Regina Miksian Magaldi

Correlação entre o estresse do cuidador e as características clínicas do paciente portador de demência

OBJECTIVE: To verify the correlation between caregiver burden in dementia and characteristics of patients and caregivers. METHODS: Analysis of medical records. Patient data: socio-demographic characteristics, comorbidities, medications (previous and current), onset of diagnosis and symptoms, type of dementia and severity (cognitive impairment and functional abilities), behavioral disorders. Caregiver data: socio-demographic characteristics, kinship, duration of caregiving and co-residency with the patient. Caregiver burden assessed by the Zarit interview. RESULTS: Sixty seven patients (76.8 years (± 6.2), 53.7% women) and 82% female caregivers were surveyed. Correlation between burden and behavior disorders (p<0.001), dependencies (p=0.003), onset of symptoms (p=0.016) and of caregiving (p<0.001), previous diagnosis (p=0.016) and co-residency (p=0.002) was studied. Cognitive test scores (Mini Mental and CAMCOG) were inversely proportional to distress (p=0.005 and p=0.023). Black caregivers demonstrated lower levels of stress (p=0.012). CONCLUSION: Burden was associated with behavioral disorders, dependencies, cognitive impairment, and onset of symptoms, caregiving and co-residency. Black caregivers demonstrated lower levels of stress.

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.

Short Assessment of Health Literacy for Portuguese-speaking Adults

OBJECTIVE To develop and validate a short health literacy assessment tool for Portuguese-speaking adults. METHODS The Short Assessment of Health Literacy for Portuguese-speaking Adults is an assessment tool which consists of 50 items that assess an individuals ability to correctly pronounce and understand common medical terms. We evaluated the instruments psychometric properties in a convenience sample of 226 Brazilian older adults. Construct validity was assessed by correlating the tool scores with years of schooling, self-reported literacy, and global cognitive functioning. Discrimination validity was assessed by testing the tools accuracy in detecting inadequate health literacy, defined as failure to fully understand standard medical prescriptions. RESULTS Moderate to high correlations were found in the assessment of construct validity (Spearmans coefficients ranging from 0.63 to 0.76). The instrument showed adequate internal consistency (Cronbachs alpha=0.93) and adequate test-retest reliability (intraclass correlation coefficient=0.95). The area under the receiver operating characteristic curve for detection of inadequate health literacy was 0.82. A version consisting of 18 items was tested and showed similar psychometric properties. CONCLUSIONS The instrument developed showed good validity and reliability in a sample of Brazilian older adults. It can be used in research and clinical settings for screening inadequate health literacy.OBJETIVO: Desenvolver e validar um instrumento breve para avaliacao de alfabetismo em saude na lingua portuguesa. METODOS: O instrumento desenvolvido consiste de 50 itens que avaliam a capacidade do individuo de pronunciar e compreender termos medicos comuns. As propriedades psicometricas foram avaliadas em uma amostra de 226 idosos brasileiros. A validade de construto foi estabelecida pela correlacao com o numero de anos de escolaridade, relato de alfabetismo funcional e desempenho cognitivo global. A validade discriminativa foi estabelecida pela acuracia do instrumento na deteccao de alfabetismo em saude inadequado, definido como a incapacidade de compreender corretamente prescricoes medicas padronizadas. RESULTADOS: As correlacoes com os criterios de construto apresentaram magnitude moderada a alta (coeficientes de Spearman = 0,63 a 0,76). O instrumento apresentou ainda consistencia interna satisfatoria (Cronbach = 0,93) e boa confiabilidade teste-reteste (coeficiente de correlacao intraclasse = 0,95). A area sob a curva caracteristica de operacao do receptor para deteccao de alfabetismo inadequado foi 0,82. Uma versao com 18 itens foi derivada e apresentou propriedades psicometricas similares. CONCLUSOES: O instrumento desenvolvido apresentou boa validade e consistencia em uma amostra de idosos brasileiros e pode ser utilizado em ambientes clinicos ou de pesquisa com a finalidade de detectar alfabetismo em saude inadequado.

