Almir Tavares

Nível educacional e idade no desempenho no Miniexame do Estado Mental em idosos residentes na comunidade

Background: Low educational level is common among Brazilian elderly and can affect the results of usual cognitive testing. Objective: To evaluate the impact of age, and educational level on MMSE performance, in a community-dwelling sample of elderly individuals. Methods: A community sample was obtained, based on the public health program “BH Vida”, Belo Horizonte, Brazil. Home visits were done between August 2001 and June 2002. A Portuguese version of the MMSE was administered to the elderly during home visits. Results: Our sample was composed of 176 individuals, aged 65-97 years old (median = 71). Educational level ranged from no formal education to 13 years of education (median = 3). The MMSE scores ranged from 1 to 30 (median = 23). Both age and educational level had a statistically significant influence in MMSE (p < 0.001 e p < 0.0001, respectively). Conclusion: Even in the low educational level elderly, length of formal education was a factor significant influencing MMSE score. Increasing age predicted lower total MMSE score.

Autopercepção da saúde e desempenho cognitivo em idosos residentes na comunidade

CONTEXTO: A autopercepcao de saude contempla varios aspectos da saude fisica, cognicao e capacidade funcional. OBJETIVO: Comparar idosos com e sem evidencia de declinio cognitivo/demencia quanto a autopercepcao de saude e variaveis sociodemograficas, destacando as variaveis associadas a autopercepcao de saude positiva e negativa dentro destes grupos. METODOS: Noventa e oito idosos residentes na comunidade foram avaliados em visitas domiciliares para este trabalho. A avaliacao cognitiva e funcional foi feita por meio da aplicacao do Mini-Exame do Estado Mental (MEEM), do Teste do Desenho do Relogio (TDR), da Escala de Demencia de Blessed (EDB) e do Questionario do Informante de Declinio Cognitivo em Idosos (IQCODE). A autopercepcao da saude foi avaliada por intermedio de um questionario adaptado do Brazil Old Age Schedule. RESULTADOS: Vinte e seis idosos (26%) apresentaram quadro de declinio cognitivo. Autopercepcao de saude negativa e menor participacao em atividades fisicas e recreativas se associaram significativamente a declinio cognitivo nesta amostra (p = 0,006, p = 0,05, p = 0,03, respectivamente). No grupo de sujeitos sem evidencia de declinio cognitivo, a historia previa de eventos cerebrovasculares se relacionou a maior frequencia de autopercepcao negativa da saude. CONCLUSAO: A autopercepcao negativa da saude esta relacionada ao provavel diagnostico de demencia. Nos idosos com declinio cognitivo, a autopercepcao positiva de saude associa-se a quadros mais graves, refletindo possivelmente menor insight quanto ao estado morbido.

Naturalistic evaluation of inpatient treatment of mania in a private Brazilian psychiatric hospital

OBJECTIVE To describe the clinical practices on the treatment of mania in a Brazilian hospital, and to compare them to other international similar reports and practice guidelines. METHODS Chart revision of 425 consecutive admissions (269 patients) for the treatment of manic or mixed episodes (ICD-10 criteria) in a private psychiatric hospital of Belo Horizonte, Brazil, from 1996 to 2000. The rates of utilization of each antimanic medication and ECT were compared to those reported in similar international observational studies (X2, bicaudate, alpha =0.05). RESULTS The observed frequencies of use of each treatment modality were: lithium (71.5%); carbamazepine (34.8%); valproate (9.4%); antipsychotics (83.3%); benzodiazepines (62.4%); antidepressants (7.5%) and ECT (33.2%). The differences detected between local practice and international guidelines were: lower rate of valproate and higher rate of carbamazepine prescription; the use of sine wave devices for ECT; frequent concomitant use of ECT with lithium (72.3%), benzodiazepines (46.8%) and/or carbamazepine (31.2%). CONCLUSIONS These results suggest the need to develop national practice guidelines for the treatment of mania and for the use of ECT, and to promote their propagation through specific medical educational programs, aiming at the standardization of practices based on the available scientific evidence.

Vasculite cerebral e uso de cocaína e crack

Cocaine and crack abuse is strongly related to stroke, particularly in young patients. The present study reports the case of a cocaine and crack abuser who developed central nervous system vasculitis, resulting in extensive cerebral infarctions, leading to dementia, behavioural disturbances and seizures. The relevance of detecting drug abuse in young stroke patients is stressed. Assessing possible brain lesions in drug abusers with cognitive impairment is also important.

