Association between Apoε4 allele and cardiometabolic and social risk factors with cognitive impairment in elderly population from Bogota / Associação entre o alelo Apoε4 fatores de risco cardiometabólicos e sociais com prejuízo cognitivo em idosos de Bogotá

ABSTRACT Being an ϵ4 carrier in the Apoϵ gene has been suggested as a modifying factor for the interaction between cardio-metabolic, social risk factors, and the development of cognitive impairment. Objective: The main objective of this study was to assess the existence of such interaction in a sample of Bogota's elderly population. Methods: A cross-sectional study was conducted with 1,263 subjects older than 50 years. Each participant was diagnosed by consensus, after neuropsychological and neuropsychiatric evaluations, under a diagnosis of normal cognition, mild cognitive impairment (MCI) according to Petersen's criteria, or dementia according to DSM-IV criteria. Apoϵ was typified and an analysis of MoCA test was performed in each group carrying or not ϵ4 allele. Results: Our study showed that 75% were women with a median age of 68 years (interquartile range 62-74 years) and a median schooling for 6 years (interquartile range 4-12 years). Dementia was related to low education level of ≤5 years OR=11.20 (95%CI 4.99-25.12), high blood pressure (HBP) OR=1.45 (95%CI 1.03-2.05), and age over 70 years OR=7.68 (95%CI 3.49-16.90), independently of being or not an ϵ4 allele carrier. Diabetic subjects with dementia carrying ϵ4 allele showed a tendency to exhibit lower scores on the MoCA test, when compared with noncarriers' diabetic subjects with dementia. Conclusions: The presence of ϵ4 allele does not modify the relationship between cognitive impairment and the different cardio-metabolic and social risk factors, except in diabetic subjects ϵ4 carriers with dementia who showed a tendency to exhibit lower scores of the MoCA test, when compared with noncarriers' diabetic subjects with dementia.

RESUMO Ser um portador ϵ4 no gene Apoϵ tem sido sugerido como um fator modificador da interação entre fatores cardiometabólicos, de risco social e o desenvolvimento de comprometimento cognitivo. Objetivo: O objetivo principal deste trabalho é avaliar a existência de tal interação em uma amostra da população idosa de Bogotá. Métodos: Um estudo transversal foi realizado com 1.263 indivíduos com mais de 50 anos. Cada participante foi diagnosticado por consenso após avaliações neuropsicológicas e neuropsiquiátricas, sob um diagnóstico de cognição normal, comprometimento cognitivo leve de acordo com os critérios de Petersen ou demência de acordo com os critérios do Manual Diagnóstico e Estatístico de Trastornos Mentais (DSM-IV). Apoϵ4 foi tipificada e uma análise do Montréal Cognitive Assessment Test (teste de MoCA) foi realizada em cada grupo portador ou não do alelo ϵ4. Resultados: Nosso estudo mostrou que 75% eram mulheres com idade mediana de 68 anos (intervalo interquartil 62 a 74 anos) e escolaridade mediana de seis anos (intervalo interquartil 4 a 12 anos). A demência estava relacionada ao baixo nível de escolaridade ≤5 anos Odds Ratio (OR)=11,20 (intervalo de confiança — IC95% 4,99-25,12), pressão alta OR=1,45 (IC95% 1,03-2,05) e idade acima de 70 anos OR=7,68 (IC95% 3,49-16,90), independentemente de ser ou não portador do alelo ϵ4. Indivíduos diabéticos com demência portadores do alelo ϵ4 mostraram tendência de exibir pontuações mais baixas no teste MoCA quando comparados com indivíduos diabéticos com demência não portadores do alelo ϵ4. Conclusões: A presença do alelo ϵ4 não modifica a relação entre o comprometimento cognitivo e os diferentes fatores de risco cardiometabólico e social, exceto em diabéticos portadores de ϵ4 com demência, que exibiram tendência a apresentar menores escores no teste MoCA quando comparados com indivíduos diabéticos com demência não portadores do alelo ϵ4.

