Claudia Sellitto Porto

Performance of illiterate and literate nondemented elderly subjects in two tests of long-term memory

Cognitive evaluation in developing countries is a difficult undertaking due to low levels of schooling and particularly the illiteracy still frequent in the elderly. This study was part of the epidemiologic evaluation of dementia in Catanduva, Brazil, and had the objective of comparing the performance of illiterate and literate nondemented elderly individuals in 2 tests of long-term memory-the delayed recall of a word list from the CERAD and the delayed recall of common objects presented as simple drawings from the Brief Cognitive Screening Battery (BCSB). Fifty-one elderly subjects (23 illiterates) were evaluated, and the performance of the illiterates and literates differed in the CERAD memory test, but not in the BCSB memory test. This test may be more suitable for the assessment of long-term memory in populations with a high frequency of illiterates, and therefore might prove to be a useful screening tool for the diagnosis of dementia.

Brief cognitive battery in the diagnosis of mild Alzheimer’s disease in subjects with medium and high levels of education

There has been an increasing trend to utilize short cognitive batteries for the diagnosis of dementia. Most of these batteries have been designed in countries with high standards of education and are less suitable for populations with low levels of education.We developed a battery that has been previously shown to be highly accurate in the diagnosis of dementia in individuals with low levels of education. The accuracy of this battery for patients with higher levels of education is unknown. Objectives To evaluate the accuracy of a brief cognitive battery in the diagnosis of Alzheimer’s disease (AD) in subjects with medium and high levels of schooling, and to develop a mathematical model that includes the most discriminative tests. Methods Seventy-three mildly demented patients with probable AD and 94 control subjects were evaluated. Sixty patients and 60 controls were randomly selected to generate a mathematical model including the most discriminative tests of the battery using logistic regression. The model was back-tested for the remaining sample of patients and controls. Results Delayed recall, learning and category fluency tests were included in a mathematical model that obtained an area of 0.917 in the ROC curve in the back-testing. Inter-rater reliabilities of these tests were high (kappa>0.8). Conclusions This model showed a high accuracy for the diagnosis of mild AD in patients with medium and high educational levels. Future studies with more heterogeneously educated individuals are necessary to investigate whether the educational level (number of years at school) should also be included in the model.

Thalamus and language: interface with attention, memory and executive functions

Subcortical structures are in a strategic functional position within the cognitive networks. Their lesion can interfere with a great number of functions. We studied six patients with thalamic vascular lesions (three left sided, two right sided and one bilateral), to characterize their repercussion in the communicative abilities and the interface between language alterations and other cognitive abilities, as attention, memory and frontal executive. All patients were evaluated through a functional interview (discourse analysis), and the following batteries: Boston Diagnostic Aphasia Examination, Boston Naming Test, Token Test, Benton Visual Retention Test, Trail Making, Wisconsin Card Sorting and frontal scripts. All patients performed MRI and five underwent SPECT. Results show that these patients present impairment in several cognitive domains, especially attention and executive functions (working memory, planning and self-monitoring); those with right lesions have an additional visuospatial impairment. Such alterations interfere with language abilities, and this fact must be considered in the rehabilitation efforts.

Comparison between two tests of delayed recall for the diagnosis of dementia

UNLABELLED Diagnosis of dementia is a challenge in populations with heterogeneous educational background. OBJECTIVE To compare the accuracies of two delayed recall tests for the diagnosis of dementia in a community with high proportion of illiterates. METHOD The delayed recall of a word list from the CERAD battery (DR-CERAD) was compared with the delayed recall of objects presented as line drawings from the Brief Cognitive Screening Battery (DR-BCSB) using ROC curves. Illiterate (23 controls and 17 patients with dementia) and literate individuals (28 controls and 17 patients with dementia) were evaluated in a community-dwelling Brazilian population. RESULTS The DR-BCSB showed higher accuracy than the DR-CERAD in the illiterate (p=0.029), similar accuracy in the literate individuals (p=0.527), and a trend for higher accuracy in the entire population (p=0.084). CONCLUSION the DR-BCSB could be an alternative for the diagnosis of dementia in populations with high proportion of illiterates.

Dementia Pugilistica with clinical features of Alzheimer's disease

A 61-year-old ex-boxer presented with a three-year history of progressive memory decline. During a seven-year follow-up period, there was a continuous cognitive decline, very similar to that usually observed in Alzheimers disease. Parkinsonian, pyramidal or cerebellar signs were conspicuously absent. Neuropathological examination revealed the typical features of dementia pugilistica: cavum septi pellucidi with multiple fenestrations, numerous neurofibrillary tangles in the cerebral isocortex and hippocampus (and rare senile plaques). Immunohistochemistry disclosed a high number of tau protein deposits and scarce beta-amyloid staining. This case shows that dementia pugilistica may present with clinical features practically undistinguishable from Alzheimers disease.

