Julio Litvoc

Estimate of Dementia Prevalence in a Community Sample from São Paulo, Brazil

Aims: To estimate dementia prevalence and describe the etiology of dementia in a community sample from the city of São Paulo, Brazil. Methods: A sample of subjects older than 60 years was screened for dementia in the first phase. During the second phase, the diagnostic workup included a structured interview, physical and neurological examination, laboratory exams, a brain scan, and DSM-IV criteria diagnosis. Results: Mean age was 71.5 years (n = 1,563) and 58.3% had up to 4 years of schooling (68.7% female). Dementia was diagnosed in 107 subjects with an observed prevalence of 6.8%. The estimate of dementia prevalence was 12.9%, considering design effect, nonresponse during the community phase, and positive and negative predictive values. Alzheimer’s disease was the most frequent cause of dementia (59.8%), followed by vascular dementia (15.9%). Older age and illiteracy were significantly associated with dementia. Conclusions: The estimate of dementia prevalence was higher than previously reported in Brazil, with Alzheimer’s disease and vascular dementia being the most frequent causes of dementia. Dementia prevalence in Brazil and in other Latin American countries should be addressed by additional studies to confirm these higher dementia rates which might have a sizable impact on countries’ health services.

Instrumentos combinados na avaliação de demência em idosos: resultados preliminares

ABSTRACT - Objective : To determine if a functional scale combined with a cognitive test would improve thediagnostic accuracy of dementia. Method : Thirty patients with mild to moderate dementia, diagnosed accordingto ICD-10 and DSM-III-R criteria, and 46 elderly controls, divided into three groups according to theirsocioeconomic status and educational level (high, medium and low) were investigated. The subjects wereassessed with the MMSE, and their informants were assessed with the scales IQCODE and B-ADL. Results : Onthe logistic regression, the MMSE isolated classified correctly 86.8% of patients and controls (80% sensitivityand 91.3% specificity). The combination MMSE + IQCODE classified correctly 92.1% of the subjects (83.3%sensitivity and 97.8% specificity), and the combination MMSE + B-ADL classified correctly 92.1% of subjects(86.7% sensitivity and 95.7% specificity). Conclusion : The results suggest that the combination of a cognitivetest with a functional scale can improve the detection of mild to moderate cases of dementia even on samplesof a very heterogeneous population regarding its socioeconomic status and educational level, as the Brazilian.KEY WORDS: dementia, diagnosis, cognitive test, functional scales.

Estudo sobre a qualidade de vida de pacientes hemiplégicos por acidente vascular cerebral e de seus cuidadores

Hemiplegia is a condition of paralysis of one side of the body usually resultant of stroke. In spite of the growing interest in the study of quality of life in several health conditions. The purpose of this work is to verify the impact of a stroke in the quality of life of patients and caregivers. Home interviews were conducted in three groups: patient, caregiver and control. The instrument used for the assessment of quality of life was the Short Form-36 questionnaire. A total of 200 subjects were interviewed: 91 control, 66 patients and 43 caregivers. It was possible to see that the mean age of the caregiver group is different from that of the control group but the mean age of the patient group is not different from that of the control group. The means obtained in the groups concerning the Body Pain domain, show that there is no statistical difference among the means of the patient, control and caregiver groups. The other seven domains showed similar outcomes, that is, no statistically significant differences were found between the patient and the caregiver groups. The control group showed higher and statistically significant, values a sign of the groups higher quality of life in the seven domains assessed. Its possible to conclude that almost all the Short Form-36 domains in this study were altered when control, patients and caregiver groups were compared, suggesting there is a decrease in the quality of life of stroke patients and their caregivers.

Clinically Significant Depressive Symptoms and Associated Factors in Community Elderly Subjects From Sao Paulo, Brazil

OBJECTIVES To determine the frequency of clinically significant depressive symptoms (CSDS) in a community sample of Brazilian elderly and to assess their relationship with sociodemographic factors, cognitive and functional impairment (CFI), and clinical diseases. DESIGN Cross-sectional study of a community-based sample of elderly subjects. SETTING City of Sao Paulo, State of Sao Paulo, Brazil. PARTICIPANTS A total of 1,563 elderly subjects aged 60 years or older. MEASUREMENTS A 10-item scale for screening of depressive symptoms in elderly people (D-10), the Mini Mental State Examination, the Fuld Object Memory Evaluation, the Informant Questionnaire on Cognitive Decline in the Elderly, the Bayer Activities of Daily Living Scale, and a sociodemographic and clinical questionnaire. RESULTS The frequency of CSDS was 13.0%. Univariate analysis identified independent factors associated with these symptoms in our sample. Logistic regression analysis indicated that being female, brown skinned, previously depressed, having CFI, using psychotropics, and not practicing physical exercise were related to CSDS. On the other hand, being older, clinically sick, employed, or married were not associated with CSDS. CONCLUSIONS : Consistent with previous reports, female gender, lack of physical activity, and CFI were significantly associated with higher frequencies of CSDS. Further investigations are necessary to clarify the occurrence of depression and possible modifiable factors in developing countries such as Brazil.

