Doença de Alzheimer: um estudo de caso sobre o transtorno neurocognitivo que mais afeta idosos / Alzheimer's disease: a case study involving the most prevalent neurocognitive disorder in older people

Resumo Objetivo Analisar a evolução clínica de um paciente acometido pela Doença de Alzheimer (DA) e discutir as repercussões de um diagnóstico precoce. Método Estudo de caso instrumental do tipo qualitativo e de caráter descritivo que se desenvolveu em três etapas: 1) seleção e delimitação do caso; 2) coleta dos dados em campo; e 3) organização e redação do relatório. Este estudo baseia-se na análise da evolução clínica descrita em prontuário de um paciente com diagnóstico de DA, atendido e acompanhado pelo Centro de Atenção Psicossocial (CAPS), por um período de 10 anos, na região do Alto Vale do Rio do Peixe. Resultados Estudo realizado com a paciente M.R., sexo feminino, 71 anos, casada e do lar, com ensino fundamental incompleto, portadora de DA e hipotireoidismo, a qual iniciou seu acompanhamento no CAPS II em 10 de setembro de 2012. Paciente submetida ao Miniexame do Estado Mental (MEEM), tendo como resultado no primeiro teste 14 pontos, abaixo do ponto de corte para o nível de escolaridade da paciente. Posteriormente, em 2018, registraram-se 10 pontos no MEEM, e em 2020 possuiu pontuação igual a 11, já em tratamento medicamentoso para DA: Memantina 10mg 2x/dia e Donepezila 5mg 1x/dia. Conclusão O diagnóstico precoce da DA é de extrema importância para tratamento adequado a fim de retardar a progressão da doença. No entanto, afecções mentais, tal como a depressão, constituem-se como barreiras na análise clínica inicial dos pacientes e ainda em certos casos apresenta-se como pródromo para a DA.

Abstract Objective To analyze the clinical evolution of a patient affected by Alzheimer's disease and discuss the repercussions of an early diagnosis. Method Instrumental case study of qualitative and descriptive type that was developed in three stages: 1) selection and delimitation of the case; 2) collection of data in the field; and 3) organization and writing of the report. This study is based on the analysis of the clinical evolution described in the medical records of a patient diagnosed with Alzheimer's disease, treated and followed-up by the Center for Psychosocial Care (CAPS), for a period of 10 years, in the Alto Vale do Rio do Peixe region. Results This study was conducted with the patient M.R., female, 71 years old, married, housewife, with incomplete elementary education, carrier of AD and hypothyroidism, who started her follow-up at CAPS II on September 10, 2012. Patient submitted to the Mini Mental State Examination (MMSE), with a result of 14 points in the first test, below the cut-off point for the patient's level of education. Later, in 2018, she scored 10 points on the MMSE, and in 2020 she scored 11, already under medication treatment for AD: memantine 10mg 2x/day and donepezilla 5mg 1x/day. Conclusion Early diagnosis of AD is extremely important for appropriate treatment to slow the progression of the disease. However, mental disorders such as depression are barriers in the initial clinical analysis of patients and in some cases presents itself as a prodrome for AD.

Análise de uma amostra de processos de Curatela de idosos com síndromes demenciais da Comarca de Belo Horizonte e proposta de um modelo de relatórios médico / Analysis of a sample of Guardianship processes for elderly people with dementia syndromes in the District of Belo Horizonte and proposal of a medical reporting model

