Roberto Alves Lourenço

Validação da escala de depressão geriátrica em um ambulatório geral

OBJECTIVE The Geriatric Depression Scale for screening depressive symptoms in the elderly has not been assessed in elderly outpatients who seek primary health care in Brazil. The objective was to determine the validity of the Short Scale for Major Depressive Episode or Dysthymia (GDS-15) in elderly outpatients. METHODS The scale was applied in 302 subjects with 65 years and older and then examined by an independent geriatrician, blinded to the results. Major depression and dysthymia were diagnosed using the Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Sensitivity and specificity were calculated at several cutoff values and a Receiver Operating Characteristic curve was plotted. RESULTS The best equilibrium was at the cutoff value of 5/6 showing 81% sensitivity and 71% specificity; the area under the Receiver Operating Characteristic curve was 0.85 (95% CI: 0.79-0.91). CONCLUSIONS The GDS-15 can be used for screening depressive symptoms in Brazilian elderly outpatients. The previously suggested cutoff value of 5/6 is adequate.OBJETIVO: A Escala de Depressao Geriatrica, utilizada para o rastreamento de sintomas depressivos em idosos, ainda nao teve suas caracteristicas de medida avaliadas em ambulatorios gerais no Brasil. O objetivo foi estudar a validade da Escala, com 15 itens (EDG-15), na identificacao de episodio de Depressao Maior ou Distimia em idosos atendidos em ambulatorio geral. METODOS: A Escala foi aplicada em 302 individuos com 65 anos ou mais, que em seguida foram examinados, de maneira independente, por um geriatra que nao tinha conhecimento dos resultados da Escala. Os diagnosticos de Depressao Maior ou Distimia foram feitos utilizando-se os criterios do Diagnostic and Statistical Manual of Mental Disorders-IV. A sensibilidade e a especificidade nos varios pontos de corte foram expressas pela curva Receiver Operating Characteristic. RESULTADOS: O ponto de corte de melhor equilibrio foi 5/6, obteve sensibilidade de 81% e especificidade de 71%; e o valor da area sob a curva Receiver Operating Characteristic foi de 0,85 (IC 95%: 0,79-0,91). CONCLUSOES: A Escala de Depressao Geriatrica pode ser utilizada para o rastreamento de sintomas depressivos na populacao geriatrica ambulatorial brasileira. O ponto de corte 5/6, sugerido inicialmente por outros autores, mostrou-se adequado.

Normative data for healthy elderly on the phonemic verbal fluency task - FAS

Phonemic verbal fluency tests assess the production of words beginning with specific letters. Of these letters, the most frequently used are F, A and S. It is a sensitive test for assessing frontal lobe functions. Objective To provide normative data for the elderly Brazilian population on the FAS test and to investigate the effects of age and schooling on test performance. Methods The individuals were divided into three age groups (60–69, 70–79 and =80 years), and into four groups according to education (1–3, 4–7, 8–11 and 12 years). All subjects were assessed by the Mini Mental State Examination and the FAS. Data were analyzed with Student’s t test, ANOVA, simple linear regression and Spearman’s correlation. Results We evaluated 345 cognitively healthy volunteers, 66.66% being female, aged 60 to 93 years, with an educational level ranging from one to 24 years. The average (number of items) ±SD for the whole sample was 28.28±11.53. No significant effect of gender was observed (p=0.5). Performance on the MMSE and education exerted a direct influence on FAS scores (p<0.001), with education being the most significant factor. A positive correlation was found between FAS and the MMSE (r=0.404; p<0.001). Conclusion The performance of Brazilian elderly on the phonemic verbal fluency tests-FAS is significantly influenced by education, where individuals with higher educational level present better performance than those with fewer years of schooling. Age and gender did not prove significant with the FAS.

