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Apraxia in Mild Cognitive Impairment and Alzheimer's Disease

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Apraxia in Mild Cognitive Impairment and Alzheimer's Disease 2.4 Apraxia in Mild Cognitive Impairment and Alzheimer’s disease: validity and reliability of the Van Heugten test for apraxia Dementia and Geriatric Cognitive Disorders, 2014 Lieke L. Smits1, Marinke Flapper1, Nicole Sistermans1, Yolande A.L. Pijnenburg1, Philip Scheltens1 1,2 and Wiesje M. van der Flier Alzheimer Center and departments of 1 Neurology and 2 Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, the Netherlands. Abstract Objective: To assess reliability and validity of Van Heugten test for apraxia (VHA), developed for and used in stroke patients, in a memory clinic population. To assess presence and severity of apraxia in Mild Cognitive Impairment (MCI) and Alzheimer’s disease (AD) and to investigate which AD patients were likely to have apraxia. Methods: We included 90 controls (age:609 years,MMSE:282), 90 MCI patients (age:657 years,MMSE:262) and 158 AD patients (age:668 years,MMSE:205). Apraxia was evaluated by VHA assessing ideational and ideomotor praxis. We retested 20 patients to assess reliability. Results: Intrarater reliability was 0.88 and interrater reliability was 0.73. AD patients performed worse on VHA (median:88;range:51-90) than controls (median:90;range:88-90) and MCI patients (median:89;range:84-90) (both p<0.001). Apraxia was prevalent in 35% of AD patients, 10% of MCI and not in controls (0%;p<0.001). In AD, dementia severity was the main risk for apraxia; 15% of mildly versus 52% of moderately demented patients had apraxia (OR(95%CI)=6.7(2.9-15.6)). The second risk factor was APOE genotype; APOE Ɛ4 non-carriers (47%) were at increased risk compared to carriers (30%) (OR(95%CI)=2.1(1-4.7)). Conclusion: Apraxia can be reliably measured with VHA. Apraxia is present in a proportion of patients with MCI and AD. Presence of apraxia in AD is related to dementia severity and APOE Ɛ4. Introduction Apraxia is defined as the inability to carry out learned movements, not caused by motor or sensory impairments, comprehension or cooperation [1]. Apraxia can traditionally be subdivided in ideomotor and ideational apraxia. Ideomotor apraxia refers to the inability to perform gesture pantomimes and imitations correctly, while the actual use of tools is less affected [2,3]. Ideational apraxia refers to the inability to carry out a sequence of actions, but it is also associated with a deficit in tool selection and use, even in single object use [3-5]. A patient with ideomotor apraxia knows what to do but doesn’t know how, while a patient with ideational apraxia doesn’t know what to do with a tool. Before the new clinical criteria for Alzheimer’s disease (AD) were proposed, memory impairment followed by impairment in other cognitive domains was considered the core feature of AD [6]. The new criteria recognize that in a subset of atypical patients cognitive domains other than memory may be the core presenting symptom [7]. In a former study, we found that among these atypical patients apraxia/visuo-spatial presentation is the most common non-amnestic presentation [8]. In AD, the presence of apraxia is most often based on clinical judgement or simple bedside tests, since a widely used, validated test is lacking. Table 1 provides a short overview of the literature on apraxia in AD. Only a small number of studies has been performed, most decades ago and in small samples. Interest seems to increase as evidenced by some recent papers. Two of those former studies showed that roughly one third of mildly demented AD-patients had apraxia on testing [9,10] and the frequency increased with disease severity [9]. Another small study in AD and healthy controls showed that patients performed worse on both ideomotor and ideational apraxia than controls, and especially pantomimes of tool use were most impaired [11]. Furthermore, it has been suggested that patients with early onset AD were more impaired on praxis than late onset patients [12]. As can be appreciated from table 1, tests were not validated. Moreover, the test that was used was often not described in detail [12]. Van Heugten and colleagues developed and validated an apraxia test in a stroke population [13]. We aimed to study its reliability and validity in our memory clinic population. Secondly, we investigated presence and severity of apraxia in MCI, AD and examined which patients with AD were most likely to have apraxia. Table 1. Overview of studies to apraxia in Alzheimer’s disease Study N Apraxia test Reliability/Validity Results Van 44 stroke The Van Heugten test for H coefficient: 0.72 The test is a simple and Heugten et patients with apraxia, based on tests by Rho-value: 0.97 consistent instrument and al., 1999 apraxia De Renzi [28,47]. Cut off of 86 can sufficiently [13] 35 stroke points: differentiate between patients without sensitivity: 0.91 persons with and without apraxia specificity: 0.90 apraxia. 