A PROFILE OF DEMENTIA PATIENTS IN A SERBIAN SAMPLE – EXPERIENCE FROM THE CENTER FOR DEMENTIA AND MEMORY DISORDERS

BACKGROUND /AIM In accordance with modern trends of organizing specialized service dealing with dementia, the first memory clinic in Serbia Center for memory disorders and dementia was established in 2008 in Belgrade at Neurology Clinic Clinical Center of Serbia (CCS) as a university-affiliated outpatient clinic for subjects with cognitive impairment and dementia. The Aim of this report is to outline the frequency of diagnosis, sociodemographic and medical characteristics of patients referring to the Center for memory disorders and dementia.

Ključne reči: Centar za poremećaje pamćenja, demencija, prevalenca INTRODUCTION With the aging of the population, dementia is becoming a growing health problem.
Inspired by philosophy and practice of the psychogeriatric movement which transformed mental health services for older people in the UK from the late 1960s [1][2][3] the first memory clinics were described in the 1980s 4 .Recognizing the need for a multidisciplinary approach to a patient with cognitive impairments, in order to provide adequate care and reduce suffering in both patients and caregivers with minimal recourse to mental hospital care, and in recent decades there has been a significant increase in the number of memory clinics all over the world [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] .They provide early diagnostic assessment, treatment, and follow up of patients with cognitive symptoms and possible dementia in an outpatient setting.But, not all complaints about memory are caused by dementia 24 .Some of them present mild cognitive impairment and/or other symptoms not specific for Alzheimer's disease, and may occur in many other conditions, including potentially reversible conditions.Therefore, and also because of an increasing number of patients, there is a need to create a register of patients covered by the work of the memory clinics.
Accessible, reliable recent and relevant data are necessary to facilitate prevention, early detection, diagnosis and treatment of dementia.The dementia registries are developing in order to improve the quality of diagnostic work-up, treatment and care of patients with dementia disorders.Data obtained in some countries cannot easily be generalized to other countries.
Because local environmental conditions and genetic make-up may be different, prevalence and/or incidence rates reported from the most famous studies in the United Kingdom 25 , Sweden 26 , Denmark 27 and Spain 28 cannot be extrapolated to other countries even in the same region 29 .
In accordance with modern trends of organizing specialized services dealing with this complex issue, the first memory clinic in Serbia -Center for memory disorders and dementia was established in 2008 in Belgrade at the Neurology Clinic, Clinical Center of Serbia (CCS) as a university-affiliated outpatient clinic for subjects with cognitive impairment, aimed to improve practice in the identification, investigation, and treatment of memory and other cognitive disorders, including dementia in Serbian patients.
Regarding that the Center covers the majority of Serbian patients, its activities also include, working on constitution the Serbian Dementia Registry -a population-based epidemiological study that registers all cases of dementia in the Serbian population.
The Aim of this study was to report on the frequency of diagnosis, sociodemographic and medical characteristics of the patients referred to the Serbian Center for memory disorders and dementia.

METHODS
The survey was conducted at the Center for dementia and memory disorders at the Clinic for Neurology -CCS and included all consecutive patients between March 2008 and December 2016.The local ethics committee approved this study.Patients and their relatives were informed of the entry into CR and had a possibility to decline participation and to have their data removed at any time.Data were de-identified before analysis.Medical and administrative data of outpatients and day clinic patients visiting the Center are routinely recorded by the Center's staff.
The CR contains information on patient demographics, principle and secondary diagnoses, and other admission and discharge data.The principle and secondary diagnoses are determined and coded using the ninth revision of the International Classification of Diseases -Clinical Modification (ICD-9-CM) 30 .

