Carolina Pinto Souza

Frontal assessment battery in a Brazilian sample of healthy controls: normative data

OBJECTIVE To show data on the performance of healthy subjects in the Frontal Assessment Battery (FAB), correlating with gender, age, education, and scores in the Mini-Mental State Examination (MMSE). METHODS Two hundred and seventy-five healthy individuals with mean age of 66.4 ± 10.6 years-old were evaluated. Mean total FAB scores were established according to the educational level. RESULTS Mean total FAB scores according to the educational level were 10.9 ± 2.3, for one to three years; 12.8 ± 2.7, for four to seven years; 13.8 ± 2.2, for eight to 11 years; and 15.3 ± 2.3, for 12 or more years. Total FAB scores correlated significantly with education (r=0.47; p<0.0001) and MMSE scores (r=0.39; p<0.0001). No correlation emerged between FAB scores, age, and gender. CONCLUSION In this group of healthy subjects, the Brazilian version of the FAB proved to be influenced by the education level, but not by age and gender.

Spinal cord stimulation improves gait in patients with Parkinson's disease previously treated with deep brain stimulation

Deep brain stimulation and levodopatherapy ameliorate motor manifestations in Parkinsons disease, but their effects on axial signs are not sustained in the long term.

An analysis of the cognitive items of the movement disorders society checklist for the diagnosis of dementia in patients with Parkinson's disease.

OBJECTIVE Some studies about the Movement Disorders Society checklist for the diagnosis of Parkinsons disease (PD) dementia (PDD) suggested that its accuracy was not totally satisfactory. Our study focused to evaluate the two items of the checklist related to the cognitive assessment. METHODS We assessed 95 consecutive patients with a diagnosis of PD using the UPDRS, Hoehn and Yahr, Schwab and England scales, Pfeffer Functional Activities Questionnaire, MMSE, Clinical Dementia Rating, clock drawing test, verbal fluency test (animals), digit span, word list battery of CERAD, Frontal Assessment Battery and the 15-item Geriatric Depression Scale The cognitive diagnosis was based on the MDS diagnostic criteria for PDD. The checklist was completed later by a blinded investigator. The data were evaluated using descriptive analysis and calculation of sensitivity, and specificity of the checklist for the diagnosis of PDD. RESULTS 33 patients (35%) were diagnosed with PDD. The ROC curve showed that the MMSE cut-off score < 26 had the highest accuracy (sensitivity: 94%, specificity: 55%) for the diagnosis of PDD. Using the checklist with original cut-off scores we found sensitivity of 97% and specificity of 58%. Using an alternative way to interpret the cognitive assessment of the checklist we found sensitivity of 94% and specificity of 89% for the diagnosis of PDD. CONCLUSIONS Our findings suggest that to improve the accuracy of the checklist, it would be necessary to adjust the way we use and interpret the cut-off scores of the MMSE and of the subtests, without the need to eliminate their use.

Executive cognitive tests for the evaluation of patients with Parkinson's disease

Parkinson’s disease (PD) is characterized by changes in movement, which are later followed by cognitive, behavioral and psychological changes. The objective of the present study was to correlate different tests used to examine executive functions in PD patients followed at a specialized outpatient clinic. Methods Thirty-five patients with idiopathic PD aged 63.0 years on average and with mean schooling of 5.5±4.2 years, were examined using the following tests: Mattis Dementia Rating Scale (MDRS), Scales for Outcomes of Parkinson’s Disease-Cognition (SCOPA-COG), Wisconsin Card Sorting Test (WCST), Frontal Assessment Battery (FAB), Digit Span – Inverse Order (IO) (a subtest of the WAIS III) and Verbal Fluency Test (category animals). Results Significant correlations were detected between FAB and MDRS Conceptualization (0.814), MDRS Initiation/Perseveration (I/P) and SCOPA-COG Executive Function (0.643), FAB and MDRS I/P (0.601), FAB and Verbal Fluency (0.602), MDRS I/P and MDRS Conceptualization (0.558), Verbal Fluency and MDRS I/P (0.529), MDRS Attention and SCOPA-COG Executive Function (0.495), MDRS Conceptualization and SCOPA-COG Executive Function (0.520), FAB and Digit Span (OI) (0.503), Verbal Fluency and MDRS Conceptualization (0.501), and WCST perseverative errors and FAB (–0.379), WCST perseverative errors and MDRS Conceptualization (0.445), WCST perseverative errors and MDRS I/P (–0.407) and WCST categories completed and MDRS Conceptualization (0.382). Discussion The results demonstrated strong correlations between most of the tests applied, but no associations were detected between the WCST and the other tests, a fact that may be explained by the heterogeneity of scores obtained in the tests by the patients evaluated. A difficulty of the present study was the lack of a control groups for the establishment of adequate standards for this population.

Visuospatial cognitive tests for the evaluation of patients with Parkinson's disease

Parkinsons disease (PD) is a neurological disorder characterized by motor disturbances, neuropsychological symptoms and cognitive changes, including cases of dementia. The most frequently described cognitive changes in these patients involve executive and visuospatial functions, which are very important for the execution of daily life activities. Objective To compare different tests used to examine visuospatial functions in patients with PD. Methods Thirty-five patients (21 women) with PD symptoms (medicated and “on”) and mean schooling of 5.5±4.2 years were examined using the following tests: Mini-Mental State Examination (MMSE), Dementia Rating Scale (DRS), Scales of Outcomes of Parkinsons Disease (SCOPA-COG), Hooper Visual Organization Test (HVOT), Judgment of Line Orientation, Form V (JLO), and Clock drawing task – CLOX (1 and 2). Results The mean MMSE score was 24.8±3.03and 54.8% of the patients performed correctly in the copy of a pentagon drawing, with a medium-level performance in most tests. Good correlations were detected between JLO versus SCOPA Assembling patterns (0.67), JLO versus HVOT (0.56), JLO versus CLOX2 (0.64), SCOPA Figure Composition versus HVOT (0.54), CLOX1 versus CLOX2 (0.43), and DRS Construction versus CLOX2 (0.42). Discussion Although correlations were detected, not all were strong, probably because the tests employed do not measure solely visuospatial functions, but also other skills such as attention, motor ability and executive functions. A limitation of the present study was the lack of a control group for the establishment of adequate standards for this population.

