Flavia Campora

Post-Mortem diagnosis of dementia by informant interview

The diagnosis of normal cognition or dementia in the Brazilian Brain Bank of the Aging Brain Study Group (BBBABSG) has relied on postmortem interview with an informant. Objectives To ascertain the sensitivity and specificity of postmortem diagnosis based on informant interview compared against the diagnosis established at a memory clinic. Methods A prospective study was conducted at the BBBABSG and at the Reference Center for Cognitive Disorders (RCCD), a specialized memory clinic of the Hospital das Clínicas, University of São Paulo Medical School. Control subjects and cognitively impaired subjects were referred from the Hospital das Clínicas to the RCCD where subjects and their informants were assessed. The same informant was then interviewed at the BBBABSG. Specialists’ panel consensus, in each group, determined the final diagnosis of the case, blind to other center’s diagnosis. Data was compared for frequency of diagnostic equivalence. For this study, the diagnosis established at the RCCD was accepted as the gold standard. Sensitivity and specificity were computed. Results Ninety individuals were included, 45 with dementia and 45 without dementia (26 cognitively normal and 19 cognitively impaired but non-demented). The informant interview at the BBBABSG had a sensitivity of 86.6% and specificity of 84.4% for the diagnosis of dementia, and a sensitivity of 65.3% and specificity of 93.7% for the diagnosis of normal cognition. Conclusions The informant interview used at the BBBABSG has a high specificity and sensitivity for the diagnosis of dementia as well as a high specificity for the diagnosis of normal cognition.

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.

Association between delirium superimposed on dementia and mortality in hospitalized older adults: A prospective cohort study

Background Hospitalized older adults with preexisting dementia have increased risk of having delirium, but little is known regarding the effect of delirium superimposed on dementia (DSD) on the outcomes of these patients. Our aim was to investigate the association between DSD and hospital mortality and 12-mo mortality in hospitalized older adults. Methods and findings This was a prospective cohort study completed in the geriatric ward of a university hospital in São Paulo, Brazil. We included 1,409 hospitalizations of acutely ill patients aged 60 y and over from January 2009 to June 2015. Main variables and measures included dementia and dementia severity (Informant Questionnaire on Cognitive Decline in the Elderly, Clinical Dementia Rating) and delirium (Confusion Assessment Method). Primary outcomes were time to death in the hospital and time to death in 12 mo (for the discharged sample). Comprehensive geriatric assessment was performed at admission, and additional clinical data were documented upon death or discharge. Cases were categorized into four groups (no delirium or dementia, dementia alone, delirium alone, and DSD). The no delirium/dementia group was defined as the referent category for comparisons, and multivariate analyses were performed using Cox proportional hazards models adjusted for possible confounders (sociodemographic information, medical history and physical examination data, functional and nutritional status, polypharmacy, and laboratory covariates). Overall, 61% were women and 39% had dementia, with a mean age of 80 y. Dementia alone was observed in 13% of the cases, with delirium alone in 21% and DSD in 26% of the cases. In-hospital mortality was 8% for patients without delirium or dementia, 12% for patients with dementia alone, 29% for patients with delirium alone, and 32% for DSD patients (Pearson Chi-square = 112, p < 0.001). DSD and delirium alone were independently associated with in-hospital mortality, with respective hazard ratios (HRs) of 2.14 (95% CI = 1.33–3.45, p = 0.002) and 2.72 (95% CI = 1.77–4.18, p < 0.001). Dementia alone did not have a significant statistical association with in-hospital mortality (HR = 1.69, 95% CI = 0.72–2.30, p = 0.385). Finally, while 24% of the patients died after discharge, 12-mo mortality was not associated with dementia or delirium in any of the diagnostic groups (DSD: HR = 1.15, 95% CI = 0.79–1.68, p = 0.463; delirium alone: HR = 1.05, 95% CI = 0.71–1.54, p = 0.810; dementia alone: HR = 1.19, 95% CI = 0.79–1.78, p = 0.399). Limitations to this study include not exploring the effects of the duration and severity of delirium on the outcomes. Conclusions DSD and delirium alone were independently associated with a worse prognosis in hospitalized older adults. Health care professionals should recognize the importance of delirium as a predictor of hospital mortality regardless of the coexistence with dementia.

Prognostic effects of delirium motor subtypes in hospitalized older adults: A prospective cohort study

Objectives To investigate the association between delirium motor subtypes and hospital mortality and 12-month mortality in hospitalized older adults. Design Prospective cohort study conducted from 2009 to 2015. Setting Geriatric ward of a university hospital in Sao Paulo, Brazil. Participants We included 1,409 consecutive admissions of acutely ill patients aged 60 years and over. We excluded admissions for end-of-life care, with missing data on the main variables, length of stay shorter than 48 hours, or when consent to participate was not given. Main outcomes and measures Delirium was detected using the Confusion Assessment Method and categorized in hypoactive, hyperactive, or mixed delirium. Primary outcomes were time to death in the hospital, and time to death in 12 months (for the discharged sample). Comprehensive geriatric assessment was performed at admission and included socio-demographic, clinical, functional, cognitive, and laboratory variables. Further clinical data were documented upon death or discharge. Multivariate analyses used Cox proportional hazards models adjusted for possible confounders. Results We included 1,409 admissions, with a mean age of 80 years. The proportion of in-hospital deaths was 19%, with a cumulative mortality of 38% in 12 months. Delirium occurred in 47% of the admissions. Hypoactive delirium was the predominant motor subtype (53%), followed by mixed delirium (30%) and hyperactive delirium (17%). Hospital mortality rates were respectively 33%, 34% and 15%. We verified that hypoactive and mixed delirium were independently associated with hospital mortality, with respective hazard ratios of 2.43 (95%CI = 1.64–3.59) and 2.31 (95%CI = 1.53–3.50). Delirium motor subtypes were not independently predictive of 12-month mortality. Conclusions One in three acutely ill hospitalized older adults who suffered hypoactive or mixed delirium died in the hospital. Clinicians should be aware that hypoactive symptoms of delirium, whether shown exclusively or in alternation with hyperactive symptoms, are indicative of a worse prognosis in this population.

Predictors of Enteral Tube Feeding in Hospitalized Older Adults

Background: Despite general recognition that enteral tube feeding (ETF) is frequently employed in long-term care facilities and patients with dementia, remarkably little research has determined which factors are associated with its use in acutely ill older adults. In this study, we aimed to investigate determinants of ETF introduction in hospitalized older adults. Methods: We examined a retrospective cohort of acutely ill patients, aged 60 years and older, admitted to a university hospital’s geriatric ward from 2014–2015, in São Paulo, Brazil. The main outcome was the introduction of ETF during hospitalization. Predictors of interest included age, sex, referring unit, comorbidity burden, functional status, malnutrition, depression, dementia severity, and delirium. Multivariate analysis was performed using backward stepwise logistic regression. Results: A total of 214 cases were included. Mean age was 81 years, and 63% were women. Malnutrition was detected in 47% of the cases, dementia in 46%, and delirium in 36%. ETF was initiated in 44 (21%) admissions. Independent predictors of ETF were delirium (odds ratio [OR], 4.83; 95% CI, 2.12–11.01; P < .001) and total functional dependency (OR, 8.95; 95% CI, 2.87–27.88; P < .001). Malnutrition was not independently associated with ETF. Conclusion: One in five acutely ill older adults used ETF while hospitalized. Delirium and functional dependency were independent predictors of its introduction. Risks and benefits of enteral nutrition in this particular context need to be further explored.

Avaliação breve de alfabetismo em saúde em português

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.

Evaluación breve de alfabetismo en salud en portugués

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.