Subjects and procedures
Diagnosis of dementia, and its subtypes, was made at a multidisciplinary consensus meeting based on internationally accepted criteria [31][32][33][34][35] .All patients are registered by a neurologist with one of 8 diagnostic category: dementia caused by Alzheimer's disease (AD), mixed dementia with AD-vascular dementia -it will be further referred to as Mixed dementia (MD), vascular dementia (VaD), dementia with Lewy bodies (DLB), frontotemporal dementia (FTD), Parkinson's disease with dementia (PDD), unspecified dementia (UD), and other diagnoses (Other).At the first visit, information about their age, gender, education, living condition and quality of self-care and activity of daily living is registered.Global cognitive status is assessed by Mini-Mental State Examination (MMSE) 36 and its score is recorded.Medical history was obtained via self-report and/or family member-report (substantiated through medical records).The presence of risk behavior such as smoking, alcohol abuse, and vascular risk factors such as arterial hypertension (HTN), diabetes mellitus (DM), dyslipidemia and thyroid gland dysfunction is also noted.Head injury with loss of consciousness and eventually, depression or psychoses symptoms are registered.
All patients received a comprehensive assessment comprised of a standardized diagnostic work-up including neurological examination, blood tests which includes: complete blood count (CBC), comprehensive metabolic panel (CMP), lipid panel (LP), thyroid gland function tests, vitamin B12 level and a VDRL test.All subjects undergo an extensive assessment of cognitive functions which results are presented in the paper and in electronic form.In the Center's clinical practice neuropsychological evaluation lasts around 1.5 to 2 hours and entails the application of tests which can roughly be divided into two groups: tests intended for general examination of cognition and tests created for assessment individual domains of cognitive functions such as: attention, memory, fluency/ executive functions, language, visual and spatial abilitiesalso known as domain oriented tests.In the first group are: Mini-Mental Status Exam (MMSE), Addenbrooke's Cognitive Examination -Revised (ACE-R) 37 , Matiss -Dementia Rating Scale (DRS) 38 and Clock Drawing Test (CDT) 39.The second group includes the following tests: Rey Auditory Verbal Learning Test (RAVLT) 40 , Free and Cued Selective Reminding Test (FCSRT) 41,42 , Verbal Fluency -Semantic and Phonemic fluency (SF and FF) 40 , Boston Naming Test (BNT) 43 .All tests were conducted by a qualified neuropsychologist in a standardized manner consistent across subjects.Applying of the test was adjusted to the overall cognitive ability (MMSE higher than 15), physical ability (lack of visual and/or hearing disability, paresis and/or behavioral difficulties).For the assessment of functional impairment in activities of daily living, we have used the Activity of daily living -International Scale (ADL-IS) applied by the Centers' nurse 44 .Patients with young onset dementia (YOD), MCI and dementia diagnosis that were able to undergo neuropsychological assessment were included in an annual follow up.
Further, patients received additional diagnostic procedures such as sonographic examination of the carotid arteries and computed tomography (CT).Depending on the indication (YOD, differential-diagnosis) approximately 66% of patients underwent a magnetic resonance imaging scan (NMR), and 38% PET scan, biomarkers and specialized laboratory and genetic analyzes.The data on follow up-visits were registered as well.

Statistical analyzes
Data are expressed as means (M) ± standard deviation (SD) for the continuous variables, as percentage for the categorical variables.First, analysis of variance and t-test were utilized to examine for group differences in demographic, clinical, and neuropsychological characteristics, χ 2 test was applied to sets of categorical data.A two-sided p value < 0.05 was considered statistically significant.Data were analyzed using the SPSS 20.0 statistical package (SPSS Inc, Chicago, Illinois, USA).

Patients characteristics
A total of 2198 patients carried out 3873 visits between 2008.and 2016.during annual visits which ranged between one to seven visits (Table 1). Table1.
