Renata Avila

Atualização sobre alterações cognitivas em idosos com síndrome depressiva

OBJETIVO: Depressao e deficits cognitivos estao entre os principais problemas de saude mental na terceira idade. E muito comum que ambas as condicoes aparecam juntas e acarretem consequencias graves, como piora da qualidade de vida, declinio funcional, aumento no uso de servicos de saude, aumento da morbidade e da mortalidade. Conhecer quais sao as principais alteracoes cognitivas causadas pelo quadro depressivo tem grande importância para confirmar o diagnostico, planejar o tratamento e estabelecer parâmetros sobre o prognostico destes pacientes. O presente artigo tem como objetivo promover uma revisao sobre estudos publicados nos ultimos anos sobre alteracoes cognitivas em idosos com diagnostico de depressao. METODO: Para tanto, foram selecionados, atraves do Medline, os estudos mais relevantes do periodo de 1991 a 2005. DISCUSSAO: Os resultados destes estudos apontam para deficits cognitivos que vao alem de dificuldades de memoria, os quais sao relevantes tanto para o diagnostico diferencial entre depressao e demencia, entre depressao e envelhecimento normal, e para acompanhar mais de perto pacientes que apresentam risco aumentado de conversao para demencia no futuro.

Neuropsychological rehabilitation of memory deficits and activities of daily living in patients with Alzheimer's disease: a pilot study

Patients with Alzheimers disease (AD) gradually lose their cognitive competence, particularly memory, and the ability to perform daily life tasks. Neuropsychological rehabilitation is used to improve cognitive functions by facilitating memory performance through the use of external aids and internal strategies. The effect of neuropsychological rehabilitation through memory training - motor movements, verbal association, and categorization - and activities of daily living (ADL) training was tested in a sample of 5 elderly out-patients (mean age: 77.4 +/- 2.88 years), with mild AD (Mini-Mental State Examination score: 22.20 +/- 2.17) and their caregivers. All patients had been taking rivastigmine (6-12 mg/day) for at least 3 months before being assigned to the rehabilitation sessions, and they continued to take the medication during the whole program. Just before and after the 14-week neuropsychological rehabilitation program all patients were assessed by interviewers that did not participate in the cognitive training, using the Mini-Mental State Examination, Montgomery-Alsberg Depression Rating Scale, Hamilton Anxiety Scale, Interview to Determine Deterioration in Functioning in Dementia, Functional Test, Memory Questionnaire of Daily Living for patient and caregiver, Quality of Life Questionnaire for patient and caregiver, and a neuropsychological battery. The results showed a statistically significant improvement in ADL measured by Functional Test (P = 0.04), and only a small improvement in memory and psychiatric symptoms. Our results support the view that weekly stimulation of memory and training of ADL is believed to be of great value in AD treatment, not only delaying the progress of the disease, but also improving some cognitive functions and ADL, even though AD is a progressively degenerative disease.

Cholinesterase inhibitors as adjunctive therapy in patients with schizophrenia and schizoaffective disorder: a review and meta-analysis of the literature

AbstractBackground: Cognitive deficits have been described in patients with schizophrenia from the first descriptions of dementia praecox to current concepts of cognitive dysmetria. Nevertheless, little is known about how to deal with them. In Alzheimer disease, cholinergic deficit is found and cholinesterase inhibitors have been used to delay the progression of memory and cognitive dysfunction. Several lines of evidence suggest that the cholinergic system may be disrupted in schizophrenia. Objective: To evaluate cognitive and clinical effects of adjunctive cholinesterase inhibitors in patients with schizophrenia and schizoaffective disorder. Method: We conducted a literature search on PubMed and EMBASE (up to December 2008) for articles that investigated adjunctive cholinesterase inhibitors in patients with schizophrenia. The terms ‘schizophrenia’, ‘acetylcholinesterase inhibitors’, ‘rivastigmine’, ‘donepezil’, ‘galantamine’ and ‘cognitive deficit’ were searched with restriction for English language and without a year limit. All articles that presented original data from randomized, double-blind, placebo-controlled trials with donepezil, rivastigmine or galantamine in patients with schizophrenia or schizoaffective disorder were included in the meta-analysis. Studies were excluded for the following reasons: (i) case study/letter/correspondence/review; (ii) animal study; (iii) molecular/genetic investigation; and (iv) inclusion of patients with schizophrenia and co-morbid dementia. Few appropriate data for meta-analysis were found because of the large heterogeneity of the assessment instruments used. Nevertheless, effects of cholinesterase inhibitors in some cognitive domains (executive function, memory and language), psychopathology (using the Positive and Negative Syndrome Scale) and extrapyramidal symptoms could be analysed. Results: Six open-label and 24 double-blind studies were found. In five open-label studies there was an improvement in memory, attention and executive functions. Thirteen double-blind studies (four with rivastigmine, six with donepezil and three with galantamine) contributed to the meta-analysis. Significant improvement was found in this analysis for memory and the Trail Making test part A. Conclusions: The reviewed studies suggest that specific cognitive deficits (memory, and the motor speed and attention part of executive function) of patients with schizophrenia and schizoaffective disorder are responsive to rivastigmine, donepezil and galantamine as adjunctive therapy. Confirmatory studies are needed to determine the clinical utility of this treatment strategy.