Introdução: as síndromes demenciais são condições crônicas de saúde que levam a importante declínio cognitivo e prejuízo funcional, especialmente para as atividades de vida diárias e atos da vida civil. O relatório médico visa nortear e auxiliar a decisão judicial e pode identificar a extensão, a gravidade e a eventual reversibilidade da incapacidade do indivíduo a ser interditado. A incapacidade é obtida por meio do processo de interdição. Objetivos: descrever e analisar as informações contidas nos relatórios médicos juntados aos processos de pessoas curateladas com síndromes demenciais; realizar entrevistas com seis magistrados das respectivas varas de família da comarca de Belo Horizonte analisadas; e após as análises dos dados, propor um modelo de relatório a ser confeccionado por médicos assistentes. Métodos: estudo transversal com dois braços, sendo um descritivo, transversal e retrospectivo de pesquisa documental de processos judiciais eletrônicos de curatela, de indivíduos acima de 18 anos portadores de diagnóstico de demência, nas 2a, 3a, 4a, 5a, 9a e 11a varas de família do Tribunal de Justiça de Minas Gerais (TJMG). O outro braço do estudo é descritivo por meio de entrevista semiestruturada com os juízes de varas de família da comarca de Belo Horizonte, com abordagens quantitativas e qualitativas. Resultados: a amostra foi formada na sua maior parte por mulheres idosas, de alta escolaridade e viúvas. A curatela foi solicitada por filhos em 76,4% dos processos analisados. Houve predomínio do sexo feminino com a nomeação do curador, na sua maioria de filhas. Geriatria e Medicina de Família e comunidade se destacaram como especialidades que mais emitiram o relatório médico inicial (54,1%). A amostra apresentou predomínio da descrição do diagnóstico etiológico por demência de Alzheimer (61,1%) com prevalência do sexo feminino em portadores dessa etiologia (45,8%). Foi realizada a concordância do laudo médico pericial e o relatório médico. A avaliação de referência foi o laudo médico pericial. Na descrição da doença, 61,1% com diagnóstico de demência de Alzheimer; e no laudo pericial, 52,8%. Houve sensibilidade de 89,47% e especificidade de 70,59% do relatório médico perante o laudo pericial. O coeficiente de Kappa foi 0,6063, indicando concordância moderada. A análise descritiva de códigos da Classificação Internacional de Doenças (CID) no relatório médico esteve presente em 66,7% e 94,4% dos laudos periciais. O tempo de tramitação do processo (em meses) apresentou mediana de 20 meses. As varas de família B e D relataram resultado estatisticamente significativo, as medianas foram, respectivamente, 13,5 e 29 meses, referente ao período de tramitação desses processos (p=0,022). Conclusões: o relatório médico no contexto do processo judicial de curatela mostrou significativa importância para o portador de uma síndrome demencial, contribuindo para o esclarecimento de quais direitos e exercícios de atos da vida civil ainda poderão ser por ele praticados. O presente trabalho apurou a necessidade de treinamento da equipe multiprofissional da rede de atenção primária à saúde, para acolher devidamente o paciente e orientar as famílias/cuidadores de forma a resguardar e preservar os direitos do curatelado.

Introduction: Dementia syndromes are chronic health conditions that lead to significant cognitive decline and functional impairment, especially in daily life activities and acts of civil life. The medical report aims to guide and assist the judicial decision and can identify the extent, severity and possible reversibility of the incapacity of the individual to be interdicted. Disability is obtained through the interdiction process. Objectives: To describe and analyze the information contained in the medical reports attached to the processes of people under care with dementia syndromes. Conduct interviews with 6 magistrates from the respective family courts of the analyzed Belo Horizonte district. After analyzing the data, propose a report model to be prepared by assistant physicians. Methods: A cross-sectional study with two arms, one of which is descriptive, cross-sectional and retrospective of documentary research on electronic judicial processes of guardianship, of individuals over 18 years of age with a diagnosis of dementia, in the 2nd, 3rd, 4th, 5th, 9th and 11th courts of family of the Court of Justice of Minas Gerais (TJMG). The other arm of the study is descriptive through semi-structured interviews with judges from family courts in the district of Belo Horizonte with quantitative and qualitative approaches. Results: The sample consisted mostly of elderly women with high education and widows. The guardianship was requested by sons in 76.4% of the processes analyzed, there was a predominance of females with the appointment of the guardian, mostly daughters. Geriatrics and Family and Community Medicine stood out as the specialties that issued the most initial medical reports (54.1%). The sample showed a predominance of the description of the etiological diagnosis of Alzheimer's dementia (61.1%) with a predominance of females in patients with this etiology (45.8%). The expert medical report and the medical report were agreed. The reference assessment was the expert medical report. In the description of the pathology, 61.1% diagnosed with Alzheimer's Dementia and in the expert report 52.8%. There was a sensitivity of 89.47% and specificity of 70.59% of the medical report compared to the expert report. The Kappa coefficient was 0.6063, indicating moderate agreement. The descriptive analysis of ICD codes in the medical report was present in 66.7% and 94.4% of the expert reports. The processing time of the process (in months) presented a median of 20 months. Family courts B and D showed a statistically significant result, the medians were respectively 13.5 and 29 months, referring to the processing period of these processes (p=0.022). Conclusions: The medical report in the context of the judicial guardianship process is of significant importance for the person with dementia syndrome, contributing to the clarification of which rights and exercises of acts of civil life can still be practiced by him. The present work pointed out the need for training of the multidisciplinary team of the primary health care network, to properly welcome the patient and guide the families/caregivers in order to safeguard and preserve the rights of the guardianship.