The largest number of visits was made by the patients with a diagnosis of MCI (44.9%) and AD (30.8%), while the least common were patients with diagnosis DLB (0.6%) (See Table 1. and Figure 1.)At the first visit the majority of participants were female (65.3%) (Figure 2), the average age of the sample was 69.8 ± 12.1 years, male patients were significantly older (70.9± 9.4) (t=3.091,p=.002), and the average educational level was 12.1 ± 3.3 years.Average MMSE score was 22.6±6.8,and average duration of disease was 2.7±2.3.Around 73.9% lived in their own home and 59.3% were independent in activity of daily living.The details of the sample in the baseline visit are shown in Table 2 and Table 3. Table 2. Table 3.
Analysis of variance (ANOVA) was utilized to examine for group differences between different diagnostic groups of age, educational level, MMSE score, duration of disease and duration of HTN; a t-test was used to examine for group differences in ages between male and female; a chi-square test was utilized to examine for group differences in gender and others characteristic (demographic, vascular risk factors and, results of blood tests, performed diagnostic procedures and type of therapy) -Table 3 and 4 4. Table 4.

DISCUSSION
The main objectives of the Center's practice are to make early diagnosis and treatment; to identify and treat disorders other then dementia that might contribute to patients' problems; to evaluate new therapeutic agents in the treatment of dementia; to reassure people who are worried that they might be losing their memory, when no real deficit is found 4 .Following these principles in every day work during an 8 year period, approximately 4000 examinations have been conducted on over 2000 subjects, all the while being backed up by the most modern diagnostic procedures that are recommended by expert groups, national and international professional associations.Even though primarily profiled for the diagnosis and treatment of dementia, among the professional and general public the Center is also recognized as a reference institution for the creation of standards and normative criteria on a national but also regional level.In that sense, an important aspect of the Center's activities is the work involving the formation of normative values for neuropsychological tests that are obtained from the results of healthy subjects, and considering the fact that a national dementia registry is not available in Serbia, as well as evidence on morbidity and mortality risks related to dementia in the Serbian population, work on forming its constitution is of utter importance.
Taking into consideration the specificity of an illness such as dementia, the activity of the Center involves the support and advice of caregivers and patients, as well as the expert education provided by professionals that are hired to work with this patient population.Realizing these aims by obeying the principles of good clinical practice, we believe that the Center has given meaning to the reasons it exists in the first place in great measure.
All patients complained about memory dysfunction and/or behavioral disturbances and were referred by a general practitioner (51.0%), a neurologist/neuropsychiatrist (30.5%), or a psychiatrist (18.5%) from primary, secondary or tertiary health care.The largest number of patients is, approximately 60 %, after performed indicated diagnostic procedures in the first visit were returned to the doctor or specialist who initially sent them to the Center.Therefore, the majority of the patients that were sent to the Center, already after their first visit, received an adequate answer regarding the problems because of which they were sent to the Center in the first place, and thus considering this aspect, the Center justifies the criteria of the tertiary level of healthcare within the scope of the health protection system of the Republic of Serbia.
After the baseline assessments almost 40.0% of all patients proceed to annually follow up visits when all indicative medical procedures are repeated (i.e. a neurological examination, general questionnaire, comprehensive neuropsychological battery with MMSE, blood test).
Significant majority of those patients were patients with diagnosis MCI (40.4%) and AD (47.8%), which is a trend continuing through all annual visits, meaning that these patients were most commonly seen in the Center.Comparing these two subgroups it is notable that the frequency of patients with AD was growing while MCI was decreasing, during the follow up period, which is expected regarding the progression of disease, mortality and comorbidity.
Due to cognitive problems, a significant majority of patients that seek help were women (almost 2/3 of the entire sample), in their late seventies and it is in then when their difficulties were also objectively verified (MMSE = 22.6).Besides this, the greater majority of patients in the group that suffer from AD were women, but there were less women patients that suffer from DLB and this is in accordance with the data from other research 45,46 .However, our female patients were younger on average than male patients, which oppose the research results which have explanations on there being more women who suffer from dementia due to a longer life span 47 .Up to this day, the majority of research on this topic involved investigating the risks of the occurrence of dementia which is connected to aging.A longer life span of women does not fully explain their greater majority among those suffering from AD, but it does raise the total prevalence of all types of dementia in women in the group made up of the oldest subjects 46 .Our sample was for the most part heterogeneous in terms of age, i.e. it included a relatively wide array of ages so it would be useful to examine the connection between dementia and gender with this sample which is stratified by our patients' years.
