Fernando Vieira Pereira

Use of the Gait Deviation Index and spatiotemporal variables for the assessment of dual task interference paradigm

Three-dimensional gait analysis (3DGA) is an important element in the quantitative evaluation of gait in subjects with Parkinsons disease (PD). Indexes, such as the Gait Deviation Index (GDI), have recently been proposed as a summary measure of gait. The aim of the present study was to investigate the effectiveness of the GDI and spatiotemporal variables in the quantification of changes in gait during a dual-task (DT) exercise. Fourteen patients with idiopathic PD and nine healthy subjects (CG) participated in the study. All subjects walked under two conditions: free walking and DT walking. The GDI was computed from the 3DGA data. The results show gait impairment during DT, a significant difference between groups regarding GDI and an interaction effect involving the group, side and task factors. The CG and PDG were different independent of interference and side, but interference was only different for the PDG group. The results also demonstrate that the GDI should be an appropriate outcome measure for the evaluation of the effects of DT on patients with Parkinsons disease.

Effects of APOE haplotypes and measures of cardiovascular risk over gender-dependent cognitive and functional changes in one year in Alzheimer's disease

ABSTRACT Background: Illiteracy, high cerebrovascular risk and copies of APOE-ϵ4 are risk factors for Alzheimers disease dementia (AD). We aimed to investigate the impacts of gender, education, coronary heart disease (CHD) risk and creatinine clearance variations, body mass index (BMI) and APOE haplotypes over the rates of cognitive and functional decline of AD in one year. Methods: Consecutive outpatients with late-onset AD were assessed for gender, schooling, BMI and APOE haplotypes, variations in one year of creatinine clearance and Framingham projections of the 10-year absolute CHD risk, and prospective scores of the Mini-Mental State Examination (MMSE), the Clinical Dementia Rating Sum-of-Boxes (CDR-SOB), the Index of Independence in Activities of Daily Living (ADL) and Lawtons Scale for Instrumental Activities of Daily Living (IADL). Results: For 191 patients, mean age at AD onset was 73.26 ± 6.4 years-old, earlier for APOE-ϵ4/ϵ4 carriers (p = 0.0039). For women, higher BMI led to improvements in CDR-SOB (β = −0.091; p = 0.037) and MMSE (β = 0.126; p = 0.017) scores, while increased creatinine clearance was associated with improvements in ADL (β = 0.028; p = 0.012) and MMSE (β = 0.043; p = 0.039) scores and higher schooling led to faster worsening of IADL (β = −0.195; p = 0.022) scores. No variables impacted cognitive or functional decline for men, whereas copies of APOE-ϵ4 and the CHD risk had no significant effects whatsoever. Conclusions: Higher BMI and creatinine clearance are protective regarding cognitive and functional decline for women, whereas higher cognitive reserve may lead to faster decline in instrumental functionality. APOE haplotypes affected the age at AD onset, but not cognitive or functional decline.

CASE REPORT: FOREIGN ACCENT—A PRODOMAL STATE OF PRIMARY PROGRESSIVE APRAXIA OF SPEECH

to test the null hypothesis of no mean difference between delayed recall memory T-scores and language and executive function, respectively. Results: This pre-dialysis sample included 27 adults with a mean age of 66, a mean education of 13 years, and a mean estimated glomerular filtration rate (eGFR, in ml/min/1.73 m) of 13; the average length of time between the last study visit and participant report of dialysis initiation was 6 months. Delayed recall memory performance was the only measure, on average, which fell in the impaired range (T < 40) and demonstrated the lowest performance (T1⁄4 37.9) compared to both language (T 1⁄4 43.7; p 1⁄4 .03) and executive function (T 1⁄4 43.2; p 1⁄4 .05). Conclusions: Delayed recall memory performance may be preferentially reduced in advanced CKD patients prior to the initiation of HD. Future studies will investigate the pattern of pre-dialysis cognitive performance in a larger sample, further characterize the course of memory changes throughout HD, and determine whether impairment in this domain prior to HD suggests an irreversible neurodegenerative process that may not improve with HD treatment.

Language Rehabilitation in Alzheimer's Disease-Verbal Fluency Clusters

Verbal Fluency (VF) is a neuropsychological tool in which the participant is asked to produce as many items (animals, fruits, vegetables and others) as quickly as possible, in 60 secs. In the present study, semantic verbal fluency animals (VFa) and fruits (VFf) were compared using clustering strategies in Mild Alzheimer Disease (MAD) subjects (100) and controls (CG) subjects (201). Results demonstrated that spoken clustering items on VFa were directed by semantic similarities in CG. On the other hand, VFf spontaneously generated phonological clusters neglecting semantic similarities. For VFa CG had the search mode component of executive function only under the premise of semantic features, leaving articulatory and phonological aside. MAD group had the search mode component under the premise of phonological features or none. Language rehabilitation in MAD should start early, considering articulatory and semantic approach to achieve greater reliability of efficacy.