Starfruit neurotoxicity mimicking an acute brainstem stroke

The carambola (Averrhoa carambola), also known as the starruit, is originally native to Southeastern Asian countries, such as he Philippines, Indonesia, and Sri Lanka. About 150 years ago, it as brought to the western land, including Brazil, where its juice is sed as a diuretic, expectorant, and cough medicine. There have een reports of patients with chronic renal failure who develped neurological alterations associated with the ingestion of this ruit. It is believed that Carambola contains neurotoxins that are sually excreted by the kidneys and may accumulate in patients ith renal insufficiency. Those toxins are thought to overcome the lood–brain barrier giving rise to a variety of presentations—from ersistent hiccups to status epilepticus and coma [1], which, thus, an be misinterpreted as a stroke. Herein, we report a case admitted t our Emergency Department with a stroke-like episode caused by tarfruit toxicity.

Effects of spinal cord stimulation on postural control in Parkinson's disease patients with freezing of gait

Freezing of gait (FoG) in Parkinson’s disease (PD) is an incapacitating transient phenomenon, followed by continuous postural disorders. Spinal cord stimulation (SCS) is a promising intervention for FoG in patients with PD, however, its effects on distinct domains of postural control is not well known. The aim of this study is to assess the effects of SCS on FoG and distinct domains of postural control. Four patients with FoG were implanted with SCS systems in the upper thoracic spine. Anticipatory postural adjustment (APA), reactive postural responses, gait and FoG were biomechanically assessed. In general, the results showed that SCS improved FoG and APA. However, SCS failed to improve reactive postural responses. SCS seems to influence cortical motor circuits, involving the supplementary motor area. On the other hand, reactive posture control to external perturbation that mainly relies on neuronal circuitries involving the brainstem and spinal cord, is less influenced by SCS.

The interlocking finger test in patients with Parkinson's disease and healthy subjects.

The interlocking finger test (ILFT) is a bedside screening test in which the subject must imitate four bimanual finger gestures without symbolic meaning. We assessed the utility of the test in the cognitive evaluation of patients with Parkinsons disease (PD). We evaluated 88 healthy subjects and 101 patients with PD using a simplified motor score of the Unified Parkinsons Disease Rating Scale (UPDRS), Hoehn and Yahr and Schwab and England scales, Geriatric Depression Scale, Pfeffer Functional Activities Questionnaire, Clinical Dementia Rating, Mini-Mental State Examination, clock drawing test, digit span, word list battery of the Consortium to Establish a Registry for Alzheimers Disease assessment, Frontal Assessment Battery, semantic verbal fluency test, and the ILFT. Diagnoses of mild cognitive impairment and dementia were made using the Movement Disorder Society diagnostic criteria. ILFT scores in healthy subjects correlated significantly with age (p=0.001) and only one healthy subject scored 2 in the test. ILFT scores were significantly lower in patients with PD and dementia (p=0.001) and significantly correlated with cognitive and functional tests, but not with depressive symptoms (p=0.607), Hoehn and Yahr scores (p=0.907), or Schwab and England scores (p=0.701). Twenty-five patients with dementia, three patients with mild cognitive impairment, and six patients with apparently normal cognition scored less than 3 in the ILFT. The area under the receiver operating characteristic curve for the ILFT to discriminate patients with dementia from those without it was 0.76 (cut-off score of 3/2: sensitivity of 61%, specificity of 0.85). In conclusion, the ILFT seems to be a useful bedside test to assess cognitive impairment in patients with PD.

Cluster analysis of cognitive performance in a sample of patients with Parkinson's disease

Background Cognitive impairment is a common feature of Parkinsons disease (PD). The diagnoses of mild cognitive impairment (MCI) in patients with PD implies an increased risk for later development of dementia, however, it is unclear whether a specific type of cognitive loss confers increased risk for faster cognitive decline. Objective Determine whether it was possible to identify distinct cognitive phenotypes in a sample of patients with PD. Methods A cross-sectional evaluation of 100 patients with PD recruited from a movement disorders clinic was conducted. The patients were evaluated using the simplified motor score of the UPDRS, the Hoehn and Yahr, Schwab and England, Geriatric Depression Scale, Pfeffer Functional Activities Questionnaire, Clinical Dementia Rating Scale, Mini-Mental State Examination, clock drawing test, digit span, word list battery of CERAD, Frontal Assessment Battery and verbal fluency test. We classified the patients as having normal cognition (PDNC), MCI (PDMCI) or dementia (PDD). Data were analyzed using the chi-square test, non-parametric statistics and cluster analysis. Results There were 40 patients with PDD, 39 with PDMCI and 21 with PDNC. Patients with PDD were older, had longer disease duration, lower education and lower MMSE scores. Cluster analysis showed 3 general distinct cognitive profiles that represented a continuum from mild to severe impairment of cognition, without distinguishing specific cognitive profiles. Conclusion Cognitive impairment in PD occurs progressively and heterogeneously in most patients. It is unclear whether the definition of the initial phenotype of cognitive loss can be used to establish the cognitive prognosis of patients.