Brain Imaging

Dementia
and Geriatric Dement GcriatrCogn Disord 1997;8:1997;8:110-116
Cognitive Disorders

Ingmar Rosén Electroencephalography as a

S r ^ “ S S r logy' Diagnostic Tool in Dementia

K e y w o rd s Abstract
EEG Clinical electroencephalography is a relatively simple and inexpensive diagnostic tool with a
Dementia high sensitivity for diffuse organic encephalopathy of various aetiologies but with a rather low
specificity for the type of diagnosis. The highest sensitivity is shown in DAT and Parkinson
dementia, and in these conditions the degree of EEG abnormality is correlated with the dis­
ease severity. Quantification of EEG makes these correlations more reliable and provides a
method for monitoring therapeutic effects. Dementias with predominantly frontal pathology
show much less EEG abnormality, and in these conditions the EEG is often normal despite
obvious clinical dementia. Also, alcohol dementias often show normal EEG patterns. At an
early stage of clinical evaluation, EEG may be useful in the discrimination of organic demen­
tia from pseudodementia, because EEG is usually normal in depression, confusion, agitation
and other psychiatric conditions. In pscudodementia due to intoxication with sedatives the
EEG is usually dominated by diffuse p activity. At the stage of differential diagnosis of an
organic brain disorder, EEG cannot reliably discriminate between encephalopathies second­
ary' to hydrocephalus, AIDS, cerebrovascular disease, B|i deficiency and primary' degenera­
tive diseases such as DAT. More specific EEG patterns are seen in acute cerebrovascular
lesions, metabolic encephalopathies, i.c. of hepatic origin, Creutzfeldt-Jakob disease, herpes
encephalitis, and nonconvulsive status epilepticus as possible causes of a rapidly deteriorat­
ing mental and neurological condition. Repeated EEG recordings over time would add signif­
icantly to the diagnostic information. New techniques such as topographical brain mapping,
analysis of the EEG during REM sleep, coherence analysis of the EEG activity, and the com­
bination of quantified EEG techniques with evoked potentials and event-related potentials
will presumably add to the sensitivity as well as the specificity of the electrophysiological
methods in the diagnosis of dementia.

Electroencephalogram -Basic N europhysiology frequencies in the 8-13 Hz (a) range and is generated by
several independent generators in the cerebral cortex and
The electroencephalogram (EEG) is a recording of cere­ thalamus [3], Slow waves between 0.5 and 4 Hz (8) prevail
bral electrical potentials by electrodes on the scalp. It is a during the deep stage of normal synchronized sleep but are
spatiotemporal average of synchronous postsynaptic po­ scarce in the normal waking condition. Both metabolic
tentials arising in radially oriented cortical pyramidal cells. and structural pathology can give rise to diffusely distrib­
Synchronous neuronal activity arises by various mecha­ uted polymorphic 8 activity. Cholinergic deafferentation
nisms. Specific pacemakers exist in the thalamocortical may play a role in the production of cortical 8 activity [4-
neuronal circuitry' that produce rhythmic synchronous ac­ 6], Localized 8 activity is usually attributed to a lesion with
tivity. These are under the influence of afferents from the some destruction of cerebral tissue. The pathophysiologi­
brain stem reticular formation, which stimulate individual cal mechanisms of slow waves in the 4- to 8-Hz range (0) is
neurones into independent asynchronous activity. These not well known. Often, 0 activity represents a slowing
effects are mediated by cholinergic and noradrenergic neu­ down of the a activity and in these cases represents the
ronal systems. Thus, synchrony is reduced by arousal and dominant background activity. There is a relationship
increases with reduced vigilance [1, 2], The rhythmic between the dominant or mean EEG frequency and the
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activity of the normal adult awake EEG is dominated by rate of cerebral blood flow and oxygen uptake in cortical
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K Ä R G F R © 1997 S. Karger AG. Basel Ingmar Rosen. MD

