Daniel Apolinario

Effects of a non-focal plasticity protocol on apathy in moderate Alzheimer's disease: a randomized, double-blind, sham-controlled trial.

BACKGROUND Apathy is the most common neuropsychiatric symptom in Alzheimers disease (AD) and it is associated with changes in prefrontal neural circuits involved with generation of voluntary actions. To date no effective treatment for apathy has been demonstrated. OBJECTIVE We aimed to investigate the effects and safety of repetitive transcranial direct current stimulation (tDCS) on apathy in moderate AD patients. METHODS Forty patients were randomized to receive either active or sham-tDCS over the left dorsolateral prefrontal cortex (DLPFC). Patients received six sessions of intervention during 2 weeks and were evaluated at baseline, at week 1 and 2, and after 1 week without intervention. Clinical raters, patients, and caregivers were blinded. The primary outcome was apathy. Global cognition and neuropsychiatric symptoms were examined as secondary outcomes. RESULTS The mean MMSE score at baseline was 15.2 ± 2.9 and the mean Apathy Scale score was 27.7 ± 6.7. Changes on apathy scores over time were not different between active and sham tDCS (P = 0.552 for repeated measures). Further analyses confirm that changes from baseline did not differ between groups after the sixth session (active tDCS -1.95 (95%CI -3.49, -0.41); sham-tDCS -2.05 (95%CI -3.68, -0.42); P = 0.989]. Similarly, tDCS had no effect on secondary outcomes (P > 0.40). tDCS was well tolerated and not associated with significant adverse effects. CONCLUSION In this adequately powered study for minimal clinically significant difference, our findings show that using the parameters we chose for this study, repeated anodal tDCS over the left DLPFC had no effect on apathy in elderly patients with moderate AD.

Short Assessment of Health Literacy for Portuguese-speaking Adults

OBJECTIVE To develop and validate a short health literacy assessment tool for Portuguese-speaking adults. METHODS The Short Assessment of Health Literacy for Portuguese-speaking Adults is an assessment tool which consists of 50 items that assess an individuals ability to correctly pronounce and understand common medical terms. We evaluated the instruments psychometric properties in a convenience sample of 226 Brazilian older adults. Construct validity was assessed by correlating the tool scores with years of schooling, self-reported literacy, and global cognitive functioning. Discrimination validity was assessed by testing the tools accuracy in detecting inadequate health literacy, defined as failure to fully understand standard medical prescriptions. RESULTS Moderate to high correlations were found in the assessment of construct validity (Spearmans coefficients ranging from 0.63 to 0.76). The instrument showed adequate internal consistency (Cronbachs alpha=0.93) and adequate test-retest reliability (intraclass correlation coefficient=0.95). The area under the receiver operating characteristic curve for detection of inadequate health literacy was 0.82. A version consisting of 18 items was tested and showed similar psychometric properties. CONCLUSIONS The instrument developed showed good validity and reliability in a sample of Brazilian older adults. It can be used in research and clinical settings for screening inadequate health literacy.OBJETIVO: Desenvolver e validar um instrumento breve para avaliacao de alfabetismo em saude na lingua portuguesa. METODOS: O instrumento desenvolvido consiste de 50 itens que avaliam a capacidade do individuo de pronunciar e compreender termos medicos comuns. As propriedades psicometricas foram avaliadas em uma amostra de 226 idosos brasileiros. A validade de construto foi estabelecida pela correlacao com o numero de anos de escolaridade, relato de alfabetismo funcional e desempenho cognitivo global. A validade discriminativa foi estabelecida pela acuracia do instrumento na deteccao de alfabetismo em saude inadequado, definido como a incapacidade de compreender corretamente prescricoes medicas padronizadas. RESULTADOS: As correlacoes com os criterios de construto apresentaram magnitude moderada a alta (coeficientes de Spearman = 0,63 a 0,76). O instrumento apresentou ainda consistencia interna satisfatoria (Cronbach = 0,93) e boa confiabilidade teste-reteste (coeficiente de correlacao intraclasse = 0,95). A area sob a curva caracteristica de operacao do receptor para deteccao de alfabetismo inadequado foi 0,82. Uma versao com 18 itens foi derivada e apresentou propriedades psicometricas similares. CONCLUSOES: O instrumento desenvolvido apresentou boa validade e consistencia em uma amostra de idosos brasileiros e pode ser utilizado em ambientes clinicos ou de pesquisa com a finalidade de detectar alfabetismo em saude inadequado.

