Sub-Cortical "Frontal" Dementia In Huntington's Disease!
Sub-Cortical “Frontal” Dementia in Huntington’s Disease
There is a very pressing need to frankly discuss one of the most debilitating symptoms in the neuropsychiatric sequelae of “softer” symptoms in Huntington’s Disease- sub-cortical “frontal” dementia. Unfortunately, since there are far more patients with Alzheimer’s Disease (AD) and the cortical dementia associated with it, virtually all medical professionals recognize it more easily and disappointingly assume that person’s with other neurological diseases, especially Huntington’s Disease (HD), should look, act and respond the same way to questioning as those with AD do.
Second, in some states, the only way you can receive state subsidized assisted-living or nursing home benefits is to be diagnosed with “dementia” and when someone with HD applies they appear to be okay since they still know their name, what date it is, where they are, who the President of the United States is and other similar questions. Virtually everyone who I have had the privilege of assisting during the Arizona Long-Term Care (ALTCS) interview process were physically capable of performing their Activities of Daily Living (ADLs), such as toileting themselves, brushing their hair and teeth, dressing themselves, cooking, taking their own medications and bathing. However, because of their sub-cortical “frontal” dementia they would never remember to do these things on a regular basis, think of doing them and then forget when distracted, or never think that they needed to be done in the first place, that is, unless they were verbally prompted and/or encouraged by physically offering to assist them. Unfortunately, most states are concerned about the person’s “physical” ability to do the ADLs so the person with HD normally fails their qualification questions miserably. In addition, it does not help the interview process at all when the person with HD is able to tell the interviewer (unlike with Alzheimer’s) that they are able to perform their ADLs every day without any problems. It is not until I gently tell the interviewer that the person with HD is also suffering from “dementia” the state interviewer is able to decrease the high scores they already received on their ability to physically perform their ADLs and their true need for higher care finally realized and approved!
Lastly, since none of the official published books and pamphlets on HD even mention “dementia” as one of HD’s devastating symptoms it is very hard to educate the medical professionals (neurologists, psychiatrists and psychologists) that we come in contact with in trying to care for the Person with HD (Phd) so unfortunately, their quality of life and care received isn’t as high as they deserve. Having medical professionals understand the basic differences between HD and AD is essential for them to understand that even though the person with HD may answer questions in the affirmative, thus indicating that “all is well,” their answers should not be taken for the “gospel” truth. I have many examples of this gleaned from having the privilege of helping dozens and dozens with HD apply and receive state benefits in the State of Arizona.
In an effort to help families and social workers who are dealing with Phds on a daily basis, I have concatenated the most current references on HD’s sub-cortical “frontal” dementia from the internet and other places. These are attached at the end of my personal examples in the next section.
Sometimes, when the whole extent of
dementia-damage isn’t easily recognized by the family or medical
professionals, because of not knowing the sequelae of HD’s “softer”
symptoms (emotional, behavioral and cognitive), the Phd doesn’t receive
the care they deserve. The myriad of benefits of utilizing the
Neuropsychological exam early in HD are discussed more thoroughly in my
previous article: “Using the Neuropsychological Exam and Other Tools To
Help Those Struggling With the “Softer” Symptoms of Huntington’s
Disease!” which can found on the Huntington’s Disease Advocacy Center
In Tiff’s case, in addition to virtually to every other interview at which I’ve accompanied the Phd, the person giving the competency test or just asking general “welfare” questions were all given “misleading” positive-sounding answers by the Phd because of their “dementia.” For example, when asked by the interviewer about bathing (one of the ADLs) Tiff responded in the affirmative, that she did so every day. In a “redirect” with the interviewer I pointed out that this couldn’t be true and asked him to look at her dirty legs, face, hair and arms to verify my point. When he asked her if she could brush her teeth she also responded affirmatively. In another “redirect” I asked him to ask her to smile and show him her teeth. They were so poorly taken care of that she had could only eat soft foods- and was only 28 years old! Shortly afterwards I had to take her to have all of her teeth pulled and fitted for dentures that a friend had donated for her. Once again, she was physically able to perform these Activities of Daily Living (ADLs) on the application for long-term care but because of her “dementia” she was mentally and cognitively unable to remember to do them on a daily basis or even care if she ever did them at all. She later qualified for ALTCS benefits once her “dementia” was appropriately factored in. Michael
In another case, an interviewer, who allegedly had an excellent knowledge of HD, thought that Michael, who had HD, was competent to stand trial because he was able to answer all of her questions about his knowledge of right and wrong and how the court system worked- after five or six verbal prompts or helps by her. After my “redirect” I pointed out that Phds are indeed successful in answering questions after lots of prompts, unlike those with Alzheimer’s Disease, but the blank stare and silence she got after most of her questions were indeed his real “answer” that indicated his real inability to mentally process and find the answer to each of her questions. She could not be swayed and it wasn’t until after Michael had a Neuropsychological exam done that not only was he found “incompetent” to stand trial, but it also showed an estimate of when he began his HD symptoms, which just happened to be several years prior to when his “uncharacteristic” use of illegal drugs began, including his most recent arrest for possession of cocaine. The Neuropsychological Exam showed that because of his “dementia” he was indeed incompetent to stand trial. The judge threw all of his charges out. The judge also mandated that I get Michael off the street and into a safe assisted-living home, since she concluded very wisely, that if allowed to return to the streets without inhibitions and forward thinking, not to mention his “dementia,” he would end up right back in her courtroom again! That would have been like putting him back on the streets with three (3) strikes already hanging over his head. Educating his defense attorney and the judge of HD’s “softer” symptoms, including “dementia” had helped Michael get into a safe and secure place. He could no longer roam the streets like a kid in a candy store being exploited by drug pushers and the likes. Don