50 older controls positive predictive Apraxia was value: 0.89 based on clinical negative predictive evaluation. value: 0.92 Della Sala 18 Mild AD (not Assesses ideomotor -- 6 (33%) patients were et al., 1987 further specified) apraxia through the apraxic. [10] with 7±2 months imitation movement test Ideomotor apraxia is not follow up by De Renzi [28]. an early feature. Rapcsak et 28 AD Assesses ideomotor and -- AD performed worse than al., 1989 (mean MMSE: ideational apraxia through HC on ideomotor and [11] 12) 33 tasks, partly based on ideational apraxia tasks. 23 HC Liepmann [43]. Patients with AD were most impaired on pantomimes of tool use (ideomotor apraxia). Edwards 142 AD Assesses ideomotor and Cronbach’s α: 0.92 Apraxia: et al., 1991 113 HC ideational apraxia. Interrater reliability: 35% mild AD (CDR 1) [9] Dementia Standardized motor r=0.81 58% moderate AD (CDR severity based performance battery 2) on Clincal designed for school 98% severe AD (CDR 3) Dementia Rating children, selected from Ideomotor apraxia was Slaon, DeRenzi & apparent in mild AD, Lucchelli and De Renzi, ideational only in Goodglass and Kaplan moderate and severe AD. and common clinical usage [5,28,48,49]. Dobigny- 55 AD Assesses and validates Interrater IAT is an easy and quick Roman et (MMSE: 15±6) the ideomotor apraxia test agreement: to perform and could al., 1998 26 HC (IAT) consisting of ICC=0.99 contribute to an early [31] imitating 10 gestures. sensitivity: 0.95 diagnosis of AD. It Based on Ajuriaguerra specificity: 0.88 correlates with severity of and clinical usage [50]. correlation MMSE: cognitive impairment. r=0.83 Derouesné 22 AD Assesses ideomotor and -- 77% of patients showed et al., 2000 (MMSE: 20±4) ideational apraxia through ideomotor apraxia. All [32] 10 HC eight tasks. patients showed ideational apraxia. Crutch et 35 AD Qualitative praxis: three Meaningful task Sequential movements al., 2007 (MMSE: 21±4) traditional gesture dominant hand; (quantitative praxis) were [51] 75 HC production tasks, to sensitivity: 0.35 validated as measures of ensure some patients specificity: 0.99, praxis and found to be were apraxic. AUC: 0.76 more sensitive than Quantitative praxis: Meaningless task qualitative methods. developed and based on dominant hand, Disease severity had two sequential sensitivity: 0.74 minimal and inconsistent movements tasks by specificity: 0.93, influence upon apraxia in Kimura; meaningful and AUC: 0.89 AD. meaningless movements. Study N Apraxia test Reliability/Validity Results Musicco 154 AD Praxis was measured by -- More severely impaired et al., 2010 (MMSE: 18±4) Rey Figure Copy Test and praxis was associated [30] with 2y follow up the Freehand Copy of with more rapid Drawings test [52]. progression. Note: visuo- constructive praxis. Sa et al., 109 Early onset Not specified: part of -- Early onset AD had a 2012 [12] AD neuropsychological test major impairment in (MMSE: 22±5) battery. praxis compared to late 171 Late onset onset AD. AD (MMSE: 21±4) Falchook et 10 AD Conceptual praxis was -- Patients with AD had al., 2012 (MMSE: 15±5) measured by the in-house conceptual apraxia and [46] 12 amnesticMCI developed Alternative tool this was associated with (MMSE: 26±2) selection test, Tool impaired knowledge of 18 HC selection test Taxonomic relations test semantic taxonomic Ideomotor praxis was relations. measured by pantomimes. Serra et al., 24 AD with Constructional praxis was -- Constructional apraxia in 2014 [45] apraxia (MMSE: measured by the AD is more often 18±4) Freehand Copy of associated with an early 24 AD no Drawings test [52]. onset, a different apraxia (MMSE: neuropsychological 20±2) profile and gray matter 20 HC distribution. N: Number of subjects included, AD: Alzheimer’s disease,HC: Healthy controls, MMSE: Mini-Mental State Examination, CDR: Clinical Dementia Rating, ICC: Intraclass correlation Coefficient, AUC: Area Under the Curve Methods Subjects 338 Patients (90 controls, 90 MCI and 158 AD) were included from the Amsterdam Dementia Cohort at the Alzheimer Center of the VU University Medical Center (VUmc) Amsterdam, between October 2010 and September 2012. All patients underwent a standardized one-day assessment including medical history, informant-based history including the disability assessment for dementia (DAD) [14], physical and neurological exam, neuropsychological assessment, laboratory tests, magnetic resonance imaging (MRI) of the brain and electroencephalogram (EEG). The neuropsychological assessment included Mini-Mental State Examination (MMSE) [15], Cambridge Cognitive Examination (CAMCOG) [16], the Visual Association Test (VAT) [17], total immediate recall and delayed recall of the Dutch version of the Rey auditory verbal learning task (RAVLT) [18,19], category fluency (animals) [20], the Dutch version of Controlled Oral Word Association Test (COWAT) (letter fluency) [21], three subtests of the Visual Object and Space Perception Battery (VOSP): incomplete letters, dot counting and number location [22], Trail Making Test (TMT) A and B [23] and the forward and backwards condition of Digit Span (extended version) [24] and Stroop [25].
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