Mild cognitive impairment (MCI) and dementia in a sample of adults in the city of Bogotá / Comprometimento cognitivo leve (CCL) e demência em uma amostra de adultos na cidade de bogotá

ABSTRACT The low prevalence of dementia described in communities is likely due to the low sensitivity of screening tests and an absence of evaluation by specialists. OBJECTIVE: To estimate the prevalence of mild cognitive impairment (MCI) and dementia in adults older than 50 years. METHODS: A two-phase, cross-sectional study was conducted by specialists to evaluate cognition and associated demographic risk factors in 1,235 independent community-dwelling adults from Bogotá. In Phase I, screening was performed using the MMSE and MoCA tests. In Phase II, after application of a comprehensive neuropsychological battery with neurologic and psychiatric evaluations, a cognitive diagnosis was established by consensus. RESULTS: The prevalence found for MCI was 34% and for dementia was 23%. MCI was associated with incomplete high school, OR=1.74 (95%CI=1.23-2.45), and with an age of 70-79 years, OR=1.93 (95%CI=1.47-2.53). A total of 73% of MCI cases were amnestic. Dementia was associated with incomplete primary education, OR=8.98 (95%CI=5.56-14.54), complete primary education, OR=6.23 (95%CI=3.70-10.47), and age older than eighty years, OR=3.49 (95%CI=2.23-5.44). CONCLUSION: The prevalence of dementia found was greater than the rates reported in previous studies. Low educational level was the main risk factor for cognitive impairment and should be considered in strategic planning for the local health system.

RESUMO A baixa prevalência de demência relatada em comunidades deve ser devida ao emprego de testes de rastreio de baixa sensibilidade e à falta da avaliação por especialistas. OBJETIVO: Estimar a prevalência de comprometimento cognitivo leve (CCL) e demência em adultos com idade superior a 50 anos. MÉTODOS: Um estudo transversal de duas fases realizado por especialistas, avaliando a cognição e os fatores de risco demográficos associados, com 1.235 adultos autônomos da comunidade em Bogotá. Em uma Fase I, foram realizados os testes de rastreio MEEM e MoCA. Na Fase II, após uma ampla bateria neuropsicológica com avaliações neurológicas e psiquiátricas, foi estabelecido um diagnóstico cognitivo por consenso. RESULTADOS: A prevalência encontrada de CCL foi de 34% e de demência, de 23%. CCL foi associado a ensino médio incompleto, OR=1,74 (IC 95%=1,23-2,45) e idade entre 70-79 anos, OR=1,93 (IC 95%=1,47-2,53). Entre os casos de CCL, 73% eram amnésticos. A demência foi associada a ensino fundamental incompleto, OR=8,98 (IC 95%=5,56-14,54), ensino fundamental completo, OR=6,23 (IC 95%=3,70-10,47) e idade superior a oitenta anos, OR=3,49 (IC 95%=2,23-5,44). CONCLUSÃO: A prevalência de demência encontrada é maior do que a relatada em estudos prévios. O baixo nível educacional foi o principal fator de risco para declínio cognitivo e deve ser considerado no planejamento estratégico do nosso sistema de saúde.

Contabilidad, validez de criterio y discriminante del Montreal Cognitive Assessment (MoCA) test, en un grupo de adultos de Bogotá / Reliability, criterion and discriminant validity of the Montreal Cognitive Assessment Test (MoCA) in a group of adults from Bogotá

