Dionísio Azevedo

Estimate of Dementia Prevalence in a Community Sample from São Paulo, Brazil

Aims: To estimate dementia prevalence and describe the etiology of dementia in a community sample from the city of São Paulo, Brazil. Methods: A sample of subjects older than 60 years was screened for dementia in the first phase. During the second phase, the diagnostic workup included a structured interview, physical and neurological examination, laboratory exams, a brain scan, and DSM-IV criteria diagnosis. Results: Mean age was 71.5 years (n = 1,563) and 58.3% had up to 4 years of schooling (68.7% female). Dementia was diagnosed in 107 subjects with an observed prevalence of 6.8%. The estimate of dementia prevalence was 12.9%, considering design effect, nonresponse during the community phase, and positive and negative predictive values. Alzheimer’s disease was the most frequent cause of dementia (59.8%), followed by vascular dementia (15.9%). Older age and illiteracy were significantly associated with dementia. Conclusions: The estimate of dementia prevalence was higher than previously reported in Brazil, with Alzheimer’s disease and vascular dementia being the most frequent causes of dementia. Dementia prevalence in Brazil and in other Latin American countries should be addressed by additional studies to confirm these higher dementia rates which might have a sizable impact on countries’ health services.

Instrumentos combinados na avaliação de demência em idosos: resultados preliminares

ABSTRACT - Objective : To determine if a functional scale combined with a cognitive test would improve thediagnostic accuracy of dementia. Method : Thirty patients with mild to moderate dementia, diagnosed accordingto ICD-10 and DSM-III-R criteria, and 46 elderly controls, divided into three groups according to theirsocioeconomic status and educational level (high, medium and low) were investigated. The subjects wereassessed with the MMSE, and their informants were assessed with the scales IQCODE and B-ADL. Results : Onthe logistic regression, the MMSE isolated classified correctly 86.8% of patients and controls (80% sensitivityand 91.3% specificity). The combination MMSE + IQCODE classified correctly 92.1% of the subjects (83.3%sensitivity and 97.8% specificity), and the combination MMSE + B-ADL classified correctly 92.1% of subjects(86.7% sensitivity and 95.7% specificity). Conclusion : The results suggest that the combination of a cognitivetest with a functional scale can improve the detection of mild to moderate cases of dementia even on samplesof a very heterogeneous population regarding its socioeconomic status and educational level, as the Brazilian.KEY WORDS: dementia, diagnosis, cognitive test, functional scales.

The Bayer: Activities of Daily Living Scale (B-ADL) in the differentiation between mild to moderate dementia and normal aging

OBJECTIVES To investigate the applicability of the Bayer - Activities of Daily Living scale and its efficiency in differentiating individuals with mild to moderate dementia from normal elderly controls. METHOD We selected 33 patients with diagnosis of mild to severe dementia, according to ICD-10 criteria, and 59 controls. All the subjects were evaluated with the Mini-Mental State Examination and the Clinical Dementia Rating Scale and the Bayer - Activities of Daily Living scale was applied to informants. RESULTS The internal consistency of the Bayer - Activities of Daily Living was high (Cronbachs alpha = 0.981). Mean Mini-Mental State Examination and Bayer - Activities of Daily Living scores of demented patients and controls were significantly different (p < 0.001). Mean Mini-Mental State Examination and Bayer - Activities of Daily Living scores were significantly different between Clinical Dementia Rating Scale 0 (controls; n = 59) versus Clinical Dementia Rating Scale 1 (mild dementia; n = 15), Clinical Dementia Rating Scale 0 versus Clinical Dementia Rating Scale 2 (moderate dementia; n = 13), and for Clinical Dementia Rating Scale 1 versus Clinical Dementia Rating Scale 2 (p < 0.003). DISCUSSION The Bayer - Activities of Daily Living scale and Mini-Mental State Examination differentiated elderly controls from patients with mild or moderate dementia, and patients with mild dementia from those with moderate dementia. CONCLUSIONS The results suggest that the Bayer - Activities of Daily Living scale applied to an informant can help in the diagnosis and follow-up of Brazilian patients with mild to moderate dementia.