Contribution to the evaluation of language disturbances in subcortical lesions: a piloty study

Subcortical structures are in a strategic functional position within the cognitive networks and their lesion can interfere with a great number of functions. In this study, we describe fourteen subjects with exclusively subcortical vascular lesions (eight in the basal ganglia and six in the thalamus) and the interrelation between their language alterations and other cognitive abilities, as attention, memory and frontal executive functions. All patients were evaluated through the following batteries: Boston Diagnostic Aphasia Examination, Boston Naming Test, Token Test, Benton Visual Retention Test, Trail Making, Wisconsin Card Sorting Test and a frontal scripts task. All patients underwent MRI and twelve underwent SPECT. Results show that these patients present impairment in several cognitive domains, especially attention and executive functions. These alterations affect language abilities, and this fact must be considered in the rehabilitation efforts.

Cognitive impairment and magnetic resonance imaging correlations in Wilson's disease

To evaluate the cognitive performance of a group of patients with Wilsons disease (WD) and to correlate the cognitive findings with changes in magnetic resonance imaging (MRI).

Subjective memory complaints in the elderly: a sign of cognitive impairment?

OBJECTIVES: Cognitive impairment in the elderly is frequently overlooked by general practitioners. The use of subjective memory complaints as a sign of cognitive impairment by the general practice is controversial. METHODS: Elderly individuals (N = 248) were asked whether they had memory complaints and underwent a cognitive impairment screening. Subjects classified as exhibiting “probable cognitive impairment” underwent a complete cognitive evaluation, and the final diagnoses were established by expert consensus. RESULTS: A total of 147 patients presented with subjective memory complaints, and 43 were further classified as demented or “cognitively impaired not demented”. Subjective memory complaints presented a sensitivity of 100% and a negative predictive value of 100%. CONCLUSION: Subjective memory complaints are an indicator for cognitive impairment screening.

Analysis of brief language tests in the detection of cognitive decline and dementia

Lexical access difficulties are frequent in normal aging and initial stages of dementia.Verbal fluency tests are valuable to detect cognitive decline, evidencing lexico-semantic and executive dysfunction. Objectives To establish which language tests can contribute in detecting dementia and to verify schooling influence on subject performance. Method 74 subjects: 33 controls, 17 Clinical Dementia Rating (CDR) 0.5 and 24 (Brief Cognitive Battery - BCB e Boston Naming Test - BNT) 1 were compared in tests of semantic verbal fluency (animal and fruit), picture naming (BCB and BNT) and the language items of Mini Mental State Examination (MMSE). Results There were significant differences between the control group and both CDR 0.5 and CDR 1 in all tests. Cut-off scores were: 11 and 10 for animal fluency, 8 for fruit fluency (in both), 8 and 9 for BCB naming. The CDR 0.5 group performed better than the CDR 1 group only in animal fluency. Stepwise multiple regression revealed fruit fluency, animal fluency and BCB naming as the best discriminators between patients and controls (specificity: 93.8%; sensitivity: 91.3%). In controls, comparison between illiterates and literates evidenced schooling influence in all tests, except for fruit fluency and BCB naming. In patients with dementia, only fruit fluency was uninfluenced by schooling. Conclusion The combination of verbal fluency tests in two semantic categories along with a simple picture naming test is highly sensitive in detecting cognitive decline. Comparison between literate and illiterate subjects shows a lesser degree of influence of schooling on the selected tests, thus improving discrimination between low performance and incipient cognitive decline.

Iatrogenic Creutzfeldt-Jakob disease following human growth hormone therapy: case report

We report the case of a 41-year-old man with iatrogenic Creutzfeldt-Jakob disease (CJD) acquired after the use of growth hormone (GH) obtained from a number of pituitary glands sourced from autopsy material. The incubation period of the disease (from the midpoint of treatment to the onset of clinical symptoms) was rather long (28 years). Besides the remarkable cerebellar and mental signs, the patient exhibited sleep disturbance (excessive somnolence) from the onset of the symptoms, with striking alteration of the sleep architecture documented by polysomnography. 14-3-3 protein was detected in the CSF, and MRI revealed increased signal intensity bilaterally in the striatum, being most evident in diffusion-weighted (DW-MRI) sequences. This is the second case of iatrogenic CJD associated with the use of GH reported in Brazil.