Women also made up the majority within the MCI diagnostic category which would, when taking this stage into consideration, explain the assumption of the greater sensitivity of this population category on cognitive changes and their readiness to seek help earlier, but also it would explain the traditionally greater pressure of different roles which continues even after women go into their retirement years in Serbia.Also, the greater eagerness to seek help in the MCI group could be explained by the patients' younger ages and their greater educational level as well, i.e. the patients were generally better informed and this difference was determined among the patients of this group in comparison to the other groups.During first contact, the subjects with the MCI diagnosis, on the cognitive screening level, showed average results which were within physiological limits (MMSE: 26,8±3,2 and TCS: 4,1±1,3).These were individuals who most often did not gravitate towards risk behavior (smoking, alcohol), and the majority of patients' reasons for coming to the Center very rarely had anything to do with them being related to individuals suffering from dementia.On the other hand, a great number of patients from the MCI group had verified reductive changes on the brain which was seen through their CT scan.
More than half of the subjects had registered HTN and also a similar percentage of patients had bilateral carotid stenosis which was registered through an ultrasound, and there was a smaller number of patients that suffer from vascular lesions and CVI.Our data are in accordance with the results by Camarda, Pipia et al., 48 which confirmed the presence of atrophic and vascular changes on the brain in patients with MCI and thus this gives great importance to conducting check-ups for cardiovascular risk factors in the prevention of dementia, which the Center also greatly insists on.Before coming to the Center the subjects from this group had very rarely undergone medicament therapy, and if they had, they had mainly taken antidepressants.This is in accordance with the information from the literature stating that depression is 2.6 times more present in individuals with MCI in comparison to the healthy population 49,50 .
The group of patients with AD diagnosis was the next group in line in terms of occurrence in the Center (28.2%).This category contained up to 211 (22.6%) patients with the onset of the illness before the age of 65 -YOD, but in spite of this the patients were on average older than the MCI subjects, the subject from the group with the affective disorder diagnosis and the OTHER heterogeneous group, as well as the FTD group 51 .On the other hand, the patients suffering from AD were significantly better educated than the subjects with VaD (within the scope of three year high school education) but also had the widest array in terms of educational range -from practically illiterate subjects to members from institutions of academic education.
Even though, according to the opinions of caregivers who often accompanied patients before their arrival to the Center, that the illness lasted for a relatively short while, (three years on average), however, the result from the screening test in the initial visit showed very extreme cognitive deterioration (MMSE =16.2).This data shows that, unfortunately, there is a high level of unknowingness and prejudices connected to what is conventionally considered normal aging.Different European health care systems have different structures and referral pathways but all seem problematic for dementia care 52 .According to the recently published data, there is a robust perception that AD is underdiagnosed and undertreated throughout Europe due to mistaken, absent and delayed diagnosis 53 .This is in line with data from primary care setting and population based epidemiological studies showing that almost one half of dementia patients remain undiagnosed in the community 54,55 .Stigma has an strong influence on delays in recognition and diagnosis in primary care and exists among all European countries, it is associated with reluctance toward an early diagnosis and pessimism about prognosis, which in turn enhaces therapeutic nihilism 56 .
Shown in Goldberg and Huxley (1980), there are three levels of access to mental health in dementia care: micro-level (the person with dementia and their family), meso-level (the professional first contacted) and macro-level (the factors shaping the responses of specialists and those providing ongoing care).At each level there may be obstacles that will make it impossible to maximize the available assistance to the patient.While at the micro level the main obstacle is the lack of awareness of patients and their families about dementia, at the median level there is limited experience of GPs on dementia and their embarrassment about discussing memory loss.
