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Clinical and Neuropsychological Profile of Patients with Dementia Cognitive neurology J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2019-321567 on 24 April 2020. Downloaded from ORIGINAL RESEARCH Clinical and neuropsychological profile of patients with dementia and chronic traumatic encephalopathy Christian LoBue ,1,2 Jeff Schaffert ,1 C Munro Cullum ,1,2,3 Matthew E Peters ,4 Nyaz Didehbani ,1 John Hart ,1,3,5 Charles L White 6 ► Additional material is ABSTRact slowness and cognitive changes have been reported published online only. To view Objective To determine whether subjects with chronic in CTE subjects using postmortem interviews with please visit the journal online informants,3 although these are nonspecific symp- (http:// dx. doi. org/ 10. 1136/ traumatic encephalopathy (CTE) and dementia have jnnp- 2019- 321567). distinct clinical features compared to subjects with toms that are seen in many other conditions. Retro- pathologically confirmedA lzheimer’s disease (AD). spective interviews are subject to recall bias, with 1Psychiatry, UT Southwestern Methods Among 339 subjects assessed for CTE potential for inaccurate reporting of symptoms,4 Medical Center, Dallas, Texas, in the National Alzheimer’s Coordinating Center and depression and substance use disorders can USA 2Neurological Surgery, UT dataset, 6 subjects with CTE and 25 subjects with AD occur for many reasons, possibly related to genetic Southwestern Medical Center, neuropathologic change matched for age (±5 years) predisposition, adverse life events and/or health Dallas, Texas, USA and sex were identified.A ll subjects had a clinical problems unrelated to brain injuries.5 Many cases 3 Neurology and diagnosis of dementia. Neurological examination, identified with CTE also show neuropathologic Neurotherapeutics, UT lesions that meet criteria for alternative neurode- Southwestern Medical Center, neuropsychological testing and emotional/behavioural Dallas, Texas, USA data were compared between CTE and AD subjects at generative diseases, including Alzheimer’s disease 4Psychiatry and Behavioral the time of dementia diagnosis and last clinical visit near (AD), Lewy body disease and frontotemporal lobar Sciences, Johns Hopkins death. degeneration (FTLD),3 6 7 but when present with University School of Medicine, Results A history of traumatic brain injury with loss of CTE, oftentimes CTE becomes the primary diag- Baltimore, Maryland, USA 5Callier Center, School of consciousness (LOC) was reported in one CTE and one nosis/classification. Whether cases with CTE have a Behavioral and Brain Sciences, AD subject; information about injuries without LOC or clinical phenotype that may be distinguished from University of Texas at Dallas, multiple injuries was unavailable. CTE and AD subjects other neurodegenerative diseases is unknown given copyright. Dallas, Texas, USA 6 did not differ significantly at the time of diagnosis or last the absence of prospective clinical studies during Pathology, UT Southwestern life. The aim of this study was to explore the clinical Medical Center, Dallas, Texas, visit on the Unified Parkinson’s DiseaseR ating Scale— USA Motor Exam, global measures of cognitive functioning and neuropsychological characteristics of subjects (Mini-Mental State Exam and Clinical Dementia Rating later diagnosed as having CTE at autopsy and to Correspondence to Scale), emotional/behaviour symptoms as assessed with compare the clinical features of subjects with CTE Dr Christian LoBue, UT the Neuropsychiatric Inventory questionnaire or across to those with AD from a large multicentre national Southwestern Medical, Dallas, neuropsychological measures. All CTE participants had database. TX 75390-8570, USA; christian. lobue@ utsw. edu co- occurring neuropathologic processes, including AD and most had TAR DNA-binding protein 43 (TDP-43) Received 3 July 2019 neuropathology. METHODS http://jnnp.bmj.com/ Revised 8 November 2019 Conclusions CTE pathology was rare in a large Data were obtained from the National Alzheimer’s Accepted 12 January 2020 multicentre national dataset, and when present, was Coordinating Center (NACC). Since 2005, NACC Published Online First 24 April has been collecting a Uniform Data Set (UDS)8 from 2020 accompanied by AD and TDP-43 pathologies. CTE was not associated with a different clinical presentation all Alzheimer’s Disease Research Centers (ADRC) from AD or with greater cognitive impairment or across the US, including detailed sociodemographic neurobehavioral symptoms. These findings suggest that information, medical history (see online supple- CTE may not have a distinct clinical profile when other mentary eMethods), neurological examination find- neuropathologic processes are coexistent with CTE ings, neuropsychological test results and psychiatric on September 26, 2021 by guest. Protected pathology. symptoms on individuals with normal cognition, mild cognitive impairment and dementia. Informa- tion about traumatic brain injury (TBI) with loss ► http:// dx. doi. org/ 10. 