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EEE Prevalence and Characteristics of Dementia in Parkinson Disease An 8-Year Prospective Study Dag Aarsland, MD, PhD; Kjeld Andersen, MD, PRD: Jan P. Larsen, MD, PhD; Anette Lotk, MD, PhD; Per Kragh-Sorensen, MD, DMSe Background: Few longitudinal studies of dementia in Parkinson disease (PD) have been reported, and the pro- portion of patients with PD who eventually develop de- ment is unknown, Objective: To examine the 8-year prevalence, charac teristics, and risk factors of dementia in patients with PD. Methods: Patients were recruited from an epidemiologt- cal study of PD in the county of Rogaland, Norway, using ‘explicit eriteria for PD. Subjects with cognitive impair ment at disease onset were excluded. A semistructured care- _ver-based interview, cognitive rating scales, and neuro- psychological tests were used to diagnose dementia according to criteria [rom the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition at base: line and 4 and 8 years later. A population-based sample of 3205 subjectsin the municipality of Odense, Denmark, was used as a comparison group and examined at baseline and after 2 and 5 years. Results: We included 224 patients with PD (116 women). At baseline, 51 patients (26%) had dementia Fifty-five patients died, and 10 refused follow-up with- out their dementia status known, Forty-three and 28 new cases of dementia were identified at the 4- and S-year evaluations, respectively. The 4-year prevalence of dementia in PD was neatly 3 times higher than in the rnon-PD group. The &-year prevalence in PD was 78.2% (05% confidence interval [Cl], 71-1-84.0). Risk factors for dementia were hallucinations before baseline (odds ratlo [OR] =3.1; 95% Cl, 1.6-6.2) and akinetic-dominant or mixed tremor/akinetic PD (OR=3.3; 95% CL 12.85). Conclusions: More than three quarters of this represen- tative PD cohort developed dementia during the 8-year study period. Early hallucinations and akinetic-dominant PD were associated with an increased risk of dementia, “Arch Neurol. 2003;60:387-392 REVALENCE STUDIES of de- hospital, were markedly younger (mean From the Section of Geriatric Psychiatry, Psychiatrie Clinic (Dr Aarsland), and Department of Neurology (Dr Larsen), ‘Central Hospital of Rogaland, Stavanger, Norway: the Institutes of Psychiatry (Br Aarsland) and Neurology (Dr Larsen), University of Bergen, Bergen, Norway; and the Department of Peychiaty (Odense University Hospital Odense, Denmark (Drs Andersen Ll, and Kragh-Sorensen) mentia in PD have focused on point prevalence, and wide variations have been re- ported." Because survival lime is shorter in patients who have PD with dementia compared with those with- out dementia,’ and development of d ‘mentia is associated with longer disease di ration? longitudinal studies are needed to explore the frequency of dementia in PD. Although longitudinal studies of de- ‘ment in PD are few and have usually re- ported an incidence of new cases,” litle fs known regarding the proportion of pa- ents with PD who will eventually d velop dementia. Recently, the cumula- Live proportion of patients who developed dementia aller a mean observation pe- riod of 5.5 years was found to be 0.38° However, because the patients we rails to a neurologteal clinic at teaching ereler- (©2003 American Med age, 57 years), and had a shorter dura- tion of disease (4.0 years) compared with other population-based PD samples," that cohort may not be fully representative of the PD popullation in general Information about which patients will eventually develop dementia may be u ful for the patient, caregiver, and phy’ cian to plan future treatment." Al- though prospective studies of the period prevalence of dementia in PD exist, no studies have implemented methodologi- cal requirements such asa representative patient sample, adequate observation time, and modern criteria for dementia. Ther fore, we performed a prospective study of the 8-year prevalence of dementia in PD Using standard criteria for the diagnosts of PD and dementia in a community-based cohort and compared our findings with those ina non-PD population, We also: 1 Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/neur/13508/ on 01/17/2017 plored risk