Avaliação dos subtipos de transtorno neurocognitivo (demência) em ambulatório de referência do Distrito Federal, Brasil de 2010 a 2018 / Evaluation of subtypes of neurocognitive disorder (dementia) in a reference outpatient clinic in the Federal District, Brazil from 2010 to 2018

Objetivos: estabelecer diagnóstico diferencial das demências em ambulatório de geriatria no Distrito Federal, calculando-se sua prevalência por meio de exame clínico e avaliação multifuncional. Método: estudo longitudinal, retrospectivo, com amostra de pessoas com 60 anos ou mais residentes no Distrito Federal-Brasil, com déficit cognitivo caracterizado por Transtorno Neurocognitivo (TNC) Maior (demência), cadastradas durante os anos de 2010 a 2018. A coleta de dados foi realizada em prontuários para selecionar e avaliar o perfil do idoso com diagnóstico de TNC seguida de avaliação geriátrica ampla e avaliação multifuncional. A análise de dados foi realizada com o cálculo da prevalência, estatística descritiva e índice V de Cramer. Resultados: 158 indivíduos conseguiram concluir todas as avalições. 52,5% possuem de 80 a 89 anos, 62,5% são mulheres e 62,7% caucasianos, 50,6% viúvos e 47,5% analfabetos. A prevalência inicial de Doença de Alzheimer (DA) foi de 45,6%, reduzindo-se para 35,4% após um período de acompanhamento e a demência vascular (DV) foi de 34,2%, inicialmente, e 45,6% ao final. Utilizou-se o Coeficiente V de Cramer, em que se encontrou uma relação fraca de fatores de risco com os diagnósticos das demências apresentados. Conclusão: DV foi a mais prevalente na área estudada. Entende-se ser a maior frequência de DA esteja relacionada à avaliação superficial uma vez que esse tipo de demência é mundialmente mais frequente

Objetivos: estabelecer diagnóstico diferencial das demências em ambulatório de geriatria no Distrito Federal, calculando-se sua prevalência por meio de exame clínico e avaliação multifuncional. Método: estudo longitudinal, retrospectivo, com amostra de pessoas com 60 anos ou mais residentes no Distrito Federal-Brasil, com déficit cognitivo caracterizado por Transtorno Neurocognitivo (TNC) Maior (demência), cadastradas durante os anos de 2010 a 2018. A coleta de dados foi realizada em prontuários para selecionar e avaliar o perfil do idoso com diagnóstico de TNC seguida de avaliação geriátrica ampla e avaliação multifuncional. A análise de dados foi realizada com o cálculo da prevalência, estatística descritiva e índice V de Cramer. Resultados: 158 indivíduos conseguiram concluir todas as avalições. 52,5% possuem de 80 a 89 anos, 62,5% são mulheres e 62,7% caucasianos, 50,6% viúvos e 47,5% analfabetos. A prevalência inicial de Doença de Alzheimer (DA) foi de 45,6%, reduzindo-se para 35,4% após um período de acompanhamento e a demência vascular (DV) foi de 34,2%, inicialmente, e 45,6% ao final. Utilizou-se o Coeficiente V de Cramer, em que se encontrou uma relação fraca de fatores de risco com os diagnósticos das demências apresentados. Conclusão: DV foi a mais prevalente na área estudada. Entende-se ser a maior frequência de DA esteja relacionada à avaliação superficial uma vez que esse tipo de demência é mundialmente mais frequente

Alteraciones en el electroencefalograma cuantitativo en relación con la coherencia en pacientes con demencia Alzheimer / Quantitative electroencephalogram alterations according to coherency in patients with Alzheimer dementia / Alterações no eletroencefalograma quantitativo em relação à coerência em pacientes com demência de Alzheimer

RESUMEN Introducción: la demencia y dentro de ella la enfermedad de Alzheimer es un síndrome clínico caracterizado por un deterioro persistente y adquirido de las funciones cerebrales superiores. Objetivo: identificar alteraciones en el electroencefalograma cuantitativo respecto a la variable coherencia interhemisférica en estos pacientes. Métodos: estudio descriptivo de corte transversal realizado en el Hospital General Universitario ¨Carlos Manuel de Céspedes¨ de Bayamo, provincia de Granma, en el período comprendido desde 1ro de enero del 2016 a 1ro mayo del 2018. Se estudiaron de forma prospectiva 40 pacientes con posible demencia Alzheimer atendidos en la consulta de Neurología. Determinándose las variables electroencefalográficas: banda y coherencia interhemisférica. Se emplearon pruebas paramétricas y no paramétricas, aplicándose el método de ajuste de Bonferroni. Resultados: predominó el grupo de edades de 60 a 64 años y el sexo femenino. Existieron diferencias significativas respecto a la coherencia interhemisférica en las cuatro bandas de frecuencia teniendo en cuenta los grupos de edades, sexo y lóbulos cerebrales (p˂0.01). Conclusiones: es posible identificar alteraciones en el electroencefalograma cuantitativo en relación con la coherencia interhemisférica en pacientes condemencia Alzheimer, permitiendo establecer diferencias en cuanto al sexo y a los distintos lóbulos cerebrales para cada banda de frecuencias. Caracterizando desde el punto de vista electroencefalográfico la enfermedad.