Don became a great teacher to me, regarding a lot of HD’s “softer” symptoms, including “dementia.” I was made aware of his piteous plight by his former wife who I was already helping because their 7 year old daughter had Juvenile HD. She was concerned about his welfare and asked me to please help him. When trying to get Don onto our state welfare program and food stamps I found out he needed an original birth certificate to prove his U.S. citizenship. The only problem was, it had to be delivered to the person’s official address on file. I called and ordered him a certified birth certificate and had it delivered Next Day Air to expedite his application process since he was completely out of food, only to have Federal Express call and tell me the delivery was unsuccessful because the occupant refused to answer the door and sign for its delivery!
When I ask him why, he bluntly told me that he never opened the door for anyone before 10:30 am. Now I knew. I called Fed Ex and asked them to attempt delivery one more time, this time I threatened to never take him to McDonalds again if he didn’t answer the door. Since he didn’t want to miss our weekly trips there, he grudgingly conceded. I spent about 30 minutes rehearsing with him why he needed to open the door and then prayed that he would remember.
In continued attempts to help Don achieve a higher standard of living than he presently had, I talked with his Neurologist about his failing condition, “dementia” and slovenly living conditions and asked for his support in helping get Don into a safe and secure assisted living home. However, his neurologist wouldn’t sign the paperwork saying he needed assisted living because during his last appointment (which I accompanied him to) he was able to answer basic questions from the doctor, like, “How are you today?” and “Isn’t it hot outside?” Vowing not to be undermined I then made an anonymous call to adult protective services to have them go check out his abhorrent living situation. Someone went out, asked him if he needed help and then you guessed it, he said “No,” that he was doing fine and didn’t need any help! Surely the investigator could have smelled him, he honestly hadn’t bathed in about two years! Later, because HD’s “dementia” and “softer” symptoms left him easy to exploit, he was arrested several times because of allowing homeless drug addicts to live with him while they look for work. His apartment manager called me and told me we had to do something or she was going to have to evict him because of complaints from his neighbors about his unsavory roommates. In the past he adamantly refused to even fleetingly consider moving.
The apartment manager and I met several more times before deciding that she would send him a 30-day notice to move out and during that time I would get him into an assisted-living facility. I made an appointment for him with ALTCS. During this interview for benefits the examiner asked the normal questions about ability to perform ADLs. When he asked him whether-or-not he could cook he stated that he had no problems cooking and did so every day. Upon my “redirect” I showed the interviewer his filthy fridge containing about ten packages of expired “green” bologna stacked on top of each other and a few slices of bread on the counter and asked the interviewer if he still thought that Don was capable of cooking on his own. Green bologna sandwiches and Fritos was not my idea of a nutritious, balanced meal. After hearing that he also bathed himself daily (the smell proved otherwise) I showed the interviewer his bathroom with its filthy dirty shower and toilet that had strange “aliens” growing out of it. He was finally approved but the whole process was impeded because of general lack of knowledge that there are other dementias out there besides that seen in persons with Alzheimer’s! Don was physically capable of performing his Activities of Daily Living (ADLs) but mentally, he could never remember to do so, or sadly, even able to see a need to do them anymore. He was granted ALTCS.Craig
One evening I got a call from Deputy Flannigan from the Maricopa County Sheriff’s Department. They had received a call from Craig’s Mom who said he had a rage attack, became uncontrollable, and pushed her. She was afraid that he would harm her the next time she disagreed with him. Craig is currently living alone and when I called to check on him he said that everything’s okay and that he doesn’t need any help. He is also not taking any medications for aggression, or anything else, because he doesn’t need to. Sound familiar? The sheriff’s deputy expressed lots of concern because Craig had lots of weapons in his apartment and “what if he answers the door with a weapon if they’re ever called again.” Well, let’s not say “what if,” let’s say “when they’re called again” because I know it’s only a matter of time before this scenario happens again. Both Craig’s Mom and sister know that he is incapable of caring for himself and think he should be in an assisted-living facility. I also know that Craig is incapable of caring for himself and that, despite what he thinks, he should be somewhere safe. His sister wants to apply for guardianship over him but she will never get it, without neuropsychological testing which will prove, beyond a shadow of a doubt, that he is indeed incapable of caring for himself and that our concerns for him are very well founded. Only afterwards will she be able to easily be awarded guardianship over him.