factors for developing dementia and charac- Leristics ofthe patients with PD who developed demen- tia at the time of diagnosts ss} ASCERTAINMENT OF PATIENTS WITH PD. ‘Total ascertainment of patients with recognized idiopathic PD in 9 municipalities with 220000 inhabitants in the southern ptt of Rogaland County, western Norway, was atempted, De- tals of the case-inding procedure have been published else- where" and are described briefly as follows. Clinical informa- tion onall patients with suspected parkinsonism was collected from the general physicians, nursing homes, district nurses, and hhome healthcare workers inthe study area, Aller a screening procedure, 400 patients were invited to participate and were interviewed and examined by Lo the neurologists in the study ‘group. Parkinson disease was diagnosed in 245 subjects, yield ing a prevalence rate of 111 per 100000 inhabitants on Jant- ary 1, 1093." During follow-up, 7 subjects were rediagnosed as not having PD (multiple system atrophy in 3, progressive Ssupranuclear palsy in 1, and other neurodegeneraive diseases in 3), leaving 238 patients eligible for our study. DIAGNOSIS AND MOTOR EVALUATION icp cesar Catt ‘paca (aepnnytep) ARCH NETROUVOU SE MART (©2003 American Med 8 diagnosis other than PD were excluded. During a follow-up evaluation 4 years later, a diagnostic reevaluation was per- formed. To avoid the inclusion of patents with other diag- noses such as dementia with Lewy bodies (DLB),” only those who fulliled the diagnostic eiteria for PD at all examinations | and were without cognitive impairment at disease onset were included. DIAGNOSIS OF DEMENTIA AND NEUROPSYCHIATRIC EVALUATION AT BASELINE ‘The diagnosis of dementia at baseline was made by the same neurologist baced on an interview with the patent and a care- iver using the Diaghostc and Statistical Manual of Mental Dis: trders, Revised Third Edition (DSM-I-R) as a guide, as well fs the administration of 3 cognitive rating scales: the Mini- Mental State Examination (MMSE),” the mentation item from the mental subscale of the UPDRS, and the Gotfres-Brine- Steen scale.” The latter rates the severity of 4 dementia domains (cognition, activities of daily living, emotional symp- toms, and other behavioral symptoms) based on observation of the patient and interview of the caregiver. To qually for a diagnosis of dementia, the patient had to meet the DSM-IL-R criteria for dementia atthe interview and atleast 1 of the fo- lowing 3 criteria: (1) MMSE score lower than for the corre- sponding quartile based on age and education”; (2) a score of| 2or higher on at least 3 items on the Goitiries-Brane-Steen scale other than the items “wakefulness” and “ability to com- centrate"; and (3) a score of 2or higher on the UPDRS intel lecwal impairment item. Presence and severity of hallcina- tions during the last 2 weeks before the baseline evaluation were assessed using the thought disorder item of the UPDRS, and severity of depression during the last week was rated using the Montgomery-Asherg Depression Rating Seale.” FOLLOW-UP EVALUATION OF PATIENTS WITH PD Survivors were invited by liter o participate inthe follow-up evaluations + and 8 years after bacline. ‘The final evaluation twas conducted from November 2000 to April 2001. The follow-up evaluations inchuded the neurological and neuro~ peychatic evaluation performed at baecline, with 1 change: the Dementia Rating Scale (DRS)> wae administered instead ofthe Gores Brine-sieen sae, Inadtion, patients withan MMSE score of 16 o higher underwent a neuropsychologicl Battery sessing executive functioning. visual memory, and visuospatial functioning A group of heathy eldely controls witha similar age and sex dstbution a the patients with PD performed the cognitive test battery to abain normative data Fidependent ater who were blind vo the diagnostic and mo- toreraluations performed the neuropeychiainc and neuropsy- chologcal aseessments “The diagnosis of dementia was made by 2 of us (B.A, and |LP.L) based on the clinical interview, the cogitve screening, and the neuropeycholoiel teste To qual for this dagho- fi, the rele of the interview rating sales, and neuropsy- Chological tests had to be compatible with a diagnose of dementia, Population-based, age- and