Maria Otilia Cerveira

Evaluation of Mini-Mental State Examination scores according to different age and education strata, and sex, in a large Brazilian healthy sample

Until better measures have been accepted for wider use, the Mini-Mental State Examination (MMSE) will continue to be utilized. In this context, knowledge on characteristics and determinants of its distribution for the Brazilian population are particularly valuable. The present study aimed to evaluate, based on multivariate analysis, the independent effect of age, educational level and sex, and their interactions, on MMSE scores in a healthy sample. Methods Demographic data and scores on the MMSE of 1,553 healthy individuals were analyzed. The sample was grouped according to age and education. Results The sample was composed of 963 females (62%), mean age ±SD was 49.6±20.7yrs (range 20 to 92 yrs). The mean years of education ±SD was 8.9±5.5yrs (range 0 to 28 yrs). The mean score ±SD on the MMSE was 27.3±2.7(range 15 to 30). A significant effect of the interaction between education and sex (p=0.011), and also between education and age was observed (p=0.003). An independent effect of education (p<0.001) and age (p<0.001) was found. Participants from the higher educated group presented higher MMSE scores than the other groups. Younger adults presented higher MMSE scores than the other age groups. Conclusions We observed an effect of education and age on MMSE scores. Younger individuals and higher educated participants presented higher scores.

Neuropsychiatric symptoms as the main determinant of caregiver burden in Alzheimer's disease

Caregiver burden is common in Alzheimer’s disease (AD), decreasing the quality of life among caregivers and patients. Projections of aging and aging-related diseases such as AD in developing countries justify additional data about this issue because people living in these countries have shown similarly high levels of caregiver strain as in the developed world. Objective The aim of this study was to analyze the association of AD caregivers’ burden with patients’ neuropsychiatric symptoms (NPS), cognitive status, severity of dementia, functional capacity, caregiver sociodemographic characteristics, and the characteristics of care provided by caregivers. Methods A cross-sectional study was conducted in a sample of 39 consecutive AD patients and their primary caregivers. NPS were evaluated using the Neuropsychiatric Inventory (NPI). Severity of dementia was assessed with the Clinical Dementia Rating (CDR) scale. Functional capacity was assessed using the Katz and Lawton scales. The burden level was rated using the Burden Interview (BI). Sociodemographic characteristics of caregivers and the characteristics of care provided by them were evaluated. The Mann-Whitney U-test, Kruskal-Wallis test and Spearman’s rho coefficient were performed. Results The BI had a moderate correlation with NPI intensity (rho=0.563), p<001. Female caregivers reported a greater level of burden (p=0.031) than male caregivers. The other variables were not significantly associated to caregiver burden. Conclusion NPS were the main determinant of burden in primary caregivers of AD patients. This result underscores the need for prevention and treatment of these symptoms. Sex also had an effect on caregiver burden, but the small male sample in this study precludes the generalization of this finding.

Clinical and demographic characteristics of elderly patients with dementia assisted at an outpatient clinic in Southern Brazil

The aging of the population is a worldwide phenomenon, where 60% of elders live in developing areas of the world such as Brazil, regions in which few studies have been carried out. Objectives The goal of this study was to evaluate the clinical and demographic profile of patients with dementing disorders seen at a specialized outpatient clinic in South Brazil. Methods A sample of 105 demented patients seen at the Dementia Outpatient Clinic from Hospital de Clínicas de Porto Alegre (HCPA), Brazil between June 2004 and June 2008. Evaluation of patients consisted of medical history, cognitive testing, assessment of functional status (Activities of Daily Living Scale - ADL; Instrumental Activities Daily Living - IADL) and application of the Neuropsychiatry Inventory (NPI) for behavioral symptoms. Severity of dementia was evaluated based on the CDR scale. All patients underwent laboratory screening tests and brain imaging exams to define etiology of dementia. Results Of the whole sample, 71% were female. Age was 79±8 years (mean±SD). Educational level was 4±3 years (mean±SD). Sixty-four patients (60%) presented the diagnosis of Alzheimer’s disease. Of the whole sample, 26.7% were classified as CDR=1, 44% as CDR=2 and 29. 3% as CDR=3. A significant difference on the Mini Mental State Examination (MMSE) and functional status scores was observed among the CDR categories (severity). No significant association was found between severity and impairment on memory tests and behavioral symptoms. Conclusions Alzheimer’s disease was the most common etiology, followed by vascular dementia. At diagnosis, most patients presented mild to moderate severity of dementia, independent of cause.

