BRIEF REPORTS
Prevalence and Impact of
Paratonia in Alzheimer
Disease in a Multiracial
Sample
Ipsit Vahia, M.D.
Carl I. Cohen, M.D.
Alla Prehogan, M.D.
Zaitoon Memon, M.D.
Objective: Paratonia is an external stimulus depen-
dent increase in muscle tone that is absent at rest. It
is thought to occur commonly in Alzheimer disease
(AD) but is understudied. This study examines para-
tonia in a multiracial sample. Methods: The sample
consisted of 80 patients who met Diagnostic and
Statistical Manual of Mental Disorders, Fourth Edi-
tion (DSM-IV) criteria for AD. They received a battery
of neuropsychiatric assessments. The authors exam-
ined the relationship between paratonia and multi-
ple variables. Results: Bivariate and logistic regres-
sion analyses revealed that paratonia correlated
significantly with disease stage (based on the Geriat-
ric Depression Scale) and number of frontal release
symptoms. There were no significant correlations of
paratonia with age, race, sex, depression, physical
health, neuroimaging findings, functioning, or neu-
ropsychiatric symptoms. The authors found signifi-
cant association with frontal symptoms. Conclu-
sions: The potential utility of paratonia as an
independent marker of disease stage in AD and its
role in signifying frontal lobe dysfunction suggests
that closer attention should be paid to its assessment.
(Am J Geriatr Psychiatry 2007; 15:351–353)
Key Words: Paratonia, Alzheimer disease, frontal lobe
degeneration
Received February 18, 2006; revised July 7, 2006; accepted July 10, 2006. From the Department of Psychiatry, Division of Geriatric Psychiatry
(IV, CIC, AP), and the Department of Neurology (ZM), State University of New York Downstate Medical Center, Brooklyn, NY. Send
correspondence and reprint requests to Ipsit Vahia, 49 Willow St. #1F, Brooklyn, NY 11201. e-mail: ipsit@hotmail.com.
© 2007 American Association for Geriatric Psychiatry
Am J Geriatr Psychiatry 15:4, April 2007
P aratonia is an alteration of tone to passive move-
ment. It can be divided into oppositional para-
tonia (also called “gegenhalten”) and facilitatory
paratonia.1 In oppositional paratonia, the patient re-
sists passive movement; in facilitatory paratonia, the
patients acts in the same direction as passive move-
ment. Our research focused only on oppositional
paratonia, and the term paratonia is used to refer to
the oppositional form in this article. It is clinically
distinguishable from parkinsonian rigidity. Parato-
nia has been shown to correlate with cognitive de-
cline in patients with dementia in general.1 Although
it may be the most commonly occurring motor dys-
function in Alzheimer disease (AD),2 it has not been
well studied in this disorder. Moreover, none of
the earlier studies have examined to what extent
various demographic and clinical variables may im-
pact on the prevalence of paratonia. Therefore, the
aims of this study will be: 1) to determine if the
presence of paratonia increases with the worsening
of AD; and 2) to examine whether any demographic
and clinical variables are associated with paratonia
in AD.
METHODS
The sample consisted of 80 consecutive DSM-IV–
diagnosed AD patients evaluated at the Brooklyn
Alzheimer’s Disease Assistance at the State Univer-
sity of New York Downstate Medical Center who
were able to complete a comprehensive exami-
nation. Persons scoring 4 or more on the Modified
Ischemia Scale3 were excluded from the study even
if they met the DSM-IV criteria for AD. Neurological
examinations were conducted a by a board-certified
neurologist who was trained in the identification of
paratonia and frontal release signs according to the
criteria of Franssen and associates.4 The final sam-
ple represented 39% of all AD patients seen at our
center. Their mean age was 76 years, 79% of the
sample population was women, 76% were black,
351
Paratonia in Alzheimer Disease

