Cíntia Fuzikawa

Norms for the mini-mental state examination: adjustment of the cut-off point in population-based studies (evidences from the Bambuí health aging study)

OBJECTIVE To estimate the prevalence of cognitive impairment in an elderly population-based cohort, using several Mini-Mental State Examination (MMSE) cut-off points recommended by Brazilian authors and to examine the percentile distribution of MMSE scores in the study population. METHOD A total of 1558 subjects aged>60 years (89.4% of the total), living in the city of Bambuí, MG, completed the MMSE and were included in the present study. RESULTS The estimated prevalences of cognitive impairment varied from 13.2% to 27.0% depending on the cut-off point and agreement varied widely between them (kappa range: 0.38 to 0.88). Cut-off point 13/14 corresponded to the 5th percentile and 21/22 corresponded to the lower quartile of the MMSE score distribution. CONCLUSION In the absence of comparable cut-off points, percentile distributions are more adequate for population-based studies of elderly with low schooling level.

Combination of antidepressants in the treatment of major depressive disorder: a systematic review and meta-analysis.

Abstract The objective was to perform a systematic review and meta-analysis of studies that assessed the effect of the combination of antidepressants from the beginning of the treatment of major depressive disorder. Studies were retrieved from PubMed (1966 to August 2010), Cochrane Library (August 2010), Embase (1980 to August 2010), PsycINFO (1980 to August 2010), Lilacs (1982 to August 2010), clinical trials registry, thesis database (www.capes.gov.br), and secondary references. All randomized controlled trials that compared a combination of antidepressants with a single antidepressant from the beginning of the treatment of major depressive disorder in adults were included. Data analysis was performed using the Review Manager 5.0. Of 3492 studies retrieved, five satisfied the inclusion criteria. In one study, only data about dropouts were included. Antidepressant combination was shown to be better than a single antidepressant considering remission (relative risk [RR], 2.71; 95% confidence interval [CI], 1.69–4.35) and response (RR, 1.55; 95% CI, 1.21–1.97). Mirtazapine plus selective serotonin reuptake inhibitor (SSRI) was superior to an isolated SSRI for remission (RR, 1.88; 95% CI, 1.06–3.33). Tricyclic antidepressant plus SSRI was superior to SSRI for remission and response (RR, 8.58; 95% CI, 1.70–43.32 and RR, 1.78; 95% CI, 1.07–2.93, respectively). There was no difference between combined and monotherapy groups in dropouts owing to adverse effects. The results suggest that antidepressant combination is more efficient than a single antidepressant without a significant decrease in tolerability. However, the small number of clinical trials and methodological problems precludes definitive conclusions.

Antidepressants for depression in Parkinson's disease: systematic review and meta-analysis.

Depression is common in Parkinson’s disease (PD) and is associated with several poor outcomes. However the literature regarding treatment with antidepressants in this population is controversial. The aim of this paper was to systematically review all randomized controlled trials that studied the efficacy of antidepressants for depression in PD (dPD). Studies were retrieved from PubMed (1966–July 2012), Cochrane Library (–July 2012, issue 7), Embase (1980–July 2012), PsycINFO (1980–July 2012), Lilacs (1982–July 2012), secondary references, clinical trials registries and a thesis database. Only double-blind, randomized controlled trials in which an antidepressant was given as the main treatment and compared with placebo and/or another antidepressant were included. Out of the 1438 studies retrieved, only six could be included. Taking into account the five placebo-controlled trials, the overall risk ratio (RR) for response was 1.36 (0.98, 1.87), indicating no statistically significant superiority of antidepressants over placebo. However, in the sensitivity analysis, the RR for response was 1.41 (1.01, 1.96) and 1.48 (1.05, 2.10) after exclusion of one study with questionable results, and when only studies with low risk of bias were considered, respectively. No specific antidepressant class was superior to placebo. In general antidepressant medications were well tolerated. The results suggest antidepressants may be efficacious in the treatment of dPD. However, the results were unstable. In fact, the small number of trials and methodological drawbacks preclude definitive conclusions about their efficacy and tolerability in dPD.

Dimensions Underlying the Mini-Mental State Examination in a Sample With Low-Education Levels: The Bambuí Health and Aging Study

OBJECTIVES To investigate the validity of previously suggested dimensions underlying the Mini-Mental State Examination (MMSE) and differences in associations of these dimensions with sociodemographic and health characteristics in an older Latin-American community sample with low levels of education. DESIGN Secondary analysis of baseline data from a population-based cohort study. SETTING Bambuí, Brazil. PARTICIPANTS Of 1,742 total residents aged 60 years or older, 1,558 (89.4%) participated at this study. MEASUREMENTS A standard Brazilian version of the MMSE. RESULTS A five-factor solution (Concentration, Language/Praxis, Orientation, Attention, and Memory) for the MMSE was generated from Principal Components Analysis, and the five-factor solutions proposed in previous studies of developed nation samples were tested in this sample by Confirmatory Factor Analysis. In the adjusted linear regression models, MMSE factors varied in their correlates: for example, female gender was associated with higher concentration, orientation, and attention but lower Language/Praxis; increased age was inversely associated only with language and attention; and activity of daily living impairment was principally associated with lower Language/Praxis. CONCLUSION This study provides support for the cross-sectional equivalence of the MMSE, suggesting that most of the items and underlying constructs remain meaningful after alteration and translation in a low-education sample with lower overall distribution of scores.

