José Roberto Wajman

Comparison between neuropsychological evaluation instruments for severe dementia

OBJECTIVE To study the correlation between two tools for cognitive evaluation, Mini-Mental State Examination-severe (MMSE-s) and Severe Impairment Battery (SIB), and the Bristol Daily Activities Functional Scale. METHOD 50 patients from the Behavioral Neurology Section--EPM-UNIFESP--were evaluated. Mean age was 76.8+/-7.9 (range 57 to 95); 32% were males; mean education was 5.0+/-2.3 years (range 4 to 15); mean disease duration was 3.9+/-1.5 years (range 2 to 10). RESULTS Preliminary results in a small sample drawn from the study group do indicate a difference between the three cognitive scales. SIB and MMSE-s had a better correlation with functional score than MMSE, and MMSE-s had a correlation slightly better than SIB. CONCLUSION These data indicate that it is possible to follow dementia patients up to severe stage as long as adequate instruments are used, and that there may be differences between scales with regard to sensitivity.

Educational bias in the assessment of severe dementia: Brazilian cutoffs for severe Mini-Mental State Examination

UNLABELLED Cognitive assessment in advanced stages of Alzheimers disease (AD) is limited by the imprecision of most instruments. OBJECTIVE To determine objective cognitive responses in moderate and severe AD patients by way of the Severe Mini-Mental State Examination (SMMSE), and to correlate performances with Mini-Mental State Examination (MMSE) scores. METHOD Consecutive outpatients in moderate and severe stages of AD (Clinical Dementia Rating 2.0 or 3.0) were evaluated and compared according to MMSE and SMMSE scores. RESULTS Overall 400 patients were included, 67.5% females, mean age 76.6±6.7 years-old. There was no significant impact of age or gender over MMSE or SMMSE scores. Mean schooling was 4.4±2.5 years, impacting SMMSE scores (p=0.008). Scores on MMSE and SMMSE were significantly correlated (F-ratio=690.6325, p<0.0001). CONCLUSION The SMMSE is influenced by schooling, but not by age or gender, and is an accurate test for assessment of moderate and severe AD.

Correlations among cognitive and behavioural assessments in patients with dementia due to Alzheimer's disease.

AIMS Primarily, we sought to verify correlations among assessments for cognition, behaviour and functional independence in a sample of patients with dementia due to Alzheimers disease (AD). Secondarily, impacts of education, APOE haplotypes, length of dementia, age and alcohol use over the neuropsychiatric assessment were estimated. METHODS Patients with AD were assessed for demographic features, neuropsychiatric symptoms, cognitive test scores, functional impairment, caregiver burden and APOE haplotypes. Statistical comparisons were undertaken by way of Kruskal-Wallis test, linear regressions and Spearman correlations, significance at ρ < 0.05. RESULTS A total of 217 patients were included. Mean schooling was 4.21 ± 3.7 years, with significant impacts over cognitive tests. Mean age at examination was 78 ± 6.19 years-old, significantly influencing instrumental functionality. The mean length of the dementia syndrome was 5.4 ± 2.9 years, significantly impacting cognitive decline and functionality. Apathy was the most common behavioural symptom, negatively correlated with anxiety and delusions, and positively correlated with lifetime alcohol load. Patients with previous smoking or drinking habits were more likely to continue smoking or drinking later in life. APOE4+ haplotypes led to earlier dementia onset and significantly lower caregiver burden in mild dementia stages. CONCLUSIONS Most correlations among test results were highly significant, confirming that cognition, behaviour and functionality are usually interrelated in all stages of AD. Caregiver burden was correlated with behaviour, but not with cognition, and was lower for patients with APOE4+ haplotypes in mild dementia stages. Education is a major impact factor for cognitive performance.

Intellectual demand and formal education as cognitive protection factors in Alzheimer’s disease

To investigate the possible association between educational level and previous professional occupation, and objective cognitive and functional evaluation in a sample of elderly patients with Alzheimer’s disease. Methods Through retrospective analysis of medical files, 174 patients with probable Alzheimer disease were randomly selected, classified and submitted to analysis according to previous professional occupation and years of formal education. Results Subjects with lower education and less intellectually-demanding occupations performed worse than higher educated subjects in all cognitive subtests and on the functional scale. Conclusions Results indicate that not only the total years of education, but also professional occupation has an impact on cognition and functioning in accordance with the hypothesis of cognitive reserve. Our findings confirmed this hypothesis, where subjects with higher education/ higher intellectual demand manifested first symptoms later than low education/ low intellectual demand subjects, with the latter group also exhibiting faster disease progression.