Cognitive impairment screening in a southern Brazilian elderly outpatient sample

Background: The elderly Brazilian population in 2008 was 20 million people. Considering the evidence of benefit of the therapeutic interventions for the initial phases of dementia, it is relevant to emphasize the early diagnosis and information of the medical class in relation to the disease and the diagnosis. Methods: The physicians were invited to refer to Neurogeriatric Outpatient Clinic those individual waiting for a consultation who presented positive screening for cognitive impairment. The MMSE and a questionnaire with demographic data were applied in elderly outpatients that were waiting for a consultation at the hospital waiting room. The results from screening were sent to assistant physician who will decide the referral to Neurogeriatric Outpatient Clinic in order to perform full diagnostic evaluation. Results: Nine hundred sixty-seven outpatients that were at the hospital waiting room were interviewed in a 4 month period. From these patients, 413 were less than 65 years-old, 82 refused to participate in the study and 472 were included. From the included patient, 326(69.1%) were women; the mean age was 73.866.4 years (range 65-94 years) and mean education years was 4.463.5 years (0-20 years). From these patients, 109(23.1%) had MMSE scores under cutoff. From the 109 positive screening, 26 patients with impairment in the MMSE were sent to a more detailed ambulatory evaluation. From these, 7.6% fulfilled criteria for dementia, 26% for depression, 26% did not showed impairment in the evaluation and 38.5% fulfilled criteria for cognitive impairment, but did not complete the etiological evaluation until now. Conclusions: The dementia frequency rate in our study realized into a tertiary university hospital was similar to that found in other study conducted in Brazil in the community population. The screening test was adequate, even with some false-positive results, since it made it possible to detect patients with cognitive impairment that would not receive adequate treatment. The referral rate of suspect cases of cognitive impairment was low and deserves further investigation.

General psychiatric or depressive symptoms were not predictive for mortality in a healthy elderly cohort in Southern Brazil

General psychiatric symptoms may interfere with the ability of individuals to take care of their health, to get involved with activities and develop social abilities, thereby increasing risk of death. Objective To evaluate general psychiatric symptoms as predictive factors for mortality in a community elderly cohort in Southern Brazil. Methods 345 healthy elderly, aged .60 years, from the catchment area of Hospital de Clinicas de Porto Alegre were followed from 1996. Data for the present study were drawn from the period 1996-2004. General psychiatric symptoms (Self-Reporting Questionnaire . SRQ), depressive symptoms (Montgomery-Asberg depressive rating scale), and Mini Mental State Examination scores at baseline were included in the study. Socio-demographic, medical conditions, and functional capacity were also analyzed. The outcome was vital status at follow-up obtained from family members, hospital records and checked against official death registers. Results Of the 345 baseline individuals, 246 were followed-up. The global mortality rate over the study period was 36.9% (N=90). Those who deceased during the period were older (73.5±7.5), more dependent overall, and more cognitively impaired than the living elderly (univariate analyses). In the logistic regression, only age (OR=0.93; p=0.003) and functional capacity (OR=0.22; p=0.007) remained significant in the final equation. Conclusion Psychiatric symptoms presented no association with mortality in the present sample. Older age and functional incapacity were risk factors for mortality.

Correlation between serum brain-derived neurotrophic factor and verbal fluency

ering “probable AD” alone as well as “probable” plus “ possible” AD. The neuropathological diagnosis of AD was defined using multiple combinations of CERAD neuritic plaque density scores and Braak neurofibrillary tangle stages.Results:The sensitivity of the clinical diagnosis of AD ranged from 65% to 87% while specificity ranged from 64% to 78%. Sensitivity was increased with more permissive clinical criteria and specificity was increased with more restrictive criteria while the opposite was true for neuropathological criteria. The highest combined diagnostic performance (sensitivity of 79% and specificity of 71%) was achieved when the clinical diagnosis was defined as including both probable and possible AD and the neuropathological diagnosis was defined as being inclusive of the following two situations: 1) frequent neuritic plaque density with Braak stage III-VI 2) moderate neuritic plaque density with Braak stage V or VI. Conclusions: Agreement between the clinical and neuropathological definitions of AD, based on data from NIA ADC’s, varies depending on the levels of clinical and neuropathological confidence, with sensitivities and specificities ranging between 64% and 87%. The rate of misdiagnosis is critical for many types of research, including the calculation of sample size for clinical trials.

Patient and caregiver's characteristics related with neuropsychiatric symptoms in Alzheimer's disease

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.