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E-Mail kargcr(a karger.ch University Hospital
Fax+41 61 306 12 34 S—221 85 Lund (Sweden)
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grey matter [7. 8]. Such slowing of the background activity have been made to stabilize the vigilance level during
is seen in mild to moderate hypoxia, cerebrovascular dis­ EEG recording by various activation procedures [16,17],
ease. dementias, and in mild degrees of metabolic ence­ Maps can be constructed from statistical values derived
phalopathies [2, 9], An increased amount of 9 waves in from quantitative comparisons. Interpolation between
combination with a activity of normal frequency may the points of real measurements makes these maps appear
represent the mildest form of polymorphic 5 activity (see very detailed. Artefacts from extracranial sources and
above) [ 1]. EEG waves with frequencies above 13 Hz ((3) is electrodes are much more difficult to reveal as compared
normally present with a symmetric frontocentral predomi­ with the routine EEG display. Short transients in the
nance. Excessive prominent p activity is usually the result EEG, i.e. epileptiform discharges or episodes of slow
of a medication effect, most frequently produced by ben­ waves, which might be highly relevant clinically, usually
zodiazepines or barbiturates. Otherwise, excessive gener­ do not appear in the frequency analysis of 1-2 min of
alized p activity is of little diagnostic significance [10]. EEG. Therefore it is mandatory' that these new techniques
of quantification and mapping are combined with careful
inspection of the original EEG recording in a professional
Interpretation and Quantification of the EEG clinical neurophysiological setting [ 18-21 ].

Interpretation of the EEG record is still, 60 years after

the initiation of clinical electroencephalography, made by EEG and the Normal Ageing
visual inspection of recordings from a large number of
electrodes distributed over the scalp. Over the years, sev­ Once the adult EEG is established around the age of 15
eral attempts have been made to quantify the EEG signal, years, this pattern is very stable over the years into healthy
making it available for statistical analysis and various dis­ senescence [22], The change of EEG most commonly
play techniques [11]. Recently, the development of com­ reported in elderly subjects is slowing of a frequency.
puter technology makes it possible to apply such tech­ Although statistically significant, most healthy elderly
niques in clinical practice. The most commonly used individuals will maintain a activity within 9.5-10 Hz [15,
method of quantified frequency analysis of EEG is based 23-25], The other frequent abnormality observed with
on the fast Fourier transform (FFT). Features commonly advancing age is local slowing over temporal regions [25,
extracted from the amplitude or power spectrum are: 26], Focal left-sided anterior temporal EEG abnormalities
(a) Absolute band amplitude or power: the area under the in normal elderly subjects have been reported to be corre­
curve between the two frequencies defining the band­ lated with deterioration of language function [27], In a
width, usually, 8,0, a, and p. (b) Relative band values: one group of elderly healthy women, 75-95 years of age, 9
absolute band value divided by another, usually one band activity increased with age without correlation with psy­
value divided by the absolute value of the whole spec­ chometric features [28]. Increase of 5 activity with age has
trum. (c) The absolute peak frequency: the peak value in a been correlated with impairment of memory function and
selected band of the spectrum, usually the a band. By to reduced acetylcholinesterase activity of the CSF [29],
introducing quantitative techniques and by collecting p activity has been reported to increase with age, particu­
normal age-matched control data, it has become possible larly in women [30] and has shown positive correlation
to substantiate the visual interpretation of the EEG by a with cognitive performance [31]. The spatial distribution
quantified estimation of the degree of deviation from nor­ of EEG activity seems to change with normal ageing with
mality, usually expressed as z scores for each band, but increasing uniformity across the brain associated with an
discriminant analysis and artificial neural networks have increased coupling of activity between areas [32].
also been proven of value in separating dementia patients
from controls and in the classification of subgroups of
dementia [12, 13], Special displays of the scalp distribu­ EEG in Dementia of Alzheim er Type
tion of recorded activity is referred to as topographic or
brain mapping. Critical evaluations of the reproducibility A pathological EEG in a histologically verified case of
of quantified EEG in senile dementia arc scarce. Results Alzheimer dementia and a correlation between EEG slow­
available indicate that this is worse in dementia patients ing and the degree of senile dementia was observed already
than in healthy controls, due to large fluctuations of the by Berger [33, 34], Since then, a large number of reports
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background activity [14, 15]. In a few studies, attempts have been published on the subject of EEG and dementia.
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Electroencephalography as a Diagnostic Dement GcriatrCogn Disord 1997:8:110-116 111