Influence of education and depressive symptoms on cognitive function in the elderly

OBJECTIVE The purpose of the present study was to investigate the influence that education and depression have on the performance of elderly people in neuropsychological tests. METHODS The study was conducted at the Institute of Psychiatry, University of São Paulo School of Medicine, Hospital das Clínicas. All of the individuals evaluated were aged 60 or older. The study sample consisted of 59 outpatients with depressive disorders and 51 healthy controls. We stratified the sample by level of education: low = 1-4 years of schooling; high = 5 or more years of schooling. Evaluations consisted of psychiatric assessment, cognitive assessment, laboratory tests and cerebral magnetic resonance imaging. RESULTS We found that level of education influenced all the measures of cognitive domains investigated (intellectual efficiency, processing speed, attention, executive function and memory) except the Digit Span Forward and Fuld Object Memory Evaluation (immediate and delayed recall), whereas depressive symptoms influenced some measures of memory, attention, executive function and processing speed. Although the combination of a low level of education and depression had a significant negative influence on Stroop Test part B, Trail Making Test part B and Logical Memory (immediate recall), we found no other significant effects of the interaction between level of education and depression. CONCLUSION The results of this study underscore the importance of considering the level of education in the analysis of cognitive performance in depressed elderly patients, as well as the relevance of developing new cognitive function tests in which level of education has a reduced impact on the results.

Effect of temporal lobe structure volume on memory in elderly depressed patients.

OBJECTIVE To compare the volume of the hippocampus and parahippocampal gyrus in elderly individuals with and without depressive disorders, and to determine whether the volumes of these regions correlate with scores on memory tests. METHOD Clinical and demographic differences, as well as differences in regional gray matter volumes, were assessed in 48 elderly patients with depressive disorders and 31 control subjects. Brain (structural MRI) scans were processed using statistical parametric mapping and voxel-based morphometry. Cognitive tests were administered to subjects in both groups. RESULTS There were no between-group gray matter volume differences in the hippocampus or parahippocampal gyrus. In the elderly depressed group only, the volume of the left parahippocampal gyrus correlated with scores on the delayed naming portion of the visual-verbal learning test. There were also significant direct correlations in depressed subjects between the volumes of the left hippocampus, right and left parahippocampal gyrus and immediate recall scores on verbal episodic memory tests and visual learning tests. In the control group, there were direct correlations only between overall cognitive performance (as assessed with the MMSE) and the volume of right hippocampus, and between the total score on the visual-verbal learning test and the volume of the right and left parahippocampal gyrus. CONCLUSIONS These findings highlight different patterns of relationship between cognitive performance and volumes of medial temporal structures in depressed individuals and healthy elderly subjects. The direct correlation between delayed visual-verbal memory recall scores with left parahippocampal volumes specifically in elderly depressed individuals provides support to the view that depression in elderly populations may be a risk factor for dementia.