Functional health literacy and glycaemic control in older adults with type 2 diabetes: a cross-sectional study

Objectives To investigate the relationship between functional health literacy and glycaemic control in a sample of older patients with type 2 diabetes. Design Cross-sectional study. Setting A government-financed outpatient geriatric clinic in São Paulo, Brazil. Participants 129 older patients with type 2 diabetes, a mean (SD) age of 75.9 (6.2) years, a mean glycosylated haemoglobin (HbA1c) of 7.2% (1.4), of which 14.7% had no formal education and 82.9% had less than a high-school diploma. Measures HbA1c was used as a measure of glycaemic control. Functional health literacy was assessed with the 18-item Short Assessment of Health Literacy for Portuguese-speaking Adults (SAHLPA-18), a validated instrument to evaluate pronunciation and comprehension of commonly used medical terms. Regression models were controlled for demographic data, depressive symptoms, diabetes duration, treatment regimen, diabetes knowledge and assistance for taking medications. Results Functional health literacy below adequate was encountered in 56.6% of the sample. After controlling for potential confounding factors, patients with inadequate functional health literacy were more likely than patients with adequate functional health literacy to present poor glycaemic control (OR=4.76; 95% CI 1.36 to 16.63). In a fully adjusted linear regression model, lower functional health literacy (β=−0.42; p<0.001), longer diabetes duration (β=0.24; p=0.012) and lack of assistance for taking medications (β=0.23; p=0.014) were associated with higher levels of HbA1c. Contrary to our expectations, illiterate patients did not have poorer outcomes when compared with patients with adequate functional health literacy, raising the hypothesis that illiterate individuals are more likely to have their difficulties recognised and compensated. However, the small subsample of illiterate patients provided limited power to reject differences with small magnitude. Conclusions Patients with inadequate functional health literacy presented with higher odds of poor glycaemic control. These findings reinforce the importance of addressing limited functional health literacy in clinical practice.

Estimating Premorbid Cognitive Abilities in Low-Educated Populations

Objective To develop an informant-based instrument that would provide a valid estimate of premorbid cognitive abilities in low-educated populations. Methods A questionnaire was drafted by focusing on the premorbid period with a 10-year time frame. The initial pool of items was submitted to classical test theory and a factorial analysis. The resulting instrument, named the Premorbid Cognitive Abilities Scale (PCAS), is composed of questions addressing educational attainment, major lifetime occupation, reading abilities, reading habits, writing abilities, calculation abilities, use of widely available technology, and the ability to search for specific information. The validation sample was composed of 132 older Brazilian adults from the following three demographically matched groups: normal cognitive aging (n = 72), mild cognitive impairment (n = 33), and mild dementia (n = 27). The scores of a reading test and a neuropsychological battery were adopted as construct criteria. Post-mortem inter-informant reliability was tested in a sub-study with two relatives from each deceased individual. Results All items presented good discriminative power, with corrected item-total correlation varying from 0.35 to 0.74. The summed score of the instrument presented high correlation coefficients with global cognitive function (r = 0.73) and reading skills (r = 0.82). Cronbachs alpha was 0.90, showing optimal internal consistency without redundancy. The scores did not decrease across the progressive levels of cognitive impairment, suggesting that the goal of evaluating the premorbid state was achieved. The intraclass correlation coefficient was 0.96, indicating excellent inter-informant reliability. Conclusion The instrument developed in this study has shown good properties and can be used as a valid estimate of premorbid cognitive abilities in low-educated populations. The applicability of the PCAS, both as an estimate of premorbid intelligence and cognitive reserve, is discussed.

Learning to read in older age improves cognitive performance: findings from a prospective observational study.

Conflict of Interest: The authors have no conflict of interest. Author Contributions: Mo: first evaluator of PIM, study design, data acquisition, analyses, supervision, data interpretation, initial manuscript preparation. Yang: data analysis. He: second evaluator of PIM, study design, data interpretation, and final manuscript preparation. Dong: data interpretation. Sponsor’s Role: This work was supported in part by National Science Foundation of China 81270926 and Outstanding Scholar Foundation of Sichuan University 2013SCU04A17 to Jinhan He.

