Paulo Henrique Ferreira Bertolucci

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.

O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade

To assess the influence of age and education on cognitive performance in our population, 530 adults were interviewed using the MMSE (Mini-Mental Status Examination). Education level, classified as illiterate, elementary and middle ( 8 years), was a significant predictor of performance (p or = 65 years). The reference cut-off values were taken from the fifth percent lowest score for each group: illiterate, 13; elementary and middle, 18; and high, 26. When compared to 94 pacients with cognitive impairment, our cut-off values achieved high sensitivity (82.4% for illiterates; 75.6% for elementary and middle; 80% for high) and specificity (97.5% for illiterate; 96.6% for elementary and middle; 95.6% for high educational level). Education-specific reference values for the MMSE are necessary in interpreting individual test results in populations of low educational level, in order to reduce the false positive results.

Chronic exposure to the fungicide maneb may produce symptoms and signs of CNS manganese intoxication.

Manganese (Mn) poisoning, a well-known hazard in miners and industrial workers, shares many features with Parkinsons disease. Two young agricultural workers with a parkinsonian syndrome, who mentioned exposure to the fungicide maneb (manganese ethylene-bis-dithiocarbamate), led us to investigate a new possible source of Mn intoxication. Fifty male rural workers with occupational exposure to maneb were compared with 19 rural workers without fungicide exposure. We noted significantly higher prevalence of plastic rigidity with cogwheel phenomenon, headache, fatigue, nervousness, memory complaints, and sleepiness in the exposed group. In addition, we saw other neurologic signs, such as postural tremor, cerebellar signs, and bradykinesia, although without statistical significance. The data suggest that occupational exposure to pesticides containing Mn is a possible source of Mn intoxication of the CNS.

Applicability of the CERAD neuropsychological battery to Brazilian elderly

There is a limited choice of psychometric tests for Portuguese speaking people which have been evaluated in well defined groups. A Portuguese version of CERAD neuropsychological battery was applied to a control group of healthy elderly (CG) (mean age 75.1 years/ education 7.9 years), 31 Alzheimer disease (AD) patients classified by clinical dementia rating (CDR) as CDR1 (71.4/ 9.0) and 12 AD patients CDR 2 (74.1/ 9.3). Cut-off points were: verbal fluency-11; modified Boston naming-12; Mini-mental State Examination (MMSE) -26; word list memory-13; constructional praxis-9; word recall-3, word recognition-7; praxis recall-4. There was a significant difference between CG and AD-CDR1 (p<0.0001) for all tests. There was a less significant difference for constructional praxis and no difference for Boston naming. Comparison between AD-CDR1 and AD-CDR2 showed difference only for MMSE, verbal fluency, and Boston naming. The performance of CG was similar to that of a US control sample with comparable education level. These results indicate that this adaptation may be useful for the diagnosis of mild dementia but further studies are needed to define cut-offs for illiterates/low education people.

Dados normativos para o teste de fluência verbal categoria animais em nosso meio

OBJECTIVE Evaluate the performance on verbal fluency (VF) in our population in a Brazilian sample checking the influence of age and literacy. METHODS 336 people without neurological or psychiatric complaints evaluated through Mini-Mental State Examination and VF (animals). For comparison, and to determine cut-off points, 65 people with cognitive loss followed at our clinic were also evaluated. RESULTS We found a mean of 13.8 animals in 1 minute, with the following distribution: illiterates, 11.9; up 4 years of education, 12.8; 4 to 7 years, 13.4; 8 years or more, 15.8 (p = 0.0001). In relation to age the means were: up to 64 years, 13.7; 65 years or more, 13.9. There was no difference between the two groups. The cut-off points were 9 for people under 8 years of education with a sensitivity of 75% for illiterates, 100% for low educational level (up 4 years), and 87% for middle level (4 to 7 years). The specificity was respectively 79%, 84%, and 88%. For the high educational level the mean was 13 with a sensitivity of 86% and specificity of 67%. CONCLUSIONS In the VF (animals) there is a significant influence of schooling and different cut-off points should be used.OBJECTIVE: Evaluate the performance on verbal fluency (VF) in our population in a Brazilian sample checking the influence of age and literacy. METHODS: 336 people without neurological or psychiatric complaints evaluated through Mini-Mental State Examination and VF (animals). For comparison, and to determine cut-off points, 65 people with cognitive loss followed at our clinic were also evaluated. RESULTS: We found a mean of 13.8 animals in 1 minute, with the following distribution: illiterates, 11.9; up 4 years of education, 12.8; 4 to 7 years, 13.4; 8 years or more, 15.8 (p= 0.0001). In relation to age the means were: up to 64 years, 13.7; 65 years or more, 13.9. There was no difference between the two groups. The cut-off points were 9 for people under 8 years of education with a sensitivity of 75% for illiterates, 100% for low educational level (up 4 years),and 87% for middle level (4 to 7 years). The specificity was respectively 79%, 84%, and 88%. For the high educational level the mean was 13 with a sensitivity of 86% and specificity of 67%. CONCLUSIONS: In the VF (animals) there is a significant influence of schooling and different cut-off points should be used.