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Tool in D em entia
particularly verified or probable dementia of Alzheimer [cf. also 53]. The heterogeneity of DAT was further illus­
type (DAT), well over 500 during the last 10 years. trated with multichannel brain mapping applied to two
EEG. conventionally interpreted, shows a high per­ groups of DAT patients, one with predominant memory
centage of abnormalities in DAT [35-39]. Most of these deficit, and one group with progressive spatial impairment
studies also showed a correlation between the degree of [54, 55] with differences located to the parietal region.
EEG abnormality and the severity of dementia. Systema­ Mapping studies usually show a widespread increase of 0
tized blind interpretation of EEG [40] in 86 patients with and 8 activity, and a more localized decrease of a and [3
DAT showed abnormal findings in 87.2% at the initial activity [28,55-57], Breslau el al. [58] found marked asym­
examination, and in 92% at follow-up. A normal EEG had metry' of8 activity over temporal lobes, in correspondence
a negative predictive value of 0.825 with respect to the with the PET findings ofFricdland ct al. [59],
diagnosis of DAT. i.e. a sensitivity not found with other Patients with Down’s syndrome developing early or­
imaging techniques. A group of patients with probable ganic dementia similar to DAT show EEG abnormalities
DAT and depression was found to have abnormal EEG. similar to those described for DAT [60-62],
whereas patients with depression or depressive pseudode­ Two groups have independently found frequency anal­
mentia had normal EEG or only mild abnormalities [41]. ysis of EEG during REM sleep onset superior to wake
This has recently been confirmed with quantified EEG EEG for the differentiation of mild DAT from normal
techniques [42-44]. controls [63-65] and from cognitively unimpaired seniors
A large number of studies have been reported, compar­ with major depressive disorder [44],
ing different quantitative EEG variables in patients with EEG mapping studies have revealed time segments of
DAT with other types of dementia and age-matched con­ spatially stationary map landscapes as characterized by
trol subjects. The criteria for the clinical diagnoses as well the locations of potential maxima and minima. The seg­
as the degree of dementia vary to a large extent and are not ments of EEG activity were significantly fewer and the
always well defined. In only a fraction of the patients the segments lasted longer in DAT patients compared to con­
diagnoses have been verified by post mortem histological trols [66]. The gross distribution of rhythmic EEG activity
examinations. In mild DAT. relative 0 power [45, 46] and of various frequencies can be estimated by FFT-dipolc
dominant occipital frequency [43] seem to provide the approximation. DAT patients showed a shift of a and 3
highest sensitivity, in the latter study with a correct classifi­ activity toward frontal brain regions and the degree of
cation rate of 77% in DAT versus control subjects. In the shift correlated with the degree of dementia [67],
study of Penttila et al. [46], using one single channel for On a semiquantitative level, early studies [68] found a
quantification, slowing of the occipital peak frequency and correlation between rCBF reduction in postcentral areas
distinct accentuation of relative 6 power only occurred in and an increase of EEG abnormality. On a quantitative
cases of advanced DAT. In a longitudinal study [47] over level the regional EEG frequency did not correlate with
2.5 years relative 8 and 0 power increased and a and (3 rCBF. although a significant correlation with white mat­
power as well as mean frequency decreased in correlation ter blood flow was found [69]. A few studies have been
with the disease progress. Again relative 0 power most unable to demonstrate clear-cut correlation between EEG
effectively distinguished between four stages of dementia. and SPECT abnormalities [17, 70], Patients with DAT
Two groups of DAT patients, one with normal or slightly with relative intactness of parietal lobe function as mea­
abnormal EEG. and one with abnormal EEG were followed sured by psychometric testing and FDG-PET showed
for 1 and 3 years [48-50]. Despite progression of the dis­ preservation of the EEG a background [71 ]. In a mapping
ease, the EEG of the first group deteriorated more slowly as study [72] anterior horn distance, lateral ventricle dis­
compared with the second group, and showed less decline tance, Evan’s index and cortical density in CT correlated
of practice, naming and automatic speech functions, less with the degree of 8-0 increase and a-3 decrease in EEG.
extrapyramidal symptoms and less risk of institutionaliza­
tion. Patients with the most marked slowing of the domi­
nant occipital rhythm were found to have the lowest con­ Differentiation between D A T and
centrations of noradrenaline in the thalamus [51] and the Cerebrovascular Dementia
lowest levels of choline acctyltranferasc activity in frontal
cortex at the postmortem examination [52], These results Several studies have compared patients selected on clin­
indicate a heterogeneity of DAT and that EEG at the onset ical grounds to suffer from DAT and multi-infarct demen­
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of the disease might predict the rate of disease progression tia (MID), respectively. The results obtained seem to
Kings's College London

