AIAN_190_13R3

Review: Progress in Medicine (Update on Advances

1AQ1 1
2 in Pathophysiology) 2
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4 4
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Visuo-cognitive skill deficits in Alzheimer’s disease 5
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and Lewy body disease: A comparative analysis 7
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9 Xuemei Li, Priyanka Rastogi1, Jeffrey A. Gibbons2, Suprakash Chaudhury3 9
10 Department of Neurology, Affiliated Hospital of Weifang Medical University, Kuiwen District, Weifang, Shandong, China, 10
11 1
Department of Clinical Psychology, Ranchi Institute of Neuropsychiatry and Allied Sciences, Kanke, Ranchi, Jharkhand, 11
12 India, 2Department of Psychology, Christopher Newport University, Newport News, VA, USA, 3Department of Psychiatry, 12
13 Pravara Institute of Medical Sciences (Deemed University), Rural Medical College, Loni, Maharashtra, India 13
14 14
Abstract
15 15
16 Introduction and Background: Dementia is a chronic neurodegenerative disorder characterized by progressive cognitive loss. Alzheimer’s 16
17 disease (AD) and the Lewy body disease are the two most common causes of age-related degenerative dementia. Visuo-cognitive skills 17
are a combination of very different cognitive functions being performed by the visual system. These skills are impaired in both AD and
18 dementia with Lewy bodies (DLB). The aim of this review is to evaluate various studies for these visuo-cognitive skills. Methodology:
18
19 An exhaustive internet search of all relevant medical databases was carried out using a series of key-word applications, including The 19
20 Cochrane Library, MEDLINE, PSYCHINFO, EMBASE, CINAHL, AMED, SportDiscus, Science Citation Index, Index to Theses, ZETOC, 20
21 PEDro and occupational therapy (OT) seeker and OT search. We reviewed all the articles until March 2013 with key words of: Visual 21
skills visual cognition dementia AD, but the direct neurobiological etiology is difficult to establish., Dementia of Lewy body disease.
22 Results: Although most studies have used different tests for studying these abilities, in general, these tests evaluated the individual’s 22
23 ability of (1) visual recognition, (2) visual discrimination, (3) visual attention and (4) visuo-perceptive integration. Performance on various 23
24 tests has been evaluated for assessing these skills. Most studies assessing such skills show that these skills are impaired in DLB as 24
compared with AD. Conclusion: Visuo-cognitive skills are impaired more in DLB as compared with AD. These impairments have evident
25 neuropathological correlations, but the direct neurobiological etiology is difficult to establish.
25
26 26
27 Key Words 27
28 28
Alzheimer’s disease, Lewy body disease, visuo-cognitive skills
29 29
30 For correspondence: 30
31 AQ2 Priyanka Rastogi, Priyanka Rastogi, #15; 15c Cross, Muthyalanagar, 31
32 Mathikere, Bangalore - 560 054, Karnataka, India. 32
33 E-mail: rastogipriyanka2121@gmail.com 33
34 34
35 Ann Indian Acad Neurol 2014;17:??-?? 35
36 36
37 37
38 Introduction system. Presence of these skills is pivotal for performance of 38
39 day-to-day activities. However, these skills are much more 39
40 Dementia is a chronic neurodegenerative disorder characterized important from the perspective of a clinician who often 40
41 by progressive cognitive loss. Alzheimer’s disease (AD) and encounters the challenge of treating neurodegenerative 41
42 the Lewy body disease are the two most common causes of dementia patients. A clinical neurologist not only requires this 42
age-related degenerative dementia. Impairment of visuo- knowledge to properly guide the patient through treatment,
43 43
cognitive skills is a common component of both these forms of but also to diagnose this disorder in the first place. From this
44 clinical stance, the implications of understanding these visual
44
45 AQ3 dementias. Visuo-cognitive skills are a combination of very
[1]

neuropsychological abilities of such dementia patients can be 45

different cognitive functions being performed by the visual
46 categorized into three important categories. The first category is 46
47 the role of visual skills in performing day-to-day activities that 47
Access this article online
48 are impaired in Lewy body disease. In advanced cases of AD, 48
Quick Response Code:
49 Website: there is a loss of navigational skills. These navigational skills 49
www.annalsofian.org constitute an important part of day-to-day activities, especially
50 50
in out-of-the-home circumstances. The second category is the
51 diagnostic implications of such visual skills for dementia with
51
52 DOI: Lewy bodies (DLB) that are often a priority, given reports of 52
53 ***************** severe neuroleptic sensitivity and a preferential response to 53
54 cholinesterase inhibitors in these patients. There have been 54

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 AQ4 2 Li, et al.: ???