and 24% were white. Their evaluation included psy-

chiatric, neurological, and physical assessments, a RESULTS
laboratory panel, and neuroimaging.
Paratonia was present in 48%, 70%, and 83% of per-
Each patient also received a battery of tests that
sons in GDS stages 4, 5, and 6, respectively. As seen
included Hamilton Depression Rating Scale (HAM-D),5 in Table 1, there were significant correlations (p
Mini-Mental State Exam (MMSE),6 Global Deteriora- ⬍0.01) between the presence of paratonia and cogni-
tion Scale (GDS),7 Behavioral Pathology in Alzheimer’s tion (MMSE), illness stage (GDS), HAM-D, BCRS
Disease Scale (BEHAVE-AD), 8 Brief Cognitive Rating Functioning and Self-Care, and the number of frontal
Scale Functioning and Self-Care,9 the presence of cog- release signs. The GDS remained significantly asso-
wheel rigidity, and a summed score of the number of ciated with paratonia even after controlling for the
physical illnesses. We combined the delusions and potential confounding effects of age, race, sex, and
hallucinations subscales of the BEHAVE-AD to create a education (Wald ␹2: 4.36, degrees of freedom: 1, p⫽
Psychoses scale and we combined the activity and ag- 0.04). There were no significant correlations with age,
gressiveness subscales of the BEHAVE-AD to create race, sex, physical health, neuroimaging findings,
an Agitation scale. We created a summed score for ischemia score, tremors, psychoses, or agitation
evidence of nine frontal release signs (maximum scores. Of the three significant noncognitive vari-
score of 14) to allow for bilateral findings based on ables, after we controlled for the effect of illness
the criteria of Franssen and colleagues.4 The signs severity using the MMSE, only the number of frontal
consisted of the glabellar blink, snout, sucking, visual release symptoms retained a significant association
sucking, rooting, forced biting, hand grasp, foot grasp, with paratonia (Table 2).
and palmomental reflexes. The criteria of Franssen
and colleagues4 were also used to rate paratonia on
a scale of 1 (none) to 7 (severe). Because scores of 2
were often equivocal, we used a cutoff score of 3 or DISCUSSION
more (i.e., mild severity or greater) as an indicator
This study aimed at clarifying the relationship of
of paratonia. Because the paratonia scores were not
paratonia to the clinical spectrum of AD as well as
normally distributed, we used only the dichotomized
indicator of paratonia in our analyses. The internal
reliability (alpha) for the MMSE, HAM-D, Psychoses, TABLE 1. Bivariate Correlations of Selected Variables With
and Agitation were 0.76, 0.60, 0.67, and 0.64, respec- Paratonia
tively. Scores of 0.60 and above were considered ac- Correlation p
Data Coefficient Value
ceptable.10
With respect to data analysis, we initially con- Women (%) 79 0.09a 0.42
White (%) 24 ⫺0.19a 0.09
ducted bivariate correlations using Spearman rho for Age 75.5 (7.0) 0.23b 0.04
continuous and nominal variables and phi for di- Education 9.9 ⫺0.14b 0.21
Mean Brief Cognitive Rating Scale
chotomous variables. We next used separate logistic Function and Self-Care 5.8 (1.9) 0.30b 0.007
regression analyses to examine the relationship be- Mean Ischemia Score 0.7 (0.8) ⫺0.07b 0.53
tween paratonia and variables that were significant Presence of vascular infarcts on
CT/MRI (%) 8 0.09a 0.42
in bivariate analyses after controlling for the severity Mini-Mental State Exam 16.1 (6.7) ⫺0.31b 0.006
of illness with the MMSE. We used the MMSE as an Global Deterioration Scale 5.1 (0.8) 0.29b 0.009
Psychoses scale 3.5 (3.6) 0.08b 0.50
indicator of illness severity instead of the GDS. This Agitation scale 3.1 (2.6) 0.03b 0.78
was because the latter incorporated the measure of Hamilton Depression Scale 7.5 (4.3) 0.28b 0.01
daily functioning (Brief Cognitive Rating Scale) into Frontal release signs 2.6 (2.3) 0.38b 0.001
Physical illnesses 1.3 (1.1) ⫺0.07b 0.55
its stage criteria, thereby making them more highly Cogwheel rigidity (%) 13 0.02a 0.86
correlated. To allow for the exploratory nature of this
Notes: Data are means (SD) unless noted; N ⫽ 80.
study, but also to take into account the multiple a
Phi.
b
comparisons, we used a conservative statistical cut- Spearman rho.
CT, cat scan; MRI, magnetic resonance imaging.
off of p ⬍0.01.

352 Am J Geriatr Psychiatry 15:4, April 2007


TABLE 2. Logistic Regression Analyses of Variables
Associated With Paratonia Controlling for
Cognitive Severitya
Degrees of p presence of paratonia does not appear to worsen
Wald ␹2 Freedom Value
Brief Cognitive Rating Scale
Function and Self-Care 0.71 1 0.40
Hamilton Depression Scale 3.68 1 0.06
Number of frontal signs 8.57 1 0.003
Notes: N ⫽ 80.
a
Controlling for Mini-Mental State Exam score.
determining whether paratonia is associated with
other factors that accompany the disorder. We found
that the only reliable predictors of paratonia in AD
were the stage of the illness and the number of
frontal symptoms. Thus, the fact that paratonia was
not associated with any demographic (i.e., age, race,
education, sex) and clinical variables (i.e., physical
health, neuropsychiatric symptoms) suggests that
paratonia may be independently related to the dis-
ease process. Our finding is consistent with earlier
reports that suggested paratonia correlates with the
severity of dementia.1
Another important finding was the strong associ-
ation that we found between paratonia and the num-
ber of frontal release signs, which was independent
of illness severity as measured by the MMSE. Be-
cause paratonia is thought to be a movement dis-
order of frontal lobe origin,1 when it is detected, it
may be a marker for frontal lobe degeneration in AD.
An examination of paratonia in frontal dementia
would provide further confirmation of this hypoth-
esis. Although we also found that paratonia corre-
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This work was supported in part by NIA Grant
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