Claudia Godinho

Incidence of Mild Cognitive Impairment and Alzheimer Disease in Southern Brazil

The objective of the study was to evaluate incident cases of Alzheimer disease (AD) and mild cognitive impairment (MCI) in an elderly community cohort in a major city of southern Brazil and to determine the variables associated with the development of cognitive dysfunction. Data were drawn from a cohort to investigate healthy aging among community elderly (N = 345) and were derived from the follow-up for a maximum of 8 years. Sociodemographic, psychiatric and medical information, the Mini-Mental State Examination (MMSE), and the Clinical Dementia Rating scale were obtained in each assessment. The Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition; DSM-IV), NINCDS-ADRDA (National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and related Disorders Association), and the Mayo Clinic criteria were applied to ascertain diagnoses of AD and MCI. The incidence rate per 1000 persons-year for MCI was 13.2 (95% confidence interval [CI] 7.79-20.91) and for AD was 14.8 (95% CI 9.04-22.94). Cognitive dysfunction was associated with education (odds ratio [OR] = 0.86; confidence limit [CL] 0.76-0.97 95%) and baseline MMSE (OR = 0.81; CL 0.70-0.94 95%). The AD incidence in this sample was higher than those reported in a previous Brazilian study. The study filled the epidemiological gap in the evaluation of MCI in Brazil.

Evaluation of Mini-Mental State Examination scores according to different age and education strata, and sex, in a large Brazilian healthy sample

Until better measures have been accepted for wider use, the Mini-Mental State Examination (MMSE) will continue to be utilized. In this context, knowledge on characteristics and determinants of its distribution for the Brazilian population are particularly valuable. The present study aimed to evaluate, based on multivariate analysis, the independent effect of age, educational level and sex, and their interactions, on MMSE scores in a healthy sample. Methods Demographic data and scores on the MMSE of 1,553 healthy individuals were analyzed. The sample was grouped according to age and education. Results The sample was composed of 963 females (62%), mean age ±SD was 49.6±20.7yrs (range 20 to 92 yrs). The mean years of education ±SD was 8.9±5.5yrs (range 0 to 28 yrs). The mean score ±SD on the MMSE was 27.3±2.7(range 15 to 30). A significant effect of the interaction between education and sex (p=0.011), and also between education and age was observed (p=0.003). An independent effect of education (p<0.001) and age (p<0.001) was found. Participants from the higher educated group presented higher MMSE scores than the other groups. Younger adults presented higher MMSE scores than the other age groups. Conclusions We observed an effect of education and age on MMSE scores. Younger individuals and higher educated participants presented higher scores.

Estimation of the risk of conversion of mild cognitive impairment of Alzheimer type to Alzheimer's disease in a south Brazilian population-based elderly cohort: the PALA study

BACKGROUND Higher mild cognitive impairment (MCI) prognostic variability has been related to sample characteristics (community-based or specialized clinic) and to diverse operationalization criteria. The aim of the study was to evaluate the trajectory of MCI of Alzheimer type in a population-based elderly cohort in Southern Brazil. We also estimated the risk for the development of probable Alzheimers disease (AD) in comparison with healthy subjects. METHODS Data were derived from a population-based cohort (the PALA study). MCI outcomes were sub-classified into three categories: conversion, stabilization, and reconversion. The risk of progression to dementia was compared between MCI and normal participants. The analysis was based on 21 MCI subjects and 220 cognitively intact participants (N = 241). RESULTS Of the 21 MCI subjects, 38% developed dementia, 24% remained stable and 38% improved. The MCI annual conversion rate to AD was 8.5%. MCI was associated with significantly higher risk of conversion to AD (HR = 49.83, p = 0.004), after adjustment for age, education, sex and Mini-Mental State Examination score. CONCLUSIONS Independent of the heterogeneity of the outcomes, MCI of the Alzheimer type participants showed significantly higher risk of developing probable AD, demonstrating the impact of the use of these MCI criteria that emphasize long-term episodic memory impairment.