1 suggestions that constructional apraxia is prevalent in DLB perceptual abilities. These tests often tap more than one of the 1
2 and may provide a sensitive marker of the disease.[2] above-mentioned abilities. Thus, for the purpose of this review, 2
3 we will evaluate one study at a time to focus on the individual 3
In fact, visuo-constructional (VC) tasks, in combination with deficits, which these studies have assessed separately. A
4 focused study assessing Visuo-perceptive skills was conducted
4
other tests, can differentiate DLB from normal aging and from
5 AD with sensitivity in excess of 80% and specificity in excess by Simard et al.,[8] whereby the Benton judgment of line 5
6 of 90%.[3] Because impairment of visual abilities in DLB is a orientation (BJLO) test was administered to 4 DLB patients 6
7 consistent finding, it has also been suggested that visuo-spatial with predominant psychosis (DLB-psy), 4 DLB subjects with 7
8 deficits may actually be a particularly salient biological marker predominant parkinsonian features (DLBPD) and 13 patients 8
9 of DLB.[1] The third and perhaps the clinically most important, with AD. An analysis of error types was applied to the results 9
category is the implications of these skills in evaluating the of the BJLO with visual attention errors, as well as visual-spatial
10 10
severity and prognosis of DLB. It has been suggested that perception errors. The results showed that DLB patients with
11 psychosis committed more significant errors of visual attention
11
visuo-cognitive skill deficits are related to the presence of other
12 symptoms of the disease, especially the visual hallucinations and visuo-spatial perception than AD patients. However, no 12
13 (VHs). Studies have shown that perceptual deficits evident in difference on the total score of the BJLO was found suggesting 13
14 DLB may be responsible for some misperceptions (i.e., illusions) severe visuo-perceptive impairments in DLB patients in the 14
15 and delusional misidentification (i.e., not recognizing family, visual attention and visuo-spatial perception domains. These 15
16 reduplicative paramnesia). Interestingly, DLB patients with results suggest that the defective visual perception could 16
VHs tend to perform more poorly on visual tasks than the actually contribute to the development of VHs in such patients.
17 17
18 subset of patients not having VHs.[3,4] Identification of visual 18
spatial impairment is important not only for designating Calderon et al. [4] used the screening (figure-ground
19 individuals whose clinical syndrome is impacted more by Lewy discrimination) test from the visual object and space perception 19
20 body formation than AD pathology, but also for predicting, (VOSP) to differentiate the performances of patients with DLB, 20
21 which patients with DLB will have a more malignant disease AD and normal controls. All three groups performed equally 21
22 course. [5] Throughout this review, we will evaluate the well indicating that patients with AD and those patients with 22
23 impairments in the background of these three dimensions. DLB were able to understand the task and both of them retained 23
basic low level visuo-perceptual abilities. On three subtests of
24 24
the VOSP, namely (a) fragmented letters (b) object decision and
25 Methodology 25
(c) cube analysis, there were, however, highly significant group
26 differences with post-hoc analyses showing impairment in the 26
27 For assessing the visuo-cognitive deficits in AD and DLB, an 27
DLB group relative to both controls and patients with AD.