Verbal Fluency Fruits as a Predictor of Alzheimer's Disease Progression in Brazilian Portuguese Speakers

Objective: Verbal Fluencies (VF) animals (VFa) and VF fruits (VFf) have previously been described to be similarly effective in discriminating normal participants from patients with Alzheimer disease (AD). Both tasks were less accurate in discriminating AD-stages for unknown reasons. Based on semantic clustering scores in VFa, a literacy depending pattern has been revealed across cultures; however, no previous analysis has been performed for VFf. Methods: Three-hundred-fourteen native Brazilian Portuguese speakers were divided in four groups: a Control Group (CG) and Mild Cognitive Impairment (MCI), Mild Alzheimer’s Disease (MAD) and Moderate Alzheimer’s Disease (ModAD) groups. A quantitative (total score - TE) and a qualitative (clusters – Cf) analysis were conducted for VFf and were compared to other cognitive tasks. As no semantic setting was found, a non-arbitrary classification of fruits based on Sub Categorical items (Cf), according to the articulatory point of Brazilian Portuguese was performed. The words were grouped as follows: 1) bilabial, 2) velars, 3) open vowels, 4) closed vowels, 5) lateral dental/ alveolar, 6) dental /alveolar, and 7) labio-dentals. Clustering strategies (Cf) in the AD Groups differed from those of the CG. Cf revealed differences beyond groups depending on which articulatory point was emitted. Results: MCI had a 73% lower chance of attaining an NV than did the CG and with AD groups presented odds ratios of using the Cf /k/, /g/ velars feature 85% lower than those of the CG. Participants who used Cf bilabial had 2.04 times higher VFTE scores than those who did not. Younger subjects had a higher probability to perform better on the task. Participants with >9 years of education had a higher probability of higher performance with respect to the VFf TS. Conclusion: Articulatory deterioration occurred in AD since the early stages. VFf seems to be a suitable task for MCI evaluation.

Balance impairment does not necessarily coexist with gait apraxia in mild and moderate Alzheimer’s disease

OBJECTIVES To assess correlations among gait apraxia, balance impairment and cognitive performance in mild (AD1, n = 30) and moderate (AD2, n = 30) AD. METHOD The following evaluations were undertaken: gait apraxia (Assessment Walking Skills); balance performance (Berg Balance Scale); Clinical Dementia Rating and Mini-mental State Examination (MMSE). RESULTS While disregarding AD subgroups, Berg Balance Scale and the MMSE correlated significantly with Assessment Walking Skills and 23% of all subjects scored below its cut-off. After stratification, Berg Balance Scale correlated significantly with Assessment Walking Skills in both AD subgroups, and with the MMSE only in AD1. CONCLUSIONS Balance impairment does not necessarily coexist with gait apraxia. Gait apraxia is more prevalent in moderate AD when compared with mild AD.

Comprometimento do equilíbrio e apraxia da marcha não necessariamente coexistem na doença de Alzheimer leve e moderada

Apraxia da marcha e desequilibrio sao condicoes subinvestigadas na doenca de Alzheimer (DA) leve e moderada. Objetivo Verificar a correlacao da apraxia da marcha com desequilibrio e cognicao em 30 idosos com DA leve (DA1) e 30 idosos com DA moderada (DA2). Metodo Foram feitas as seguintes avaliacoes: apraxia da marcha (Assessment Walking Skills); equilibrio (Berg Balance Scale); Clinical Dementia Rating e Mini-exame do estado mental – MEEM. Resultados Desconsiderando-se os grupos, Berg Balance Scale e MEEM correlacionaram-se significativamente com a Assessment Walking Skills, enquanto 23% dos participantes pontuaram abaixo da note de corte da mesma. Considerando-se os grupos, Berg Balance Scale correlacionou-se significativamente com a Assessment Walking Skills em ambos os grupos, embora o MEEM o tenha feito apenas em DA1. Conclusoes Desequilibrio e apraxia da marcha nao necessariamente coexistem com apraxia da marcha. Prevalencia de apraxia da marcha foi maior na DA moderada do que na DA leve.

Severe Dementia: A Protocol for Clinical Assessment

Background: Severe dementia (SD) is relatively neglected, and its prevalence is unclear, but it is estimated that one-third of dementia patients are in the severe stages. There is a lack of assessment tools for cognition with standardized neuropsychological tests and patients are labelled “untestable”. Behavioral symptoms are responsible for most distress that both sufferers and caregivers experience and decline in functional autonomy is a major component. Our aim is to present a pilot study of a protocol to evaluate cognition, behavior and functionality in patients with SD. Methods: 30 subjects with SD were assessed in one year (2010). SD was defined based on scores on global rating scales, observation of subjects’ residual abilities and interview with the patient’s caregiver. According with the literature, we defined SD as a score of 3 or higher in the Clinical Dementia Rating (CDR); or categories 6a to 7f in the Functional Assessment Staging Test (FAST); or a score of 6 or 7 in the Global Deterioration Scale (GDS). The protocol we applied includes the Mini-Mental State Examination (MMSE) and Severe Mini-Mental State Examination (SMMSE) to evaluate cognitive functions; CDR and FASTas two different staging systems; Katz scale for functional assessment; Neuropsychiatric Inventory (NPI) for behavior. A nutritional evaluation was also applied; the Functional Outcome Questionnaire for Aphasia (FOQ-A) and a Brazilian version of the Southampton Assessment of Mobility (SAM-BR). Our intention with this study is to evaluate the performance in different types of dementia and make correlations to determine the best tools for followup. Results: Our results showed that most of patients were AD’s women with apathy or agitation/aggression as more frequently behavior disturbs. SMMSE was better than MMSE to evaluate cognition in this population. Conclusions: In severe cognitive impairment, differential diagnosis is often difficult. A complete multidisciplinary group is essential to make it possible. Without a good multidisciplinary group and a comprehensive non-pharmacological intervention it is not possible to treat patients in this stage. With our extend protocol we expect to study all these functions and make a correct disease and problems diagnosis to improve treatment and follow-up.