Neuropsychiatric symptoms as the main determinant of caregiver burden in Alzheimer's disease

Caregiver burden is common in Alzheimer’s disease (AD), decreasing the quality of life among caregivers and patients. Projections of aging and aging-related diseases such as AD in developing countries justify additional data about this issue because people living in these countries have shown similarly high levels of caregiver strain as in the developed world. Objective The aim of this study was to analyze the association of AD caregivers’ burden with patients’ neuropsychiatric symptoms (NPS), cognitive status, severity of dementia, functional capacity, caregiver sociodemographic characteristics, and the characteristics of care provided by caregivers. Methods A cross-sectional study was conducted in a sample of 39 consecutive AD patients and their primary caregivers. NPS were evaluated using the Neuropsychiatric Inventory (NPI). Severity of dementia was assessed with the Clinical Dementia Rating (CDR) scale. Functional capacity was assessed using the Katz and Lawton scales. The burden level was rated using the Burden Interview (BI). Sociodemographic characteristics of caregivers and the characteristics of care provided by them were evaluated. The Mann-Whitney U-test, Kruskal-Wallis test and Spearman’s rho coefficient were performed. Results The BI had a moderate correlation with NPI intensity (rho=0.563), p<001. Female caregivers reported a greater level of burden (p=0.031) than male caregivers. The other variables were not significantly associated to caregiver burden. Conclusion NPS were the main determinant of burden in primary caregivers of AD patients. This result underscores the need for prevention and treatment of these symptoms. Sex also had an effect on caregiver burden, but the small male sample in this study precludes the generalization of this finding.

Association of caregiver demographic variables with neuropsychiatric symptoms in Alzheimer's disease patients for distress on the Neuropsychiatric Inventory (NPI)

Behavioral symptoms are frequently observed in Alzheimer’s disease patients and are associated to higher distress for patients and caregivers, early institutionalization, worst prognosis and increased care. Objectives The objective of the present study was to evaluate the frequency of neuropsychiatric symptoms in a sample of Alzheimer’s disease patients and to analyze association between caregiver demographic characteristics and patient symptoms. Methods Sixty Alzheimer’s disease patients (NINCDS-ADRDA) and their caregivers were consecutively included in the investigation by the Dementia Outpatient clinic of Hospital de Clínicas de Porto Alegre. The Neuropsychiatric Inventory (NPI) was applied to evaluate behavioral symptoms and their impact upon caregivers. Age, sex, educational attainment, relationship to the patient, and time as caregiver were obtained from all caregivers. Results Apathy was the symptom responsible for the highest distress level, followed by agitation and aggression. A significant correlation between total severity NPI and distress NPI was observed. None of the caregiver demographic data showed association to distress. The most frequent symptoms were apathy and aberrant motor behavior. Patients’ relatives also considered apathy as the most severe symptom, followed by depression and agitation. Conclusions Apathy was the most frequent and severe neuropsychiatric symptom. No relationship between caregiver demographic characteristics and distress was observed.

Cognitive, functional and behavioral assessment. Alzheimer’s disease

A review of the evidence on cognitive, functional and behavioral assessment for the diagnosis of dementia due to Alzheimer’s disease (AD) is presented with revision and broadening of the recommendations on the use of tests and batteries in Brazil for the diagnosis of dementia due to AD. A systematic review of the literature (MEDLINE, LILACS and SCIELO database) was carried out by a panel of experts. Studies on the validation and/or adaptation of tests, scales and batteries for the Brazilian population were analyzed and classified according to level of evidence. There were sufficient data to recommend the IQCODE, DAFS-R, DAD, ADL-Q and Bayer scale for the evaluation of instrumental activities of daily living, and the Katz scale for the assessment of basic activities of daily living. For the evaluation of neuropsychiatric symptoms, the Neuropsychiatric Inventory (NPI) and the CAMDEX were found to be useful, as was the Cornell scale for depression in dementia. The Mini-Mental State Examination has clinical utility as a screening test, as do the multifunctional batteries (CAMCOG-R, ADAS-COG, CERAD and MDRS) for brief evaluations of several cognitive domains. There was sufficient evidence to recommend the CDR scale for clinical and severity assessment of dementia. Tests for Brazilian Portuguese are recommended by cognitive domain based on available data.

Validity of the Brazilian version of the Neuropsychiatric Inventory Questionnaire (NPI-Q)

UNLABELLED The NPI-Q (Neuropsychiatry Inventory-Questionnaire) was developed to facilitate the evaluation of neuropsychiatric symptoms. This study evaluated the internal consistency, the test-retest reliability of the Brazilian NPI-Q version and its convergent validity with the original NPI. METHOD The NPI-Q and the NPI were administered to 64 caregivers of dementia patients. Thirteen informants were asked to complete a second NPI-Q form. RESULTS The internal consistency of the Brazilian NPI-Q version was 0.67 for the severity scale and 0.81 for the distress scale. The test-retest reliability of the total NPI-Q severity and the distress scales were 0.97 and 0.92, respectively (p < 0.001). There were significant correlations between the total NPI-Q severity score and the NPI (r = 0.75) and between the total NPI-Q distress score and the total NPI standard distress (r = 0.74). CONCLUSION The Brazilian NPI-Q version showed evidence of good psychometric properties and can be used in general clinical practice.