Were elderly patients, who were escorted by family members for medical appointments, more likely to present cognitive dysfunction?

the strongest associations. The estimated relative risks with 95% confidence intervals were 0.94 (0.89 to 0.99) per 10 year increase in age, 0.33 (0.23 to 0.49) comparing blacks to non-blacks, and 1.61 (1.37 to 1.89) for individuals with a college education or more compared to those with less than college education. These estimates are all adjusted for family and clinical characteristics. Conclusions: Performance of autopsy does not occur randomly, in fact, many factors appear to play a role. This study was among the first attempts to approach the problem using multivariate statistical methods. Our results suggest that autopsy was much more likely to be performed on younger subjects, Caucasians, and subjects with higher education. These results show that neuropathological data are available on a rather select sample, which influences generalizability. We also illustrate how such results can be used to help correct for selective sampling in neuropathology studies.

Did patient's cognitive status correlate with functional impairment assessment?

daytime sleepiness were measured using the SCOPA-SLEEP scale during the 6-week treatment period (Baseline and Days 8, 15, 29 and 42). Results: Mean baseline (pretreatment) SCOPA Part B (nighttime sleep) scores were 10.5 for the placebo and 40 mg dose groups (N 1⁄4 97 and 92, respectively). Statistically significant improvement in nighttime sleep scores were observed in the 40 mg pimavanserin group vs. placebo as early as Day 8 (-1.0 vs. no change, p 1⁄4 0.003) and continued through Day 29. At the end of treatment (Day 42), a trend toward significance remained (-1.7 40-mg vs. -1.2 placebo; p 1⁄4 0.066). The 10 mg pimavanserin group was not significantly different from placebo at any timepoint. Daytime sleepiness scores were unaffected by pimavanserin treatment indicating no sedative effects of the drug. Conclusions: Pimavanserin appears to improve nighttime sleep without negative effects on daytime sleepiness in patients with PDP. Studies of pimavanserin in Alzheimer’s psychosis, where sleep impairment is also a common comorbidity, are planned. Evaluation of sleep in these studies may be of interest.

Burden interview versus neuropsychiatric inventory: Evaluation of burden in caregivers of Alzheimer's disease patients

This study aims to evaluate patient and caregiver’s characteristics related with neuropsychiatric symptoms. Methods: A cross-sectional study was conducted in a sample of 58 probable Alzheimer’s disease (AD) patients (NINCDS-ADRDA criteria). The neuropsychiatric symptoms were evaluated by the Brazilian version of the Neuropsychiatric Inventory (NPI). The dementia severity was assessed with the Clinical Dementia Rating (CDR), Brazilian version. The analyzed patient’s variables were sex, age, age of onset of AD symptoms and education. The analyzed caregiver’s variables were sex, type of relationship, age, education, time as caregiver, weekly time of care, residing with patient and type of job. Student’s t test and one-way Anova were performed for parametric variables. Spearman’s rho was used for correlations. Results: NPI intensity and distress were similar in both patient’s sex (p 1⁄4 0.742 and p 1⁄4 0.902, respectively) and in the three stages of severity of dementia (F1⁄4 1.951, p1⁄4 0.152; F1⁄4 0.763, p1⁄4 0.471, respectively). Patient’s education was inversely correlated with NPI frequency, intensity and distress (rho1⁄4 -0.283, rho1⁄4 -0.276, rho1⁄4 -0.262, p1⁄4 0.05). NPI intensity and distress were similar in both caregiver’s sex (p1⁄4 0.809 and p1⁄4 0.743, respectively), relationship type (p> 0.5) and caregiver’s type of job (p > 0.5). However, a tendency for statistical difference was observed between caregivers who resided and those who not resided with patients (p 1⁄4 0.05), caregivers who resided with patients showed higher NPI intensity and NPI distress. Caregiver’s education was inversely correlated with NPI frequency, intensity and distress (rho1⁄4 -0.302, rho1⁄4 -0. 272, rho1⁄4 -0. 300, p1⁄4 0.05). Caregiver’s age was inversely correlated with NPI severity (rho 1⁄4 -0.270, p 1⁄4 0.05). Weekly time of care was correlated with NPI frequency (rho 1⁄4 0. 291, p1⁄4 0.05). Conclusions: Some variables may interfere on neuropsychiatric symptoms evaluation by caregivers of AD patients, as age, education, weekly time of care and residing with patients. Some of them can be modified through different approaches improving quality of care.