exhaustive internet search of all relevant medical databases was
28 The DLB patients showed more severe impairments than the 28
carried out using a series of key-word applications including
29 AD patients on tests tapping both ventral stream (fragmented 29
The Cochrane Library, MEDLINE, PSYCHINFO, EMBASE,
30 letters and object decision) and dorsal stream (cube analysis) 30
CINAHL, AMED, SportDiscus, Science Citation Index, Index to
aspects of visual perception. However, no difference was
31 Theses, ZETOC, PEDro and occupational therapy (OT) Seeker
observed between controls and the AD group. The silhouette
31
32 and OT search. We reviewed all the articles until March 2013 identification task requires subjects to name or identify the 32
33 with the key words of: visual skills, visual cognition, dementia, silhouette profile of objects and animals viewed from unusual 33
34 AD, dementia of Lewy body disease. Our search revealed that perspectives and it represents both the perceptual and semantic 34
the visual skills being studied in dementia patients can be
35 abilities. On the silhouette identification test, the AD and DLB 35
divided into four categories: groups were equally impaired relative to control tasks. The
36 1. Deficits in visuo-perceptive skills 36
37 simple recognition of a silhouette as a real (vs. unreal) object 37
2. Deficits in visuo-spatial skills or animal is thought to require an intact structural description
38 3. Deficits in visuo-constructive skills that has been linked to the right temporal lobe. Naming and
38
39 4. Deficits in other visual cognitive functions. other forms of accurate item specific identification require 39
40 additional semantic processes that are associated with the 40
41 Deficits in visuo-perceptive skills left temporal lobe. The other tests from the VOSP that were 41
42 Perceptual abilities are the results of very dynamic interactions failed by patients with DLB do not require semantic processes 42
between several of our basic visuo-perceptive skills. These for their completion and can be considered, pure tests of
43 perceptual skills have been classified in various was across many
43
perceptual ability. In contrast to the findings of Calderon
44 studies. Most studies have used different tests for studying these 44
et al.,[4] Mori et al.[6] found that not only higher-order visual
45 abilities. In general, the domains of these tests can be divided into perceptual functions, but also elementary visual perception 45
46 1. Visual recognition (size discrimination task) are affected in DLB. They also found 46
47 2. Visual discrimination that patients with DLB performed significantly worse on both 47
48 3. Visual attention and elementary and complex visuo-perceptual tasks than did those 48
49 4. Visuo-perceptive integration.[4,6,7] patients with probable AD. The DLB patients performed poorly 49
50 on tests of elementary visual perception (size discrimination), 50
Thus visual perception needs much more complex processing Complex visuo-perceptual functioning requiring analysis of
51 as compared to the visual spatial skills, which are actually 2-dimensional visual stimuli (form discrimination), the ability
51
52 based on visual attention. However, a major challenge of to actively extract concrete shapes and to recognize objects 52
53 reviewing the studies evaluating visuo-spatial skills is that (overlapping figure identification) and the ability to identify 53
54 different studies have used different tests for evaluating visuo- the spatial relation of visual stimuli (visual counting tests). 54

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 AQ4 Li, et al.: ??? 3

1 Mosimann et al.[7] found that DLB and Parkinson disease with probable DLB scored significantly low on the picture 1
2 dementia (PDD) patients showed more severe impairments arrangement, block design, object assembly and digit symbol 2
3 than AD patients on tests tapping both ventral stream (tests of substitution test and Raven colored progressive matrices test 3
the object and form perception) and dorsal stream functioning as compared with the probable AD group. However, this DLB
4 group scored significantly higher on the mini-mental state
4
(tests of dot position and motion perception). They found
5 significant impairments in both Parkinsons Disease and examination (MMSE) locational orientation subtest, because 5
