Paulo Caramelli

Sugestões para o uso do mini-exame do estado mental no Brasil

Mini-metal state examination (MMSE) is a screening test to detect cognitive impairment. The objectives of the present study are to describe some adaptations for use of MMSE in Brazil and to propose rules for its uniform application. METHOD: We evaluated 433 healthy subjects using the MMSE and verified the possible influence of demographic variables on total scores. RESULTS: Educational level was the main factor that influenced performance, demonstrated by ANOVA: F(4,425) = 100.45, p<0.0001. The median values for educational groups were: 20 for illiterates; 25 for 1 to 4 yrs; 26.5 for 5 to 8 yrs; 28 for 9 to 11 yrs and 29 for higher levels. CONCLUSION: The MMSE is an excellent screening instrument and definitive rules are necessary for comparison purposes.

Epidemiologic survey of dementia in a community-dwelling Brazilian population

The authors report the prevalence of dementia in a community-dwelling Brazilian elderly population and correlate prevalence data with educational and socioeconomic levels. The study was conducted in Catanduva, Brazil. A total of 1,656 randomly selected subjects aged 65 years or more were submitted to a health questionnaire, the Mini-Mental State Examination (MMSE), and the Pfeffer Functional Activities Questionnaire (PFAQ). According to the PFAQ and MMSE scores, selected subjects were submitted to clinical, neurologic, and cognitive evaluations. The subjects diagnosed with dementia underwent laboratory tests and brain computed tomography (CT). Dementia was diagnosed in 118 subjects, corresponding to a prevalence of 7.1%. The main clinical diagnoses were Alzheimer disease (AD; 55.1%), vascular dementia (9.3%), and AD with cerebrovascular disease (14.4%). The prevalence increased with age and was higher in women. There was an inverse association with education (3.5% among persons with 8 or more years of schooling to 12.2% among those who were illiterate). Multivariate analysis disclosed significant association between these three variables and dementia. The prevalence of dementia in this Brazilian population was 7.1%, and AD was the most frequent diagnosis. Age, female gender, and low educational level were significantly associated with a higher prevalence of dementia.

Performance of illiterate and literate nondemented elderly subjects in two tests of long-term memory

Cognitive evaluation in developing countries is a difficult undertaking due to low levels of schooling and particularly the illiteracy still frequent in the elderly. This study was part of the epidemiologic evaluation of dementia in Catanduva, Brazil, and had the objective of comparing the performance of illiterate and literate nondemented elderly individuals in 2 tests of long-term memory-the delayed recall of a word list from the CERAD and the delayed recall of common objects presented as simple drawings from the Brief Cognitive Screening Battery (BCSB). Fifty-one elderly subjects (23 illiterates) were evaluated, and the performance of the illiterates and literates differed in the CERAD memory test, but not in the BCSB memory test. This test may be more suitable for the assessment of long-term memory in populations with a high frequency of illiterates, and therefore might prove to be a useful screening tool for the diagnosis of dementia.

Parkinsonism and Parkinson's disease in the elderly: A community-based survey in Brazil (the Bambuí study)

Several community‐based surveys on the prevalence of Parkinsonism and Parkinsons disease have been conducted worldwide, with variations on their methodology and results. The objective of this study is to assess the prevalence of Parkinsonism and its causes in a cohort of individuals age 64 years or older in Bambuí, a Brazilian town. In phase I, 1,186 people older than 64 years responded to a 9‐question screening questionnaire for Parkinsonism. In phase II, all subjects who scored ≥ 2 points on the test were examined independently by at least 2 movement disorder‐trained physicians. A movement disorder senior specialist excluded or confirmed the diagnosis in all suspected cases. The response rate was high for both phases (96% for phase I and 94% for phase II). The prevalence rate per 100 population over 64 years of age in this group was 7.2% for Parkinsonism of all types (n = 86). The most frequent causes were idiopathic Parkinsons disease and drug‐induced Parkinsonism, with prevalence rates of 3.3% (n = 39) and 2.7% (n = 32), respectively. The prevalence of vascular Parkinsonism was 1.1% (n = 13). We found 1 case of posttraumatic Parkinsonism and another with multiple system atrophy. In this first population‐based study of Parkinsonism conducted in Brazil, the prevalence in a cohort of elderly subjects was higher than the observed in other populations worldwide, especially because of the high rates of drug‐induced and vascular Parkinsonism. The prevalence of Parkinsons disease was similar to that observed in elderly people in door‐to‐door surveys in other American, European, and Eastern countries.