I know that if he goes to court now, he will undoubtedly tell the judge he is perfectly fine and doesn’t need any help and the judge will assume nothing is the matter with him because he can still talk and answer a few questions, again unlike those with Alzheimer’s, so therefore he must still be okay. The judge will error on the side of Craig’s independence and autonomy. There are several problems with this: number one, he will never consent to go for neuropsychological testing (because he honestly feels he doesn’t need it because of the HD symptom called “anosognosia” which has rendered him unable to comprehend the severity of his symptoms and how they are adversely affecting him and two, we cannot force him to go either. He’s a powder keg waiting to explode the next time he has an altercation with his Mom or someone else and the deputies have to be called to his home to arrest him. I did tell his Mom to not hesitate to call 911 if she ever feels threatened by him again in the future but to tell 911 that he’s suffering from “dementia” and HD which is a “mental” disease and that they need to bring “non-lethal force” or taser guns, when they come to question and/or arrest him the next time. However, we all know that if he has to be confronted in his home, he may come to the door brandishing one of his own guns and the deputies will then be forced to not use “non-lethal” force if they feel threatened by him or his actions.
In defiance of his Mom and Sister, Craig recently moved to Prescott to get away from them all. I advised them to call the local police and sheriff departments to advise them of his condition. The waiting game begins as the next time he has a rage attack and is potentially jailed or hospitalized, then his sister can request temporary guardianship from a judge and we’ll finally have him where we can then begin helping him more! Unfortunately, in the meantime, he is still living by himself and shouldn’t be!David
Another example that comes to mind is David. His Mom lives in Silver City, New Mexico and has called me several times for help with him as he lives in the Duncan/Virden area of Arizona. He was arrested and put into a psychiatric unit twice while living in New Mexico but when I talked with the psychiatrists there and told them that he had “dementia” and would they please recommend that he be put into a safe assisted-living home they laughed at me because they said he was able to respond, knew his name, where he was, felt sorry for what he had done, etc. so therefore could not possibly have “dementia” and be unable to care for himself. I asked them to please have a neuropsychological test done on him, while he was committed for observation, and they stated that New Mexico would not pay for that test, because it was unnecessary in their professional opinions. Where are the educational books and pamphlets stating the opposite? I told them that because of his “dementia” that he would never remember to continue taking the medications they prescribed for him, once on his own again. They assured me that he told them he would continue taking them and that he understood the need to take them. In my opinion, David would probably tell them anything to get released. He is also suffering from anosognosia too and isn’t aware of all of his problems. They didn’t have the benefit of hearing about the problems he was having from his Mom because he wouldn’t put her on his visitation or communication list so she was never allowed to tell the doctors how he had been acting recently, like intentionally wrecking and totaling his new truck and ATV and threatening his brother’s pregnant wife if they tried to interfere with him!
Sadly, he is back on the streets now, vulnerable and incapable of caring for himself, just waiting to be arrested again- however, this time I will have this paper and all of its references to provide to those who will care for him and he will end up where he can be safe and kept from harm’s way, not in a prison cell.Sheri
Another sad example that comes to mind is Sherri. Unfortunately, as I was boarding the bus to head to Phoenix International Airport to fly to Costa Rica for my honeymoon, I got a frantic call from her Grandmother stating that she was being arraigned at that very moment for drug charges. I frantically made a call to her defense attorney before Dina and I boarded our plane and explained to him about all of HD’s “softer” symptoms and “dementia” and told him she should not be sent to prison for possession of cocaine, but should be given a Neuropsychological exam to see if she was competent enough to stand trial. He laughed loudly and told me that he knew that she was capable of standing trail and did not have dementia and had never heard of HD, let alone all of the “softer” symptoms I had just rambled off to him. Well, because of his pompous attitude he didn’t bring up HD or dementia with the judge and she was sentenced to several years in prison.
