Cited by 548Dementia and Cognitive Impairment ResearchAlzheimer's disease research and treatmentsHistorical and Modern Theater Studies

The behavioural/dysexecutive variant of Alzheimer’s disease: clinical, neuroimaging and pathological features

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Ossenkoppele, Rik, Pijnenburg, Yolande A. L., Perry, David C., Cohn-Sheehy, Brendan I., Scheltens, Nienke M. E., Vogel, Jacob W., Kramer, Joel H., van der Vlies, Annelies E. +13 more·2015·Brain

Abstract

A 'frontal variant of Alzheimer's disease' has been described in patients with predominant behavioural or dysexecutive deficits caused by Alzheimer's disease pathology. The description of this rare Alzheimer's disease phenotype has been limited to case reports and small series, and many clinical, neuroimaging and neuropathological characteristics are not well understood. In this retrospective study, we included 55 patients with Alzheimer's disease with a behavioural-predominant presentation (behavioural Alzheimer's disease) and a neuropathological diagnosis of high-likelihood Alzheimer's disease (n = 17) and/or biomarker evidence of Alzheimer's disease pathology (n = 44). In addition, we included 29 patients with autopsy/biomarker-defined Alzheimer's disease with a dysexecutive-predominant syndrome (dysexecutive Alzheimer's disease). We performed structured chart reviews to ascertain clinical features. First symptoms were more often cognitive (behavioural Alzheimer's disease: 53%; dysexecutive Alzheimer's disease: 83%) than behavioural (behavioural Alzheimer's disease: 25%; dysexecutive Alzheimer's disease: 3%). Apathy was the most common behavioural feature, while hyperorality and perseverative/compulsive behaviours were less prevalent. Fifty-two per cent of patients with behavioural Alzheimer's disease met diagnostic criteria for possible behavioural-variant frontotemporal dementia. Overlap between behavioural and dysexecutive Alzheimer's disease was modest (9/75 patients). Sixty per cent of patients with behavioural Alzheimer's disease and 40% of those with the dysexecutive syndrome carried at least one APOE ε4 allele. We also compared neuropsychological test performance and brain atrophy (applying voxel-based morphometry) with matched autopsy/biomarker-defined typical (amnestic-predominant) Alzheimer's disease (typical Alzheimer's disease, n = 58), autopsy-confirmed/Alzheimer's disease biomarker-negative behavioural variant frontotemporal dementia (n = 59), and controls (n = 61). Patients with behavioural Alzheimer's disease showed worse memory scores than behavioural variant frontotemporal dementia and did not differ from typical Alzheimer's disease, while executive function composite scores were lower compared to behavioural variant frontotemporal dementia and typical Alzheimer's disease. Voxel-wise contrasts between behavioural and dysexecutive Alzheimer's disease patients and controls revealed marked atrophy in bilateral temporoparietal regions and only limited atrophy in the frontal cortex. In direct comparison with behavioural and those with dysexecutive Alzheimer's disease, patients with behavioural variant frontotemporal dementia showed more frontal atrophy and less posterior involvement, whereas patients with typical Alzheimer's disease were slightly more affected posteriorly and showed less frontal atrophy (P < 0.001 uncorrected). Among 24 autopsied behavioural Alzheimer's disease/dysexecutive Alzheimer's disease patients, only two had primary co-morbid FTD-spectrum pathology (progressive supranuclear palsy). In conclusion, behavioural Alzheimer's disease presentations are characterized by a milder and more restricted behavioural profile than in behavioural variant frontotemporal dementia, co-occurrence of memory dysfunction and high APOE ε4 prevalence. Dysexecutive Alzheimer's disease presented as a primarily cognitive phenotype with minimal behavioural abnormalities and intermediate APOE ε4 prevalence. Both behavioural Alzheimer's disease and dysexecutive Alzheimer's disease presentations are distinguished by temporoparietal-predominant atrophy. Based on the relative sparing of frontal grey matter, we propose to redefine these clinical syndromes as 'the behavioural/dysexecutive variant of Alzheimer's disease' rather than frontal variant Alzheimer's disease. Further work is needed to determine whether behavioural and dysexecutive-predominant presentations of Alzheimer's disease represent distinct phenotypes or a single continuum.

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Crossref · 10.1093/brain/awv191

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  • In fvAD there is greater temporal than frontal atrophy, particularly in the perisylvian area compared to bvFTD.

    “In fvAD there is greater temporal than frontal atrophy, particularly in the perisylvian area compared to bvFTD [21, 33].”

    From Diagnosing the frontal variant of Alzheimer’s disease: a clinician’s yellow brick road (2017) · cites this paper as [21]

    The voxel-based morphometry results (p. 9) describe predominant temporoparietal atrophy with limited frontal atrophy in behavioural Alzheimer’s disease. The neuroimaging comparison (p. 14) contrasts this posterior pattern with the anterior atrophy seen in bvFTD. Our copy does not identify the perisylvian area as a particular focus of the difference. (LLM, conf=0.84)

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  • An early amnestic phase, with memory dysfunction preceding changes in behavior, may be more common in fvAD.

