Juliana Santos Varela

The Mini Mental State Examination : review of cutoff points adjusted for schooling in a large Southern Brazilian sample

The increase in life expectancy can influence the prevalence of dementias in the population. Instruments that evaluate cognitive functions such as the Mini Mental State Examination (MMSE) are necessary for the investigation of dementia. The supposition that patient score on the MMSE can be influenced by academic level points to the need for establishing cut-off values that take into account educational level. The aim of this study was to review MMSE cut-off values adjusted for schooling in a large southern Brazilian sample. Method Demographic data and MMSE scores of 968 subjects, of which 162 were dementia patients and 806 healthy participants, were analyzed. The sample was grouped according to education. The cut-off values were established by ROC Curve analysis. Results The total sample mean age was 70.6±7.3 years, and the mean years of education was 7.2±5.3. The cut-off score of 23 points (sensitivity=86%, specificity=83%) was observed as the optimal level to detect dementia on the MMSE instrument for the overall sample. Regarding level of schooling, the cut-off values were: 21 for the illiterate group (sensitivity=93%, specificity=82%), 22 for the low education group (sensitivity=87%, specificity=82%), 23 for the middle education group (sensitivity=86%, specificity=87%) and 24 for the high education group (sensitivity=81%, specificity=87%). Conclusions The cut-off values revealed by this analysis, and adjusted for level of schooling, can improve the clinical evaluation of cognitive deficits.

Comparison of the Mini Mental State Examination and depressive symptoms between high cardiovascular risk and healthy community elderly groups

The aging of the population is a universal phenomenon with direct consequences upon the public health system. One of the main repercussions of the growth in this sector of the population is the increased prevalence of disorders such as dementia and depression which are very frequent among the elderly. The relationship between cardiovascular risk factors, dementia and depression have been addressed in many recent investigations. Objectives To evaluate the relationship of cognitive performance and depressive symptoms with cardiovascular risk in the elderly. Methods 94 high cardiovascular risk elderly patients and 160 healthy community elderly were evaluated cross-sectionally. The Mini Mental State Examination (MMSE) and the Geriatric Depression Scale (GDS-15) were used as the main measures. The cutoff for presence of depression was 6 on the GDS. Results The high cardiovascular risk elderly group showed significantly lower scores on the MMSE (p<0.001) and was significantly associated to depression (p<0.001), independently of education. The logistic regression analysis for depression as the dependent variable, age and group (healthy community or high cardiovascular risk elderly) were kept in the final equation. Higher age (Odds Ratio=0.92; 95% CI 0.86–0.98) and high cardiovascular risk elderly (OR=2.99; 95% CI 1.36–6.59) were associated to depression. Conclusions The present findings corroborate the different cognitive performance of elderly with high cardiovascular risk factors and the association of depressive symptoms with this group.

The Complex Role of Having Confidant on the Development of Alzheimer's Disease in a Community-Based Cohort of Older People in Brazil

Background: Social interaction is a lifestyle factor associated with a decreased risk of dementia in several studies. However, specific aspects of these social factors influencing dementia are unknown. This study aimed at evaluating the role of the distinct aspects of social support on the incidence of dementia in a community-based cohort of older people in Brazil. Methods: A total of 345 healthy and independent elderly subjects living in the community were followed by 12 years. Incident cases of dementia and probable Alzheimers disease were defined by DSM-IV criteria and NINCDS-ADRDA criteria, respectively. Social variables evaluated were marital status, living arrangement, living children, living sibling, confidant and attending recreational groups. Sex, age, education, Mini-Mental State Examination (MMSE) score, depressive symptoms and family income were entered as co-variates in a Cox proportional hazard model. Results: The absence of confidant was the only social variable associated to higher risk of developing dementia (HR = 5.31; p < 0.001), even after adjustment for age (HR = 1.08; p = 0.048) and baseline MMSE score (HR = 0.79; p = 0.002). Conclusions: Our data suggest that to have a confidant could be an important lifestyle factor associated with dementia.

