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SUMMARY
Aims It is now well established that there are abnormalities in the sense of smell in patients suffering from Alzheimer's
disease (AD). They have both raised olfactory thresholds and impaired odour identication. The situation in vascular dementia is unclear. We used the University of Pennsylvania Smell Identication Test (UPSIT), a 40-item, forced choice, cued,
`scratch-and- sniff' test, to examine olfactory identication in vascular dementia and to determine whether it would differentiate the disorder from AD and normal elderly.
Methods We investigated three matched subject groups: 13 people having a Cambridge Examination for Mental Disorders
in the Elderly (CAMDEX) diagnosis of denite senile dementia of Alzheimer type, 13 having a CAMDEX diagnosis of denite vascular dementia and 13 non-cognitively impaired controls. The subjects were then tested with the UPSIT in their own
home by an independent blind researcher to see if the test could distinguish the different diagnostic groups in this setting.
Results The median UPSIT score was 30 (out of a maximum of 40) for controls, 12 for the vascular group and 15 for the AD
group. The difference was signicant ( p 0.05) between both demented groups and the normal controls. Similarly there was a
signicant difference in the UPSIT score between the AD group and controls ( p 0.001) and between the vascular dementia
group and controls ( p 0.001), but there was no signicant difference between the AD group and the vascular dementia
group. The UPSIT score correlated strongly with the degree of cognitive impairment as measured by the CAMCOG
(rs 0.683, p 0.01)
Conclusions Patients with vascular dementia had a similar degree of olfactory impairment to those with AD. The UPSIT
successfully differentiated between dementia patients and normal elderly British subjects tested in their own homes. The
UPSIT did not differentiate between those with AD and vascular dementia. Copyright # 2001 John Wiley & Sons, Ltd.
key words Alzheimer's disease; vascular dementia; olfaction; olfactory discrimination; diagnosis; differential diagnosis
INTRODUCTION
Olfactory impairments in Alzheimer's disease (AD)
were rst reported by Waldton in 1974 and it is now
well established that those with AD have abnormal
olfactory function. Impairments have been shown on
tests of olfactory identication, olfactory recognition
memory and olfactory threshold (Mesholam et al.,
514
a. j. gray et al.
METHOD
Potential subjects were identied from case records of
patients under the care of the Mental Health Services
for Older Adults in South Birmingham, UK. Informed
consent was obtained from the patient and, where
appropriate, a carer. Patients were then interviewed
with the Cambridge Examination for Mental Disorders in the Elderly (CAMDEX) (Roth et al., 1988).
Two patient groups were selected, those with a CAMDEX diagnosis of `denite senile dementia of Alzheimer-type' and those with a diagnosis of `denite
vascular dementia'. Patients were excluded if they
suffered from disorders, or were taking medication
known to impair olfaction or if their dementia was
severe. Subjects with vascular dementia were then
individually matched with AD subjects by: age
(within 10 years), gender, smoking status and Clinical
Dementia Rating (CDR) stage (Hughes et al., 1982).
Normal controls were recruited from spouses of
patients from a mixed clinic population. The controls
had no signicant evidence of cognitive impairment
on the CAMDEX. They were again individually
matched with the vascular subjects on the above criteria except CDR stage.
Subjects were then tested at home, on another occasion, by a second investigator blind to their diagnosis,
with the University of Pennsylvania Smell Identication Test (UPSIT) (Doty et al., 1984). The UPSIT has
been widely used to study olfactory identication deficits in many different groups, correlates well with
Copyright # 2001 John Wiley & Sons, Ltd.
515
Table 1. Controls, vascular dementia (VaD) and Alzheimer's disease (AD) groups: background demographic data, performance on
dementia measures and UPSIT scores with statistical analysis
Three-group
comparison
(two-tailed)
Two-group
comparison
(two-tailed)
AD group
VaD group
Control group
Gender
male
female
4
9
4
9
4
9
Smoking status
smoker
non-smoker
1
12
1
12
1
12
75.4
(71.679.2)
79.2
(76.182.4)
75.6
(72.879.2)
ANOVA:
f 2.046, p 0.144
75
(5379)
62
(3279)
94
(82102)
KruskalWallis
2 18.8, p 000
0
11
2
0
11
2
13
0
0
15 (1027)
12 (827)
30 (1634)
KruskalWallis
2 21.987, p 0.001
0.403
0.172
0.374
0.208
0.683z
< 0.01z
CDR#
stage 0
stage 1
stage 2
Median (range) UPSITy
Correlation between
UPSIT and CAMCOG
rs
p
0.200
0.512
a. j. gray et al.
516
Figure 1. UPSIT score (median and 95% condence interval) by diagnostic group.
on odour identication, showing that odour identication on the UPSIT is poorer than picture identication
on the PIT in patients with probable and questionable
AD. Similarly they found that odour identication
remained poor even when the lexical demands of
the task were eliminated. Positive correlations
between UPSIT and CAMCOG scores would also
be expected if cognitive decline and progressive
impairment of olfactory abilities were parallel but largely independent processes. Our ndings may support
a view that patients with clinically diagnosed vascular
dementia frequently have a signicant admixture of
Alzheimer-type pathological changes (Kalaria and
Ballard, 1999). The UPSIT was designed and validated in the USA and contains some culturally bound
items which may explain the slightly lower scores in
the normal controls, but not the marked impairment
seen in the vascular dementia group. With minimal
modication the test was readily applicable to an
elderly British population.
The UPSIT is easy to administer, requires little
training and is well tolerated by patients. Other
advantages of using this test include the portability
of the test itself (if required it can be posted) and
the stability of the reagents. It costs around $30 per
Int J Geriatr Psychiatry 2001; 16: 513517.
KEY POINTS
Odour identication in vascular dementia is
abnormal to a similar extent to that found in AD.
The UPSIT can distinguish those with vascular
dementia or AD from normal controls in a
British population.
REFERENCES
Bacon AW, Bondi MW, Salmon DP, Murphy C. 1998. Very early
changes in olfactory functioning due to Alzheimer's disease
and the role of apolipoprotein E in olfaction. Ann NY Acad Sci
855: 723731.
Doty RL, Shaman P, Dann M. 1984. Development of the University
of Pennsylvania Smell Identication Test: a standardised microencapsulated test of olfactory function. Physiol Behav 32:
489502.
517
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