Upon returning from my honeymoon I found that we had 90 days to appeal the judge’s decision. At this point I immediately contacted this lawyer again and asked him to file an appeal for her. He got real pompous again and told me that, because of the number of criminal defendants which he represented daily, that he was qualified to tell which ones were competent and which ones were not. Imagine that! Since he had made this medical diagnosis on Sheri I asked if he had performed a Neuropsychological Exam on her, or if he also had degrees in neurology or psychiatry since he was so confident with his diagnosis. I mentioned that it usually took one of those to determine how severely a person was suffering from the neuropsychiatric sequelae of “softer” symptoms associated with Huntington’s Disease! He assured me that he didn’t need any additional degrees to know that she was competent and how dare I challenge this “gift” which he had. Sadly, he refused to take the paperwork to Sherri to sign because he believed it was waste of his time and I couldn’t get approved in time to take it in to her myself because of bureaucratic red tape. Unfortunately, she served out her two years behind bars where she was undoubtedly exploited sexually and in other ways because of her HD and its associated “dementia!”
If you do not know of any examples locally like the ones I’ve mentioned then I recommend you get to know your families better. I shudder to think how many additional individuals with HD and their families have had to go through “hell” because of lack of education on HD’s “dementia” and “softer” symptoms. Please help me spread the word to give those struggling with HD the quality of life they deserve!
The first section (I) is from the Medline website of the National Institutes of Health (NIH) and clearly details some of the “softer” symptoms, including “dementia” that those with HD suffer from.
Section two (II) is taken from the “We Move Movement Disorder Virtual University” website and also details HD’s “softer” symptoms, including “dementia!”
Section III is taken from the American Psychiatric
Association’s DSM-IV 294.1 Dementia Due to Other General Medical
Conditions- Huntington’s Disease. It details which symptoms you have to
be experiencing to be diagnosed as having dementia and even has a
specific section noted for “Dementia Due to Huntington's Disease –
Sections Five through Thirteen are representative references of governmental sites to national organizations, each noting “dementia” as one of HD’s most debilitating symptoms!
I. Medline Plus Medical Encyclopedia (A Service of the U.S. National Library of Medicine and the National Institutes of Health)
·Abnormal and unusual movements
Dementia that slowly gets worse, including
Additional symptoms that may be associated with this disease:
II. Movement Disorder Virtual University
Early signs of cognitive decline may include:
As HD progresses, additional symptoms may develop including:
In addition, communication difficulties may include problems expressing thoughts in words, initiating conversations, or comprehending others' words and responding appropriately.
Emotional or behavioral disturbances tend to develop gradually over time and may become apparent before or concurrent with the motor manifestations of HD.
In some patients, initial symptoms of HD may include personality changes, such as:
Additional behavioral, emotional, or psychiatric disturbances may also become apparent, including:
Severe distortions in thinking may also occur, including false beliefs or delusions, such as fears of persecution. In addition, hallucinations may develop, such as the perception of sounds, sights, or other sensations in the absence of external stimuli.
(Diagnostic and Statistical Manual of Mental Disorders,
Dementia Due to Other General Medical Conditions:
A. The development of multiple cognitive (Thinking, memory and other functions of the mind.
(1) memory (The cognitive function of capture, registration, assimilation, retention, and retrieval of mental, emotional, and physiological information. Impairment (impaired ability to learn new information or to recall previously learned information)
(2) one (or more) of the following cognitive disturbances:
(a) aphasia (While
this term taken literally means absence of speech, it may include all
forms of speech or language impairment. (language disturbance)
B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
C. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of one of the general medical conditions listed below.
D. The deficits do not occur exclusively during the course of a Delirium.
Code based on presence or absence of a clinically significant behavioral disturbance.
DSM-IV 294.1 Dementia Due to Huntington's DiseaseA characteristic movement disorder accompanies the Dementia resulting from this progressive inherited disease.
Diagnostic Criteria: Dementia Due to Other General Medical Conditions
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994
Medline Plus Medical
Encyclopedia (A Service of the U.S. National Library of Medicine and the
National Institutes of Health)
Problems may involve language, memory, perception, emotional behavior or personality, and cognitive skills (such as calculation, abstract thinking, or judgment). Dementia usually first appears as forgetfulness.