education-corected normative data for the MMSE" and DRS were used, and Scores lower than the lowest quartile (MMSE) or lower than the Toth percentile (DRS) were considered to indicate cogn tive impalrment. For the neuropsychologial tess, a score 2 SDs or more lower than the mean ofthe control group was consiered to indcate impairment in cases of inconsistencies between thece measures ll of the avallable material was reviewed, and both raters made an independent diagnose of dementia or no dementia according fo BSMHL-R ceria, In cases of disagreement, a consensus diagnosis was made. Ia 1 Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/neur/13508/ on 01/17/2017 definite diagnosis of dementia or no dementia could not be made after this procedure, patients were classified as having possible dementia and were included in the no-dementia {proup. The data for this cohort in 1993 and 1997 have previ- ‘ously been reported. ASCERTAINMENT AND EVALUATION ‘OF CONTROL SUBJECTS To calculate the relative risk of developing dementia in patients who have PD compared with subjects without PD, we used a population-based study of dementia based of a tan- domly drawn sample of 3237 subjects aged 65 to 84 years in the municipality of Odense, Denmark total of 3346 sub- jects participated in the baseline examination, conducted between February 1992 and March 1004; 3205 did not have PD. The diagnosis of PD was based on self-report during an interview at baseline. Furthermore, the participants wnder- venta phased gnome proce in which the fit pase svas a screening for dementia with the cognitive section ofthe Cambridge Mental Disorders of the Elderly Examination (CAMDEN) » Subjects with a positive result underwent the second phase, which consisted of the remainder of the CAMDEX and a neuropsychological test batery. The diagno- sis of dementia was made by consensus between the pari paling physicians and a neuropsychologist according to cr Ha from the National Institute of Newrological and Communicative Disorders and Stroke-Alzheimers Disease and Related Disorders Association” for probable Alzheimer disease and the DSM-IILR for vascular dementia and dementia of other types. Participants were reexamined 2 and 5 years later. statistics Four- and 8-year prevalence of dementia were calculated by add- ing the number of eases with dementia at baseline and all new ‘cases divided by the mean population during the middle ofthe ‘observation period» Ratesand confidence intervals (Cis) were also calculated. For the patients with PD, demographic and clini- ‘al characteristics that occurred before the inital evaluation were First idemufied as potential risk factors for developing demen- tin by using bivariate analyses (test) Variables associated with dementia ata significance level of P=.10 were included in a multivariate logistic regression analysts Es} Two subjects died between the baseline neurological and mental assessments, 1 patient refused to participate atthe ‘mental evaluation, and 11 patients had cognitive impair- ment at disease onset. Thus, 224 patients with PD were included. Baseline characteristics of patients with PD and control subjects are shown in Fable ¥. A total of 139 patients (mean4SD age, 7438.1 years) were assessed at the 4-year follow-up visit, and 87 (meansSD age, 76.1484 years) at the 8-year follow-up. Among pa- tients previously diagnosed as not having dementia, 7 (4.0%) and 3 3.4%) relused to participate, and 36 (20.8%) and 19 (21.8%) had died, at the 4- and 8-year evalua- tions, respectively. Thus, a total of 65 patients (29%) dropped out without dementia being diagnosed, 55 (85%) fof these because of death. A baseline comparison of pa- tients with PD who dropped out of the study without being, diagnosed as having dementia and the other patients is shown in Table 2. (©2003 American Med Table 1. Baseline Characteristics” Po croup cont orp (a=328) iewy Taaske Feral,“ 38 Eduction y Sis30 1217 <001 ‘ge tonsa of Py 643208 Duran of sae, y 92259 Hosinand Yabreclescorw 2821.1 Monigomary-Asbrg Depression 7.9263 ating Sele Score ‘Abbreviations: Elise, not applicable: PD, Parkinson dszase “tata are expeseed a mean «SD nize cherie etd, Groupe ‘were compared using the test oF x et Filty-one patients with PD (26%) were diagnosed as having dementia at baseline. In this group, the meanaSD duration of PD at baseline was 11.5273 years. Forty-three and 28 new cases of dementia we diagnosed atthe 4 and 8-year evaluations, respectively This total of 122 patients with dementia were identi fied inno eases were patients with dementia later ding hosed as not having dementia. Reversible demenda was hot observed. The average population in the middle of the observation period was (224487)/2: so the S-year prevalence rate was calculated to be 78.2% (95% Cl 71. 