Illiteracy: The neuropsychology of cognition without reading

Illiterates represent a significant proportion of the worlds population. Written language not only plays a role in mediating cognition, but also extends our knowledge of the world. Two major reasons for illiteracy can be distinguished, social (e.g., absence of schools), and personal (e.g., learning difficulties). Without written language, our knowledge of the external world is partially limited by immediate sensory information and concrete environmental conditions. Literacy is significantly associated with virtually all neuropsychological measures, even though the correlation between education and neuropsychological test scores depends on the specific test. The impact of literacy is reflected in different spheres of cognitive functioning. Learning to read reinforces and modifies certain fundamental abilities, such as verbal and visual memory, phonological awareness, and visuospatial and visuomotor skills. Functional imaging studies are now demonstrating that literacy and education influence the pathways used by the brain for problem-solving. The existence of partially specific neuronal networks as a probable consequence of the literacy level supports the hypothesis that education impacts not only the individuals day-to-day strategies, but also the brain networks. A review of the issues related to dementia in illiterates is presented, emphasizing that the association between the education level and age-related cognitive changes and education remains controversial. The analysis of the impact of illiteracy on neuropsychological test performance represents a crucial approach to understanding human cognition and its brain organization under normal and abnormal conditions.

Versão brasileira da Escala Cornell de depressão em demência (Cornell depression scale in dementia)

ABsTRACT - Objective: Translating and adapting the Cornell scale for depression in dementia to the Por-tuguese language and verifying the interrater and test-retest reliability of the translated and adapted version. Method: The Cornell scale was translated into Portuguese and back translated into english. Di-vergences of translation were identified and discussed, resulting in a version which was submitted to a pre-test for cross-cultural adaptation. The final version was administered to a sample of 29 patients with probable AD and to their caregivers. Results: The Cornell scale presented good interrater (Kappa=0,77; p<0,001) and test-retest reliability (Kappa=0,76; p<0,001). The final version was easy to administer and well understood by the caregivers. Conclusion: The Brazilian version of the Cornell scale is an instrument with good reliability to evaluate depression in patients with dementia. This tool will contribute to the evalua-tion and follow-up of depressed patients with dementia in our population and may also be used in multi-centric studies with Brazilian population.Key woRDs: depression, scales, adaptation, reproducibility of results.OBJECTIVE Translating and adapting the Cornell scale for depression in dementia to the Portuguese language and verifying the interrater and test-retest reliability of the translated and adapted version. METHOD The Cornell scale was translated into Portuguese and back translated into English. Divergences of translation were identified and discussed, resulting in a version which was submitted to a pre-test for cross-cultural adaptation. The final version was administered to a sample of 29 patients with probable AD and to their caregivers. RESULTS The Cornell Scale presented good interrater (Kappa=0,77; p<0,001) and test-retest reliability (Kappa=0,76; p<0,001). The final version was easy to administer and well understood by the caregivers. CONCLUSION The Brazilian version of the Cornell Scale is an instrument with good reliability to evaluate depression in patients with dementia. This tool will contribute to the evaluation and follow-up of depressed patients with dementia in our population and may also be used in multicentric studies with Brazilian population.

Recognition memory for emotional pictures in Alzheimer's patients

Objective– The purpose of the present study was to examine whether Alzheimer’s Disease (AD) patients can benefit from the emotional content of visual stimuli in a picture recognition test. Method– Sixteen patients with AD and 19 normal controls matched for age and years of education, were studied. Sixteen pictures (with varying emotional contents) were presented to each participant. Thirty minutes later, a recognition test was applied with the target‐pictures mixed among 34 others of similar content. The subjects were instructed to rate them as pleasant, unpleasant or indifferent. Results– The total of pictures correctly recognized by the AD patients (75.4% of the target‐pictures) was smaller than that of the controls (96.4%). Controls recognized more emotional pictures than indifferent pictures. Conclusions– Emotional content enhanced recognition of pictures in normal subjects, whereas for the Alzheimer’s subjects the emotional significance attached to the pictures was of no benefit to enhance recognition.

Promoter methylation analysis of SIRT3, SMARCA5, HTERT and CDH1 genes in aging and Alzheimer's disease.

Longevity related genes were investigated concerning promoter methylation. SIRT3, SMARCA5, HTERT and CDH1 promoters were analyzed in peripheral blood in relation to gender, age and Alzheimers disease (AD). Methylation Specific PCR assay (MSP) was used. There were no significant differences in methylation frequencies of SIRT3, SMARCA5 and CDH1 among young, elderly and AD groups (p> 0.05), showing no association with aging or AD. On the other hand, HTERT methylation frequency was associated with the aging process, in that AD patients differed from elderly controls (p=0.0086), probably due to telomere and immune dysfunctions involved in AD pathogenesis.

Microlinguistic aspects of the oral narrative in patients with Alzheimer's disease.

BACKGROUND Alzheimers disease (AD) is characterized by memory loss and cognitive impairment. Phonological, syntactic, semantic and discursive aspects of language may also be affected. Analysis of micro- and macrolinguistic abilities of discourse may assist in diagnosing AD. The aim of this study was to identify changes in the discourse (lexical errors and syntactic index) of AD patients. METHODS 121 elderly subjects narrated a story based on a seven-figure picture description. RESULTS Patients with AD presented more word-finding difficulties, revisions and repetitions, and the syntactic index was lower than controls. CONCLUSION Performance in microlinguistics at the lexical and syntactic levels was lower than expected in participants with AD.