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LettersFull Access

The “Closing-In” Phenomenon in Parkinson’s Disease Dementia and Lewy-Body Dementia

Published Online:1 Oct 2012https://doi.org/10.1176/appi.neuropsych.11110327

Letter to the Editor: The closing-in phenomenon, that is, the tendency to close in on a model while performing a constructive task, has been reported in Alzheimer’s disease (AD),1 frontotemporal dementia,2 and vascular dementia.3 Recent studies suggested that closing-in probably reflects a compensatory strategy to overcome basic visuospatial dysfunctions involved in the preliminary visuo-perceptual analysis and/or in the on-line maintenance of the visual representation of the model while performing a copying/drawing task.4 Although visuospatial impairment is also a common cognitive feature in synucleinopathies, such as Parkinson’s disease dementia (PDD) and Lewy-body dementia (LBD),5 closing-in has never been reported in these disorders. We report on four cases of synucleinopathies (three PDD and one DLB) in which we detected closing-in phenomena.

Case 1: “GM” is a 76-year-old, right-handed man. He received a diagnosis of Parkinson’s disease (PD) when he was 67 years old. When he was 74, he began to show mild cognitive difficulties (MMSE: 25/30), especially related to executive functions (Frontal Assessment Battery [FAB] score: 12/18). Two years later, he developed a clear dementia associated with PD (levodopa daily dose: 940 mg/day; UPDRS-II/III: 15/32; Hoehn & Yahr [H&Y] rating, 3). GM then showed impaired cognitive status (MMSE: 20/30), with severe impairments of executive functions (FAB score: 8/18) and visuospatial functions (Benton’s Judgment of Line Orientation [JOL] score: 12/30; Raven's Colored Progressive Matrices [CPM], 16/36). During constructional praxis tasks, he showed closing-in of the “overlap” subtype.3

Case 2: “DM” is a 71-year-old, right-handed man. He received a diagnosis of PD when he was 64 years old. When he was 69, he began to show mild cognitive difficulties (MMSE: 23/30), especially related to executive functions (FAB: 11/18) and visuospatial functions (Benton’s JOL: 18/30; Raven's CPM: 19/36). One year later, he developed visual hallucinations, and, after 2 years, he developed PDD (levodopa daily dose: 675 mg/day; UPDRS-II/III: 19/24; H&Y: 3). DM presented a worsened cognitive status (MMSE: 16/30) and a severe and worsened impairment of executive (FAB: 7/18) and visuospatial functions (Benton’s JOL: 13/30; Raven's CPM: 15/36). During constructional praxis tasks, he showed closing-in of the “adherent” subtype.3

Case 3: “QB” is a 79-year-old, right-handed man. He received a diagnosis of PD when he was 74 years old. He shows cognitive difficulties (MMSE: 21/30), especially related to executive (FAB: 8/18) and visuospatial functions (Benton’s JOL: 18/30), that led to the diagnosis of PDD (levodopa daily dose: 750 mg/day; UPDRS-II/III: 10/31; H&Y: 2.5). During constructional praxis tasks, he showed closing-in of the “overlap” subtype.3

Case 4: “SD” is an 81-year-old, right-handed, married man. Six months ago, he began to show fluctuating mild cognitive impairment and visual hallucinations; then a mild parkinsonism also appeared. The DaT-SCAN- SPECT revealed bilateral putaminal degeneration. His global cognitive status was impaired (MMSE: 22/30), especially related to executive (FAB: 8/18) and visuospatial functions (Benton’s JOL: 15/30; Raven's CPM: 19/36). He received a diagnosis of LBD. During constructional praxis tasks, he showed closing-in of the “adherent” subtype.3

These cases show that the closing-in phenomenon may be present also in synucleinopathies associated with dementia, as PDD and DLB, in which visuospatial impairment is often a cognitive hallmark.

Dept. of Neuroscience, University of Pisa, Italy Neurology Unit, USL of Viareggio, Italy
Neurology Unit, USL of Viareggio, Italy
Dept. of Neuroscience, University of Pisa, Italy Neurology Unit, USL of Viareggio, Italy
Neurology Unit, USL of Viareggio, Italy
Dept. of Neuroscience, University of Pisa, Italy Neurology Unit, USL of Viareggio, Italy
Correspondence: Prof. Ubaldo Bonuccelli, Dept. of Neuroscience, University of Pisa, Italy; e-mail:

Conflict of interest relative to the research covered in this manuscript: none.

References

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5 Kurita A, Murakami M, Takagi S, et al.: Visual hallucinations and altered visual information-processing in Parkinson disease and dementia with Lewy bodies. Mov Disord 2010; 25:167–171Crossref, Medline, Google Scholar