Prevalence of Cognitive and Functional Impairment in a Community Sample from São Paulo, Brazil

Aims: To present the prevalence of cognitive and functional impairment (CFI) in community-dwelling elderly subjects from the city of São Paulo. Methods: The population was aged 60 years and older (n = 1,563; 68.7% women and 31.3% men) and lived in different socioeconomic areas. The following instruments were administered to the elderly: the Mini Mental State Examination and the Fuld Object Memory Evaluation. The Informant Questionnaire on Cognitive Decline in the Elderly and the Bayer-Activities of Daily Living scale were administered to an informant. Results: The prevalence of CFI (n = 250) was 16% (95% confidence interval, CI: 14.2–17.8%) or 15.8% (95% CI: 13.8–17.8%). In regression models, the increase in the odds ratio (OR) of CFI was associated with age, for elderly individuals aged 75 years or older, illiterates or with 1–4 years of schooling, and with a history of stroke and diabetes mellitus. On the other hand, for subjects with a tumor history, the OR of CFI was significantly reduced. Conclusion: CFI was high and increased at older ages and in subjects with low education. Potentially changeable factors were identified (stroke and diabetes), and the possible ‘protective effect’ of tumor/cancer against CFI should be further investigated by longitudinal studies.

Performance of Brazilian long and short IQCODE on the screening of dementia in elderly people with low education.

BACKGROUND Dementia screening in elderly people with low education can be difficult to implement. For these subjects, informant reports using the long (L) (26 items) and short (C) (16 items) versions of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) can be useful. The objective of the present study was to investigate the performance of Brazilian versions of the IQCODE L, S and a new short version (SBr) (15 items) in comparison with the Mini-mental State Examination (MMSE) for dementia screening in elderly people with low education. METHODS Thirty-four patients with mild to moderate dementia, diagnosed according to ICD-10 criteria, and 57 controls were evaluated and divided into three groups based on their socioeconomic status and level of education. Patients were evaluated using the MMSE and the informants were interviewed using the IQCODE by interviewers blind to the clinical diagnosis. RESULTS Education was correlated with MMSE results (r = 0.280, p = 0.031), but not with the versions of the IQCODE. The performance of the instruments, evaluated by the ROC curves, was very similar, with good internal consistency (Cronbachs alpha = 0.97). MMSE correctly classified 85.7% of the subjects while the three IQCODE versions (L, S and SBr) correctly classified 91.2% of the subjects. CONCLUSIONS The long, short and the new short Brazilian IQCODE versions can be useful as a screening tool for mild and moderate patients with dementia in Brazil. The IQCODE is not biased by schooling, and it seems to be an adequate instrument for samples with low levels of education.

Combined instruments for the screening of dementia in older people with low Education

OBJECTIVE To determine which combination of cognitive tests and informant reports can improve the diagnostic accuracy of dementia screening in low educated older people. METHOD Patients with mild to moderate dementia (n=34) according to ICD-10 and DSM-III-R criteria and 59 older controls were assessed with the Mini-Mental State Examination (MMSE) and the Fuld Object Memory Evaluation (FOME). Informants were assessed using the Informant Questionnaire on Cognitive Decline in the Elderly and the Bayer-Activities of Daily Living Scale. RESULTS The 4 instruments combined with the mixed rule correctly classified 100% and the logistic regression (weighted sum) classified 95.7% of subjects. The weighted sum had a significantly larger ROC area compared to MMSE (p=0.008) and FOME (p=0.023). The specificity of the tested combinations was superior to the MMSE alone (p=0.002). CONCLUSIONS Cognitive tests combined with informant reports can improve the screening of mild to moderate dementia in low educated older people.