Resultados da reabilitação neuropsicológica em paciente com doença de Alzheimer leve

Binoculars have a pair of objective units for forming an image separated with a fixed spacing, a pair of erecting prism units for transforming the image received from the pair of objective units to an erect image, and a pair of eyepiece units. Each of the pair of erecting prism units has a Pechan roof prism having a roof face, a disparity existing between luminous flux center incident on each of said pair of erecting prisms and an optical axis along which light exits from each of said pairs of erecting prisms. Each one of the pair of prisms rotates around an optical axis of a corresponding one of the pair of objective units. The eyepiece units receive the erect image from the erecting prism units, respectively, with each of the pair of eyepiece units being rotatable around an optical axis of a corresponding one of the pair of objective units.

Neuropsychological rehabilitation in mild and moderate Alzheimer's disease patients

Objective: The purpose of this study was to analyze the effect of a neuropsychological rehabilitation (NR) program on patients with Alzheimer’s disease (AD). Methods: The sample was composed of 16 elderly outpatients who participated in an open trial with rivastigmine (6 to 12 mg/day) for 4 months and were randomized to 3 different groups: 1. group NR (N = 5), 2. individualized NR (N = 6) and 3. NR at home under supervision of a relative or caregiver (N = 5). All 3 groups fulfilled the same NR protocol consisting of a once a week session. Just before and after the 22 week period of rehabilitation, all patients were evaluated using psychiatric and functional scales, and neuropsychological tests by interviewers that did not participate in the cognitive training. Results: The intervention did not produce any statistically significant change, but small gains were observed on some cognition tests, activities of daily living (ADL), and psychiatric symptoms in groups 1 and 2. Conclusion: Group NR is recommended for reducing psychiatric symptoms, and individualized NR for improving ADL. NR at home either has no associated benefits, or the training sessions were not appropriately conducted by the caregiver. However, additional research with larger samples is necessary to confirm these observations.

DTI voxelwise analysis did not differentiate older depressed patients from older subjects without depression.

INTRODUCTION Neuroimaging has been widely used in studies to investigate depression in the elderly because it is a noninvasive technique, and it allows the detection of structural and functional brain alterations. Fractional anisotropy (FA) and mean diffusivity (MD) are neuroimaging indexes of the microstructural integrity of white matter, which are measured using diffusion tensor imaging (DTI). The aim of this study was to investigate differences in FA or MD in the entire brain without a previously determined region of interest (ROI) between depressed and non-depressed elderly patients. METHOD Brain magnetic resonance imaging scans were obtained from 47 depressed elderly patients, diagnosed according to DSM-IV criteria, and 36 healthy elderly patients as controls. Voxelwise statistical analysis of FA data was performed using tract-based spatial statistics (TBSS). RESULTS After controlling for age, no significant differences among FA and MD parameters were observed in the depressed elderly patients. No significant correlations were found between cognitive performance and FA or MD parameters. CONCLUSION There were no significant differences among FA or MD values between mildly or moderately depressed and non-depressed elderly patients when the brain was analyzed without a previously determined ROI.

Efeitos do treinamento auditivo em idosos com Comprometimento Cognitivo Leve

INTRODUCAO: Pesquisas demonstram a existencia do Transtorno do Processamento Auditivo em individuos com Comprometimento Cognitivo Leve.OBJETIVO: Verificar os efeitos de um treinamento auditivo, em individuos com comprometimento cognitivo leve.METODOS: Participaram 25 individuos, com idades entre 69 e 91 anos e diagnostico de Comprometimento Cognitivo Leve, sendo que, 10 receberam treinamento auditivo (grupo estudo), 10 receberam treinamento visual (grupo alternativo) e cinco nao receberam intervencao (grupo controle). Testes cognitivos e de processamento auditivo foram aplicados antes e apos os treinamentos.RESULTADOS: Apenas o grupo estudo apresentou melhora significante para todas as habilidades auditivas testadas, mas com piora do desempenho para as habilidades cognitivas.CONCLUSAO: O treinamento auditivo foi efetivo em relacao as habilidades auditivas, mas nao em relacao as habilidades cognitivas.

Validation of a treatment algorithm for major depression in an older Brazilian sample.

The aim of this study was to investigate the effectiveness of a modified version of the Duke Somatic Algorithm Treatment for Geriatric Depression (STAGED) in a Brazilian sample of older patients with major depression. Besides, we aimed to investigate possible baseline predictive factors for remission in this sample.