At macro level, these are the issues of coordination of the service within the system and the question of taking over or transferring responsibilities within certain elements of the system 57 .
Nearly two thirds of patients with AD from our sample lived in their own home, but only a quarter were capable of self-care.This can primarily be explained through cultural distinctions which insist on the family being responsible for taking care of the ill family member on one side, but also the poor financial support, insufficient institutional care and insufficient aid from society for the individuals suffering from illnesses and their families, all due to which caregivers are subject to great and long lasting pressure 58 .Even for the 30% of the subjects suffering from AD, from our sample the observers listed the presence of cognitive changes in relatives as well.
However, this hetero-anamnesis fact does not have a high specific value considering that it is present in a similar percentage as are the other diagnostic categories of the patients.Namely, family members rarely had reliable information on the illness existing among relatives which is objectively determined.For the most part, these were merely statements based on the opinions of the caregivers/relatives, which, in the majority of cases, is a very heterogeneous group of possible disorders.Subjects suffering from AD, in our sample, more often than not, in comparison to the others, had a deficit in vitamin B12, as well as HTN which is in accordance with published data which confirm the presence of vascular risk factors in this group of patients along with the importance of conducting check-ups in order to control those 59 .Despite the advanced stage of cognitive changes heading towards dementia, only every ninth patient had an appropriate therapy assigned prior to coming to the Center.This worrying fact shows us that this group is not directed towards a sufficient number of specialized services which would over a period of time recognize the illness and treat it in an adequate way.In the EU countries the situation is not unified but there is a concordance between specialists and GPs that dementia patients are undertreated (except for specialist in Spain, 54% of whom believed patients is adequately treated) 53 .Research Moore and Cahill (2013) showed that despite the availability of highly sophisticated pre and post-diagnostic tools, the majority of Swedish and Irish GPs showed therapeutic nihilism and reluctance to openly speak to their patients about dementia 60 .The reasons relate to insufficient diagnosis or excessively delayed diagnosis, the limited therapeutic effect, cost of the drug to the health care system and government restrictions 53 .
In comparison to all subcategories of dementia in our sample of subjects, the second place in terms of frequency was the VaD category (7.8%), which is slightly less than what is published in epidemiological research 61,62,63 .In our sample women made up the majority of this group, in their early eighties, and, in comparison to the majority of the other patients, they also had the lowest level of education.This lower level of education is recognized as a very important risk factor for the development of dementia, especially of the vascular type, because it is closely connected to tendencies of risk behavior and absence of control 64,65 .When they came to the Center for their first visit, cognitive changes are already evident at the screening test level (MMSE) and they were under the borderline score for dementia.The majority of the patients from this group suffered with long-term HTN, with lesions and CVI which were seen on CT scans along with confirmed significant hemodynamic changes in terms of bilateral carotid stenosis.Less the one fifth were smokers and an equal fraction consumed alcohol.In this group, the highest number of patients with a DM diagnosis, mainly type 2 but rarely with a thyroid dysfunction was also presented.A very small number of patients were on therapy before visiting the Center.The most frequent therapy involved medicine from one of the groups for the medical treatment of dementia, much less frequent for the treatment of depression, which is unexpected considering that depression often, follows cerebrovascular changes 66,  67   .
Besides MCI, AD, and VaD, a particular number of patients that were referred to the Center were those from the group with affective disorder such as depression, anxiety disorder and some forms of psychosis (3.8%).This group of patients represented a differentialdiagnostic challenge in terms of the importance of differentiating treatable forms from "real" dementia where emotional changes are the prodromal signs of illness.In our sample, the youngest patients belonged to this group, and on average had roughly what is equal to three years of high school education, cognitive abilities within limits of normal values (MMSE=25.9)and, in accordance with the majority of other characteristics, were similar to the patients from the MCI group.This shows that it is highly likely that there is overlapping within these two diagnostic categories due to which these patients are further being observed in the span of one year in the Center.