Prevalence of dementia in Latin America: a collaborative study of population-based cohorts

BACKGROUND Dementia is becoming a major public health problem in Latin America (LA), yet epidemiological information on dementia remains scarce in this region. This study analyzes data from epidemiological studies on the prevalence of dementia in LA and compares the prevalence of dementia and its causes across countries in LA and attempts to clarify differences from those of developed regions of the world. METHODS A database search for population studies on rates of dementia in LA was performed. Abstracts were also included in the search. Authors of the publications were invited to participate in this collaborative study by sharing missing or more recent data analysis with the group. RESULTS Eight studies from six countries were included. The global prevalence of dementia in the elderly (> or =65 years) was 7.1% (95% CI: 6.8-7.4), mirroring the rates of developed countries. However, prevalence in relatively young subjects (65-69 years) was higher in LA studies The rate of illiteracy among the elderly was 9.3% and the prevalence of dementia in illiterates was two times higher than in literates. Alzheimers disease was the most common cause of dementia. CONCLUSIONS Compared with studies from developed countries, the global prevalence of dementia in LA proved similar, although a higher prevalence of dementia in relatively young subjects was evidenced, which may be related to the association between low educational level and lower cognitive reserve, causing earlier emergence of clinical signs of dementia in the LA elderly population.

Testes neuropsicológicos de aplicação simples para o diagnóstico de demência

Thirty patients with dementia defined by DSM-III-R criteria (Alzheimers disease (22), vascular dementia (3), Parkinsons disease, frontal lobe dementia, possible diffuse Lewy body dementia, normal pressure hydrocephalus and uncertain diagnosis), with scores below 24 points in the Mini-Mental Status Examination and more than 4 years of education were submitted to a neuropsychological evaluation. The scores in the neuropsychological tests were compared to those obtained by thirty normal volunteers paired for age, sex and education. Sensivity, specificity and accuracy of the tests in the distinction of demented and normal volunteers were determined. The accuracies were calculated using ROC curves. Blesseds information-memory-concentration test showed greatest accuracy, followed by copy of simple figures, delayed memory of 10 figures (after 5 minutes), recognition of 10 figures and verbal fluency test (animals). A linear discriminant function, composed by 6 tests: visual perception, incidental memory, delayed memory (after 5 minutes), drawing of a clock, verbal fluency (animals) and calculation tests, was able to discriminate all controls from patients and only one patient was wrongly classified as normal control. These tests were chosen because they can be applied in less than 10 minutes and are very easy to interpret. This discriminant function must be applied in another group of patients and controls in order to demonstrate its value. When associated to the MMSE it may be useful to discriminate patients with dementia from normal people in epidemiological studies.Thirty patients with dementia defined by DSM-III-R criteria (Alzheimers disease (22), vascular dementia (3), Parkinsons disease, frontal lobe dementia, possible diffuse Lewy body dementia, normal pressure hydrocephalus and uncertain diagnosis), with scores below 24 points in the Mini-Mental Status Examination and more than 4 years of education were submitted to a neuropsychological evaluation. The scores in the neuropsychological tests were compared to those obtained by thirty normal volunteers paired for age, sex and education. Sensitivity, specificity and accuracy of the tests in the distinction of demented and normal volunteers were determined. The accuracies were calculated using ROC curves. Blesseds information-memory-concentration test showed greatest accuracy, followed by copy of simple figures, delayed memory of 10 figures (after 5 minutes), recognition of 10 figures and verbal fluency test (animals). A linear discriminant function, composed by 6 tests: visual perception, incidental memory, delayed memory (after 5 minutes), drawing of a clock, verbal fluency (animals) and calculation tests, was able to discriminate all controls from patients and only one patient was wrongly classified as normal control. These tests were chosen because they can be applied in less than 10 minutes and are very easy to interpret. This discriminant function must be applied in another group of patients and controls in order to demonstrate its value. When associated to the MMSE it may be useful to discriminate patients with dementia from normal people in epidemiological studies.