Volumetric evidence of a left laterality effect in epileptic psychosis

We investigated anatomic alterations and lateralization effect in the mesial temporal lobe structures (amygdala and hippocampus) in epileptic psychosis MRI volumetric measurements. Patients with epileptic psychosis and normal controls were studied. Left hippocampus values were significantly smaller for patients (P<0.001). Hippocampal ratio was significantly greater for patients (P<0.01). Group (patients x normal) was the only factor explaining the statistically significant variation of left hippocampus and hippocampal ratio (P<0.001 and P<0.05). Twenty patients had hippocampal atrophy (4 on the right side, 15 on the left side, and 1 bilateral) associated with mesial temporal sclerosis. These results confirm the existence of anatomic alterations and a left laterality effect in the mesial temporal lobe structures of patients with epileptic psychosis.

Confiabilidade de medidas volumétricas de estruturas temporais mesiais

MOTIVO DO ESTUDO: O desenvolvimento de tecnicas confiaveis para a realizacao de medidas volumetricas de estruturas temporais mesiais (amigdala, hipocampo e giro para-hipocampal) em exames de ressonância magnetica (RM) pode fornecer dados para o estudo de varios transtornos neuropsiquiatricos, particularmente epilepsia do lobo temporal, doenca de Alzheimer e esquizofrenia. METODO: Investigamos essas tecnicas realizando estudo de confiabilidade intra-observador (IO) e entre-observador (EO), envolvendo controles normais, pacientes com epilepsia e pacientes com doenca de Alzheimer, atraves do coeficiente de correlacao intra-classe (CCI). RESULTADOS: A confiabilidade IO para as estruturas analisadas variou de 0,93 a 0,99 (p<0,001). A confiabilidade EO variou de 0,70 a 0,95 (p £ 0,001). CONCLUSAO: Os resultados sugerem que a tecnica de morfometria por RM de regioes temporais mesiais constitui instrumento confiavel, que pode auxiliar na investigacao diagnostica de transtornos neuropsiquiatricos, desde que utilizado por clinicos e pesquisadores adequadamente treinados.

Proton spectroscopy in Alzheimer's disease and cognitive impairment no dementia: a community-based study.

Objective: To describe the findings of proton magnetic resonance spectroscopy (1H-MRS) in Alzheimer’s disease (AD) and cognitive impairment, no dementia (CIND) elderly from a community-based sample. Methods: Thirteen patients with AD, 12 with CIND and 15 normal individuals were evaluated. The 1H-MRS was performed in the right temporal, left parietal and medial occipital regions studying the metabolites N-acetylaspartate (NAA), creatine (Cr), choline (Cho) and myoinositol (mI). The clinical diagnosis was based on standardized cognitive tests – MMSE and CAMDEX – and the results correlated with the 1H-MRS. Results: Parietal Cho was higher in control individuals and lower in CIND subjects. AD and control groups were better identified by temporal and parietal mI combined with the temporal NAA/Cr ratio. CIND was better identified by parietal Cho. Conclusion: The 1H-MRS findings confirmed the hypothesis that metabolic alterations are present since the first symptoms of cognitively impaired elderly subjects. These results suggest that combining MRS from different cerebral regions can help in the diagnosis and follow-up of community elderly individuals with memory complaints and AD.

Clinical aspects of epileptic psychosis in Brazil

We investigated a series of patients with epileptic psychosis in Brazil and compared our findings with those of other authors. We evaluated 38 outpatients with epileptic psychosis with a semistructured clinical interview, Annett inventory for hand dominance, international classifications for seizures and syndromes, and DSM-IV for psychosis diagnoses. We studied course and outcome for epilepsy and psychosis. Gender distribution was approximately even. Epilepsy and psychiatric disorders among relatives and early CNS insults in personal histories were frequent findings. Mean age of epilepsy onset was 9.3 years. Epilepsy started before psychosis in all cases, and evolved to clinical refractoriness. There was a predominance of temporal lobe epilepsy. Mean age of psychosis onset was 27.4 years, after a mean duration of epilepsy of 18.1 years, with predominance of schizophrenic presentations with interictal onset, frequent psychiatric admissions, suicide attempts, and postpsychosis functional decline. Tumors or lesions of an embryologic nature were uncommon, but mesial temporal sclerosis was frequent.