6 Lewy body dementia (LBD) patients on tasks requiring visual of poor performance on even untimed measures like the AD 6
7 discrimination, space-motion and object form perception in assessment scale construction subtest and the raven colored 7
8 patients with PDD, DLB and AD. These comparisons of bottom- progressive matrices. Therefore, they concluded that the results 8
9 up visual spatial processing suggest severe posterior cortical were unlikely to be explained by psychomotor slowing in these 9
dysfunction in LBD. patients and thus, were better explained by visuo-perceptive skill
10 10
deficits in such patients. They also found that Wechsler Adult
11 Intelligence Scale Revised (WAIS-R) block design scores were 11
Although these studies focus on predominant deterioration of
12 amongst the best discriminant factors. Block design, which is one 12
visuo-perceptive skills in LBD, the fact remains that even AD
13 can impact most aspects of visual processing, consistent with of the most commonly used test for the visuo-spatial ability, was 13
14 the impact of the disease on both dorsal and ventral stream also among the best discriminant factors in this study. 14
15 areas. Similar to LBD patients, AD patients are impaired in 15
16 both dorsal stream functions, such as angle discrimination and Similar results on the block design subtest were obtained 16
motion perception,[9-12] and ventral stream functions, such as by Salmon et al.[16] where they found that four of the five
17 17
the perceptual discrimination and recognition of faces, colors patients were at floor performance on the on this test and
18 the fifth patient, although not at floor, demonstrated severe
18
AQ5 and objects (Rizzo et al., 2000; Cronin-Golomb et al., 1993).[11,13]
19 impairment. Their findings also revealed severe impairment 19
Enhancing the strength of stimuli has been shown to ameliorate
20 performance on tests of letter identification, word reading, on the performances of parts A and B of trail making test 20
21 picture naming and face discrimination.[14] (TMT) for all the five patients. They also concluded that this 21
22 impairment was mainly visuo-spatial rather than impaired 22
23 executive functions as patients performed adequately on other 23
With this background of the visuo-perceptive skill deficits in
executive function tests of WAIS-R.
24 LBD and AD, their implications in day-today life seems to be 24
25 obvious. Visuo-perceptive skills are needed for identification of 25
the person and objects, which are lost in DLB. Similarly, visual An important difference between DLB and AD was provided
26 by Gnanalingham et al.[20,21] who pointed out the usefulness of 26
discrimination involves the ability to detect the difference
27 the clock face test that assesses both executive and visuo-spatial 27
between two similar looking visual stimuli, such as two
28 different roadways. Thus, DLB patients have more chances to functioning in differentiating DLB from AD. Patients with AD 28
29 do well on the copy part of the test despite doing poorly on the 29
get lost outside the home or even inside the home as compared
30 draw part while patients with DLB do equally poorly on both 30
with AD patients and would need more training in these issues.
parts of the test. A tendency to get lost is a common and often
31 31
early symptom of AD (Monacelli et al., 2003; Pai and Jacobs, AQ6
32 To summarize, both simple and higher order perceptual
2004), consistent with the critical role of the medial temporal 32
33 abilities are impaired in LBD as well as in AD. Most studies 33
lobes and parietal cortex in navigation learning and spatial
34 depict that the impairment is more severe in LBD as compared memory (Astur et al., 2002; Burgess, 2008; Morris et al., 1982). 34
AQ7
with AD. These deficits are also found very late in the course
35 Navigation learning has been extensively studied in transgenic 35
of AD, whereas they appear quite early in LBD. However, few mouse models of AD. For example, transgenic human amyloid
36 studies evaluate this issue and the sample sizes have been 36
37 precursor protein mice with hippocampal damage are impaired 37
small. Better studies with larger sample sizes are needed for in the use of allocentric cues on a Morris Water Maze task
38 improved evaluations in this domain. (Deipolyi et al., 2008). By translating findings from the rodent
38
AQ8
