Etelvina Santos

The Pietà study: epidemiological investigation on successful brain aging in Caeté (MG), Brazil. Methods and baseline cohort characteristics

OBJECTIVES To present the methods and baseline characteristics of the Pietà study, a population-based survey investigating successful brain aging in the oldest-old. METHOD The study was conducted in Caeté (MG), Brazil. In 2007, 1,251 individuals aged 75+ years were living in the city and were invited to participate. Participants responded to a general health questionnaire and were submitted to clinical, neurological, cognitive, psychiatric and functional evaluations. A subgroup was submitted to neuropsychological testing, blood tests and magnetic resonance of the skull. Individuals were classified as having cognitive impairment-no dementia, dementia, parkinsonism, psychiatric disorders or successful brain aging. RESULTS We evaluated 639 individuals (51.1% of the target population; 64% women), aged 81.4±5.2 years and with 2.7±2.6 years of schooling. Almost 30% of the elderly were illiterates and 82.1% belonged to middle/middle-low socioeconomic levels. Almost 50% were widows, but only 14.3% were living alone. CONCLUSION The Pietà cohort is representative of the oldest-old Brazilian population. We believe the results of the study may contribute to increase our knowledge about healthy and pathological brain aging in the oldest-old.

Dementia caregiver burden in a Brazilian sample: Association to neuropsychiatric symptoms

Taking care of elderly demented individuals, especially when they present behavioral changes, can be very exhaustive for both family and caregivers. Generally, this leads to changes in the family lifestyle, and the caregiver must deal with a range of problems. Information on this topic in Latin America, including Brazil, remains scarce. Objective To investigate the relationship between the presence of neuropsychiatric symptoms and the level of caregiver burden in a group of Brazilian elderly with dementia. Methods The Brazilian versions of the Zarit Caregiver Burden Interview (ZBI) and of the Neuropsychiatric Inventory (NPI) were administered to a total of 83 family-caregivers of patients with dementia followed at a university-affiliated outpatient clinic. Pearson’s correlations were calculated to measure the level of association between the scores on both instruments. Results Among the caregivers, 83.1% were women, and had a mean age of 55.6±12.8 years. The ZBI scores ranged from 3 to 79 (mean=31.4). Patients’ NPI scores ranged from 0 to 102 (mean=26.9), consistent with a significant degree of behavioral manifestations in most patients. A significant positive correlation was found between ZBI and NPI scores (r=0.402; p=0.000). Conclusion The presence and severity of behavioral manifestations assessed by the NPI were associated with a high level of caregiver burden in this sample of Brazilian elderly with dementia.

Brazilian caregiver version of the Apathy Scale

No Brazilian version of a specific scale for evaluating apathy in dementia is available. Objectives To introduce a translated version of the Apathy Scale (AS) for use with caregivers. Methods The instrument was formally translated and then administered to the caregivers of a small sample of dementia patients, in order to assess scale comprehensibility and make final adjustments. The scale was subsequently administered to the caregivers of a second, independent sample of Alzheimers disease (AD) patients. The content validity of the scale was tested by correlating the AS scores with the Neuropsychiatric Inventory (NPI) - apathy sub-score and Disability Assessment in Dementia (DAD) total scores. Results The first sample consisted of eleven subjects with dementia, most of whom had AD. The second sample comprised twenty patients with probable or possible AD (10 with mild dementia), a mean age of 84.1±5.8 years, and 2.2±1.6 years of schooling. The AS scores correlated with both NPI-apathy sub-score (r=0.756, p=0.001) and DAD total scores (r=-0.793, p=0.0005). Conclusions The final version had good comprehensibility and correlated strongly with standardized apathy and functional activities of daily living measures.

Prevalence of major psychiatric disorders in a cohort of oldest old in Brazil: The Pietà study

consensus discussion. Results: 639 individuals (55.3% of the total oldestold population) were fully evaluated, being 408 women (63.8%) and 231 men(36.2%),aged81.1 65.2years,withmeanschoolingof2.6 62.8years. Dementia was diagnosed in 176 subjects, (prevalence¼27.5%), while CIND was identified in 166 (prevalence¼26.0%). Among dementia patients, only 39 cases (6.1%) had a previous diagnosis of this condition. Patients with dementia were significantly older (p<0.0001) and less educated (p¼0.001). Prevalence of dementia was also higher in women, although the difference was not statistically significant (p¼0.06). CIND prevalence was similar in both genders. When compared with the cognitively healthy individuals (n¼227),CINDsubjectsweresignificantlyolder(p¼0.004),buthadasimilar schooling. A previous history of depression was more frequent among dementia (p¼0.002) and CIND (p¼0.007) patients. Conclusions: Prevalence of CIND and dementia was high in this oldest-old population, although dementia was highly under-diagnosed. Age and previous history of depression were associated with both diagnoses, while low education dementia was associated only with dementia.