Resumen Introducción: el MoCA-test es un instrumento breve de tamizaje, sensible y específico, utilizado para la detección del deterioro cognitivo leve (DCL) y la demencia, con puntos de corte que varían según la población estudiada. Objetivo: evaluar la confiabilidad y validez discriminante del MoCA-test, en un grupo de adultos de Bogotá, con diferentes escolaridades. Material y Métodos: se aplicó el MoCA-test y el MMSE, a 1174 adultos mayores de 50 años de diferentes localidades de Bogotá. Los sujetos con MoCA-test < 26 y MMSE <24, fueron citados a una segunda evaluación aplicándoseles un protocolo amplio y fueron analizados por consenso, para determinar normalidad o deterioro cognitivo. Se determinó la consistencia interna (con coeficiente alpha de Cronbach), confiabilidad test-retest (con coeficiente de Lin), la validez de criterio (con coeficiente de Spearman) y validez discriminante (por medio de curvas ROC) del MoCA-Test. Resultados: la consistencia interna (alfa-Cronbach=0.851) y la confiabilidad test-retest (Lin=0.62) fueron aceptables. La validez de criterio respecto al MMSE, fue moderada (r=0.65). El MoCA mostró capacidad para discriminar entre diferentes grupos diagnósticos y sociodemográficos. El área bajo la curva fue 0.76 para DCL y 0,81 para demencia; el punto de corte para discriminar entre normalidad y DCL en el grupo en general fue 20/21 y entre DCL y demencia 17/18. Estos puntos variaron con el grado de escolaridad. Conclusión: el MoCA-test puede ser el instrumento de tamización en atención primaria, para detectar deterioro cognitivo en nuestra población adulta, considerando los puntos de corte propuestos según la escolaridad. (Acta Med Colomb 2016; 40: 221-228).

Abstract Introduction: the MoCA-Test is a brief, sensitive and specific screening tool used to detect mild cognitive impairment (MCI) and dementia, with cut-off points that vary according to the population studied. Objective: to evaluate the reliability and discriminant validity of the MoCA-test, in a group of adults from Bogotá, with different levels of schooling. Material and Methods: the MoCA-test and the MMSE were applied to 1174 adults over 50 years old from different locations in Bogotá. Subjects with MoCA-test <26 and MMSE <24, were referred to a second evaluation by applying a broad protocol and were analyzed by consensus, to determine normality or cognitive impairment. Internal consistency (with Cronbach's alpha coefficient), test-retest reliability (with Lin coefficient), criterion validity (with Spearman's coefficient) and discriminant validity (using ROC curves) of the MoCA-Test were determined. Results: internal consistency (alpha-Cronbach = 0.851) and test-retest reliability (Lin = 0.62) were acceptable. The criterion validity with respect to MMSE was moderate (r = 0.65). The MoCA-test showed the capacity to discriminate between different diagnostic and sociodemographic groups. The area under the curve was 0.76 for MCI and 0.81 for dementia; the cutoff point for discriminating between normality and MCI in the group in general was 20/21 and between MCI and dementia 17/18. These points varied with the level of schooling. Conclusion: the MoCA-test can be the screening tool in primary care in order to detect cognitive impairment in our adult population, considering the proposed cutoff points according to schooling. (Acta Med Colomb 2016; 40: 221-228).

Acuerdo intra-interobservador en las pruebas Minimental State Examination (MMSE) y Montreal Cognitive Assessment (MoCA test) aplicados por personal en entrenamiento / Intra and interrater reliability of the Minimental State Exmination (MMSE) and Montréal Cognitive Assessment (MoCA test) applied by health personnel in training