Patients diagnosed with FTD, DLB, PDD and Mixed Dementia were much less frequent in our sample, in comparison to epidemiological data from other research 68,69,70 .The reason for this may be due to the dispersion of the patients towards other subspecialized centers (for example there is an FTD variant with motor neuron diseases which is in the scope of other current epidemiological research in Serbia or VaD or Mixed Dementia which is included in CVB Clinics for neurology and other national centers for CVB) which is why they were unavailable for our records.The FTD group was made up of relatively younger patients in our sample and male patients were the majority, however, taking the heterogeneousness of this diagnostic category into consideration which we have not analyzed, and also the difference in distribution of the patients by the gender within each subcategory, this data cannot be compared with the epidemiological data from other research.The patients from our FTD group were of a somewhat higher educational levelon average completed four years of high school education, but were also significantly cognitively compromised at their first visit (MMSE 18.1±7.3).Also, a very small number of subjects were independent in activities for everyday functioning (17.4%), and slightly above average on the level of our entire sample were the subjects from the FTD group who in their medical history had serious head injuries with loss of consciousness.Even though more than half of the patients had HTN and carotid stenosis, slightly over a third had vascular lesions confirmed via a CT scan, but however, much less frequently registered were the cases with CVI.On the other hand, in this group of subjects, brain atrophy was registered in over 90% of cases.In comparison to the other patient groups, a significant number of patients prior to coming to the Center were given therapy for dementia as well as neuroleptic therapy.
In our sample, the DLB group contained the least number of patients (0.6%) which is a statistic which significantly differs from published data 71,72 .One explanation could be found in the clinical features because of which this category of patients is for the most part referred to psychiatric establishments.The patient profile from our sample included the oldest patients, in which were men significantly more frequent, had a completed high school education, but had globally more significantly deteriorated cognitions at the moment of their first visit (MMSE 19.8±5.3).Accordingly, less than a third of patients were independent in everyday life.Almost two thirds of these subjects have had hypertension for several years, bilateral carotid stenosis, and applied imaging techniques showed that a third had vascular lesions, and nearly three quarters also had brain atrophy.
In the evaluation of cognitive changes that are typical for dementia in comparison to normal aging, neuropsychological testing nowadays prevails over all other methods 73 .General diagnostic or also called screening tests such as MMSE and CDT are relatively rough tests and are isolated as less efficient in diagnostics, however when applied together have an overall greater efficiency 74 .Accordingly, MMSE and CDT have the greatest application among our sample -96% and 78.2%, and then there is ACE -R testing which is applied on slightly less than two thirds of the patients.The less frequent application of this test is due to it requiring greater effort regarding the complexity of the task at hand and its duration, which in the case of subjects that have severe cognitive deficit, becomes impossible to carry out.From the domain oriented tests, the most frequently applied are fluency tests due to their simplicity in terms of application on the one side, and the high sensitivity in the differentiating of cognitive deficit etiology on the other 40,75 .Following this test is the verbal declarative memory test -RAVLT (68.2%) which turned out to be more applicable with patients who have visual or reading deficits in comparison to other tests of verbal memory -FCSRT (51.4%).Both tests are highly sensitive and specific to distinguish MCI from AD as well as healthy population of respondents, but exact data on this as well as their metric characteristics in our population are under preparation.
It is important to emphasize that the Center is considered to be on a tertiary level of health care system in Serbia which is why its access to individual patients is all the greater.That, in particular, presents the main limitation of this overview, i.e. the inaccessibility of the entire population data and the absence of integrated access are the primary reasons as to why the results can be deemed as preliminary and representationally limited.