Assistência ambulatorial geriátrica: hierarquização da demanda

In Brazil, the rapid growth of the elderly population has been causing a great impact on the healthcare system, with increased costs and service utilization. The inefficiency of traditional models for geriatric healthcare has made it essential to change the healthcare concepts for this population. This can take place through the development of new healthcare models that include the means to identify, assess and treat elderly patients with a variety of morbid and functional conditions, and which can be applied diverse healthcare scenarios. An outpatient model is proposed, with two stages that differ in the depth and coverage of their actions. These stages are organized as increasing levels of complexity and are capable of selecting subgroups of individuals that, because of their risk characteristics, should follow different paths through the healthcare structure. This paper discusses the first stage of this model, which involves risk identification among large groups of elderly people, by means of structuring a hierarchical flow of actions and using assessment tools of adequate sensitivity and specificity. Individuals aged 65 years or over who are detected through walk-in outpatient consultation, home visits or telephone interview are classified using a rapid screening risk evaluation instrument composed of eight items. Depending upon the level of risk presented, the individual will either be referred to another level of functional evaluation (medium-high and high risk levels), or to normal clinical care and old peoples community centers (low and medium risk levels). The second stage will be the subject of a subsequent paper.No Brasil, o rapido crescimento da populacao de idosos vem produzindo grande impacto no sistema de saude, com elevacao dos custos e da utilizacao dos servicos. A ineficiencia dos modelos tradicionais de assistencia ao idoso torna imprescindivel a mudanca no paradigma de atencao a saude dessa populacao, por meio do desenvolvimento de novos modelos de atencao que incorporem a identificacao, a avaliacao e o tratamento de idosos com perfis morbidos e funcionais variados, passiveis de serem aplicados nas diversas modalidades assistenciais. Propoe-se um modelo ambulatorial, em duas etapas, que se diferencia pela profundidade e abrangencia das acoes, organizadas em niveis crescentes de complexidade e capazes de selecionar subgrupos de individuos que, por suas caracteristicas de risco, devem progredir, diferenciadamente, na estrutura de atencao. Descreve-se a primeira etapa, que pressupoe a captacao e identificacao de risco de grandes grupos de idosos, por meio de um fluxo hierarquizado de acoes e o uso de instrumentos de avaliacao com sensibilidades e especificidades adequadas. O individuo com 65 anos ou mais, captado por demanda espontânea ambulatorial, captacao domiciliar ou busca telefonica, e classificado segundo avaliacao de risco, denominada Triagem Rapida, composta de oito itens. Dependendo do risco encontrado, o individuo sera encaminhado para acompanhamento clinico usual e atividades em centros de convivencia de idosos (risco baixo e medio) ou para outra etapa da avaliacao funcional (riscos medio-alto e alto). A segunda etapa sera tema de artigo posterior.

Prevalence and factors associated with frailty in an older population from the city of Rio de Janeiro, Brazil: the FIBRA-RJ Study

OBJECTIVE: Frailty syndrome can be defined as a state of vulnerability to stressors resulting from a decrease in functional reserve across multiple systems and compromising an individuals capacity to maintain homeostasis. The purpose of this study was to determine the prevalence of frailty and its association with social and demographic factors, functional capacity, cognitive status and self-reported comorbidities in a sample of community-dwelling older individuals who are clients of a healthcare plan. METHODS: We evaluated 847 individuals aged 65 years or older who lived in the northern area of the city of Rio de Janeiro, Brazil. The subjects were selected by inverse random sampling and stratified by gender and age. To diagnose frailty, we used the scale proposed by the Cardiovascular Health Study, which consisted of the following items: low gait speed, grip strength reduction, feeling of exhaustion, low physical activity and weight loss. The data were collected between 2009 and 2010, and the frailty prevalence was calculated as the proportion of individuals who scored positive for three or more of the five items listed above. To verify the association between frailty and risk factors, we applied a logistic regression analysis. RESULTS: The prevalence of frailty syndrome was 9.1% (95% confidence interval [CI], 7.3-11.3); 43.6% (95% CI, 40.3-47) of the individuals were considered robust, and 47.3% (95% CI 43.8-50.8) were considered pre-frail (p<0.001). The frail individuals tended to be older (odds ratio [OR] 13.2, 95% CI, 8.7-20) and have lower education levels (OR 2.1, 95% CI, 1-4.6), lower cognitive performance (OR 0.76, 95% CI, 0.73-0.79) and reduced health perception (OR 65.8, 95% CI, 39.1-110.8). Frail individuals also had a greater number of comorbidities (OR 6.6, 95% CI, 4.4-9.9) and worse functional capacity (OR 3.8, 95% CI, 2.9-5). CONCLUSION: The prevalence of frailty was similar to that seen in other international studies and was significantly associated with educational level, cognition, comorbidities, functional capacity, perception of health and old age.

Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): adaptação transcultural para uso no Brasil

This article presents the results of the translation and cross-cultural adaptation of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) and the test-retest reliability of a version to be used in Brazil. An instrument review committee analyzed the conceptual and item equivalence. In order to analyze semantic equivalences, three translations and three back-translations were performed; a summary version was devised and pre-tested, and a test version elaborated. The Cronbachs +/- coefficient and intraclass correlation coefficient (ICC) were used to measure the internal consistency and test-retest reliability, respectively. Of the 169 informants assessed, 97 were retested. A Cronbachs +/- of 0.94 and an ICC of 0.92 were found. The reliability levels lead to the conclusion that the IQCODE-BR version is easy to comprehend. Satisfactory equivalence to the original version was observed.

Age and educational level effects on the performance of normal elderly on category verbal fluency tasks

Cognitive decline, particularly executive dysfunction, is observed in normal aging. In Brazil, the elderly population presents broad educational diversity. Category verbal fluency tests are frequently used to detect cognitive impairment, assessing executive function, language and semantic memory. Objective To investigate the effects of age and education on category animal fluency task (CAF) in healthy elderly. Methods We evaluated 319 healthy elderly from outpatient care units of two university reference centers of Rio de Janeiro and São Paulo. The sample was divided into two age, and five schooling subgroups. To be included participants had to demonstrate preservation of global cognitive functioning, independence for activities of daily living and not fulfill diagnostic criteria for dementia. All participants were submitted to neurological and neuropsychological evaluations. Results There was a correlation between age and CAF performance (r= –0.26, p<0.01), which was not confirmed when years of education were included as a covariant in univariate ANCOVA. Significant differences were found in CAF performance among the different educational level groups on correlation analysis (r=0.42, p<0.01) and ANCOVA analysis (F=18.8, p<0.05). Illiteracy was associated with worst CAF performance, while university level was associated with best performance. Conclusion The best CAF performance was found in the first years of schooling (literacy learning process) compared to illiteracy, and when finishing high school and starting university courses compared to all other educational levels. These stages are associated with significant gains in semantic memory and executive function which are critical for verbal fluency performance.

Performance of the European Working Group on Sarcopenia in Older People algorithm in screening older adults for muscle mass assessment.

BACKGROUND There is a lack of consensus on the diagnosis of sarcopenia. A screening and diagnostic algorithm was proposed by the European Working Group on Sarcopenia in Older People (EWGSOP). OBJECTIVE To assess the performance of the EWGSOP algorithm in determining the proportion of subjects suspected of having sarcopenia and selected to undergo subsequent muscle mass (MM) measurement. DESIGN A cross-sectional study. SETTING The cohorts, Frailty in Brazilian Older People Study-Rio de Janeiro (FIBRA-RJ), Brazil; Coyoacan Cohort (CC), Mexico City, Mexico; and Toledo Study for Healthy Aging (TSHA), Toledo, Spain. SUBJECTS Three thousand two hundred and sixty community-dwelling individuals, 65 years and older. METHODS Initially, the EWGSOP algorithm was applied using its originally proposed cut-off values for gait speed and handgrip strength; in the second step, values tailored for the specific cohorts were used. RESULTS Using the originally suggested EWGSOP cut-off points, 83.4% of the total cohort (94.4% in TSHA, 75.5% in FIBRA-RJ, 67.8% in CC) would have been considered as suspected of sarcopenia. Adapted cut-off values lowered the proportion of abnormal results to 34.2% (quintile-based approach) and 23.71% (z-score approach). CONCLUSIONS The algorithm proposed by the EWGSOP is of limited clinical utility in screening older adults for sarcopenia due to the high proportion of subjects selected to further undergo MM assessment. Tailoring cut-off values to specific characteristics of the population being studied reduces the number of people selected for MM assessment, probably improving the performance of the algorithm. Further research including the objective measure of MM is needed to determine the accuracy of these specific cut-off points.

