The genesis of closing-in in Alzheimer disease and vascular dementia: A comparative clinical and experimental study.

Abstract

CI is related to the tendency to deviate toward a salient model and can be released by frontal-executive impairments in demented patients, independently from clinical diagnosis.

Drawing Disorders in Alzheimer’s Disease and Other Forms of Dementia

“…Among the peculiar drawing patterns that are observed in the moderate-to-severe forms of dementia the most important is certainly the 'closing-in' symptom (see Figs. 2 and 3), which is significantly more frequent and more severe in AD than in vascular forms of dementia [24,25], because AD patients tend to put the pencil directly over the model, or to overlap the lines of the model with those of the copy (adherent-CI), whereas VaD patients more often draw in close proximity to the model without overlapping onto it diagnosis between AD and VaD, it is less useful in the distinction between AD and FTD, because the role of the frontal lobes in its production is still under scrutiny. From this point of view, it is important that recent neuroanatomical data demonstrated the selective association of atrophy in the orbito-frontal areas, implied in inhibiting primitive reflexes, with the closing-in phenomenon [198].…”

“…However, this hypothesis specifically envisages strong correlations between CI and frontal/executive dysfunction, and foresees that CI can be triggered by high attention-demanding task conditions. Several converging pieces of evidence supported this account, since a significant correlation between CI and frontal/executive dysfunction has been reported in MCI [196], AD [191], VaD [25], and Parkinson's disease [189], and in such diseases copying geometrical figures in dual-task conditions enhanced CI [25,184,197]. A first attempt at identifying the neural correlates of CI in AD patients would point to bilateral orbito-frontal cortex as the area in which atrophy was significantly associated to presence of CI [198].…”

“…Among dementing syndromes, CI is predominant in AD [88,184], suggesting the idea that CI might represent a neuropsychological marker for clinical diagnosis of AD [90,185,186]. One more recent study [25] confirmed that CI is more frequent in AD with respect to VaD patients, and that the two patient groups also tended to show qualitatively different CI phenomena, as AD patients more often overlapped at least one element of the copy onto the model (adherent-CI), whereas VaD patients more often drew close to the model without overlapping onto it (near-CI). On the other hand, one retrospective study showed that CI is as frequent in AD as in FTD patients, but did not provide qualitative observations [187].…”

“…In the next section we will consider the features of drawing disorders that could differentiate AD from vascular dementia and from the most frequent forms of degenerative dementia, namely frontotemporal dementia (FTD) and the Lewy body disease (LBD). In the last section we will take into account some peculiar aspects of drawing disorders in dementia, paying particular attention to the 'closing-in' phenomenon [23][24][25].…”

The closing-in phenomenon in Parkinson's disease

“…the tendency to reproduce drawings close to or superimposed on the model, has been observed in patients affected by several kinds of dementia [1], and in non-demented patients [2].…”