15%684.0%). The 4-year prevalence of dementia was 51.0% (95% Cl, 44.48%-58.8%) compared with a 53 prevalence of 18.5% (17.1%-20.0%) in the non-PD. froup. At the time they first fuliled the dementia erite- fia, the meanaSD data for patients with PD were as fol lows: age, 78-4457 years: duration of PD, 13.846.3 years; Hochn and Yahr scale score, 3.80.9; MMSE score, 1746.2 (n=105); Montgomery-Asborg Depres- sion Rating Seale score, 10.0479: and daly levodopa dose, 5724575 mg ‘Characteristics of patients with and without demen- tis are shown in Table 3. Forty-three (35%) of those twho developed dementia had experienced hallucina- tions prior to the beseline evaluation compared with only 14 (496) of those without (P=001). Among the 199 pa tients with akinetie-dominant or a mixed tremor! kinetic patten of PD, 115 (589%) developed dementia Compared with 7 (28%) of 25 with tremor-dominant PD (®=.005). Seventeen (74%) of 25 patients with syrmmet cal PD developed dementia compared with 105 (53%) ©1200 patients in whom PD symptoms were most wore om the llt or right side (P=.05). Variables assoc zed with dementia atthe level of P=.10 were included inva logistic regression analysis using conditional for- ward stepping, Significant predictors of demenuia were hallucinations before baseline (odds ratio [OR] =3.1;95% Ci, 16-6.2) and mixed temorlakineic PD (OR=3.3,95% 1.2.85), whereas symmetrial PD did not reach the sisal criterion of significance. eee We found that 78% of population-based and represen- tative cohort of patients with PD developed dementia dur- 1 Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/neur/13508/ on 01/17/2017 ‘Table 2, Baseline Comparisons of Patents With PO Who Dropped Out of the Study Without Being Di as Having Dementia andthe Remaining Palents” ‘Completers oncompete| 238) fixtvaue Prva Fama, % a at Any ros01 mags67 16 Edveation y eo.z8 97333 a ‘Ag at onset PO, y 633.102 658.85 25 Darton of disse, 7260 2 Hoshn and Yee score poet 4 MSE score 240269 4 “bbrviaions: HSE, Min Mena Sita Examination; P,Panineon dae, “Data ae oxresad ae man SO unless ota nated. Group wee comgared using the test ora ‘fortis comparison hay: etwas usd al ear values were compated using te ts. ‘Table 3, Characteristics of Patients With PO Who Did and Did Not Develop Dementia ‘Dementia, wo) ‘Wo Dementia, wo. (2) (=i) (n=1t2) tvatue Paws Sm 18 7 " 5565 5249) F ern 50143) 03 “0 50163) saan 6368) 9144) 25 2 2) 46 62) 7169 sa(4t) Subdagrasis ona 0 DefintPO (n= 131) 7083 eran) 38,68) 2044) 14168) 14) at 05 a7 6.25) Asymmetical (n= 200) 105 (3) 95 (47) Te "iemac-domiant (a =25) 729 187) 86 1 nt dominant = 42) 22162) 20(48) Haluciationsbeloe bale 133 Yes =57) 205) 14,25) No (n= 184) 75,48) 3562) ‘obrviation PD, Prinon dese, ing the 8-year study period. The 4-year prevalence was participate at follow-up; thus, 65 patients were lost to nearly 3 times higher in the PD compared with thenon-PD follow-up without their dementia status known, Demen- ‘group. Patients with akinetic-dominant PD and halluci- ia may reduce survival in patients with PD,” and pa- nations prior to the baseline evaluation were at higher ents might have developed dementia between the last risk of developing dementia than those with tremor- evaluation and death, indicating that the prevalence ob- dominant parkinsonism and without hallucinations. Our served isa conservative estimate. Neurapsychological as- prevalence finding is consistent with those in previous sessment was not used at the baseline evaluation. Pa- longitudinal studies," although considerably lower tients who had PD with mild dementia might therefore results have been reported®”"* in studies using less rig-_have heen misclassified as not having dementia. If