Introducción: en el proceso del diagnóstico neuropsicológico, los instrumentos de tamizaje cognitivo, son una herramienta útil en la identificación de cambios mentales del sujeto, en momentos puntuales o a través del tiempo. Su uso se fundamenta en el análisis psicométrico. Objetivo: determinar el acuerdo inter e intra-observador en el MoCA test y el MMSE, aplicado por profesores y estudiantes en procesos de entrenamiento de tamización cognitiva. Materiales y métodos: a los estudiantes y profesores en entrenamiento en la puntuación del MoCA test y el MMSE, se les presentó un video en dos sesiones, con un intervalo de 5 meses, mostrando el desempeño de dos adultos mayores, respondiendo el MoCA test y el MMSE, previo consentimiento informado. Se compararon los puntajes dados en las dos sesiones por los sujetos en entrenamiento, con los de ellos mismos (intra-observador), usando el coeficiente de concordancia y correlación de Lin(rho) y con los del grupo restante (inter-observador) usando el coeficiente de correlación intra-clase (ICC). Resultados: participaron 46 evaluadores. Se encontró alta confiabilidad inter-observador para el MoCA (ICC=0.86), pero baja para el MMSE (ICC=0.24) y baja confiabilidad intra-observador tanto para el MoCA (rho paciente 1=0.012 y rho paciente 2=0.152) como para el MMSE (rho paciente 1=0.008 y rho paciente 2=0.012). Aunque los puntajes difirieron, las clasificaciones diagnósticas realizadas por los evaluadores fueron similares a las del patrón de oro. Conclusión: la correcta aplicación del test, requiere varios entrenamientos, y aunque hubo pocas diferencias entre los puntajes, los errores cuando se está cerca del punto de corte propuesto, aumentan el riesgo de sesgo.

Introduction: The instruments for screening cognitive functions, applied to subjects in clinical settings and research, are useful for determining if this person has any trouble in cognition or show changes in the time. The usefulness of these instruments is defined with the evaluation of their psychometrics properties. Objective: This study allows to determine the intra and inter-observer agreement, when the MoCA test and MMSE were applied by a group in training process Materials and methods: The study group who attended two training sessions, with an interval of 5 months, scored the MoCA test and MMSE, from two patients which were filmed responding the tests, previous informed consent signature. We compared how close were the scores of participants among themselves by concordance correlation coefficient of Lin (rho) and with those given from the others by intra-class correlation coefficients (ICC). Results: In total, 46 participants were included. Intra-rater reliability was high for MoCA test (ICC = 0.86), but it was poor for MMSE (ICC=0.24). Inter-rater was poor for MoCA test (rho patient 1= 0.012, rho patient 2= 0.152) and MMSE (rho patient 1 = 0.008, rho patient 2 = 0.012). Although the scores between participants and gold standard were different, the diagnoses were similar. Conclusion:The correct scoring of the test, requires several trainings to clinical and research groups, and although they can be found few differences between scores applied by non-expert personnel, if the scores mistakenly given, are close to the cut-of point proposed for each test, the bias increases.

Consistencia interna y validez de contenido del instrumento DELBI / Internal consistency and content validity of DELBI scale

Objetivos: Evaluar la consistencia interna y la validez de contenido de la escala DELBI para evaluación de guías de práctica clínica (GPC). Métodos: Fueron seleccionadas 146 GPC de cáncer de mama, colorrectal y de próstata, a las que se aplicó el instrumento DELBI. Se evaluó la consistencia interna de la escala completa y por dominios utilizando el coeficiente alfa de Cronbach y se evaluó la validez de contenido de la escala por medio de un análisis factorial exploratorio (AFE) con rotación ortogonal y uno confirmatorio (AFC) a través de ecuaciones estructurales; para el AFE se determinó que la matriz fuera factorizable por medio del test de esfericidad de Bartlett y el criterio KMO y para el AFC se utilizaron matrices policóricas y métodos de estimación asintótica, teniendo en cuenta que las opciones de respuesta son ordinales. Resultados: Se observó una consistencia interna buena para la escala total (0,89), la cual varió entre 0,46 y 0,74 en los dominios. El AFE mostró una estructura de cuatro factores sugiriendo una agrupación de los ítems en cuatro dominios: aplicabilidad, claridad y presentación, rigor en la elaboración y participación de los implicados. El AFC mostró un mejor ajuste de la escala organizada en cuatro dominios que en los ocho dominios de la escala original, los cuales tuvieron mejor consistencia interna. Conclusiones: Se concluye que la escala tiene propiedades psicométricas aceptables y se sugiere considerar cuadro dimensiones de calidad de las GPC en la interpretación de las evaluaciones realizadas con el DELBI.