Functional health literacy and glycaemic control in older adults with type 2 diabetes: a cross-sectional study

Objectives To investigate the relationship between functional health literacy and glycaemic control in a sample of older patients with type 2 diabetes. Design Cross-sectional study. Setting A government-financed outpatient geriatric clinic in São Paulo, Brazil. Participants 129 older patients with type 2 diabetes, a mean (SD) age of 75.9 (6.2) years, a mean glycosylated haemoglobin (HbA1c) of 7.2% (1.4), of which 14.7% had no formal education and 82.9% had less than a high-school diploma. Measures HbA1c was used as a measure of glycaemic control. Functional health literacy was assessed with the 18-item Short Assessment of Health Literacy for Portuguese-speaking Adults (SAHLPA-18), a validated instrument to evaluate pronunciation and comprehension of commonly used medical terms. Regression models were controlled for demographic data, depressive symptoms, diabetes duration, treatment regimen, diabetes knowledge and assistance for taking medications. Results Functional health literacy below adequate was encountered in 56.6% of the sample. After controlling for potential confounding factors, patients with inadequate functional health literacy were more likely than patients with adequate functional health literacy to present poor glycaemic control (OR=4.76; 95% CI 1.36 to 16.63). In a fully adjusted linear regression model, lower functional health literacy (β=−0.42; p<0.001), longer diabetes duration (β=0.24; p=0.012) and lack of assistance for taking medications (β=0.23; p=0.014) were associated with higher levels of HbA1c. Contrary to our expectations, illiterate patients did not have poorer outcomes when compared with patients with adequate functional health literacy, raising the hypothesis that illiterate individuals are more likely to have their difficulties recognised and compensated. However, the small subsample of illiterate patients provided limited power to reject differences with small magnitude. Conclusions Patients with inadequate functional health literacy presented with higher odds of poor glycaemic control. These findings reinforce the importance of addressing limited functional health literacy in clinical practice.

Effects of Tai Chi Chuan on cognition of elderly women with mild cognitive impairment

OBJECTIVE To detect the effects of Tai Chi Chuan practice on the cognition of elderly subjects with Mild Cognitive Impairment. METHODS This is a pilot study with 26 elderly patients (mean age of 74 years) with Mild Cognitive Impairment. The evaluation instruments were Subjective Memory Complaint Scale (SMC), Rivermead Behavioral Memory Test (RBMT) and Digit Span Forward and Backward (DSF and DSB) from the Wechsler Adult Intelligence Scale (WAIS). One group of 13 patients received two weekly 60-minute classes of Tai Chi Chuan (Yang style) for 6 consecutive months, and the rest formed the Control Group. The Tai Chi Chuan Group was also evaluated as to learning of the Tai Chi Chuan practical exercises by means of a Specific Learning Test applied after three months of intervention. RESULTS After six months of intervention, the TCC Group showed significant improvement on the RBMT and the SMC (p = 0.007 and p = 0.023, respectively). The Control Group showed no significant differences in the cognitive tests during the study. There was a significant correlation between the Tai Chi Chuan Learning Test and RBMT (p = 0.008), showing that patients with a better performance in exercising TCC also showed a better performance in memory. CONCLUSIONS In this study, a six-month program of Tai Chi Chuan afforded a significant improvement of the performance of memory complaints in the elderly with Mild Cognitive Impairment. Additional randomized studies with larger samples and more prolonged follow-up are needed to confirm these benefits.

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.