Is there correlation between cognition and functionality in severe dementia? The value of a performance-based ecological assessment for Alzheimer’s disease

OBJECTIVE Besides significant cognitive decline, patients in later stages of Alzheimers disease (AD) also present global functional impairment, usually reported by their caregivers. This study searched for preserved activities of daily living by investigating correlations among specific instruments for severe dementia with a performance-based functional scale. METHOD A sample of 95 moderate to severe AD patients and their caregivers underwent a neuropsychological battery consisting of screening tools, the Functional Assessment Staging Test (FAST), the Severe Mini-Mental State Examination (MMSEsev) and a performance-based ecological scale, the Performance Test of Activities of Daily Living (PADL). RESULTS Consistent findings emerged from the comparisons among tests. PADL showed significant statistical correlation with MMSEsev (ρ<0.001), according to FAST subdivisions. CONCLUSION Upon suspicion of unreliable caregiver reports, ecological scales may be useful for disease staging. Variable degrees of functionality and cognition may be present even in later stages of AD, requiring proper assessment.

Correlation and adaptation among functional and cognitive instruments for staging and monitoring Alzheimer?s disease in advanced stages

Contexto : Apesar de a doenca de Alzheimer (DA) ser a forma de demencia mais prevalente, pouco se sabe sobre aspectos cognitivos e funcionais em suas fases avancadas. Objetivo: Foi objetivo deste trabalho a adaptacao e correlacao entre instrumentos especificos para a DA em fases avancadas no que diz respeito a sua cognicao objetivamente ponderada, alem da comparacao entre aspectos da capacidade funcional estatica e ecologica. Metodos : Noventa e cinco pacientes (33 homens e 62 mulheres) com DA moderada, moderadamente grave e grave foram submetidos as escalas CDR (Clinical for Dementia Rating), FAST (Functional Assessment Scale), MEEM (Mini-Mental State Examination), MMSEsev (Severe Mini-Mental State Examination), SIB-8 (Severe Impairment Battery) e TSI (Test for Severe Impairment) para comparacao com uma escala ecologica padrao-ouro, a PADL (Performance Activities of Daily Living). Resultados : As evidencias encontradas sugerem uma correlacao linear crescente e estatisticamente significativa entre a escala funcional ecologica e os testes cognitivos conforme a estratificacao das fases da DA uma vez ponderadas pela escala funcional estatica. Conclusao : Os resultados indicam que, para pacientes em fases avancadas da DA, testes cognitivos apropriados e escalas funcionais baseadas no desempenho sao uteis na avaliacao mais acurada do estadiamento da doenca e acompanhamento de sua progressao.

Caregiver awareness of cerebrovascular risk of patients with dementia due to Alzheimer's disease in São Paulo, Brazil

Background Proper control of cerebrovascular risk is essential to prevent cognitive change in dementia due to Alzheimer’s disease (AD). Objective To investigate whether caregiver awareness to control cerebrovascular risk impacts the lifestyles of patients with AD. Methods Consecutive outpatients with AD were assessed for demographic features, Clinical Dementia Rating scores, cerebrovascular risk, pharmacotherapy, dietary therapy and practice of physical activities. Patients and caregivers were inquired on awareness of the importance of measures to control cerebrovascular risk. Chi-square test was employed for statistics, significance at ρ < 0.05. Results A total of 217 patients were included; whereas 149 caregivers (68.7%) were aware of the need to control cerebrovascular risk, only 11 patients (5.1%) simultaneously practiced physical activities and received pharmacological treatment and dietary therapy. Patients with hypertension and diabetes mellitus were more likely to receive dietary therapy (ρ = 0.007). Male patients were more engaged in physical activities (ρ = 0.018). Patients in earlier AD stages exercised (ρ = 0.0003) and received pharmacological treatment more often (ρ = 0.0072). Caregiver awareness of the need to control cerebrovascular risk was higher when patients had hypertension (ρ = 0.024) and/or hypercholesterolemia (ρ = 0.006), and influenced adherence to dietary therapy (ρ = 0.002) and to pharmacological treatment (ρ = 0.001). Discussion Caregiver awareness of the need to control cerebrovascular risk has positive impacts for patients with AD.