39 literature, researchers have been able to design tests to evaluate 39
40 Deficits in visuo-spatial skills navigation learning in AD in an anatomically-focused manner. 40
41 Visuo-spatial skills are a distinct group of visuo-cognitive Deipolyi et al. (2007) tested patients with mild AD on a real- 41
AQ8
42 abilities that are needed for visual attention to work in a three- world test of navigation learning. Compared with controls, 42
dimensional space. Compared with AD patients, DLB patients patients were more likely to get lost and were deficient at
43 43
show more severe deficits on tests of visuo-spatial skills, learning the locations of landmarks, and these impairments
44 especially ones requiring visual tracking and visual attention 44
were associated with smaller right posterior hippocampal
45 shifting.[15,16] Hansen et al.[17] found that the Lewy body variant and parietal volumes. New virtual reality techniques are 45
46 (LBV) and AD patients exhibited equivalent deficits in cognitive showing promise in translational research for refining our 46
47 abilities usually affected by AD (e.g., memory, confrontation understanding of navigation impairments in AD and tests that 47
48 naming), but that the LBV patients displayed disproportionately emphasize allocentric navigation may be particularly sensitive 48
49 severe deficits in attention, fluency and visuo-spatial processing. (Bohbot et al., 2007; Burgess et al., 2006; Cushman et al., 2008; AQ9
49
Visual search tasks are another group of important visuo-spatials Ishii et al., 2005). In the study by Noe et al.,[22] patients with
50 50
skills impaired in dementia. Sahgal et al.[18] found that although DLB performed significantly slower than patients with AD-P
51 both DLB and AD groups were impaired, the DLB groups on both (shape and TMX) forms of the cancellation test and
51
52 visual search matching-to-sample performance was however, showed a greater number of omission errors on the Shape 52
53 worse than that seen in AD patients (who performed at nearly version of this test. Because DLB patients performed poorly 53
54 control levels). In the study by Shimomura et al.,[19] the group not only in the timed aspect of the tasks, but also demonstrated 54

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 AQ4 4 Li, et al.: ???

1 increased omission errors, it reflects a difficulty in processing patients with AD. Walker et al.[32] demonstrated that patients 1
2 visuo-spatial information. with DLB performed worse than patients with AD who were 2
3 similar in overall degree of cognitive impairment on the praxis 3
Deficits in visual constructional skills subtest of the CAMCOG , including visuo-constructive tasks.
4 Furthermore Gnanalingham et al.[20] pointed out the usefulness
4
The inclusion of VC abilities in the cognitive profiling of
5 neurodegenerative dementias is especially important to of the clock face test that assesses executive and visuo-spatial 5
6 address two questions: functioning in differentiating DLB from AD: Whereas, patients 6
7 1. How important are visuo-constructive tests in distinguishing with DLB do equally poorly on both the parts, patients with 7
8 severe cases of LBD and AD? AD perform adequately on the “copy part” of the test despite 8
9 doing poorly on the “draw” part. 9
10 This question is important because in later stages of all forms 10
of cortical dementias, there is impairment in the constructional Whereas these studies have evaluated general praxis, other
11 11
abilities. Therefore, detecting impairment in the constructional studies have evaluated individual components of visuo-
12 abilities can become a tool to differentiate the dementias in spatial praxis, such as copying and drawing. Copying a 12
13 the early stages as compared with the later stages. Cormack diagram requires a coordinated function of various cognitive 13
14 et al.[2] examined the pentagon drawings of 100 DLB patients, functions. It seems that this coordination is lost in both AD 14
15 50 AD patients, 81 PD patients, with 36 of them suffering from and DLB, but worse performance by DLB patients has been 15
16 dementia (PDD). Performance on this task was correlated universally found. Ala et al.[29] found significant differences 16
17 with cognitive performance on the MMSE and Cambridge between pentagon copying of AD and DLB patients with 17