these ‘orous methods than our investigation, In terms of eare- subjects were not assessed at the 4-year evaluation, this giver burden," nursing home admission," hallucina- would also have led to an underestimation of dementia tons,” and mortality,’ these findings underline the prevalence. importance of cognitive impairment in addition to the The baseline population was a cross-sectional PD. motor symptoms of the disease sample with a mean duration of disease at baseline of The major methodological limitation of our study nearly 10 years. Therefore, our results may not be appli- was the extended periods between assessments,andade- cable to patients with early PD. An optimal design would agree of attrition in this group of elderly subjects was to _be to include successive, recently diagnosed PD eases and be expected. Fifty-five patients died, and 10 refused to assess them annually (©2003 American Medical Association A rights reserved, ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/neur/13508/ on 01/17/2017 The patients with PD and control subjects lived in different countries and were assessed by physicians [rom different research groups using slightly different diag- nostic procedures to identify dementia, However, Den- markand Norway are socially and culturally similar, and turban and rural populations were included in both samples, Dementia was diagnosed according to DSM- LR criteria im both groups. A standardized interview (CAMDEX) was used inthe control group, whereas sem structured interview based om the DSM-IILR criteria was administered to the patients with PD and their eare- zivers. We have previously found that the accuracy of these 2 diagnostic procedures is comparable. Minor varia- lions may exist in the Norwegian and North American norms for the MMSE, which might have influenced the Findings The Danish non-PD group was based on sell- report, and whether this might cause an underestima- lion oF an overestimation ofthe risk of dementia inthis group cannot be further examined. However, the non-PD group was less educated than the PD group, and the data ‘were based on a 5-year observation period compared with ‘only 4 years in the PD group, which suggests that the S-fold higher risk among patients with PD isa minimal difference. The strengths ofthe study include the large and rep- resentative community-based PD population, standard- ized diagnostic erteria lor the diagnosis of PD and de rmenta, comprehensive evaluation battery, independent ‘evaluation of motor and mental symptoms, inclusion of a large and representative control group, a long fol- low-up period, and the low attrition rate duc to causes ‘other than death, Most previous studies have used smaller dnd less representative PD samples” and a shorter fol- low-up time.”® Depression could potentially conteibute to cognitive impairment and thus lead to an overesti- mate of dementia in the PD group. However, because the depression score al the time of dementia was only slightly higher than that ofthe total population at baseline, and no cases of reversible dementia were observed, its un- likely that this effeet would have influenced the preva- lence of dementia in our study. Clinical and neurobiological overlaps exist between PD and DLB."” Patients with cognitive impairment at dis- ‘ease onset were not included in this stady so that pa- tients fullilling DLB criteria were excluded. Its possible that a proportion of patients with dementia atthe base line evaluation developed this condition within the first Year alter disease onset, thereby fling conventional DLB ‘aiteria, However, because these patients had had PD for 115 yearsat the baseline evaluation, weassumed that most ‘ofthem would develop dementia alter several years of mo- tor symptoms and this would not fll elinieal DLB er teria, The prevalence of dementia did not difler among pa- tients with definite, probable, and possible PD, indicating that even in patients with a highly specie typeof PD, de rentia wil eventually develop in most cases. Recent sttd- ies have found nearly identical clinical symptoms in patients with DLB and PD with dementia” Clinico- pathologic studies suggest that cortical Lewy bodies are associated with dementia in PD" therefore, we hypoth ‘size