Paulo Rossi Menezes

Global prevalence of dementia: a Delphi consensus study.

BACKGROUND 100 years after the first description, Alzheimers disease is one of the most disabling and burdensome health conditions worldwide. We used the Delphi consensus method to determine dementia prevalence for each world region. METHODS 12 international experts were provided with a systematic review of published studies on dementia and were asked to provide prevalence estimates for every WHO world region, for men and women combined, in 5-year age bands from 60 to 84 years, and for those aged 85 years and older. UN population estimates and projections were used to estimate numbers of people with dementia in 2001, 2020, and 2040. We estimated incidence rates from prevalence, remission, and mortality. FINDINGS Evidence from well-planned, representative epidemiological surveys is scarce in many regions. We estimate that 24.3 million people have dementia today, with 4.6 million new cases of dementia every year (one new case every 7 seconds). The number of people affected will double every 20 years to 81.1 million by 2040. Most people with dementia live in developing countries (60% in 2001, rising to 71% by 2040). Rates of increase are not uniform; numbers in developed countries are forecast to increase by 100% between 2001 and 2040, but by more than 300% in India, China, and their south Asian and western Pacific neighbours. INTERPRETATION We believe that the detailed estimates in this paper constitute the best currently available basis for policymaking, planning, and allocation of health and welfare resources.

Chronic non-communicable diseases in Brazil: burden and current challenges

Non-communicable diseases (NCDs) have become a major health priority in Brazil--72% of all deaths were attributable to NCDs in 2007. They are also the main source of disease burden, with neuropsychiatric disorders being the single largest contributor. Morbidity and mortality due to NCDs are greatest in the poor population. Although the crude NCD mortality increased 5% between 1996 and 2007, age-standardised mortality declined by 20%. Declines were primarily for cardiovascular and chronic respiratory diseases, in association with the successful implementation of health policies that lead to decreases in smoking and the expansion of access to primary health care. Of note, however, the prevalence of diabetes and hypertension is rising in parallel with that of excess weight; these increases are associated with unfavourable changes of diet and physical activity. Brazil has implemented major policies for the prevention of NCDs, and its age-adjusted NCD mortality is falling by 1·8% per year. However, the unfavourable trends for most major risk factors pose an enormous challenge and call for additional and timely action and policies, especially those of a legislative and regulatory nature and those providing cost-effective chronic care for individuals affected by NCDs.

