Leonardo da Costa Lopes

Effects of a non-focal plasticity protocol on apathy in moderate Alzheimer's disease: a randomized, double-blind, sham-controlled trial.

BACKGROUND Apathy is the most common neuropsychiatric symptom in Alzheimers disease (AD) and it is associated with changes in prefrontal neural circuits involved with generation of voluntary actions. To date no effective treatment for apathy has been demonstrated. OBJECTIVE We aimed to investigate the effects and safety of repetitive transcranial direct current stimulation (tDCS) on apathy in moderate AD patients. METHODS Forty patients were randomized to receive either active or sham-tDCS over the left dorsolateral prefrontal cortex (DLPFC). Patients received six sessions of intervention during 2 weeks and were evaluated at baseline, at week 1 and 2, and after 1 week without intervention. Clinical raters, patients, and caregivers were blinded. The primary outcome was apathy. Global cognition and neuropsychiatric symptoms were examined as secondary outcomes. RESULTS The mean MMSE score at baseline was 15.2 ± 2.9 and the mean Apathy Scale score was 27.7 ± 6.7. Changes on apathy scores over time were not different between active and sham tDCS (P = 0.552 for repeated measures). Further analyses confirm that changes from baseline did not differ between groups after the sixth session (active tDCS -1.95 (95%CI -3.49, -0.41); sham-tDCS -2.05 (95%CI -3.68, -0.42); P = 0.989]. Similarly, tDCS had no effect on secondary outcomes (P > 0.40). tDCS was well tolerated and not associated with significant adverse effects. CONCLUSION In this adequately powered study for minimal clinically significant difference, our findings show that using the parameters we chose for this study, repeated anodal tDCS over the left DLPFC had no effect on apathy in elderly patients with moderate AD.

Prevalence of hearing impairment in patients with mild cognitive impairment

The correlation between hearing and cognition is well established in dementia, but not in mild cognitive impairment (MCI). Objective The aim of the present study was to define the prevalence of hearing impairment in elderly patients with MCI and in controls. Methods Twenty-nine patients with MCI and 24 control subjects were analyzed. We evaluated memory and hearing impairments through clinical tests, including the Mini Mental Status Examination, Clinical Dementia Rating (CDR) and Hearing Handicap Inventory for the Elderly Screening (HHIE-S). Audiometries were performed in 22 patients with MCI and 19 subjects in a control group. Results MCI patients showed more hearing complaints (68.9%) compared to the control group (25%) (p=0.001). No differences in the intensity of hearing complaints, measured by the HHIE-S, were detected. Nonetheless, differences between mean hearing threshold (MCI group=23.4±11.3dB and control group=16.0±10.1dB) (p=0.03) were identified. Conclusions There is a significant association between MCI and hearing impairment. Hearing impairment in MCI patients may be a contributory factor to cognitive decline. This may however be related to the same neuropathological process, due to lesions of cortical areas related to hearing. The early diagnosis of hearing impairment in MCI patients may offer a more appropriate approach to this disease.

Cognitive impairment and driving. A review of the literature

Although some drivers with mild dementia may continue to drive after the condition has been diagnosed, the ability to drive a motor vehicle safely is eventually lost as the disease progresses. Clinicians involved in dementia care are often asked to make an assessment on whether a patient is fit to drive, even though they often lack basic knowledge and formal training in this area. The purpose of this review was to identify the factors that may differentiate safe from unsafe drivers with cognitive impairment and to discuss management strategies. Isolated information about staging measures or particular cognitive tests was found to be insufficient for decision making. Driving fitness counseling for patients with cognitive impairment requires a solid knowledge base, comprehensive assessment and thoughtful communication.

Characterizing spontaneously reported cognitive complaints: the development and reliability of a classification instrument.

BACKGROUND The characteristics and associated risks of spontaneously reported cognitive complaints have not been investigated due to the lack of a classification instrument. METHODS In phase 1, a classification system with descriptive categories and cognitive domains was developed by experts through a modified Delphi technique. In phase 2, 180 elderly patients seeking medical attention for cognitive complaints provided free reports of their cognitive difficulties and each complaint was recorded verbatim. Three observers were asked to classify each complaint into a descriptive category. Perceived cognitive function was further characterized using the Memory Complaint Questionnaire (MAC-Q). RESULTS The patients reported 493 spontaneous complaints, with a range of 1-6 complaints per patient and a mean of 2.7 (±1.3). The proportion of complaints that could be classified into a category by each of the three observers varied from 91.9% to 95.7%. Inter-observer agreement assessed using the κ statistic varied from 0.79 to 1 for descriptive categories and 0.83 to 0.97 for domains. Compared with the MAC-Q, spontaneously reported complaints provided complementary information by avoiding the cueing effect provoked by the questionnaire. The total number of complaints and their occurrences in specific domains were associated with important sociodemographic and clinical factors, indicating that their meaning and associated risks need to be further investigated. CONCLUSION The instrument developed in this study proved to be a practical tool for classifying the majority of spontaneously reported cognitive complaints with high reliability. Further studies are needed to investigate clinical usefulness of this approach.

Evaluating Communication Skills of Geriatrics Fellows: interrater Agreement of an Objective Structured Clinical Examination

To the Editor: Evaluating communication skills of geriatric fellows is a matter of paramount importance, but there has been limited work on this topic. The Division of Geriatrics of the University of S~ao Paulo Medical School conducts an annual Objective Structured Clinical Examination (OSCE), but a concern related to interrater agreement on communication skills has been raised. The purpose of this study was to evaluate the interrater reliability of a communication assessment scale.

Clinical conditions and memory complaints in outpatient elderly

Memory complaints are common in elderly, and may be associated with many clinical problems. Objective To identify clinical conditions and possible factors related to memory complaints in elderly outpatients presenting at a tertiary unit. Methods Patients with memory complaints and normal cognitive screening tests were submitted to clinical and laboratorial testing. Radiological evaluation was performed as needed for diagnosis. Results One hundred and seventy-seven subjects were initially evaluated, 12 were excluded because of poor and inconsistent memory complaints. Of the remainder, seventeen had criteria for dementia diagnosis. Ninety-two (55.4%) had one or more comorbid conditions possibly related to their complaints. Major depression was present in 26.0%. Sixteen patients (9.6%) had vitamin B12 deficiency, 8 were in use of inappropriate medications, and 7 (4.2%) had hypothyroidism. Other conditions diagnosed were: generalized anxiety disorder, obstructive sleep apnea syndrome, hyperparathyroidism, normal pressure hydrocephalus. Three patients had severe hearing loss (in 22 with hearing complaints); one had severe visual impairment (in 22 with visual complaints). Conclusions Comprehensive evaluation was able to identify treatable conditions possibly related to memory complaints.