Manic patients receiving ECT in a Brazilian sample

BACKGROUND Characterization of manic inpatients receiving electroconvulsive therapy (ECT) has not been done. METHODS The charts of 425 consecutive admissions of 269 inpatients treated for manic or mixed episodes, between 1996 and 2000, in a Brazilian private psychiatric hospital were reviewed. A logistic model was built to determine the predictors of use of ECT for mania. Median total length of stay (LOS) and LOS deducted from the delay until ECT was started were compared between ECT and non-ECT admissions. The risk of readmission was estimated using Coxs regression. RESULTS Significant predictors of ECT prescription were: history of previous admission (OR=4.09), psychotic features (OR=1.60), female gender (OR=2.04), married (OR=1.79), and treatment by a psychiatrist who assisted more than 20 manic inpatients in the index period (OR=1.97). Co-morbidity with cardiovascular disease was negatively associated with ECT use (OR=0.49). Median LOS after starting ECT was similar to that of non-ECT admissions (12 vs. 13 days). ECT reduced (HR=0.678) and previous psychiatric admissions increased (HR=2.320) the risk of readmission after a manic episode. LIMITATIONS Only one hospital was included in this study. CONCLUSIONS The presence of psychotic features and violent behavior during manic episodes and indicators of chronicity of bipolar illness (history of previous admissions, duration of disease) were predictors of ECT use for the treatment of mania. Suicidality was not associated with the use of ECT for mania. LOS after ECT was started was similar to LOS of non-ECT admissions. The use of ECT for mania reduced the risk of readmission.

Impact of ECT on duration of hospitalizations for mania.

Objective To assess the impact of the use of electroconvulsive therapy (ECT) on the length of hospital stay of manic patients. Materials and Methods We reviewed 425 consecutive admissions of 269 patients with manic or mixed affective episodes in a Brazilian private psychiatric hospital. Lengths of stay (LOSs) were compared for admissions in which ECT versus exclusive pharmacologic treatment was administered. A mixed model for repeated measures was developed to control for intraindividual correlations and potential demographic, clinical, and treatment confounder variables. The analyses were repeated using LOS minus the time until ECT was first given in each admission (LOS-tECT) as the response variable. Results Use of ECT was associated with longer LOS than exclusive pharmacologic treatment (18.78 versus 12.51 days; p < 0.001). This effect disappeared when using LOS-tECT as the response variable (11.57 versus 12.16 days; p = 0.530). Violent behavior and in-hospital use of antipsychotics and benzodiazepines were also associated with longer LOS, whereas being married was associated with shorter LOS. Conclusion The use of ECT during hospitalizations for mania was associated with longer lengths of stay. This effect was caused mostly by delays in commencing ECT treatments rather than by the duration of treatment itself.

Demência com corpos de Lewy: uma revisão para o psiquiatra

Dementia with Lewy bodies: a review for psychiatrists Lewy body dementia became today a distinct nosological entity, considered by many authors the second cause of degenerative dementia, after Alzheimers disease. Its neuropathology is caracterized by the presence of Lewy bodies both in cortical and subcortical areas of the brain. The main clinical manifestations are: progressive cognitive impairment, recurrent visual hallucinations, fluctuating cognitive status and parkinsonian signs. There is greater sensitivity to side effects of neuroleptic drugs and the response to cholinesterase inhibitors is generally good.A demencia com corpos de Lewy (DCL) tornou-se hoje uma entidade nosologica distinta, considerada por muitos autores a segunda causa principal de demencia degenerativa, atras apenas da doenca de Alzheimer. Sua neuropatologia e caracterizada pela presenca de corpos de Lewy tanto em regioes corticais como em areas subcorticais do encefalo. As principais manifestacoes clinicas incluem: declinio cognitivo progressivo, alucinacoes visuais recorrentes, flutuacao no estado cognitivo e sinais parkinsonianos. Observa-se maior sensibilidade a efeitos indesejaveis de medicamentos neurolepticos e a resposta a medicacoes inibidoras da acetilcolinesterase e geralmente boa.

Electroconvulsive therapy (ECT) effective for psychotic recrudescence and suicidality after varenicline adjunctive therapy for smoking cessation in a schizoaffective patient