Objectives: To assess internal consistency and content validity of the DELBI scale used to evaluate clinical practice guidelines (CPG). Methods: The DELBI scale was applied to a selection of 146 CPG for breast, colorectal and prostate cancer. Internal consistency of the full scale and by domains was assessed using Cronbach's alpha coefficient, and the content validity was assessed using an Exploratory Factor Analysis (EFA) with orthogonal rotation and a Confirmatory Factor Analysis (CFA) applying structural equation modelling. Bartlett's test of sphericity and KMO test were used to determine the factorability of the intercorrelation matrix, with the ordinal nature of the item-scores as a Likert-type scale. Estimation methods were performed using polychoric correlation, and asymptotic covariance matrices. Results: For the full scale, a good internal consistency was observed (0.89), which varies between 0.46 and 0.74 by domains. A four-factor structure was found: applicability, clarity and presentation, rigour of development, and stakeholder involvement. The goodness-of-fit tests of the scale organised by 4 domains was better than the 8 domains from the original scale and had a better internal consistency. Conclusions: It is concluded that the scale has acceptable psychometric properties and it is suggested to consider four dimensions of quality of CPGs in the interpretation of the evaluations performed with the DELBI scale.

¿Son la religiosidad y la espiritualidad dimensiones diferentes? / Are religiosity and spirituality different dimensions?

Objetivo: Establecer si la espiritualidad y la religiosidad son dimensiones independientes. Método: En una muestra de 251 pacientes con diagnóstico de cáncer se efectuaron mediciones simultáneas usando dos cuestionarios para evaluar espiritualidad (FACIT-Sp) y religiosidad (DSES). Se usó análisis de correlación y técnicas de análisis multivariado (análisis factorial y escalamiento multidimensional) para evaluar la asociación entre las dos dimensiones. Resultados: Los niveles de correlación fueron más altos en el componente dentro de las escalas, viéndose los mayores valores de coeficientes de correlación en la escala DSES. EL análisis factorial sugiere una estructura multidimensional (4 componentes explican el 66% de la varianza), donde los ítems de la escala DSES dan cuenta de la variabilidad de sólo uno de los cuatro componentes. Dos de los ítems de la escala DSES (D13, D14) parecen no ajustarse al constructo. EL análisis de escalamiento multidimensional sugiere que los ítems correspondientes a las escalas DSES y FACIT-Sp miden dimensiones independientes. Conclusión: Los resultados de este estudio sugieren que la religiosidad y la espiritualidad son conceptos teóricos independientes.

Objective: To establish if spirituality and religion are independent dimensions. Method: Simultaneous measurements using two questionnaires for evaluating spirituality (FACIT-Sp) and religiosity (DSES) in a sample of 251 patients diagnosed as having cancer. Correlation analysis and multivariate techniques (factor analysis and multidimensional scaling) were used to evaluate associations between dimensions. Results: Correlation levels were higher in the intra-scale component, with the DSES items having the better correlation coefficients. Factor analysis suggests a multidimensional structure (4 components explaining 66% of the total variance), whereas DSES items account for the variance of only one factor. Two of the items of the DSES scale (D13, D14) do not seem to fit. Multidimensional scaling suggests that items corresponding to DSES and FACIT-Sp measure independent dimensions. Conclusion: Results suggest that religiosity and spirituality seem to be independent theoretical concepts.

Adaptación transcultural del cuestionario EORTC QLQ-OES18 para medir calidad de vida en pacientes con cáncer de esófago en Colombia / Cross-cultural adaptation of the EORTC QLQ-OES18 questionnaire to measure quality of life in patients with esophageal cancer in Colombia