Other symptoms that may occur with dementia:
V.Colombia University’s College of Physicians and Surgeons
Update for the Practitioner
Huntington's disease is not strictly a Frontotemporal
dementia but may still be considered one of the frontal dementias.
University of Kansas Medical Center
The three most profound behavioral problems in Huntington's disease come from the dementia (loss of the ability to reason), the altered perception of the world and the changes in family dynamics…The dementia is technically called a sub-cortical dementia.”
The dementia is technically called a sub-cortical dementia. Translated into real world terms this means that a person with Huntington's disease has difficulty performing a sequence of tasks, especially when distracted, while their ability to form new memory and to recall old memories is relatively well preserved. Thus a patient maybe able to do the wash if there is a list of instructions posted in the laundry room, but may fail at doing the wash if they are also trying to make a meal.
Distracting influences can impair the ability of a person with Huntington's disease to accomplish a task. For example, one may be able to eat easily in a quiet environment, but have great difficulty eating in a noisy, crowded room with both a television set and a radio playing.
VII. About.com: Alzheimer’s
Huntington’s is a degenerative disease characterized by jerking uncontrollable movement of the limbs, trunk, and face, progressive psychiatric difficulties and loss of mental abilities.
Huntington’s Disease Dementia
§Memory frequently is not impaired until late in the disease, but attention, judgment, and executive functions may be seriously deficient at an early stage.
§Early signs of dementia often include forgetfulness, disorganization, and affective disorders.
§Free recall may be severely impaired.
§Memory deficits involve both recent and remote function. Studies show that patients with HD can accurately recognize recently presented verbal material only when cues are used in memory retrieval. Other studies show that the patients sometimes recall words the next day that they had not recalled during testing sessions, further supporting a delayed-retrieval hypothesis.
§Patients have significant problems with frontal executive functions, such as problems with maintenance, cognitive flexibility, abstraction, judgment, reasoning, sequencing, organizing, planning, and adapting.
§Skilled motor-procedural learning deficits are reported. Working memory may be affected in patients with HD because of frontal lobe dysfunction associated with the bidirectional connections with the caudate.
§Insight, orientation, factual information, and overall intelligence quotient scores are preserved relatively well into the disease process.
Other Conditions Associated With Dementia
IX. National Institutes of Neurological Disorders and Stroke (National Institutes of Health)
NINDS Dementia Information Page
Symptoms of HD
Neuron loss can cause some of the following symptoms:
All of these symptoms of Huntington's disease become more severe over time as the cells in the brain continue to die. Sometime within fifteen to twenty years of the onset of the symptoms of Huntington's disease, the patient dies. Death is usually due to infection. Sadly, suicide is also a common cause of death, due to the suffering related to the heartbreaking symptoms of Huntington's disease.
If reversible dementias are ruled out and it is determined that the person has a degenerative or irreversible dementia, it is important that families and medical personnel seek the cause of the problem. This will help ensure that the person affected receives proper medical care, and families can plan their Caregiving and find appropriate support and resources.
The following are the most common degenerative dementias:
New Techniques for
Understanding Huntington's Disease (J Neuropsychiatry Clin
Neurosci 11:173-175, May 1999)
All patients with HD develop a progressive
subcortical dementia that is characterized by frontal lobe
executive dysfunction and memory deficits. Neuropsychological
testing reveals deficits in recent and remote memory;
impaired visuospatial function; difficulty with shifting
sets, planning, and organization; and overall decreasing IQ.
Psychiatric syndromes (present in up to 79% of patients) most
commonly include impulse control disorders, depression,
personality changes, and, more rarely, psychosis or mania.
Symptoms include disinhibition, irritability, aggression,
apathy, and Neuro-vegetative markers of depression. The suicide
rate has been reported to be up to 20 times that of the general
population over age 50. Increased criminal behavior and
hypersexuality have often been reported in HD patients. A
recent Danish study found that there is a statistically
significant increase in nonviolent crime in male HD patients
compared with their non-affected relatives and control
subjects. These criminal behaviors, as well as the
psychiatric syndromes, are felt to be related to the
destruction of the medial caudate, which disrupts the memory
and emotion tracts descending from the frontal lobes.
Cognitive decline is characteristic of HD, but the rate of progression among individual patients can vary considerably. Dementia and the psychiatric features of HD are perhaps the earliest and most important indicators of functional impairment.