that most patients with PD develop DLB alt ade. (aepnnytep) ARCH NETROUVOU GE MART (©2003 American Med cade of pure motor disease. The overlap with DLB is un- derlined by the finding that akinetic-dominant PD and early hallucinations, features typical of DLB," predicted the sub- sequent development of dementia, Furthermore, there was trend toward a higher risk of dementia in patients with symmetrical PD (more common in DLB than PD)* com- pared with patients who had right-of left-sided parkin- sonism. Prospective clinicopathologie studies with repre- sentative populations of patients with DLB and PD are needed to explore the clinical, pathologic, and nosologic relationship between DLB and PD and the causes of de- smentia in PD. “Accepted for publication September 27, 2002. ‘Author contributions: Study concept and design (Drs Aarsland, Andersen, Larsen, Lolk, and Kragh- Sorensen); acquisition of data (Drs Aarsland, Andersen, Larsen, Lolk, and Kragh-Sorensen); analysis and inter” pretation of data (Drs Aarsland, Andersen, and Larsen): drafting of the manuscript (Dr Aarsland); critical revision of the manuscript for important intellectual content (Drs Aarsland, Andersen, Larsen, Lolk, and Kragh- Sorensen); statistical expertise (Dr Andersen); obtained {funding (Drs Aarsland and Larsen); administrative, tech- nical, and material support (Dr Larsen); study supervision (Drs Aarsland and Larsen). Corresponding author and reprints: Dag Aarsland, MD, PhD, Section of Geriatric Psychiatry, Psychiatric Clinic, Cen- tral Hospital of Rogaland, PO 1163, Hillevag, N-#095 Sta- vanger, Norway (e-mail: daa@post.rps.no) LES} 1. Ton Fargo J, rian , Lets, Baler Apr A Oe remain Pans’ dese 2 opulaton sed syn aula it strusonaze niu Meo. 108545705708 2 rsd Tebrg Laren Curing. gun ocantiinPat- iso's sae. Arch aua 1HGS8538 52 2. Mayeuc Denaro J Hemsegdo Wt A poultn- bse mestigaton ot Parka ena with ad whom, Arch earl 192204017. 4 Tar A Suny J, Lng AE-Demerapealecs in Painso’s dase ans 1851087 5 Madar Leung, Tang Ml re deen pants ith Patios = sacra eft n prone suey? una aay, Newly. ‘ont a0, 6 Hughes TA, Ross HF Musa eal A 1-year sy tenes fan tors prdeingcomenia Patios tee. Nol. 200054506 ‘aa 1 Bc K, Cle SA, Crawford, twa Lesson JO, Muh Lin ‘alfaturespeding demain pate Patnson's ease: 2 folow-ap Stuy eur. 06040'1220-206 8 Marder Tang HX Cat Stem ,Mayeux The oqoney an associa "skate donetainfatets wit Pukinse's seve. Arch eal 105; 005-7 ©. ars, Anat K, Larsen JP, Lok Nels Kah Soresen ik fone inParreon's ease acrid, prospective su Ne "oly. 20158 730-738, Pari Rime UX Pein ctr for cope dtioraon and dementia iPass tse, Aa eur 9864541116 1 Tanda Laan Hes. Re, Aa Te pie fain. sors dsm county of Rope, Nowy Mov soe 105.1054 58 Paral, Larsen, areenk, Lint, Tene. arial smponsin Pa “iso's ear aeinprart onibuors to caregiver toss nt J Sra Paya. 108814985 474 Ars, Larsen, TenbagE, Lanka. Preis of nursing bane pac 1 population-based, prospective sty. Am) 1 Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/neur/13508/ on 01/17/2017 1M. 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Lancet 2001358 08-1052 Parlin Bard Latsen J, Meet. compara eee pychit "symptoms in dean wth Ly bodes and Paris's dite wah and tou emer. in. erat Psyeniny. 2007 162856, rss Dal C, Meath Pry RH, Lson JP. Compas of ex rami signin deren with Len bis nd Pakison' ise, "ops Mews, 208374379 Gnanalnghsn KK, ye, Thomond SanbrookMA, mister Moar ané ognvetunon ney boy dean conparsn ih Aina and Pa sos sass Marl Marosug Pent 10972243252 Parlin aon D, Livan Gal, Laren JP Cope dysuncton in eran ith Lay Boi nd Pasinen's ese comparison wth proges tiv supranacer alah eae [beta Nol 200258 (sup s)at8 Hogs A, iil SE, BanionS, Lets L.A cincopatolagie tay of 100 (soe of aio s aac. Arh euro 105501048, “linge K Neropstelogil crates of mea yhoo in Pakosa's ‘ean nut Wore EC Sane PA arene, ce. ea ‘uncon in Parkinson: Des IU te Narn: Rede Phar Imaal Pracuton; 100 82106, Hur Hl Teopnows J, Gain et Aph-symuckin coil Lewy ods Corre wth dame in Patinaons dace, Meu. 2000581916 iat (©2003 American Medical Association, All rights reserved. ‘Downloaded From: http:/jamanetwork.com/pdfaccess.ashx?url=/data/journals/neur/13508/ on 01/17/2017

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