Brief cognitive assessment of Alzheimer's disease in advanced stages: Proposal for a Brazilian version of the Short Battery for Severe Impairment (SIB-8)

The measurement of cognitive abilities of patients with severe dementia can serve a wide range of methodological and clinical needs. OBJECTIVE To validate a proposed severe impairment battery SIB-8 for a Brazilian population sample as part of the neuropsychological assessment of patients with Alzheimers disease (AD) in advanced stages. METHODS After a systematic process of translation and back-translation, the SIB-8 was applied to 95 patients with AD at different stages; moderate, moderately severe and severe according to FAST subdivisions (5, 6 and 7), with scores on the Mini-Mental State Examination (MMSE) of between 5 and 15 and followed by the Division of Behavioral Neurology and the Center for Aging Brain of the Federal University of São Paulo - UNIFESP. RESULTS Inferential data revealed that the SIB-8 instrument behaved differently at each stage of the disease with a statistical value of sensitivity p<0.001, gradually reflecting the expected course of the dementia, inherent with the decline of cognitive functions. CONCLUSION Findings indicated that the SIB-8 is a useful tool for the evaluation and prospective comparison of AD patients in advanced stages, retaining its original characteristics in our population.

Brief screening for mild cognitive impairment: initial validation of the Montreal cognitive assessment (MoCA) in Brazilian elderly

were analyzed. Results: A 3 (group) x 2 (trial) analysis of variance (ANOVA), with repeated measures on the last factor, was conducted on the semantic clustering scores. The significant main effects of group [F(2,138)1⁄431.06, p < 0.01] and trial [F(1, 138)1⁄454.76, p < 0.01] were modified by a significant interaction [F(2, 138)1⁄416.60, p < 0.01]; clustering increased from learning to the long delay in healthy controls [t(52)1⁄4 8.00, p < 0.01] and to a lesser degree in MCI [t(55)1⁄43.54, p < 0.01], but not inAD [t(31)1⁄41.54, p> 0.05]. For the recall data, a similar analysis found significant main effects of group [F(2,138)1⁄488.47, p < 0.01] and trial [F(1, 138)1⁄4196.34, p< 0.01] that were modified by a significant interaction [F(2, 138)1⁄412.13, p < 0.01]; still, all three groups showed better trial 5 performance than delayed free recall (all t’s > 6.13, all p’s < 0.01). Conclusions: These results indicate that healthy controls exhibit increased strategy use even after information is already learned. Individuals with MCI show this increase in strategy use, but to a lesser degree, while persons with AD show no change in clustering. These findings were not mirrored by the recall data, in which all groups showed declines in performance from the last learning trial to delayed free recall. Our findings suggest that changes in strategy use are reflective of early cognitive difficulties in MCI.

Lifestyle patterns as a modifiable risk factor for late-life cognitive decline: a narrative review regarding dementia prevention

BACKGROUND Dementias due to neurodegenerative disorders and more specifically, Alzheimers disease (AD) are the most frequent of all diseases within the industrialized world. Besides this alarming fact, it is noted too that almost three-quarter of people with AD reside in low or middle- income nations. In recent years, cognitive and behavioral neuroscientists have focused on a possible correlation between environmental agents and genetic risk factors for these dementias. METHODS In this narrative review, a close review of Medical Literature Analysis and Retrieval System was conducted. The authors aimed at analyzing possible interactions between lifestyle patterns and major risk factors responsible for cognitive decline and dementia, considering that the prevention or treatment of midlife modifiable risks may possibly reduce population-wide late-life pathological neurodegeneration. RESULTS This review focuses on modifiable risk factors for late-life cognitive decline. A growing number of studies have indicated that the impact of genetics and epigenetic factors on dementia risk is dependent on different lifestyle factors, ranging from leisure activities and nutritional habits, through to social interaction and toxic exposure. CONCLUSION Despite all evidence regarding modifiable risk factors possibly reducing the risk of developing dementia in later life, many unanswered questions remain regarding the direct influence of these variables in later life. People who regularly and actively participate in different lifelong activities (social, cultural and intellectual) do tend to perform better on formal cognitive tests, experience fewer cognitive complaints, and are less likely to develop neurodegenerative disorders.