Objetivos: Llevar a cabo la adaptación transcultural al contexto colombiano de la escala de calidad de vida EORTC QLQ-OES18 para pacientes con cáncer de esófago. Métodos: De acuerdo con el proceso de adaptación propuesto por la organización EORTC, se ejecutaron los siguientes pasos: solicitud de adaptación transcultural, primera prueba piloto, aprobación de adaptación y validación lingüística, segunda prueba piloto y versión final. En cada prueba piloto se aplicó la escala y posteriormente una entrevista estructurada a un grupo de pacientes con cáncer de esófago que asistieron a consulta en el Instituto Nacional de Cancerología, con el fin de identificar problemas de comprensión, confusión, palabras ofensivas o un parafraseo más adecuado de los items, para hacer un ajuste lingüístico de estos. Resultados: En cada prueba piloto participaron 12 pacientes. En la primera prueba se identificaron problemas en seis ítems, para los cuales se propuso un parafraseo más adecuado. El grupo de traducción EORTC y el grupo solicitante determinaron cuáles modificaciones lingüísticas propuestas podían ser adaptadas, conservando la equivalencia de la versión sugerida en español colombiano con la versión original en inglés. En la segunda prueba piloto no se observaron dificultades con los ítems. Un total de cinco ítems fueron modificados y adaptados culturalmente. Conclusiones: El proceso de adaptación resultó en un cuestionario fácilmente comprensible en el entorno cultural colombiano. Se dispone de una versión de la escala QLQ-OES18 en español colombiano para ser validada y utilizada en estudios de calidad de vida en pacientes con cáncer de esófago.

Objectives: To make a cross-cultural adaptation of the EORTC QLQ-OES18 quality of life scale to the Colombian context for patients with esophageal cancer. Methods: Using the adaptation procedure proposed by the EORTC organization, the following steps were performed: transcultural adaptation request, first pilot test, linguistic adaptation and validation, second pilot test, and final version. In the first pilot test the scale was applied followed by a structured interview with a group of patients with esophageal cancer who attended a clinic in the National Institute of Cancerology. The aim of this was to identify problems of comprehension, confusion, offensive words, or more suitable paraphrasing of the items, and to make a linguistic adjustment of them. Results: A group of 12 patients took part in each pilot test. Problems in six items were identified in the first test, for which more suitable paraphrasing was proposed. The EORTC translation group and the applicant group determined which of the proposed linguistic modifications could be adapted, in order to preserve the equivalence of the suggested Colombian Spanish version with the original English version. No difficulties in the items were observed in the second pilot test. A total of five items were modified and culturally adapted. Conclusions: The adaptation process resulted in an easily understood questionnaire in Colombian cultural environment. A version of the QLQ-OES18 scale is available in Colombian Spanish to be validated and used in quality of life studies on patients with esophageal cancer.

Dimensiones que conforman el constructo de calidad de vida en pacientes con cáncer / Dimensions of quality of life construct for cancer patients

Objetivo: En el presente trabajo se evaluaron los componentes del constructo "Calidad de vida" a partir de la respuesta dada por 707 pacientes a la pregunta: Para usted, ¿qué es calidad de vida? Los pacientes tenían diagnóstico de cáncer de cuello uterino, colorrectal o de próstata. Métodos: Se efectuó un análisis lexicográfico para ubicar las respuestas características utilizando como criterio el valor test. Resultados: Se encontró que hay ocho dimensiones subyacentes: espiritualidad, familia, sistema de salud, social, funcional, síntomas, componente económico y componente emocional. Dichas dimensiones son representadas de manera diferente según el sexo o el diagnóstico del paciente. Conclusiones: Se destaca la importancia de considerar las dimensiones de espiritualidad y sistema de salud para efectuar una medición más válida y confiable de la calidad de vida de los pacientes.

Objective: To evaluate the components which constitute a "quality of life" construct based upon answers given by 707 patients to the question: "In your opinion, what makes up quality of life?". Participating patients had been diagnosed with cervical, colorectal or prostate cancer. Methods: Lexicographic analysis was used to locate characteristic responses based upon the values test. Results: Eight underlying dimensions were pinpointed: spirituality, family, health care system, social structure, functional ability, symptoms, economic factors, and coping with emotions. Each dimension is represented differently according to gender or patient´s diagnosis. Conclusions: Emphasis should be given to the importance of spirituality and the health care system in order to carry out a more valid and precise measure of patients´ quality of life criteria.