Métodos para estimar razão de prevalência em estudos de corte transversal

OBJETIVO: Comparar empiricamente las regresiones de Cox, log-binomial, Poisson y logistica para estimar razones de prevalencia en estudios de cohorte transversal. METODOS: Fueron utilizados datos de un estudio epidemiologico transversal (n=2.072), de base poblacional, realizado con ancianos en la ciudad de Sao Paulo (Sureste de Brasil), entre mayo de 2003 y abril de 2005. Diagnosticos de demencia, posibles casos de trastorno mental comun y autopercepcion de salud pesima fueron escogidos como resultados con prevalencia baja, intermedia y alta, respectivamente. Fueron utilizadas variables de confusion con dos o mas categorias o valores continuos. Valores de referencia para estimaciones por punto y por intervalo para las razones de prevalencia (RP) fueron obtenidos por el metodo de estratificacion de Mantel-Haenszel. Estimaciones ajustadas fueron calculadas utilizando regresiones de Cox y Poisson con varianza robusta, y regresion log-binomial. Odds ratios (OR) brutos y ajustados fueron obtenidos por la regresion logistica. RESULTADOS: Las estimaciones por punto y por intervalo obtenidas por las regresiones de Cox y Poisson fueron semejantes a la obtenida por la estratificacion de Mantel-Haenszel, independientemente de la prevalencia del resultado y de las covariables del modelo. El modelo log-binomial presento dificultad de convergencia cuando el resultado tenia prevalencia alta y habia convariable continua en el modelo. La regresion logistica produjo estimaciones por punto y por intervalo mayores de las obtenidas por los otros metodos, principalmente para los resultados con mayores prevalencia iniciales. Si se interpretaban como estimaciones de RP, los OR superestimarian las asociaciones para los resultados con prevalencia inicial baja, intermedia y alta en 13%, casi 100% y cuatro veces mas, respectivamente. CONCLUSIONES: En analisis de datos de estudios de cohorte transversal, los modelos Cox y Poisson con varianza robusta son mejores alternativas que la regresion logistica. El modelo de regresion log-binomial produjo estimaciones sin sesgo de la RP, pero puede presentar dificultad de convergencia cuando el resultado es muy frecuente y la variable de confusion es continua.OBJECTIVE To empirically compare the Cox, log-binomial, Poisson and logistic regressions to obtain estimates of prevalence ratios (PR) in cross-sectional studies. METHODS Data from a population-based cross-sectional epidemiological study (n = 2072) on elderly people in Sao Paulo (Southeastern Brazil), conducted between May 2003 and April 2005, were used. Diagnoses of dementia, possible cases of common mental disorders and self-rated poor health were chosen as outcomes with low, intermediate and high prevalence, respectively. Confounding variables with two or more categories or continuous values were used. Reference values for point and interval estimates of prevalence ratio (PR) were obtained by means of the Mantel-Haenszel stratification method. Adjusted PR estimates were calculated using Cox and Poisson regressions with robust variance, and using log-binomial regression. Crude and adjusted odds ratios (ORs) were obtained using logistic regression. RESULTS The point and interval estimates obtained using Cox and Poisson regressions were very similar to those obtained using Mantel-Haenszel stratification, independent of the outcome prevalence and the covariates in the model. The log-binomial model presented convergence difficulties when the outcome had high prevalence and there was a continuous covariate in the model. Logistic regression produced point and interval estimates that were higher than those obtained using the other methods, particularly when for outcomes with high initial prevalence. If interpreted as PR estimates, the ORs would overestimate the associations for outcomes with low, intermediate and high prevalence by 13%, almost by 100% and fourfold, respectively. CONCLUSIONS In analyses of data from cross-sectional studies, the Cox and Poisson models with robust variance are better alternatives than logistic regression is. The log-binomial regression model produces unbiased PR estimates, but may present convergence difficulties when the outcome is very prevalent and the confounding variable is continuous.

IQ and non-clinical psychotic symptoms in 12-year-olds: results from the ALSPAC birth cohort

Background Non-clinical psychotic symptoms appear common in children, but it is possible that a proportion of reported symptoms result from misinterpretation. There is a well-established association between pre-morbid low IQ score and schizophrenia. Psychosis-like symptoms in children may also be a risk factor for psychotic disorder but their relationship with IQ is unclear. Aims To investigate the prevalence, nature and frequency of psychosis-like symptoms in 12-year-old children and study their relationship with IQ. Method Longitudinal study using the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. A total of 6455 children completed screening questions for 12 psychotic symptoms followed by a semi-structured clinical assessment. IQ was assessed at 8 years of age using the Wechsler Intelligence Scale for Children (3rd UK edition). Results The 6-month period prevalence for one or more symptoms was 13.7% (95% CI 12.8–14.5). After adjustment for confounding variables, there was a non-linear association between IQ score and psychosis-like symptoms, such that only those with below average IQ score had an increased risk of reporting such symptoms. Conclusions Non-clinical psychotic symptoms occur in a significant proportion of 12-year-olds. Symptoms are associated with low IQ and also less strongly with a high IQ score. The pattern of association with IQ differs from that observed in schizophrenia.

Methods for estimating prevalence ratios in cross-sectional studies.

