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Fluctuating cognition in dementia with Lewy bodies and Alzheimer’s disease is qualitatively distinct
  1. J Bradshaw1,2,
  2. M Saling1,2,
  3. M Hopwood1,3,
  4. V Anderson2,
  5. A Brodtmann1
  1. 1Austin Health. Heidelberg. Australia
  2. 2Department of Psychology, The University of Melbourne, Parkville, Australia
  3. 3Department of Psychiatry, The University of Melbourne, Parkville, Australia
  1. Correspondence to:
 Michael M Saling
 Department of Psychology, The University of Melbourne, Parkville, Victoria, 3010, Australia; Email:


Objectives: To document and illustrate qualitative features of fluctuating cognition as described by care givers of patients with probable dementia with Lewy bodies (DLB) and Alzheimer’s disease (AD). To determine whether the quality of the fluctuations differs between DLB and AD. To examine the clinical utility of two recently developed rating scales.

Methods: Care givers of 13 patients with early probable DLB and 12 patients with early probable AD were interviewed using the Clinician Assessment of Fluctuation and the One Day Fluctuation Assessment Scale, both developed recently. Descriptions of fluctuating cognition were recorded verbatim, analysed, and rated.

Results: Descriptions of fluctuating cognition in DLB had a spontaneous, periodic, transient quality, which appeared to reflect an interruption in the ongoing flow of awareness or attention that impacted on functional abilities. Descriptions of fluctuations in AD frequently highlighted episodes of memory failure, or a more enduring state shift in the form of “good” and “bad” days, typically occurring in response to the cognitive demands of the immediate environment. These qualitative differences could be detected reliably by independent raters, but were not always captured in standard severity scores.

Conclusion: Fluctuations occuring in DLB have particular characteristics that are distinguishable from fluctuations occurring in AD. Interpretation and application of the fluctuation criterion continues to limit the diagnostic sensitivity of the consensus criteria for DLB. Findings suggest that explicit documentation and a wider appreciation of these distinctions could improve the reliability with which less experienced clinicians identify this core diagnostic feature in the clinical setting.

  • Alzheimer’s disease
  • behavioural features
  • dementia with Lewy bodies
  • diagnosis
  • fluctuating cognition
  • AD, Alzheimer’s disease
  • BPRS, Brief Psychiatric Rating Scale
  • CDR, Clinical Dementia Rating Scale
  • DLB, dementia with Lewy bodies
  • FC, fluctuating cognition
  • FSIQ, Full Scale IQ
  • HADS, Hospital Anxiety and Depression Scale
  • MMSE, Mini Mental State Examination
  • NART, National Adult Reading Test
  • PIQ, Performance IQ
  • SDLT, senile dementia of Lewy body type
  • UPDRS, Unified Parkinson’s Disease Rating Scale
  • VaD, vascular dementia
  • VIQ, Verbal IQ
  • WASI, Wechsler Abbreviated Scale of Intelligence

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  • Funding support: Austin Hospital Medical Research Foundation (AHMRF), Australian Association of Gerontology (AAG)

  • Competing interests: none