RISK OF CARDIOVASCULAR DISEASE MORBIDITY AND MORTALITY IN FRAIL AND PRE-FRAIL OLDER ADULTS: RESULTS FROM A META-ANALYSIS AND EXPLORATORY META-REGRESSION ANALYSIS

Frailty is common and associated with poorer outcomes in the elderly, but its role as potential cardiovascular disease (CVD) risk factor requires clarification. We thus aimed to meta-analytically evaluate the evidence of frailty and pre-frailty as risk factors for CVD. Two reviewers selected all studies comparing data about CVD prevalence or incidence rates between frail/pre-frail vs. robust. The association between frailty status and CVD in cross-sectional studies was explored by calculating and pooling crude and adjusted odds ratios (ORs) ±95% confidence intervals (CIs); the data from longitudinal studies were pooled using the adjusted hazard ratios (HRs). Eighteen cohorts with a total of 31,343 participants were meta-analyzed. Using estimates from 10 cross-sectional cohorts, both frailty and pre-frailty were associated with higher odds of CVD than robust participants. Longitudinal data were obtained from 6 prospective cohort studies. After a median follow-up of 4.4 years, we identified an increased risk for faster onset of any-type CVD in the frail (HR=1.70 [95%CI, 1.18-2.45]; I2=66%) and pre-frail (HR=1.23 [95%CI, 1.07-1.36]; I2=67%) vs. robust groups. Similar results were apparent for time to CVD mortality in the frail and pre-frail groups. In conclusion, frailty and pre-frailty constitute addressable and independent risk factors for CVD in older adults.

Prevalence of fear of falling in older adults, and its associations with clinical, functional and psychosocial factors: The Frailty in Brazilian Older People‐Rio de Janeiro Study

The present study estimated the prevalence of fear of falling in older adults, and its associations with clinical, functional and psychosocial factors.

Complexity of lifetime occupation and cognitive performance in old age

BACKGROUND Occupation is recognized as a modifiable factor related to cognitive reserve in older adults. AIMS To examine the association between levels of complexity in lifelong occupations and cognitive performance in later life. METHODS A cross-sectional study of older adult users (aged 65 or more) of a private health care plan, resident in the north zone of Rio de Janeiro City, Brazil, and participating in the Rio de Janeiro section of the Study of Fragility in Brazilian Older Adults (FIBRA-RJ). Cognitive performance scores were obtained using the Mini-Mental State Examination. The level of complexity of their work was assessed in three domains: work with data, persons and things. Associations between the complexity of work in each domain and cognitive performance were evaluated using multivariate linear regression, adjusted for socio-demographic variables and duration of occupation. RESULTS A total of 624 older adults (94% of the study group) performed lifelong work activities. Among those working with data, the high complexity group had cognitive performance scores 1.08 points higher (P < 0.05) than low complexity. In work with things, scores in the intermediate complexity group were 0.53 points higher (P < 0.05) than low complexity. There was no statistically significant difference in the cognitive performance between levels of complexity of work with people. CONCLUSIONS Complexity in work with data and things was associated with better cognitive performance in later life, independent of age, schooling, income and duration of occupation.