Body mass index, cognitive deficit and depressive symptoms in high cardiovascular risk patients

To evaluate the relationship of obesity, cognitive impairment and depressive symptoms in patients with high cardiovascular risk. Methods A sample of 93 patients aged 50 years or older was selected from the Center of Dyslipidemia and High Cardiovascular Risk from Hospital de Clínicas de Porto Alegre (HCPA). Patients with stroke were excluded. For cognitive evaluation, the MMSE (Mini Mental State Examination) was used. A score of 24 or less was considered as cognitive impairment, and for those who had 4 years or less of education, the cutoff point was 17. The GDS-15 (Geriatric Depression Scale) was also used, with the cutoff of 6 for presence of depressive symptoms. Results Obese patients showed lower mean MMSE scores compared to non-obese patients (p=0.0012). Additionally, for every one point increase in BMI above 30 there was a 27% increase in the chances of the patient having cognitive impairment. The obese patients presented 31% chance of having cognitive impairment compared with overweight subjects. Conclusions Our findings corroborated the association between obesity and cognitive impairment in high cardiovascular risk patients. This association however, was not observed for depressive symptoms.

Dementia and hearing impairment: Diferential diagnosis

was associated with support service need, worse psychologial well-being, and patient’s neuropsychiatric symptoms. Time spent caring was related to patient’s functional status. There was no relationship between the patient’s cognitive functioning/depression and burden. Conclusions: Caregivers of individuals with MCI report greater burden in caring for their loved ones and this level of burden appears to be related to the patient’s neurobehavioral and functional status. Early identification of MCI patients with psychiatric issues may be particularly important for predicting caregiver burden.

Cardiovascular risk and its consequences in the cognition of patients of an university hospital

independently associated with CIND. An interaction was found between education and job physical demand; persons with a high level of education but a high job physical demand showed an association with CIND, both if they were employed as manual or non-manual workers (OR 1⁄4 4.4;95%CI 1⁄4 1.03-18.9, and OR 1⁄4 4.3;95%CI 1⁄4 1.6-11.7, respectively). Conclusions: Different lifetime’s socioeconomic factors are associated with CIND in late life. Early-life education seems to play the most important role. However, being in a job that is highly physically demanding might modify the effect of education, independently of occupation.

The role of social network in dementia incidence: Porto Alegre Longitudinal Aging (PALA) study

and to assess the influence of other variables such as gender, age, education, manual activities and reading habits in this sample. Methods: The sample consisted of 520 individuals of both sexes from three different health care institutions (School Hospital, Center for Living and Unit-Family Health). All participants received a questionnaire and the standard Mini Mental State Examination (MMSE), which is an auxiliary method of treatment of possible cognitive deficits in individuals at risk, such as the elderly. The cutoff used was 13 points for illiterates, 18 for primary and secondary education and 26 for high school graduates (Bertolucci, 1994). Results: The mean age was 66.3 years. The mean score of MMSE in the total sample was 24.8 points.19.6% of the total sample had scores suggestive of dementia, with similar distribution between the sexes. Frequency of manual activity and reading are inversely related to the frequency of cognitive impairment. Conclusions: It was observed that the prevalence rates suggesting dementia were lower in the Center for Living, which may be correlated with the frequent practice of physical and social activities, and possibly greater interpersonal contact. Individuals from the primary unit and tertiary care displayed similar prevalence.

Obesity and dementia: Protection or risk?

Background: Late-life depression has been associated with increased dementia risk, but it is unclear whether this association is consistent across all types of dementia. To address this question, we examined associations between depression symptoms and development of clinical Alzheimer’s disease (AD), vascular, mixed (due to multiple etiologies), and other (non-AD, non-vascular) dementias in participants of the Adult Changes in Thought study, a community-based prospective study. Methods: A combined cohort of 3, 410 cognitively normal participants aged 65 years (60% female, mean age-at-entry 74.9 years [range 65 101]) underwent biennial assessments for dementia using DSM-IV criteria for dementia of the Alzheimer’s, vascular, mixed, and other types. Depression was assessed using the 11-item version of the Center for Epidemiologic Studies Depression Scale (CESD11, total score: 0 33). The primary exposure of interest for this study was depression at baseline, with significant depression symptoms designated as CESD-11 score > 10. Self-reported history and age at onset of depression episodes were also collected at baseline interview. Cox proportional hazards regression with delayed entry and age as the time axis was used to assess the association between baseline CESD-11 > 10 and hazard of each dementia subtype. Results: Mean follow-up was 7.1 years. During follow-up, 386 participants were diagnosed with AD, 89 vascular, 109 mixed, and 73 with other dementia. CESD-11 score > 10 at baseline was present in 14% of participants who developed dementia. Compared with participants with a baseline CESD-11 score of 0-10, the hazard ratio of depression symptoms at baseline for AD was 1.43 (95% CI 1.05, 1.94), vascular dementia 1.78 (95% CI 0.98, 3.22), mixed dementia 2.30 (95% CI 1.39, 3.79), and other dementia 2.42 (1.32, 4.43) after adjusting for ageat-entry categories, gender, education, and cohort. Self reported past history of depression at baseline was only associated with the ‘‘other dementia’’ subtype (adjusted hazard ratio 1.95 [1.17, 3.26]) but not with AD, vascular, or mixed dementia. Conclusions: These data suggest that depression symptoms in late life may be associated with increased dementia risk across all dementia subtypes, but possibly particularly with subtypes other than AD and vascular dementia.