Ø The dementia syndrome associated with HD includes early onset behavioral changes, such as irritability, untidiness, and loss of interest. Slowing of cognition, impairment of intellectual function, and memory disturbances are seen later. This pattern corresponds well to the syndrome of subcortical dementia, and it has been suggested to reflect dysfunction of frontal-subcortical neuronal circuitry. (The so-called cortical dementias primarily involve the cerebral cortex and are associated with aphasia, agnosia, apraxia, and severe amnesia.)
Ø Early stages of HD are characterized by deficits in short-term memory, followed by motor dysfunction and a variety of cognitive changes in the intermediate stages of dementia. These deficits include diminished verbal fluency, problems with attention, executive function, visuospatial processing, and abstract reasoning. Language skills become affected in the final stages of the illness, resulting in a marked word-retrieval deficit.
written by Phillip J. Hardt, BA, MA, Phd on 6/11/2009
My good friend from Germany, Dr. Herwig Lange, MD responded to my article in 2009 with the following letter. I tried unsuccessfully to get it posted earlier but to no avail. Now I'm in charge!:
The bad thing about the cortical atrophy in HD is its topographical distribution: starting in the posterior cortical areas, visual and acoustic input is not processed properly - PHDs easily miss some important, relevant information. So they have a hard time to read facial expressions, esp. bad mood expressions like anger or disgust. A PHD will not pick up subtle signs early enough to prevent escalation in a situation like that. That's why very early on i taught relatives not to rely on making a frown if the PHD behaves in an unbecoming way, but to explain to the PHD that the relative feels annoyed and not at ease with that behaviour.
Since visual and auditory input is not properly analyzed and processed in the posterior cortex, faulty information is transmitted to the “executive” frontal cortex. Just as in management or politics, decisions based on faulty information will lead to bad results – just look on the current financial and economic crisis. Or if captains or pilots take false action based on neglected or false information, catastrophic results are the consequences e.g. Titanic or Air France flight 4447.
Secondly, the frontal cortex in HD shows atrophy in a very critical region: the orbito-frontal region. This basal frontal cortex is often damaged in head injuries, leading to deviant behaviour afterwards – see the striking case reports in Damasio’s books.
Thirdly, the limbic system – the brain system involved in emotion – is damaged in HD as well. There is atrophy in gyrus cinguli and amygdale, leading to labile affect. This phenomenon is increased when the orbito-frontal cortex is impaired in function, just as shown in normal people, when they are sleep deficient. The anger reaction is greatly increased if people haven’t slept enough. That is why PHDs and the rest of the family need sufficient sleep to keep their brains in good function. Power naps during the day will also be helpful to restore brain functions – just as in normal hard working people.
Damage to amygdale will further reduce the recognition of facial mood expression and thus add to the problems caused by faulty processing of visual information in the occipital cortex.
The next problem is the atrophy of corpus callosum, the major connection between the 2 hemispheres. It’s easy to imagine that things don’t work well, if “the right hand doesn’t know what the left hand is doing” – analogous to miserable politics or management, as we learn every day.
So I suggest that
You change the title of You paper to The cortical-subcortical dementia
Already George Huntington in his historical report “On Chorea” (http://en.wikisource.org/wiki/On_Chorea) wrote about “the tendency to insanity … As the disease progresses the mind becomes more or less impaired, in many amounting to insanity, ... At present I know of two married men, whose wives are living, and who are constantly making love to some young lady, not seeming to be aware that there is any impropriety in it. They are suffering from chorea to such an extent that they can hardly walk, and would be thought, by a stranger, to be intoxicated. They are men of about 50 years of age, but never let an opportunity to flirt with a girl go past unimproved. The effect is ridiculous in the extreme. …”
Practically all textbooks on neurology and psychiatry that i have read mention the psycho-organic changes in PHDs, albeit not always in a comprehensive or competent way.
Your paper on “The Neuropsychological Exam and Other Tools to Help PHDs” is very helpful again.
I would suggest that You change this citation from OMIM (http://www.ncbi.nlm.nih.gov/entrez/dispomim.cgi?id=143100)
“Typically, there is a prodromal phase of mild psychotic and behavioral symptoms which precedes frank chorea by up to 10 years.”
My clinical experience of more than 27 years of service for PHDs and HD families has brought to my attention PHDs who had psychiatric symptoms like depression or schizophrenia-like psychosis up to 27 years before onset of motor symptoms. To prove my point, look at this distribution chart i presented in 1998:
Thank you Dr. Lange for your recommendations and comments!.....Phil