Apathy Is not Associated with Performance in Brief Executive Tests in Patients with Mild Cognitive Impairment and Mild Alzheimers Disease

Neuropsychological correlates of apathy in Alzheimers disease (AD) may shed some light on the neurobiology of this behavioral disorder. Whereas previous research has suggested an association between apathy and executive functions in AD, amnestic mild cognitive impairment (aMCI) cohorts point to an association with memory tests. We aimed to further investigate this issue in a sample of low educated, hitherto unexposed to cholinesterase inhibitors, aMCI (n=26) and mild AD (n=28) patients using brief executive tests, namely the Executive Interview (EXIT-25) and the Frontal Assessment Battery (FAB). Patients and controls (n=33) were included from a community-based survey of successful brain aging in Brazilian elderly (75+ years), The Pietà Study. The participants were submitted to a comprehensively neuropsychological assessment and apathy evaluation through the Apathy Scale (AS).We found a strong correlation in AD group between AS scores and functional performance measured by the Disability Assessment in Dementia (rho =-0.7 ; p<0,001). No association was found between any executive test performance and apathy symptoms. Apathy symptoms were also associated with the performance in memory tests and in the attention subscale of the Mattis Dementia Rating Scale. These findings reinforce the functional effect of apathy even in the mildest stages along the AD cognitive impairment spectrum, and challenges previous assumptions regarding the association between apathy and classical executive functions.

Variables associated with cognitive impairment-no dementia in a low-educated cohort aged 75+ years: The Pietà study

Background: Older adults with memory-centered and informant-validated cognitive complaints (CC) in the absence of neuropsychological deficits or depression represent a potential at-risk group for progression to amnestic MCI and Alzheimer’s disease (AD). The goals of the present study were to evaluate 1) the rate of conversion of CC participants to MCI over two years and 2) potential antecedent markers associated with future progression to MCI, including baseline cognition, self and informant ratings, genetics, and atrophy on MRI. Amyloid and TSPO/microglial PET and fluid biomarkers were available for a subgroup. Methods: 42 CC participants with baseline and 2-year follow-up data were analyzed from an ongoing 2-site study of memory and aging (Dartmouth and Indiana University). The CognitiveComplaint Index [1]was used to quantitate self and informant ratings. CC participants were categorized as converters to MCI (CC-C) or stable (CC-S) based on clinical consensus. 44 cognitively normal controls (HC) were included for comparison. Baseline structural MRI scans were processed using voxel-based morphometry (VBM) and Freesurfer to extract grey matter density (GMD)andvolumetricmeasures from targeted regions of interest (ROIs). Demographics and medical history, APOE ε4 status, baseline cognitive performance, selfand informant-ratings of cognition, and neuroimaging ROI measures were compared between groupswith age, gender, education and intracranial volume (ICV) included as covariates where appropriate. Results: 10 of 42CC participants (23.8%) converted to early (5) or late (5)MCIwithin 2 years (annualized rate, 12%).At baseline, CC-Cdidnot show consistent differences in cognition from CC-S, except for lower Mattis Dementia Rating Scale total score. Higher self and especially informant-based cognitive complaints at baseline were associated with conversion. Converters compared to CC-S trended toward decreasedMRI volumes andGMDbut this did not reach significance due to insufficient power. Additional imaging and genetic pathway data are being evaluated. Conclusions: Euthymic older adults with elevated levels of cognitive complaints, particularly based on informant ratings, appear to be at-risk for conversion toMCI even in the context of generally normal neuropsychological performance. Additional studies in larger samples are warranted as this this may represent the earliest symptomatic stage of preclinical AD. [1] Saykin Neurology; 2006;67:834-842.

Successful brain aging in a cohort of oldest old in Brazil: The Pietà study

evaluation (delayed recall task, category fluency and clock drawing), the Geriatric Depression Scale, the Mini International Neuropsychiatric Interview and to physical and neurological examination. Individuals with suspected cognitive impairment and a subset of cognitively healthy individuals were also submitted to a comprehensive neuropsychological and functional evaluation. Dementia and CIND were diagnosed according to standard criteria, accounting for the educational level, after an extensive two-phase clinical consensus discussion. Results: 639 individuals (55.3% of the total oldestold population) were fully evaluated, being 408 women (63.8%) and 231 men (36.2%), aged 81.1 6 5.2 years, with mean schooling of 2.6 6 2.8 years. Dementia was diagnosed in 176 subjects, (prevalence1⁄427.5%), while CIND was identified in 166 (prevalence1⁄426.0%). Among dementia patients, only 39 cases (6.1%) had a previous diagnosis of this condition. Patients with dementia were significantly older (p<0.0001) and less educated (p1⁄40.001). Prevalence of dementia was also higher in women, although the difference was not statistically significant (p1⁄40.06). CIND prevalence was similar in both genders. When compared with the cognitively healthy individuals (n1⁄4227), CIND subjects were significantly older (p1⁄40.004), but had a similar schooling. A previous history of depression was more frequent among dementia (p1⁄40.002) and CIND (p1⁄40.007) patients. Conclusions: Prevalence of CIND and dementia was high in this oldest-old population, although dementia was highly under-diagnosed. Age and previous history of depression were associated with both diagnoses, while low education dementia was associated only with dementia.