Prevalence of cognitive impairment and depressive symptoms in patients with ischemic heart disease of an university hospital

Background: Dementia is a large and growing problem but is often not diagnosed in its earlier stages. Screening and earlier treatment could reduce the burden of suffering of this syndrome. Recently, the relation between cardiovascular risk factors, dementia and depression have been approached in many investigations. Cardiovascular risk factors such as hypertension may be associated with an increased risk for Alzheimer disease. This study aims to evaluate the relation of cognitive performance and depressive symptoms in patients with ischemic heart disease. Methods: 57 high cardiovascular risk elderly patients were evaluated using cognitive screening tests. Subjects were patients that maintained a regular follow-up in the Coronary Artery Disease Clinics of Hospital de Clinicas de Porto Alegre for 6,07 years (mean time of follow-up). The Mini Mental State Examination (MMSE) and the Geriatric Depression Scale (GDS-15) were used for the main measures. The cutoff for presence of depression was 6 on GDS. A score of 24 or less in the MMSE was considered as cognitive impairment, and in case the patient had 4 years or less of education, the cutoff point was 17. Results: The sample mean age was 67,54 years and 59,6% were male patients. The mean MMSE score was 25.88 (SD: 3,47). The mean GDS score was 3,93; 63,2% of the patients showed no depressive symptoms (GDS<6), 33,3% showed mild symptoms (GDS 6-10) and 1,8% showed severe symptoms (GDS>10). Conclusions: The present findings describe preliminary results of the cognitive performance of elderly with high cardiovascular risk factors, showing a possible association of depressive symptoms in this group. Vascular risk factors are a promising pathway of research for this condition, since they could represent preventable factors associated with depression, a common mental disorder of the elderly.

Functional decline concomitant to mental status stability in a 12-Year follow-up of Brazilian healthy elderly

Background: Age is a well-established risk factor for dementia, however cognitive decline is not mandatory among all individuals who get older. Studies on cognition and functional status among the non-demented elderly deserve more attention. The aim of this study was to evaluate longitudinally the performance on MMSE and the functional status in a healthy elderly populationbased cohort from South Brazil. The interaction between changes on MMSE scores and functional capacities and of these variables with socio-demographic and socioeconomic variables was also evaluated. Methods: Participants are derived from an elderly cohort. These data came from a 12-year follow-up. At baseline they were individuals from the community, with 60 years or more, healthy and independent. All non-demented living subjects were thoroughly assessed for at least three times during the follow-up. Each assessment was composed of demographic and medical information, family income, social support and engagement into leisure activities, ADL scale for functional status, the Montgomery-Asberg Rating Depression Scale, the Self-Report Questionnaire, the Mini-Mental State Examination, and the CDR scale. Results: A statistically significant increase on MMSE scores and decrease on functional status were observed. No interaction was observed between the evaluated variables and MMSE change along time of observation. On the other hand, there was a statistically significant interaction between functional status evolution and MMSE baseline scores (p 1⁄4 0.009), individuals with MMSE below cutoff showed greater decline in their functional status. Conclusions: The mental and functional status during the 12-year follow-up in healthy elderly showed decline of the functional status concomitant to stability of the MMSE scores.