Cognitive Examination (CAMCOG) scales. Patients with DLB an unacceptable copy of the pentagon being associated
18 with DLB with a sensitivity of 88% (95% confidence interval
18
were found to draw significantly worse pentagons than patients
19 with AD or PD, but not patients with PDD. Drawing scores [CI] 0.64-0.99) and specificity of 59% (95% CI 0.39-0.78). 19
20 were significantly correlated with MMSE scores for the AD Similarly, in the study by Tiraboschi et al.,[1] visuo-spatial/ 20
21 and PDD groups, but not patients with DLB. More detailed constructional functioning was rated on the basis of MMSE 21
22 analysis of the neuropsychological correlates of constructional intersecting pentagons and/or dementia rating scale (DRS) 22
23 performance for patients with AD and DLB revealed that construction subscale (DRS-C), which involves copying. Each 23
patients with AD showed a broad cognitive basis to their patient’s copy of the intersecting pentagons was regarded as
24 24
impairment, but drawing was linked only to perception and acceptable only when all 10 angles were present and two of
25 praxis in DLB patients. Thus this test has the potential of acting them intersected (Folstein et al., 1975). Ratings on the DRS-C, 25
AQ10
26 as an important contributor to the diagnostic clarification of which is composed of six tasks including a copy of two 26
27 AD and DLB patients, especially in the background of other dimensional figures, were also dichotomized, because each 27
28 cognitive test scores. patient’s performance was considered acceptable only when 28
29 2. Does the impairment in VC tests indicate cortical/ the maximal score was obtained. Testing procedures were 29
30 subcortical involvement? modified in that all six subscale items were administered to 30
all patients. As opposed to less restrictive original criteria
31 (Mattis, 1976), patient was given maximum credit when he/
31
AQ11
The deterioration of constructive abilities in LBD is indicated
32 by the finding of poorer construction subscale performance in she accomplished all of the tasks, not the first one alone 32
33 patients with PD than in patients with AD.[23] This finding was (reproduction of a diamond within a square). Presence/ 33
34 also demonstrated by other studies[17,24] showing visuo-spatial recent history of VH were the most specific (99%) to DLB. 34
35 and constructional deficits in patients with LBV. The absence of As a result, early VH emerged as the best positive predictor 35
36 this difference in the group with moderate to severe dementia of DLB (positive predictor value: 84% vs. 32% or less for all 36
appears to be because it could be an indicator of severity of the other variables), while lack of visuo-spatial/constructional
37 37
disease. Interestingly, one of the most difficult items from the impairment on the DRS-C was the best negative predictor
38 value (NPV) (NPV: 90%). They found that differences in the 38
Initiation/Perseveration subscale that taps both constructional
39 and executive abilities (i.e., copying the ramparts figure) was frequency of flawed MMSE pentagon copying between DLB 39
40 significantly more impaired in patients with LBV than in and AD patients only approached statistical significance 40
41 patients with pure AD across the full MDRS range. Therefore, (30% vs. 16%, P = 0.1), an impaired performance on the 41
42 the cognitive deficits of patients with LBV appear to express DRS-C subscale was significantly more common in the 42
43 characteristics of both subcortical and cortical dysfunctions. It DLB group (74% vs. 45%, P = 0.01). An erroneous “vertical 43
has been suggested that the neuropathological changes in the lines” reproduction was by far the most frequent mistake
44 in both groups. Fewer DLB subjects (30%) experienced
44
substantia nigra of patients with diffuse Lewy body disease
45 and the corresponding depletion of dopaminergic input to the the difficulty with the MMSE pentagon copy, suggesting 45
46 striatum,[25] most likely contribute to the neuropsychological that the DRS-C may be more sensitive to visuo-spatial/ 46
47 deficits that are usually associated with subcortical dysfunction, constructional impairment early in the course of the disease. 47
48 such as impaired learning, attention, visuo-constructive They suggested that early visuo-spatial deficits should be 48
49 abilities and psychomotor performance (for review, see considered as a core clinical feature of DLB and that clinical 49