Clinical and demographic characteristics of elderly patients with dementia assisted at an outpatient clinic in Southern Brazil

The aging of the population is a worldwide phenomenon, where 60% of elders live in developing areas of the world such as Brazil, regions in which few studies have been carried out. Objectives The goal of this study was to evaluate the clinical and demographic profile of patients with dementing disorders seen at a specialized outpatient clinic in South Brazil. Methods A sample of 105 demented patients seen at the Dementia Outpatient Clinic from Hospital de Clínicas de Porto Alegre (HCPA), Brazil between June 2004 and June 2008. Evaluation of patients consisted of medical history, cognitive testing, assessment of functional status (Activities of Daily Living Scale - ADL; Instrumental Activities Daily Living - IADL) and application of the Neuropsychiatry Inventory (NPI) for behavioral symptoms. Severity of dementia was evaluated based on the CDR scale. All patients underwent laboratory screening tests and brain imaging exams to define etiology of dementia. Results Of the whole sample, 71% were female. Age was 79±8 years (mean±SD). Educational level was 4±3 years (mean±SD). Sixty-four patients (60%) presented the diagnosis of Alzheimer’s disease. Of the whole sample, 26.7% were classified as CDR=1, 44% as CDR=2 and 29. 3% as CDR=3. A significant difference on the Mini Mental State Examination (MMSE) and functional status scores was observed among the CDR categories (severity). No significant association was found between severity and impairment on memory tests and behavioral symptoms. Conclusions Alzheimer’s disease was the most common etiology, followed by vascular dementia. At diagnosis, most patients presented mild to moderate severity of dementia, independent of cause.

Validation of a telephone screening test for Alzheimer's disease

ABSTRACT Financial constraints, mobility issues, medical conditions, crime in local areas can make cognitive assessment difficult for elders and telephone interviews can be a good alternative. This study was carried out to evaluate the reliability, validity and clinical utility of a Brazilian telephone version of the Mini Mental State Examination (Braztel-MMSE) in a community sample of healthy elderly participants and AD patients. The MMSE and the Braztel-MMSE were applied to 66 AD patients and 67 healthy elderly participants. The test–retest reliability was strong and significant (r = .92, p = .01), and the correlation between the Braztel-MMSE and the MMSE were significant (p = .01) and strong (r = .92). The general screening ability of the Braztel-MMSE was high (AUC = 0.982; CI95% = 0.964–1.001). This telephone version can therefore be used as a screening measure for dementia in older adults that need neuropsychological screening and cannot present for an evaluation.

Cognitive complaints compared to performance on a mental state screening test in elderly outpatients

Memory and other cognitive complaints are common in the elderly population. However, the clinical meaning of these complaints remains controversial. Objectives The goal of this study was to investigate the association between cognitive complaints and performance on a mental state screening test in elderly patients attended for the first time at the Neurogeriatric and Dementia (NGA) Outpatient Clinic within a major University hospital. Methods Two hundred patients referred to the NGA Clinic during 2005, 2006 and 2007 first semesters participated in the study. The variables of interest were: (a) source of and reason for referral; (b) whether or not they had previously been evaluated with the screening test (Mini Mental State Exam - MMSE) by their physicians before referral to our specialized clinic; (c) cognitive complaints; and (d) performance on the screening test (MMSE) at the NGA Clinic. Results The main reason for referral to the NGA clinic was cognitive complaints 63% (N=126), where only 5% (N=10) of the referred patients had been previously evaluated by the cognitive screening test (MMSE or equivalent). Of the 135 patients who presented cognitive complaints during the first appointment, 52 (38%) presented MMSE scores below the education-adjusted cut-off. No association between cognitive complaint and performance on the MMSE during the first evaluation at the NGA Clinic was observed (χ2=3.04, p=0.1). Conclusions Although cognitive complaints among elders should not be disregarded, the mental state screening evaluation is crucial for the detection of clinically significant cognitive impairment.