CONCLUSION
According to the knowledge of researchers, this paper is the first of its kind which aims to show the profile of patients from a heterogeneous group of illnesses known as dementia in the Serbian population.In that sense, we tried to give a general overview of patients through most frequent diagnostic categories in order to provide a framework for planning activities of the Center but also of the health care system in Serbia.Also, through this overview, we wanted provide an organizational model which would inspire the establishment and the networking of medical centers specialized for dementia on a national level, the standardization of epidemiological criteria and the formation of a unique registry for dementia for the Republic of Serbia.This represents a prerequisite for the establishment of a national strategy for the battle against this, by the looks of it, illness of the future which will spread on a greater population level, and this paper presents a single step towards that journey.
. Group differences were observed for Ages F (9, 2188) =12.496, p= .000),with participants with DLB being the oldest and those who have affective disorder diagnosis (ANXIETY & DEPRESSION disorder group) were the youngest.Group differences were observed for Gender χ 2 (9) = 26.643,p= .002.Namely, in all groups female were more frequent, except in the DLB and FTD group.Significant, multiple differences emerged, also in Education -F (9, 2188) =7.983, p=.000, with VaD being the lowest educated and MCI the highest.Multiple group difference was emerged for MMSE group score F (9, 2188 ) = 191.223,p=.000 with the lowest scores in group DEMENTIA UNSPECIFIED, and the highest in the MCI group.Group differences were observed in the Duration of disease F(9,2188) =2.184, p = .022,with patients in the category OTHER having a diagnosis for the longest period of time, and DLB the shortest.Group differences were observed also in: Living in their own home χ 2 (9)=9.976,p=.004 with difference between the MCI group in comparison to all other subgroups; Independence in ADL χ 2 (9)=38.236,p=.004 with a difference between patients in group MCI, ANXIETY & DEPRESSION disorders group and group OTHER on the one side and other subgroups on the other side; Existence of HTN χ 2 (9)=27.438p=.037, with the largest number of the patients with HTN among VaD and MIXED DEMENTIA compared to other groups; Duration of HTN F(9, 2188) =2.224, p=.018 which was the longest in patients with DLB compared to all other subgroups; Confirmed CVI χ 2 (9)=84.536p=.000 -the majority was in subgroup VaD and MIXED DEMENTIA; CT confirmed vascular lesions χ 2 (9)=38.255p=.000 -the majority was in subgroup VaD and MIXED DEMENTIA; Brain atrophy χ 2 (9)=25.997p=.002 with the lowest number in the subgroup OTHER comparing to the others subgroups; Vitamin B12 deficit χ 2 (9)=22.125p=.004 which was significantly the most frequent in AD patients, FTD and VaD compared to all the other; Carotid stenosis on right χ 2 (9)= 31.061p= .000and on left χ 2 (9)=43.984p=.000 which was more often in patients in VaD, MIXED DEMENTIA, PDD and AD subgroups compared to other subgroups; LP performed χ 2 (9)=43.147p=.000 which is mostly performed on patients with diagnosis FTD, AD and UNSPECIFIED DEMENTIA contrary to the patients with MIXED DEMENTIA, MCI and OTHER.Finally, group differences were emerged in DEMENTIA MEDICATION χ 2 (9)=72.975P=.000 with main difference between FTD, DEMENTIA UNSPECIFIED, AD contrary to the other subgroups where patients usually did not take drugs for dementia; and at the end, group differences were observed in neuroleptic medication χ 2 (9)=54.111p=.000 this medication was taken by patients with FTD diagnosis in comparison to all the other.No significant difference emerged in Positive hereditary χ 2 (18)=24.69p=.134, Head injury χ 2 (18)=17.01p=.522, Diabetes mellitus χ 2 (18)=26.05p=.099; Smoking χ 2 (18)=17.01p=.522, Alcohol abuse χ 2 (9)=50.51p=.757; presence of Thyroidal disorders χ 2 (18)=17.57p=.484, VDRL positive blood test χ 2 (9)=32.925p=.438.The details on the number performed neuropsychological tests in the baseline across different diagnosis are shown in Table

Figure 2 .
Figure 2. GENDER DISTRIBUTIONS ACCORDING TO DIAGNOSIS