The Bayer: Activities of Daily Living Scale (B-ADL) in the differentiation between mild to moderate dementia and normal aging

OBJECTIVES To investigate the applicability of the Bayer - Activities of Daily Living scale and its efficiency in differentiating individuals with mild to moderate dementia from normal elderly controls. METHOD We selected 33 patients with diagnosis of mild to severe dementia, according to ICD-10 criteria, and 59 controls. All the subjects were evaluated with the Mini-Mental State Examination and the Clinical Dementia Rating Scale and the Bayer - Activities of Daily Living scale was applied to informants. RESULTS The internal consistency of the Bayer - Activities of Daily Living was high (Cronbachs alpha = 0.981). Mean Mini-Mental State Examination and Bayer - Activities of Daily Living scores of demented patients and controls were significantly different (p < 0.001). Mean Mini-Mental State Examination and Bayer - Activities of Daily Living scores were significantly different between Clinical Dementia Rating Scale 0 (controls; n = 59) versus Clinical Dementia Rating Scale 1 (mild dementia; n = 15), Clinical Dementia Rating Scale 0 versus Clinical Dementia Rating Scale 2 (moderate dementia; n = 13), and for Clinical Dementia Rating Scale 1 versus Clinical Dementia Rating Scale 2 (p < 0.003). DISCUSSION The Bayer - Activities of Daily Living scale and Mini-Mental State Examination differentiated elderly controls from patients with mild or moderate dementia, and patients with mild dementia from those with moderate dementia. CONCLUSIONS The results suggest that the Bayer - Activities of Daily Living scale applied to an informant can help in the diagnosis and follow-up of Brazilian patients with mild to moderate dementia.

Prevalence of Cognitive and Functional Impairment in a Community Sample from São Paulo, Brazil

Aims: To present the prevalence of cognitive and functional impairment (CFI) in community-dwelling elderly subjects from the city of São Paulo. Methods: The population was aged 60 years and older (n = 1,563; 68.7% women and 31.3% men) and lived in different socioeconomic areas. The following instruments were administered to the elderly: the Mini Mental State Examination and the Fuld Object Memory Evaluation. The Informant Questionnaire on Cognitive Decline in the Elderly and the Bayer-Activities of Daily Living scale were administered to an informant. Results: The prevalence of CFI (n = 250) was 16% (95% confidence interval, CI: 14.2–17.8%) or 15.8% (95% CI: 13.8–17.8%). In regression models, the increase in the odds ratio (OR) of CFI was associated with age, for elderly individuals aged 75 years or older, illiterates or with 1–4 years of schooling, and with a history of stroke and diabetes mellitus. On the other hand, for subjects with a tumor history, the OR of CFI was significantly reduced. Conclusion: CFI was high and increased at older ages and in subjects with low education. Potentially changeable factors were identified (stroke and diabetes), and the possible ‘protective effect’ of tumor/cancer against CFI should be further investigated by longitudinal studies.

Performance of Brazilian long and short IQCODE on the screening of dementia in elderly people with low education.

BACKGROUND Dementia screening in elderly people with low education can be difficult to implement. For these subjects, informant reports using the long (L) (26 items) and short (C) (16 items) versions of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) can be useful. The objective of the present study was to investigate the performance of Brazilian versions of the IQCODE L, S and a new short version (SBr) (15 items) in comparison with the Mini-mental State Examination (MMSE) for dementia screening in elderly people with low education. METHODS Thirty-four patients with mild to moderate dementia, diagnosed according to ICD-10 criteria, and 57 controls were evaluated and divided into three groups based on their socioeconomic status and level of education. Patients were evaluated using the MMSE and the informants were interviewed using the IQCODE by interviewers blind to the clinical diagnosis. RESULTS Education was correlated with MMSE results (r = 0.280, p = 0.031), but not with the versions of the IQCODE. The performance of the instruments, evaluated by the ROC curves, was very similar, with good internal consistency (Cronbachs alpha = 0.97). MMSE correctly classified 85.7% of the subjects while the three IQCODE versions (L, S and SBr) correctly classified 91.2% of the subjects. CONCLUSIONS The long, short and the new short Brazilian IQCODE versions can be useful as a screening tool for mild and moderate patients with dementia in Brazil. The IQCODE is not biased by schooling, and it seems to be an adequate instrument for samples with low levels of education.