Diagnóstico de doença de Alzheimer no Brasil: avaliação cognitiva e funcional. Recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia

The educational and cultural heterogeneity of the Brazilian population leads to peculiar characteristics regarding the diagnosis of Alzheimers disease (AD). This consensus had the objective of recommending evidence-based guidelines for the clinical diagnosis of AD in Brazil. Studies on the diagnosis of AD published in Brazil were systematically evaluated in a thorough research of PUBMED and LILACS databases. For global cognitive evaluation, the Mini-Mental State Examination was recommended; for memory evaluation: delayed recall subtest of CERAD or of objects presented as drawings; attention: trail-making or digit-span; language: Boston naming, naming test from ADAS-Cog or NEUROPSI; executive functions: verbal fluency or clock-drawing; conceptualization and abstraction: similarities from CAMDEX or NEUROPSI; construction: drawings from CERAD. For functional evaluation, IQCODE, or Pfeffer Questionnaire or Bayer Scale for Activities of Daily Living was recommended. The panel concluded that the combined use of cognitive and functional evaluation based on interview with informant is recommended.The educational and cultural heterogeneity of the Brazilian population leads to peculiar characteristics regarding the diagnosis of Alzheimers disease (AD). This consensus had the objective of recommending evidence-based guidelines for the clinical diagnosis of AD in Brazil. Studies on the diagnosis of AD published in Brazil were systematically evaluated in a thorough research of PUBMED and LILACS databases. For global cognitive evaluation, the Mini-Mental State Examination was recommended; for memory evaluation: delayed recall subtest of CERAD or of objects presented as drawings; attention: trail-making or digit-span; language: Boston naming, naming test from ADAS-Cog or NEUROPSI; executive functions: verbal fluency or clock-drawing; conceptualization and abstraction: similarities from CAMDEX or NEUROPSI; construction: drawings from CERAD. For functional evaluation, IQCODE, or Pfeffer Questionnaire or Bayer Scale for Activities of Daily Living was recommended. The panel concluded that the combined use of cognitive and functional evaluation based on interview with informant is recommended.

Brazilian version of the Mattis dementia rating scale: diagnosis of mild dementia in Alzheimer's disease

OBJECTIVES To verify the diagnostic accuracy of the Brazilian version of the Mattis Dementia Rating Scale (DRS) in the diagnosis of patients with mild dementia in Alzheimers disease (AD); to verify the interference of the variables age and schooling on the performance of the DRS. METHOD The DRS was administered to 41 patients with mild AD and to 60 controls. In order to analyze the effects of age and schooling on the performance of the tests, patients and controls were separated into three age groups and three levels of schooling. RESULTS The cutoff score of 122 showed a sensitivity of 91.7 % and specificity of 87.8 %. Age and schooling interfered in the DRS total score and in the scores of its subscales. CONCLUSION The DRS showed good diagnostic accuracy in the discrimination of patients with mild AD from the control individuals. In the sample examined, the effects of schooling were more marked than age.

Wilson's disease: MRI with clinical correlation

We tried to establish possible correlations between clinical data and MRI in a group of patients with Wilsons disease. Eleven patients (6 male, 5 female), aged between 11 and 50 years old, with a duration of illness from 5 months to 32 years, were submitted to MRI on a 1.5 T System. Three patients were asymptomatic, two had mild neurological disturbances, two were moderately affected and the remaining four had a severe form of the disease. All were receiving D-penicillamine at the time of the study. In the most symptomatic patients there were abnormalities in five or more sites on MRI. The putamen was affected in all symptomatic patients, including five with dystonia. A striking feature was the peripheral location of high signal putaminal lesions on T2-weighted images. In five cases, lesions in the corpus striatum or substancia nigra explained the patients Parkinsonian features. MRI is an efficient method for studying involvement of the central nervous system in Wilsons disease, and allows some interesting anatomoclinical correlations.

Declínio da capacidade cognitiva durante o envelhecimento

Decline of cognitive capacity (DCC) is due to normal physiological aging processes or to pre-dementia stage. Epidemiological studies show that elderly with decline of cognitive capacity have higher risk to develop Alzheimers disease (AD), especially those with episodic memory deficits. This review presents the most important diagnosis criteria, neuropathological and neuropsychological findings of decline of cognitive capacity during aging.