Estimating Premorbid Cognitive Abilities in Low-Educated Populations

Objective To develop an informant-based instrument that would provide a valid estimate of premorbid cognitive abilities in low-educated populations. Methods A questionnaire was drafted by focusing on the premorbid period with a 10-year time frame. The initial pool of items was submitted to classical test theory and a factorial analysis. The resulting instrument, named the Premorbid Cognitive Abilities Scale (PCAS), is composed of questions addressing educational attainment, major lifetime occupation, reading abilities, reading habits, writing abilities, calculation abilities, use of widely available technology, and the ability to search for specific information. The validation sample was composed of 132 older Brazilian adults from the following three demographically matched groups: normal cognitive aging (n = 72), mild cognitive impairment (n = 33), and mild dementia (n = 27). The scores of a reading test and a neuropsychological battery were adopted as construct criteria. Post-mortem inter-informant reliability was tested in a sub-study with two relatives from each deceased individual. Results All items presented good discriminative power, with corrected item-total correlation varying from 0.35 to 0.74. The summed score of the instrument presented high correlation coefficients with global cognitive function (r = 0.73) and reading skills (r = 0.82). Cronbachs alpha was 0.90, showing optimal internal consistency without redundancy. The scores did not decrease across the progressive levels of cognitive impairment, suggesting that the goal of evaluating the premorbid state was achieved. The intraclass correlation coefficient was 0.96, indicating excellent inter-informant reliability. Conclusion The instrument developed in this study has shown good properties and can be used as a valid estimate of premorbid cognitive abilities in low-educated populations. The applicability of the PCAS, both as an estimate of premorbid intelligence and cognitive reserve, is discussed.

Criteria for the diagnosis of Alzheimer's disease: Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology

This consensus prepared by the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology is aimed at recommending new criteria for the diagnosis of dementia and Alzheimer’s disease (AD) in Brazil. A revision was performed of the proposals of clinical and of research criteria suggested by other institutions and international consensuses. The new proposal for the diagnosis of dementia does not necessarily require memory impairment if the cognitive or behavioral compromise affects at least two of the following domains: memory, executive function, speech, visual-spatial ability and change in personality. For the purpose of diagnosis, AD is divided into three phases: dementia, mild cognitive impairment and pre-clinical phase, where the latter only applies to clinical research. In the dementia picture, other initial forms were accepted which do not involve amnesia and require a neuroimaging examination. Cerebrospinal fluid biomarkers are recommended for study, but can be utilized as optional instruments, when deemed appropriate by the clinician.

Efeitos da prática de Tai Chi Chuan na cognição de idosas com comprometimento cognitivo leve

Objetivo: Detectar os efeitos da pratica de Tai Chi Chuan na cognicao de idosas com comprometimento cognitivo leve. Metodos: Estudo piloto com 26 idosas (media de idade de 74 anos) com comprometimento cognitivo leve. Os instrumentos de avaliacao foram: Escala Subjetiva de Queixas de Memoria (EQM), Teste Comportamental de Memoria de Rivermead (RBMT) e Amplitude de Digitos Verbal Direta e Indireta (DD e DI, respectivamente) derivadas do Weschler Adult Intelligence Scale (WAIS). Um grupo de 13 pacientes recebeu duas aulas semanais de 60 minutos de Tai Chi Chuan (estilo Yang) por 6 meses consecutivos, e o restante formou o Grupo Controle. O grupo Tai Chi Chuan tambem foi avaliado quanto ao aprendizado da pratica dos exercicios de Tai Chi Chuan atraves de um Teste de Aprendizado Especifico aplicado apos tres meses de intervencao. Resultados: Apos seis meses de intervencao, o grupo Tai Chi Chuan apresentou melhora significativa no RBMT e na EQM (p = 0,007 e p = 0,023, respectivamente). O Grupo Controle nao apresentou diferencas significativas nos testes cognitivos no decorrer do estudo. Houve correlacao significativa entre o Teste de Aprendizado de Tai Chi Chuan e o RBMT (p = 0,008), apontando que os pacientes com melhor performance na pratica de Tai Chi Chuan apresentaram melhor desempenho da memoria. Conclusoes: Neste estudo, um programa de seis meses de Tai Chi Chuan propiciou uma melhora significativa do desempenho e das queixas de memoria de idosas com comprometimento cognitivo leve. Estudos adicionais randomizados com casuistica maior e seguimento mais prolongado sao necessarios para confirmar estes beneficios.

Learning to read in older age improves cognitive performance: findings from a prospective observational study.

Conflict of Interest: The authors have no conflict of interest. Author Contributions: Mo: first evaluator of PIM, study design, data acquisition, analyses, supervision, data interpretation, initial manuscript preparation. Yang: data analysis. He: second evaluator of PIM, study design, data interpretation, and final manuscript preparation. Dong: data interpretation. Sponsor’s Role: This work was supported in part by National Science Foundation of China 81270926 and Outstanding Scholar Foundation of Sichuan University 2013SCU04A17 to Jinhan He.