Cummings, 1990).[26] Visuo-spatial praxis is a general term given history plus a brief assessment of visuo-spatial function may
50 50
to all the cognitive abilities involved in constructional abilities be of the greatest value in correctly identifying DLB early in
51 several studies have documented impairment in visuo-spatial the course of the disease. 51
52 praxis in both AD and DLB.[15,16,19,27] Most investigators,[2,8,21,28-31] 52
53 have recorded greater visuo-spatial/constructional (and visual- Drawing is another ability, which seems to be particularly impaired 53
54 perceptual) deficits in patients with DLB as compared with in DLB. Salmon et al.[16] comparing the neuropsychological 54

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AQ4 Li, et al.: ??? 5

1 deficits of 5 patients with neuropathologically confirmed improving diagnostic assessment of DLB and helping to 1
2 diffuse Lewy body disease with the neuropsychological deficits develop specific neurobiological treatments for these individual 2
3 of 5 patients with neuropathologically confirmed pure AD cognitive deficits. Various studies have correlated visuo- 3
matched by dementia severity found poor visuo-constructive cognitive deficits in DLB and AD. However, these correlations
4 functioning on both the command and copy conditions of suffer from non-specificity. These correlations can at best be
4
5 the clock drawing test. Similarly, in the study by Noe et al.,[31] carried out with the disease condition rather than individual 5
6 the DLB group performed significantly worse on the Rosen neuropsychological deficits because the disease consists of 6
7 Drawing Test than AD patients. many symptoms and signs in addition to neuropsychological 7
8 deficits. Therefore, these correlations can only be considered 8
9 Deficits in other visual cognitive skills as indirect and presumptive at the best. 9
10 As we mentioned in the introduction, there are several visuo- 10
cognitive skills that could be impaired in various forms of In spite of the fact that all the lobes of the brain have been
11 implicated in its neuropathology, some important areas can
11
dementia. In addition to the specific visual skills mentioned in
12 the previous sections, there are several other domains of visuo- be highlighted in these studies. For example, the unique 12
13 cognitive skills that are impaired in various forms of dementia. visual-perceptual and attentional-executive impairments that 13
14 However, few studies have explored these domains. Here, we characterize DLB are consistently associated with the locations 14
15 present only a brief report of the studies that have evaluated of Lewy bodies in frontal, cingulate and inferior temporal 15
16 other complex visual skills in addition to the visuo-perceptive cortex and may be related to the characteristic VHs and clinical 16
and visuo-spatial skills mentioned previously. These skills fluctuations of this disease. However, these findings have been
17 17
mainly include higher cognitive modulation of visual attention mostly deducted from retrospective meta-analytic studies by
18 Collerton et al.[30] and they need to be confirmed in prospective, 18
such as divided visual attention, visual integration, visual set
19 shifting and visual memory. longitudinal, clinico-pathological studies. 19
20 20
21 Tests of visual cognition that require the integration of visual Although originally conceived in terms of right versus left 21
22 information processed by separate regions in visual association hemispheric function, the cognitive abilities underlying 22
23 cortex can be particularly sensitive to the effects of AD (e.g., performance on the spatial and perceptual abilities can be 23
tests of complex figure copy, mental rotation and visual better understood in terms of ventral (what) versus dorsal
24 24
AQ12 organization (Festa et al., 2005; Freeman et al., 2000; Lineweaver (where) visual processing streams (Goodale and Milner, 1992;
25 Ungerleider and Mishkin, 1982-FONT???). [35,36] According
25
AQ13
et al., 2005; Paxton et al., 2007), perhaps due to the effects of the
26 disease on multiple visual areas that are compounded by these to this accepted dichotomy, the ventral pathway or stream 26
27 integration tasks. of information, proceeds from primary visual to visual 27