OBJETIVO: Comparar empiricamente las regresiones de Cox, log-binomial, Poisson y logistica para estimar razones de prevalencia en estudios de cohorte transversal. METODOS: Fueron utilizados datos de un estudio epidemiologico transversal (n=2.072), de base poblacional, realizado con ancianos en la ciudad de Sao Paulo (Sureste de Brasil), entre mayo de 2003 y abril de 2005. Diagnosticos de demencia, posibles casos de trastorno mental comun y autopercepcion de salud pesima fueron escogidos como resultados con prevalencia baja, intermedia y alta, respectivamente. Fueron utilizadas variables de confusion con dos o mas categorias o valores continuos. Valores de referencia para estimaciones por punto y por intervalo para las razones de prevalencia (RP) fueron obtenidos por el metodo de estratificacion de Mantel-Haenszel. Estimaciones ajustadas fueron calculadas utilizando regresiones de Cox y Poisson con varianza robusta, y regresion log-binomial. Odds ratios (OR) brutos y ajustados fueron obtenidos por la regresion logistica. RESULTADOS: Las estimaciones por punto y por intervalo obtenidas por las regresiones de Cox y Poisson fueron semejantes a la obtenida por la estratificacion de Mantel-Haenszel, independientemente de la prevalencia del resultado y de las covariables del modelo. El modelo log-binomial presento dificultad de convergencia cuando el resultado tenia prevalencia alta y habia convariable continua en el modelo. La regresion logistica produjo estimaciones por punto y por intervalo mayores de las obtenidas por los otros metodos, principalmente para los resultados con mayores prevalencia iniciales. Si se interpretaban como estimaciones de RP, los OR superestimarian las asociaciones para los resultados con prevalencia inicial baja, intermedia y alta en 13%, casi 100% y cuatro veces mas, respectivamente. CONCLUSIONES: En analisis de datos de estudios de cohorte transversal, los modelos Cox y Poisson con varianza robusta son mejores alternativas que la regresion logistica. El modelo de regresion log-binomial produjo estimaciones sin sesgo de la RP, pero puede presentar dificultad de convergencia cuando el resultado es muy frecuente y la variable de confusion es continua.OBJECTIVE To empirically compare the Cox, log-binomial, Poisson and logistic regressions to obtain estimates of prevalence ratios (PR) in cross-sectional studies. METHODS Data from a population-based cross-sectional epidemiological study (n = 2072) on elderly people in Sao Paulo (Southeastern Brazil), conducted between May 2003 and April 2005, were used. Diagnoses of dementia, possible cases of common mental disorders and self-rated poor health were chosen as outcomes with low, intermediate and high prevalence, respectively. Confounding variables with two or more categories or continuous values were used. Reference values for point and interval estimates of prevalence ratio (PR) were obtained by means of the Mantel-Haenszel stratification method. Adjusted PR estimates were calculated using Cox and Poisson regressions with robust variance, and using log-binomial regression. Crude and adjusted odds ratios (ORs) were obtained using logistic regression. RESULTS The point and interval estimates obtained using Cox and Poisson regressions were very similar to those obtained using Mantel-Haenszel stratification, independent of the outcome prevalence and the covariates in the model. The log-binomial model presented convergence difficulties when the outcome had high prevalence and there was a continuous covariate in the model. Logistic regression produced point and interval estimates that were higher than those obtained using the other methods, particularly when for outcomes with high initial prevalence. If interpreted as PR estimates, the ORs would overestimate the associations for outcomes with low, intermediate and high prevalence by 13%, almost by 100% and fourfold, respectively. CONCLUSIONS In analyses of data from cross-sectional studies, the Cox and Poisson models with robust variance are better alternatives than logistic regression is. The log-binomial regression model produces unbiased PR estimates, but may present convergence difficulties when the outcome is very prevalent and the confounding variable is continuous.

O Brasil está envelhecendo: boas e más notícias por uma perspectiva epidemiológica

The worlds population is under an aging process, and this demographic revolution is now affecting developing countries such as Brazil. The dramatic increase in the number of older adults observed in the last few years has had significant implications in health planning and delivery of health services, including mental health. This study reviews the current demographic profile of elderly population and its consequences for the practice of psychiatry and organization of mental health services in Brazil.

High prevalence of dementia among older adults from poor socioeconomic backgrounds in Sao Paulo, Brazil

BACKGROUND The aim of this study was to determine the prevalence of dementia in a socioeconomically disadvantaged population of older adults living in the city of São Paulo, Brazil. METHODS A cross-sectional one-phase population-based study was carried out among all residents aged > or = 65 in defined census sectors of an economically disadvantaged area of São Paulo. Identification of cases of dementia followed the protocol developed by the 10/66 Dementia Research Group. RESULTS Of 2072 individuals in the study, 105 met the criteria for a diagnosis of dementia, yielding a prevalence of 5.1%. Prevalence increased with age for both men and women after age 75 years, but was stable from 65 to 74 years. Low education and income were associated with increased risk of dementia. CONCLUSIONS The prevalence of dementia among older adults from low socioeconomic backgrounds is high. This may be partly due to adverse socioeconomic conditions and consequent failure to compress morbidity into the latter stages of life. The increasing survival of poorer older adults with dementia living in developing countries may lead to a rapid increase in the prevalence of dementia worldwide.

