fathers name, or their country of birth. Requires increasing assistance with activities of daily living such as dressing (putting on their clothes) and showering
41、. Difficulty with control of urination and, generally later, bowel movements, develops as this stage progresses. Increased behavioral problems (for example, agitation or aggression) or other personality problems are common. Stage 7: Severe Dementia. Few understandable words or no speaking abilities
42、(very severe thinking impairment). Incontinent of both urine and feces unless assistance is provided to prevent toileting accidents, such as frequent escorting to the bathroom. Loses the ability to walk as this stage evolves. Later basic abilities such as the ability to sit-up independently, to smil
43、e, and to move and/or to hold up the head independently, are progressively lost. .,Global Deterioration Scale for Concerned Persons, Families and FriendsChoose the most appropriate stage based mainly on thinking and functioning abilities,Copyright 1983, 2008, 2009, 2010 Barry Reisberg, M.D. All righ
44、ts reserved. Abridged Global Deterioration Scale published in Canadian Medical Association Journal, 2008; 179(12); p. 1281. Modified from Reisberg, B., Ferris, S.H., de Leon, M.J. et al. The global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 1
45、982, 139:1136-1139.,Stage 1: NCI. No Thinking (Cognitive) Impairment. No self evident decline in memory or thinking abilities; no thinking related problems with daily activities or work. Stage 2: SCI. Subjective (Self Evident) Cognitive (Thinking) Impairment. Personal belief that thinking abilities
46、have declined in comparison with the persons abilities five or ten year previously. Persons may notice that they are forgetful, such as of having trouble with recall of names, and/or of misplacing objects. Stage 3: MCI. Mild Cognitive (Thinking) Impairment. Earliest noticeable problems with memory a
47、nd, or thinking abilities. For example, problems or difficulties with thinking abilities and performance may be noted at work; the person may have gotten lost; the person may have misplaced a valuable object. Sometimes other people notice that the person repeats things that the person has already sa
48、id. Also, anxiety may be evident.,Global Deterioration Scale for Concerned Persons, Families and FriendsChoose the most appropriate stage based mainly on thinking and functioning abilities,Copyright 1983, 2008, 2009, 2010 Barry Reisberg, M.D. All rights reserved. Abridged Global Deterioration Scale
49、published in Canadian Medical Association Journal, 2008; 179(12); p. 1281. Modified from Reisberg, B., Ferris, S.H., de Leon, M.J. et al. The global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 1982, 139:1136-1139.,BRIEF COGNITIVE RATING SCALE
50、(BCRS)INSTRUCTIONS Each axis of the Brief Cognitive Rating Scale is scored independently. Each axis is designed to be optimally concordant with the other axes and with the numerically corresponding Global Deterioration Scale stage. Consequently, each axis of the BCRS conveys important staging relate
51、d information. For clinical purposes scores can be reported conveniently as consecutive axis scores, e.g., “6,5,6,4,5“. This reporting methodology indicates relative capacity in each axis modality, i.e., concentration, recent memory, etc. For therapeutic trials the axes can be added and total scores for the five axes can be utilized. For staging, the Global Deterioration Scale stage is very closely equivalent to the average score of the BCRS axes. Ideally, for staging purposes, the BCRS can be used as a semistructured procedure for guiding final GDS stage assignments.,