Combined instruments for the screening of dementia in older people with low Education

OBJECTIVE To determine which combination of cognitive tests and informant reports can improve the diagnostic accuracy of dementia screening in low educated older people. METHOD Patients with mild to moderate dementia (n=34) according to ICD-10 and DSM-III-R criteria and 59 older controls were assessed with the Mini-Mental State Examination (MMSE) and the Fuld Object Memory Evaluation (FOME). Informants were assessed using the Informant Questionnaire on Cognitive Decline in the Elderly and the Bayer-Activities of Daily Living Scale. RESULTS The 4 instruments combined with the mixed rule correctly classified 100% and the logistic regression (weighted sum) classified 95.7% of subjects. The weighted sum had a significantly larger ROC area compared to MMSE (p=0.008) and FOME (p=0.023). The specificity of the tested combinations was superior to the MMSE alone (p=0.002). CONCLUSIONS Cognitive tests combined with informant reports can improve the screening of mild to moderate dementia in low educated older people.

High Prevalence of Dementia in a Community-Based Survey of Older People from Brazil: Association with Intellectual Activity Rather than Education

Although several surveys have been conducted around the world, few surveys have investigated the prevalence of dementia in Latin America. The aim of this study was to estimate dementia prevalence in a community sample in Ribeirão Preto, Brazil, and to evaluate its distribution across several socio-demographic and clinical characteristics and habits. The population was aged 60 years and older and a representative sample from three different social regions. The screening instruments used in the first phase were the Mini-Mental State Examination, the Fuld Object-Memory Evaluation, the Informant Questionnaire on Cognitive Decline in the Elderly, and the Bayer Activities of Daily Living Scale. In the second phase, the Cambridge Examination was employed to diagnose dementia according to the DSM-IV criteria. The estimate of dementia prevalence was adjusted for screening instrument performance, using the positive and negative predictive values. The data were weighted to compare frequencies, considering the sampling and the non-response effect, and subjected to multivariate analysis. In all, 1.145 elderly subjects were evaluated (mean age: 70.9 years), of whom 63.4% were female and 52.8% had up to 4 years of schooling (participation rates at the first and the second phases were 62.6 and 60%, respectively). The observed and estimated prevalences of dementia were 5.9% and 12.5%, respectively (n = 68). Alzheimers disease was the main cause (60.3%). Dementia was associated with old age, low education, stroke, absence of arthritis, and not reading books. The estimated prevalence of dementia was higher than the prevalence previously found. Associated factors confirmed the importance of intellectual activities in prevention.

Agressão física e classe social

OBJECTIVE Considering the increase of violence and the scarcity of informations about the relation between social class and victimization by physical aggression, a study was conducted to investigate this association. METHODS A hospital-based case-control study. Cases and controls were recruited at a hospital, first-aid clinic, from 1/10/93 to 19/1/95. The study included 191 cases and 222 controls selected from among patients with non-violent clinical-surgical complaints, frequency-matched to cases by sex and age. Using a standardized questionnaire applied by trained interviewers, information obtained included social class, skin color, marital status, smoking habits, alcohol consumption and illicit drug use. RESULTS Adjusting for sex and age, the risk of victimization by physical aggression was significantly higher for the subproletariat, Odds Ratio (OR) 4.20, 95% Confidence Interval (95% CI) 1.99-8.84; single (OR = 2.10) or informal union (OR = 2.62) as marital status (reference group = married); smokers of more than 10 cigarettes/day (OR = 2.75); alcohol consumption (OR = 2.08 for < or = 240 grams/week and OR = 24.05 for > 240 grams/week); and illicit drug users (OR = 3.07). After adjusting for all factors studied a significant risk remained for the subproletariat (OR = 3.28, 95% CI 1.42-7.59); single as marital status (OR = 2.05, 95% CI 1.09-3.88); and alcohol consumption (OR = 2.01, 95% IC 1.07-3.77 for < or = 240 and OR = 15.93, 95% CI 5.09-49.8 for > 240 grams/week) CONCLUSION Social class is an important factor in the phenomenon of victimization by physical aggression, with the subproletariat deserving special attention in the strategies of intervention regarding this problem.