Correlation and agreement between the Mini-mental State Examination and the Clock Drawing Test in older adults with low levels of schooling: the Bambuí Health Aging Study (BHAS)

BACKGROUND The aim of the study was to determine the correlation and agreement between the Mini-mental State Examination (MMSE) and Clock Drawing Test (CDT), administered and scored using Shulmans method (2000), in elderly Brazilian adults with very low levels of formal education. METHODS CDT and MMSE tests, performed by a sample of 1118 elderly subjects from a population-based cohort, were evaluated. Spearmans correlation coefficient was calculated for the total sample and according to gender, age and schooling level. Agreement was assessed using receiver operating characteristic (ROC) analysis. RESULTS CDTs with high scores had high corresponding MMSE scores whereas CDTs with low scores had a wide range of corresponding MMSE scores. Correlation was moderate (rho=0.64) and no difference was found according to gender, age or schooling level. For CDT cut-off 3/4, the best MMSE cut-off was 27/28 and agreement between tests was 75.1%. CONCLUSIONS Correlation between tests was moderate. Subjects who performed well on the CDT could be expected to obtain high MMSE scores. Although one test does not substitute for the other, the CDT may be more practical in developing countries where resources are limited and low education is common in the elderly, as well as in situations where time for assessment or screening is limited. Moreover, the CDT may be sensitive to cognitive domains not assessed by the MMSE.

Prevalence of excessive daytime sleepiness in Brazilian community-dwelling older adults with very low levels of schooling, and its association with sociodemographic characteristics and lifestyle: the Bambuí Health and Ageing Study (BHAS)

OBJECTIVE: Population-based studies on excessive daytime sleepiness (EDS) in older adults living in less developed countries are scarce. The purpose of this paper was to estimate the prevalence of EDS and its association with sociodemographic characteristics and lifestyle factors in Brazilian community-dwelling older adults. METHODS: The study was carried out in Bambui, a city in the state of Minas Gerais, Brazil. EDS was defined as the presence of sleepiness in the last month occurring three or more times per week, with any interference in usual activities. The exploratory variables were: gender, age, skin color, marital status, schooling level, current employment status, religion, recent migration, smoking, binge drinking and physical activities during leisure time. RESULTS: Of 1,742 residents aged > 60 years, 1,514 (86.9%) participated. The prevalence of EDS was 13%. After adjustment for confounders, female gender and low schooling level remained positively and independently associated with EDS. CONCLUSIONS: The prevalence of EDS in the study population was within the range observed in studies carried out in developed countries. The most impressive finding was the association of EDS with schooling, indicating that even in a population with low levels of schooling, this was an important factor to explain the distribution of EDS.

Insomnia subtypes and their relationship to excessive daytime sleepiness in Brazilian community-dwelling older adults.

STUDY OBJECTIVES To investigate the association between different types of insomnia as exposures and excessive daytime sleepiness (EDS) as a binary outcome in older Brazilian residents. DESIGN The baseline examination of the Bambuí Health and Ageing Study (BHAS), which is an ongoing population-based prospective cohort study of older adults. SETTING Bambuí (15,000 inhabitants), a city in the State of Minas Gerais, Southeast Brazil PARTICIPANTS All residents aged ≥ 60 years were eligible to take part in the BHAS baseline. Of 1742 residents identified who were ≥ 60 years, 1606 (92.2%) were interviewed and received comprehensive examinations of health status. INTERVENTIONS None. MEASUREMENTS AND RESULTS EDS was defined as the presence of sleepiness ≥ 3 times per week in the last month, causing any interference in usual activities. All insomnia subtypes were significantly associated with EDS in unadjusted analyses, and these associations were only modestly altered after adjusting incrementally for the other covariates. In a final model, the 3 insomnia subtypes were entered into a fully adjusted model simultaneously to investigate mutual independence, giving prevalence ratios of 1.63 (95% CI 1.14-2.31) for initial insomnia, 2.13 (95% CI 1.48-3.07) for middle insomnia, and 1.36 (95% CI 0.94-1.96) for terminal insomnia. The population attributable fractions for initial, middle, and terminal insomnia on prevalence of EDS were 17.6%, 32.9%, and 9.7%, respectively. CONCLUSIONS Middle insomnia emerged as the insomnia subtype most strongly associated with EDS. Further research is required to clarify causal pathways underlying this cross-sectional association.