28 association areas in the inferior-temporal region and underlies 28
29 In the study by Doubleday et al., [33] inattention, visual object recognition by the association of visual information 29
30 distractibility, impairment in establishing and shifting mental with semantic knowledge about the perceived objects. In 30
set, incoherent line of thought, confabulation, perseveration the subtests of the VOSP, the tests that depend on ventral
31 processing are, therefore, the object decision, silhouette
31
32 and intrusions were all significantly more common in the 32
DLB group than in the AD group and many of the features identification and fragmented letters subtests. The dorsal
33 stream is responsible for computing the location of objects in 33
were specific to DLB. However, these findings are contrast
34 the findings of Sahgal et al. [18] where the authors found that space, the guidance of hand movements during grasping and 34
35 visual set-shifting abilities were equally impaired in both DLB complex visuo-spatial analysis. These abilities are included 35
36 in the cube analysis subtest of the VOSP draws heavily on 36
and AD patients. Divided attention has been more specifically
the dorsal pathway. Based on the current findings, it seems
37 studied by Kraybill et al.,[34] who found that Part A of the TMT 37
that patients with DLB have severe deficits in both dorsal and
38 did not differ among groups, but DLB patients performed much 38
ventral processing streams. Impairments of this type are seen
39 more poorly on Part B of the TMT than did the AD patients. 39
in AD, but typically occur at a later stage of the disease (Hof
These findings suggested that LBP patients were actually more
40 et al., 1987; Mendez et al., 1990).[37,38] 40
AQ14
impaired in terms of divided attention and not overall just
41 slow-performers due to their motor slowing. 41
42 Recently, radio-nuclear studies have demonstrated that glucose 42
43 metabolism and blood flow are significantly decreased in 43
Visual retention or short-term visual memory is another
the occipital lobes, including the primary visual cortex and
44 aspect of visual cognition that has been only rarely studied in 44
the visual association areas in DLB as compared with the
45 dementia patients. In the comparative study by Noe et al.,[31]
AD (Imaura et al., 1997; Ishii et al., 1998; Ishi et al., 1999). The
45
AQ15
46 the DLB group performed significantly worse than the AD 46
involvement of the visual cortex may, thus, be the cause for
47 patients on the matching and recognition subtests of the Benton 47
dysfunction of the elementary visual sensation that may be
visual retention test.
48 involved in development of visual cognitive deficits and vision- 48
49 related behavioral symptoms. These findings are consistent 49
Discussion: Neuropathological Correlation with the findings of Mosimann et al.,[7] who demonstrated
50 of Visual Skill Deficits
50
that both DLB and AD patients showed hypoperfusion and
51 hypometabolism in the parietal and temporal lobes, but only
51
52 The basis for the visual deficits in DLB and AD needs to DLB patients showed hypoperfusion and hypometabolism 52
53 be understood not only for clarifying their underlying in the occipital lobes, including the primary visual cortex 53
54 neuroanatomic mechanisms, but also for the purposes of (Lobotesis et al., 2001; Inoshima et al., 2001; Sato et al., 2007; 54
AQ16

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 AQ4 6 Li, et al.: ???

1 Shimizu et al., 2008), which is the most critical cortical region 13. Cronin-Golomb A, Corkin S, Growdon JH. Visual dysfunction 1
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1 35. Goodale MA, Milner AD. Separate visual pathways for perception 1
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6 syndrome in Alzheimer’s disease: Specific disruption of the How to cite this article: We will update details while making 6
occipito-parietal visual pathway. Brain Res 1989;493:368-75. issue online***
7 38. Mendez MF, Mendez MA, Martin R, Smyth KA, Whitehouse PJ. Received: 27-04-13, Revised: 07-07-13, Accepted: 05-08-13
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8 Complex visual disturbances in Alzheimer’s disease. Neurology 8
Source of Support: Nil, Conflict of Interest: Nil
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Annals of Indian Academy of Neurology, January-March 2014, Vol 17, Issue 1