Cognitive impairment and driving. A review of the literature

Although some drivers with mild dementia may continue to drive after the condition has been diagnosed, the ability to drive a motor vehicle safely is eventually lost as the disease progresses. Clinicians involved in dementia care are often asked to make an assessment on whether a patient is fit to drive, even though they often lack basic knowledge and formal training in this area. The purpose of this review was to identify the factors that may differentiate safe from unsafe drivers with cognitive impairment and to discuss management strategies. Isolated information about staging measures or particular cognitive tests was found to be insufficient for decision making. Driving fitness counseling for patients with cognitive impairment requires a solid knowledge base, comprehensive assessment and thoughtful communication.

Cognitive predictors of limited health literacy in adults with heterogeneous socioeconomic backgrounds.

The purpose of this study was to explore the relationship between health literacy and specific cognitive abilities in hospital users. A neuropsychological battery was administered and the Short Test of Functional Health Literacy in Adults was used to classify individuals as having adequate or limited functional health literacy. Of the 322 participants, 102 (31.7%) presented limited health literacy. Even after adjusting for demographics, years of education, and quality of education, health literacy was strongly associated with measures of cognitive performance, but the strength of association was variable across different cognitive abilities.

The Geriatric Day Hospital: Preliminary Data on an Innovative Model of Care in Brazil for Older Adults at Risk of Hospitalization

Older adults have a greater risk of experiencing functional decline and iatrogenic complications during hospitalization than younger individuals. Geriatric day hospitals (GDHs) have been implemented mainly for rehabilitation. The goal of the current study was to expand the GDH spectrum of care to prevent hospital admissions in this population. This study details an innovative model of GDH care that offers short‐term, nonrehabilitative treatment to older adults who have experienced an acute event, those with a decompensated chronic disease, or those in need of a minor procedure that would be unattainable in a regular outpatient setting. During the 6‐hour visits made weekly for up to 2 months, participants receive integrated evaluations of their various health domains, education, and rapid access to examinations and procedures based on a multidisciplinary approach. In the first 6 years, 2,322 individuals attended the GDH. The analysis of a representative sample (n = 645) revealed that 81% were treated in the GDH without the need for another type of hospital care. This percentage was high for the different reasons for referral (infection, 71%; delirium, 73%; decompensated chronic disease, 81%). Between baseline and discharge, participants maintained their functional status, and their self‐reported health improved. This study represents the first step in describing the role of the GDH as a possible alternative to emergency department use or hospitalization for older adults. Future studies are needed to determine the optimal individual for this model of care and to ensure its cost‐effectiveness.

Using temporal orientation, category fluency, and word recall for detecting cognitive impairment: the 10-point cognitive screener (10-CS).

A screening strategy composed of three‐item temporal orientation and three‐word recall has been increasingly used for detecting cognitive impairment. However, the intervening task administered between presentation and recall has varied. We evaluated six brief tasks that could be useful as intervening distractors and possibly provide incremental accuracy: serial subtraction, clock drawing, category fluency, letter fluency, timed visual detection, and digits backwards.

Characterizing spontaneously reported cognitive complaints: the development and reliability of a classification instrument.

BACKGROUND The characteristics and associated risks of spontaneously reported cognitive complaints have not been investigated due to the lack of a classification instrument. METHODS In phase 1, a classification system with descriptive categories and cognitive domains was developed by experts through a modified Delphi technique. In phase 2, 180 elderly patients seeking medical attention for cognitive complaints provided free reports of their cognitive difficulties and each complaint was recorded verbatim. Three observers were asked to classify each complaint into a descriptive category. Perceived cognitive function was further characterized using the Memory Complaint Questionnaire (MAC-Q). RESULTS The patients reported 493 spontaneous complaints, with a range of 1-6 complaints per patient and a mean of 2.7 (±1.3). The proportion of complaints that could be classified into a category by each of the three observers varied from 91.9% to 95.7%. Inter-observer agreement assessed using the κ statistic varied from 0.79 to 1 for descriptive categories and 0.83 to 0.97 for domains. Compared with the MAC-Q, spontaneously reported complaints provided complementary information by avoiding the cueing effect provoked by the questionnaire. The total number of complaints and their occurrences in specific domains were associated with important sociodemographic and clinical factors, indicating that their meaning and associated risks need to be further investigated. CONCLUSION The instrument developed in this study proved to be a practical tool for classifying the majority of spontaneously reported cognitive complaints with high reliability. Further studies are needed to investigate clinical usefulness of this approach.