112 Dement GeriatrCogn Disord 1997:8:110-116 Rosen

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depend upon the clinical degree of dementia studied. A features and rCBF [57], Further observations in a larger
number of studies failed to demonstrate any significant group of patients [Passant et al., unpubl. data] localized the
differences [38, 40, 73-75], A higher incidence of focal maximum 0 abnormality over the posterior parts of the
abnormalities in MID has been repeatedly observed [38. brain. In Huntington’s chorea the EEG is uncharacteristic
73]. The uneven distribution of EEG abnormality in MID in early phases becoming of very low voltage during later
is most clearly demonstrated by multichannel EEG map­ phases [87, 88]. Patients with Steele-Richardson-Olszcws-
ping, providing 63% correct classification [72], In mild ki syndrome show a low voltage EEG with preserved occi­
cerebrovascular dementia the EEG is often normal or pital a classified as normal in half of the cases [89],
slightly abnormal [68], Quantitative studies have repeated­
ly found the occipital a activity to be more preserved in
MID in comparison with DAT [57, 76-78]. Functional EEG in Parkinson Dementia
connections between different cortical areas can be studied
by coherence analysis of the EEG activity. Areas linked by In Parkinson’s disease (PD) without dementia the
longcorticocortical connections showed great reduction of EEG has been reported to be abnormal in 30-50% with
coherence in DAT but not in MID. Areas linked by broad an abnormal diffuse increase of low frequency activity
connective networks showed reduced coherence mainly in and slowing of the occipital a frequency. The degree of
MID. Ratios of different coherences correctly classified abnormality could be correlated with the degree of motor
76% of subjects into DAT and MID categories [79]. Simi­ disability [90-92], PD patients with dementia differed
lar techniques may be used to demonstrate white matter from those without dementia with more advanced diffuse
disease in the ageing brain [80], EEG slowing, particularly with more 6 activity. In prac­
tice. it would not be possible to differentiate PD with
dementia from DAT on the basis of EEG features.
EEG in Therapeutical Trials of D A T

EEG can be repeated without the limitations inherent EEG in Creutzfeldt-Jakob Disease
with radioactive isotope techniques (rCBF. SPECT.
PET), and have been extensively used for testing of psy­ About 200 reports have been published since 1975
choactive drugs [pharmaco-EEG, 81]. In DAT. phvsostig- describing EEG in this rare (incidence about 0.4/million)
mine infusion produced significant improvement which disease. The characteristic feature is diffuse or focal slow­
correlated with rCBF changes [82], It has also been uti­ ing developing into periodic sharp wave complexes
lized in trials with oral tetrahydroaminoacridine [83, 84], (PSWC). The PSWC pattern appears within 12 weeks of
The pretreatment EEG as well as drug effect on EEG dif­ disease in 88% of the cases, usually correlated with a
fered in clinical responders and nonresponders. Electro- marked worsening of the clinical picture [93-95], Focal or
physiologic brain mapping has also been found useful in asymmetric PSWC arc common at onset (about 50%)
trials in DAT patients with CDP-choline [85], and several with correspondence with focal clinical signs. A subgroup
nootropic drugs [72]. The effect on quantitative EEG of of patients (10%) had unusually long courses, and showed
single intravenous doses of scopolamine has been suggest­ PSWC in only 55%. The EEG pattern is not pathogno­
ed as a test of the degree of cholinergic deficiency in Alz­ monic for Creutzfeldt-Jakob disease and has been re­
heimer’s disease [86], ported in cases of severe postanoxic encephalopathy [96],
AIDS dementia complex [97], herpes encephalitis [98],
lithium toxic encephalopathy [99. 100], Binswanger’s dis­
EEG in P ic k 's Disease and Frontal Lobe ease [101], and severe DAT [102].
Dem entias

EEG in patients with histologically verified frontotem­ EEG in Dementia of V arious Aetiologies
poral cortical atrophy were found to be normal or moder­
ately abnormal despite prolonged dementia of increasing EEG changes are uncommon and mild in alcoholic
severity [37, 68]. Quantified EEG showed a moderate and dementia unless it is combined with hepatic encephalopa­
diffuse increase of relative 9 activity in a group of fronto­ thy [103, 104], EEG is usually normal in neuro-psvcholog-
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temporal dementia patients, identified by their clinical ically unimpaired patients infected with / / / f ' [ 105], In
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Electroencephalography as a Diagnostic Dement Gcrialr Cogn Disord 1907;S: 110—116 113

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 Fig. 1 . Practical use of EEG as a diagnostic tool in dementia.

AIDS and AIDS-related complex, the incidence and sever­ dialytic encephalopathy is characterized by synchronous
ity of abnormal EEG increases with the development of and symmetrical frontal intermittent rhythmic 8 waves
AIDS-related dementia with diffuse and/or focal slowing and frontocentral spike waves [ 108] (fig. I).
and in 10% focal epileptiform activity [106]. In normal
pressure hydrocephalus the EEG shows a diffuse slowing
A cknow ledgem ent
which is correlated with the CSF outflow resistance. The
EEG response to a CSF tap test was not significant and Supported by the Swedish Medical Research Council, grant No.
therefore of limited diagnostic value [ 107]. Progressive B95-14X-0008A-31B.

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