Dear Editor, Schizoaffective patients present the highest rates of smoking and heavy smoking among all diagnostic groups, including schizophrenia and bipolar disorder. Smoking cessation is a major treatment objective, but many patients experience difficulties and relapse. Adjunctive pharmacotherapy with varenicline brings new hopes. A 56-year-old schizoaffective obese woman, with arterial hypertension and mild chronic obstructive pulmonary disease was frustrated in previous attempts to quit smoking, either with the aid of psychosocial treatment alone or combined with nicotine gum and patch. Bupropion had to be discontinued due to the irruption of manic symptoms. Her mother had bipolar I disorder. From age 18 (first psychiatric hospitalization), haloperidol was the main antipsychotic drug for thirty years. She did not want to quit during these initial years, and smoked up to 100 cigarettes per day. Adherence to psychiatric treatment was incomplete, with eight lifethreatening suicide attempts. In subsequent years, haloperidol was substituted for lithium plus ziprasidone, improving compliance and stability. Thirty months later, she started to express a desire to quit cigarettes. Varenicline was titrated from 0.5mg once a day to 1mg twice a day, and the first month passed with only minor mood changes. In the second month, the following escalating mixed symptomatology built up rapidly: increased energy, logorrhea, grandiosity, irritability, impulsivity, voices commenting on her, paranoid ideation, nihilistic ideas about the future, intense selfcriticism, frequent crying, and continuous suicidal ideation, with a specific plan. She recovered with 6 bilateral, bitemporal ECT sessions. As for the consequences attributable to varenicline, she later evaluated such treatment as highly beneficial and valuable to her health. She now completed two years of tobacco abstinence. Varenicline-aided smoking cessation treatment may have had a role in triggering psychotic recrudescence and suicidal behavior. Current smoking, smoking cessation, and medications for smoking cessation (bupropion, rimonabant, and varenicline) were all previously associated with suicide. Schizoaffective disorder is also significantly associated with suicide. Cigarette smoking decreases serotonin turnover and inhibits brain monoamine oxidase, increasing impulsivity and suicidality in a recently abstinent schizoaffective patient. Mood improving and antidepressant augmenting properties of varenicline have been previously described, and such a drug might concur to generate unstable mood. Particular vulnerabilities to nicotine, nicotine abstinence, and varenicline might be determined by variants of the nAChR gene recently found in schizoaffective disorder, which might favor fast built up of impulsivity and suicidality with varenicline use. GABA-A receptor beta subunits, GABRB4 and GABR1, could also be envolved. According to the American Psychiatric Association, ECT is currently the best treatment for a rapid response to psychosis or suicidality. In spite of this, ECT has no visibility in the literature of smoking cessation treatments. We recommend that ECT be considered for psychotic recrudescence and suicidality in the context of varenicline adjunct therapy for smoking cessation in schizoaffective patients.

Involuntary emotional expression disorder

CONTEXTO: O transtorno da expressao emocional involuntaria (involuntary emotional expression disorder ou IEED) consiste em um transtorno do afeto, caracterizado por uma dificuldade em controlar a expressao emocional, que se apresenta por episodios breves e estereotipados de riso e/ou choro incontrolaveis. Pode estar relacionado a diversas patologias encefalicas, em variadas localizacoes anatomicas. OBJETIVOS: Revisar aspectos clinicos, epidemiologicos e fisiopatologicos envolvidos no transtorno da expressao emocional involuntaria e apresentar as opcoes atuais e futuras na abordagem terapeutica. METODOS: Pesquisa de base de dados MEDLINE/PUBMED e LILACS utilizando os termos transtorno da expressao emocional involuntaria, afeto pseudobulbar, riso e choro patologicos, acidente vascular cerebral, doenca de Alzheimer, esclerose multipla, esclerose lateral amiotrofica. RESULTADOS: No trantorno da expressao emocional involuntaria, as crises de choro e/ou riso, alem de serem incontrolaveis, tendem a ser desproporcionais ao estimulo recebido, podendo estar completamente dissociada do estado de humor do paciente ou mesmo ser contraditoria ao contexto no qual o estimulo esta inserido. Outros termos sao usados na nosografia desse transtorno, como afeto pseudobulbar, riso e choro patologicos, labilidade emocional, emocionalismo e desregulacao emocional. Termos como choro forcado, choro involuntario, emocionalidade patologica e incontinencia emocional tambem tem sido utilizados com menor frequencia. Os mecanismos fisiopatologicos especificos envolvidos nesse transtorno ainda nao estao bem esclarecidos. Lesoes que podem causa-lo estao amplamente distribuidas no encefalo, mas parecem envolver o lobo frontal, o sistema limbico, o tronco cerebral e o cerebelo, assim como a substância branca que interconecta essa rede. Seu principal diagnostico diferencial e a depressao. As terapias farmacologicas hoje disponiveis se baseiam em inibidores seletivos de recaptacao de serotonina (ISRS), antidepressivos triciclicos e, em menor extensao, em drogas dopaminergicas. O composto AVP-923 esta sendo estudado como um possivel tratamento especifico. CONCLUSAO: Apesar de ser conhecido ha seculos, ainda que sob diferentes nomenclaturas, o IEED permanece subdiagnosticado e, considerando a possibilidade dos efeitos deleterios desse transtorno no funcionamento social, ocupacional e familiar do paciente acometido, seu reconhecimento e conduta adequados sao decisivos para possibilitar uma melhoria na qualidade de vida do paciente.

Treatment of paraphilic hypersexuality in dementia

meeting annual recruitment goals. There was no correlation between presence of recruitment staff and 1) preferred method of recruitment or 2) a center’s ability to meet recruitment goals. Furthermore, although all ADRCs have a website, few (35%) see it as an active tool for recruitment. Conclusions: These data suggest that successful recruitment is a result of a comprehensive recruitment plan. The successful ADRC 1) promotes study participation while conducting community educational events, and 2) partners with outside physicians. Those interviewed agreed that without the support of lay community and physicians, recruitment goals are not met. The successful ADRC has built their program using educational seminars, free screenings, and a willingness to serve to the community.