Impacto em cuidadores de idosos com demência atendidos em um serviço psicogeriátrico

OBJETIVO: O numero de idosos com demencia no Brasil esta crescendo rapidamente, e ha carencia de dados empiricos sobre o impacto em cuidadores informais. O objetivo do estudo foi avaliar o impacto sobre cuidadores informais de pacientes com sindrome demencial. METODOS: Estudo de corte transversal foi conduzido em um servico psicogeriatrico da cidade de Sao Paulo, Brasil. Entrevistas estruturadas e semi-estruturadas foram aplicadas em 49 idosos com demencia e em seus cuidadores informais. O impacto em cuidadores foi avaliado com a Zarit Burden Interview. RESULTADOS: Os pacientes eram em sua maioria do sexo feminino, apresentavam escore medio no mini exame do estado mental de 12,2 e alta frequencia de transtornos de comportamento. Os cuidadores eram predominantemente mulheres, filhas ou esposas, e co-residiam com seus pacientes. A media de impacto foi de 32,4 (dp: 16,7). As variaveis estatisticamente associadas a niveis de impacto foram o grau de parentesco do cuidador com o paciente (p=0,011), sintomas psiquiatricos do cuidador (p<0,001) e tempo em que o cuidador exercia o papel de cuidar (p=0,001). CONCLUSOES: Observou-se alta media de impacto em cuidadores de idosos, com demencia, que necessitam de atendimento psicogeriatrico. E necessario que os profissionais de saude estejam aptos a prover suporte adequado a esses cuidadores, com o objetivo de minimizar problemas tanto para pacientes, quanto para cuidadores.

Investigating whether adverse prenatal and perinatal events are associated with non-clinical psychotic symptoms at age 12 years in the ALSPAC birth cohort

BACKGROUND Non-clinical psychosis-like symptoms (PLIKS) occur in about 15% of the population. It is not clear whether adverse events during early development alter the risk of developing PLIKS. We aimed to examine whether maternal infection, diabetes or pre-eclampsia during pregnancy, gestational age, perinatal cardiopulmonary resuscitation or 5-min Apgar score were associated with development of psychotic symptoms during early adolescence. METHOD A longitudinal study of 6356 12-year-old adolescents who completed a semi-structured interview for psychotic symptoms in the Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort. Prenatal and perinatal data were obtained from obstetric records and maternal questionnaires completed during pregnancy. RESULTS The presence of definite psychotic symptoms was associated with maternal infection during pregnancy [adjusted odds ratio (OR) 1.44, 95% confidence interval (CI) 1.11-1.86, p=0.006], maternal diabetes (adjusted OR 3.43, 95% CI 1.14-10.36, p=0.029), need for resuscitation (adjusted OR 1.50, 95% CI 0.97-2.31, p=0.065) and 5-min Apgar score (adjusted OR per unit decrease 1.30, 95% CI 1.12-1.50, p<0.001). None of these associations were mediated by childhood IQ score. Most associations persisted, but were less strong, when including suspected symptoms as part of the outcome. There was no association between PLIKS and gestational age or pre-eclampsia. CONCLUSIONS Adverse events during early development may lead to an increased risk of developing PLIKS. Although the status of PLIKS in relation to clinical disorders such as schizophrenia is not clear, the similarity between these results and findings reported for schizophrenia indicates that future studies of PLIKS may help us to understand how psychotic experiences and clinical disorders develop throughout the life-course.

Age-related gray matter volume changes in the brain during non-elderly adulthood

Previous magnetic resonance imaging (MRI) studies described consistent age-related gray matter (GM) reductions in the fronto-parietal neocortex, insula and cerebellum in elderly subjects, but not as frequently in limbic/paralimbic structures. However, it is unclear whether such features are already present during earlier stages of adulthood, and if age-related GM changes may follow non-linear patterns at such age range. This voxel-based morphometry study investigated the relationship between GM volumes and age specifically during non-elderly life (18–50 years) in 89 healthy individuals (48 males and 41 females). Voxelwise analyses showed significant (p < 0.05, corrected) negative correlations in the right prefrontal cortex and left cerebellum, and positive correlations (indicating lack of GM loss) in the medial temporal region, cingulate gyrus, insula and temporal neocortex. Analyses using ROI masks showed that age-related dorsolateral prefrontal volume decrements followed non-linear patterns, and were less prominent in females compared to males at this age range. These findings further support for the notion of a heterogeneous and asynchronous pattern of age-related brain morphometric changes, with region-specific non-linear features.