1136/ of consciousness (LOC) is documented as absent, jnnp- 2019- 322310 INTRODUCTION recent/active (occurring within 1 year of visit or Chronic traumatic encephalopathy (CTE) is a currently requiring treatment) or remote/inac- neuropathologic condition often reported to be tive (occurring >1 year of visit and not currently associated with repetitive head injuries.1 The iden- receiving treatment); data about TBI without LOC © Author(s) (or their employer(s)) 2020. No tification of CTE requires a single collection of or multiple injuries were unavailable for subjects commercial re-use . See rights hyperphosphorylated tau in neurons, astrocytes in the dataset. For each ADRC visit, a multidis- and permissions. Published or cell processes around small blood vessels at the ciplinary team or a single clinician determines a by BMJ. depths of sulci within the brain.2 While the neuro- clinical diagnosis based on established guidelines. To cite: LoBue C, Schaffert J, pathological features of CTE have been defined, the NACC has been collecting neuropathology data Cullum CM, et al. J Neurol clinical manifestations of CTE are not well under- on AD, Lewy body disease (LBD), FTLD and other Neurosurg Psychiatry stood. Impulsivity, depression/suicidality, substance neurological conditions from participants autopsied 2020;91:586–592. misuse, anxiety, anger, gait instability, motor at ADRCs since 2002 into a Neuropathology Data 586 LoBue C, et al. J Neurol Neurosurg Psychiatry 2020;91:586–592. doi:10.1136/jnnp-2019-321567 Cognitive neurology J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2019-321567 on 24 April 2020. Downloaded from Set.9 The UDS clinical data can be paired with neuropatholog- Neuropsychological evaluation ical information on individual subjects to capture comprehensive A brief neuropsychological battery assessing attention, memory, clinical symptoms in autopsy-confirmed cases. NACC launched language and executive functioning was completed (see box 1). neuropathological data collection procedures for CTE in 2014. Standardised scores were calculated based on a regression algo- Research using the NACC dataset has been approved by the rithm previously created in NACC subjects14 and were further University of Washington IRB. defined as being within normal limits (t- scores ≥40), mildly impaired (t- scores 30–39), moderately impaired (t- scores 21–29) and severely impaired (t- scores ≤20). The frequency of scores Study population falling into each category of functioning was examined in order A cohort of subjects with CTE was identified by selecting to compare the level and pattern of cognitive function between participants who received a neuropathologic diagnosis of CTE CTE and AD subjects. using previously defined criteria (see online supplementary eMethods).10 For a comparison group, patients who had a clin- Psychiatric assessment ical diagnosis of dementia during ADRC visits, an absence of CTE Psychiatric symptom data included a history of depression pathology at autopsy and significant AD pathology reflecting (coded as consulting a clinician, being prescribed medication or a neuropathologic diagnosis of AD by NIA- AA criteria11 were receiving a diagnosis related to depressed mood), a depressive selected (see online supplementary eMethods). AD subjects were symptoms scale (Geriatric Depression Scale-Short Form), history matched to CTE subjects on sex and age (±5 years). of pseudobulbar affect, history of substance use disorder and the Neuropsychiatric Inventory Questionnaire (NPI- Q) assessing Neuropathological evaluation presence/absence of 12 neurobehavioral symptoms (see online 15 ADRC neuropathologists used well- established diagnostic supplementary eMethods). criteria to identify a variety of pathologic conditions at autopsy in addition to CTE and AD. These neuropathologic conditions Statistical analysis included other tauopathies (eg, FTLD), synucleinopathy (eg, The CTE and AD groups were compared on sociodemographic, LBD), cerebral amyloid angiopathy and vascular brain injury (see medical history, neurological examination, neuropsychological online supplementary eTable 1 for full listing). The frequency of evaluation and psychiatric variables using t-tests for continuous these pathologic conditions was examined in order to account variables and χ2 analyses for categorical variables. Because all for their presence and potential influence on the clinical and of the cases with CTE received a clinical diagnosis of dementia, neuropsychological profiles. characteristics from the initial encounter when dementia
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