    “Nevertheless, an early amnestic phase, with memory dysfunction preceding changes in behavior may be more common in fvAD [21].”
  • In bvFTD, frontal regions are more affected, particularly the anterior cingulate, orbitofrontal cortex, middle and superior frontal gyrus.

    “In bvFTD, frontal regions are more affected, particularly the anterior cingulate, orbitofrontal cortex, middle and superior frontal gyrus [21, 33].”
  • In one small series, APOE ε4 carriers were observed in 52% of patients with fvAD compared to 19% with bvFTD and 17% controls.

    “In one small series, APOE ε4 carriers were observed in 52% of patients with fvAD compared to 19% with bvFTD and 17% controls [21].”
  • Differential diagnosis of frontotemporal dementia from psychiatric disorders and other neurodegenerative diseases is often aided by neuroimaging using MRI and PET, with predominant asymmetrical frontal and temporal atrophy associated with hypometabolism and hypoperfusion; amyloid imaging assists differential from frontal variant Alzheimer's disease.

    “Differential diagnosis from psychiatric disorders and other neurodegenerative diseases is often aided by neuroimaging, using MRI and PET. There is predominant atrophy of frontal and temporal lobes, which is asymmetrical in the early stages, and this is associated with hypometabolism and hypoperfusion in these regions. Differential diagnosis from the frontal variant of Alzheimer's disease is”

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Research works printed but not linked: 2

  1. Herrero-San Martin,A, Villarejo-Galende, A, Rabano-Gutierrez, A Guerrero-Marquez C, Porta-Etessam J, Bermejo-Pareja F. Frontal variant of Alzheimer's disease. Two pathologically confirmed cases and a literature review [in Spanish]. Rev Neurol 2013; 57: 542-8.
  2. Moller C, Vrenken H, Jiskoot L, Versteeg A, Barkhof F, Scheltens P, et al. Different patterns of gray matter atrophy in earlyand lateonset Alzheimer's disease. Neurobiol Aging 2013; 34: 2014-22.

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Authors
Ossenkoppele, R., Pijnenburg, Y. A. L., Perry, D. C., Cohn-Sheehy, B. I., Scheltens, N. M. E., Vogel, J. W., Kramer, J. H., van der Vlies, A. E., Joie, R. L., Rosen, H. J., van der Flier, W. M., Grinberg, L. T., Rozemuller, A. J., Huang, E. J., van Berckel, B. N. M., Miller, B. L., Barkhof, F., Jagust, W. J., Scheltens, P., Seeley, W. W., & Rabinovici, G. D.
Affiliations
  • University of California, San Francisco (US)
  • Amsterdam UMC Location Vrije Universiteit Amsterdam (NL)
  • University of California, Berkeley (US)
  • Gemeente Amsterdam (NL)
Venue
Brain
Published
2015-07-02
Volume
138
Issue
9
Pages
2732-2749
ISSN
  • 0006-8950 (ISSN-L)
  • 1460-2156
OpenAlex
W1892456310
Cited by
548
References
107
Citations by year
2026: 41 · 2025: 43 · 2024: 47 · 2023: 58 · 2022: 60 · 2021: 68 · 2020: 66 · 2019: 48 · 2018: 44 · 2017: 35 · 2016: 32 · 2015: 5
FWCI
31.42
Type
journal article
Language
en
Open access
Locations
  • Brain (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (publishedVersion)
  • eScholarship (California Digital Library) (submittedVersion)
  • UCL Discovery (University College London) (submittedVersion)
  • Pure Amsterdam UMC (submittedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
Funders
  • BrightFocus Foundation
  • Vanderbilt University Medical Center
  • European Commission (628812)
  • University of California, San Francisco
  • National Institute on Aging (P01-AG1792403, R01AG045611, R01AG027859, R01AG032306, P01AG003991, K23AG045289, P01AG019724, P50AG023501)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
  • Health Sciences › Medicine › Physiology › Alzheimer's disease research and treatments
  • Social Sciences › Psychology › Clinical Psychology › Historical and Modern Theater Studies
Keywords
disease, dysexecutive syndrome, behavioral variant frontotemporal dementia, apathy, APOE ε4, brain atrophy, executive function, memory impairment, amyloid PET, FDG-PET, Alzheimer's disease pathology, differential diagnosis
MeSH terms
Adult, Aged, Aged, 80 and over, Alzheimer Disease, Analysis of Variance, Apolipoproteins E, Mental Disorders, Brain, Cognition Disorders, Female, Humans, Image Processing, Computer-Assisted, Magnetic Resonance Imaging, Male, Mental Status Schedule, Middle Aged, Neuropsychological Tests, Positron-Emission Tomography, Executive Function

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