ABSTRACT Introduction: Alzheimer dementia is a clinical syndrome characterized by a persistent and acquire cerebral dysfunctions. Objective: identify alterations in quantitative electroencephalograms according to interhemispheric coherency was our objective. Methods: a descriptive study with transversal cortes was carried out in Carlos Manuel of Cespedes hospital in Bayamo of Granma province, in the period of January (2016) to May (2018). We determinated the electroencephalographic variables: bands and interhemispheric coherency. We used statistical methods with a parametric and no parametric tests according our muestric. Results: the age group of 60 to 64 years and the female sex predominated. There were significant differences regarding interhemispheric coherence in the four frequency bands taking into account the age groups, sex and brain lobes (p˂0.01).. Conclusions: It is possible to identify alterations in the quantitative electroencephalogram in relation to interhemispheric coherence in patients with Alzheimer's disease, allowing to establish differences regarding sex and the different brain lobes for each frequency band. Characterizing the disease from the electroencephalographic point of view.

RESUMO Introdução: a demência e dentro de la a doença de Alzheimer é uma síndrome clínica caracterizada por uma deterioração persistente e adquirida das funções cerebrais superiores. Objetivo: esta pesquisa é realizada como objetivo de identificar alterações no eletroencefalograma quantitativo quanto à variável de coerência inter-hemisférica nesses pacientes. Métodos: estudo descritivo transversal realizado no Hospital Geral da Universidade ¨Carlos Manuel de Céspedes¨ em Bayamo, província de Granma, no período de 1 de janeiro de 2016 a 1 de maio de 2018. Foram estudados prospectivamente 40 pacientes com possível demência em tratamento no Consulta de neurologia. Determinação das variáveis ​​eletroencefalográficas: banda e coerência inter-hemisférica. Foram utilizados testes paramétricos e não paramétricos, aplicando-se o método de ajuste de Bonferroni. Resultados: predominou a faixa etária de 60 a 64 anos e o sexo feminino. Houve diferenças significativas em relação à coerência inter-hemisférica nasquatro bandas de frequência levando em consideração as faixas etárias, sexo e lobos cerebrais (p˂0,01). Conclusões: épossível identificar alterações no eletroencefalograma quantitativo em relação à coerência inter-hemisférica em pacientes com doença de Alzheimer, permitindo estabelecer diferenças quanto ao sexo e aos diferentes lobos cerebrais para cada faixa de frequência. Caracterizando a doença do ponto de vista eletroencefalográfico.

Biomarcadores gliais da doença de Alzheimer / Glial biomarkers of Alzheimer's disease

Introdução: A neuroinflamação associada às células gliais é um elemento importante do processo patológico da doença de Alzheimer (DA). Este estudo apresenta uma revisão dos marcadores gliais quitinase 3-like 1 (YKL-40), do receptor desencadeado expresso nas células mieloides 2 (Triggering receptor expressed on myeloid cells 2 ­ TREM2), da proteína acídica fibrilar glial (GFAP) e da proteína B S100 ligante de cálcio (S100B). Métodos: Nesta revisão são analisados os marcadores gliais YKL-40, TREM2, GFAP e S100B presentes em sangue e/ou líquido cefalorraquidiano (LCR), a partir de estudos publicados até 2020 nos bancos de dados do PubMed, Medline e Periódicos Capes. Resultados: Foram recuperados 233 documentos, dentre os quais foram incluídos 60. Todos os marcadores se encontram aumentados na DA em LCR ­ YKL-40 e TREM2 solúvel (sTREM2), já na fase pré-clínica ­, e em sangue, e estão correlacionados ao declínio cognitivo. No entanto, nenhum dos marcadores analisados apresentou grande potencial para o diagnóstico diferencial. Além da proteína TREM2 solúvel no LCR, no sangue também se pode identificar alteração nos níveis do RNAm de TREM2. GFAP sanguíneo mostra ser o melhor em distinguir controles de pacientes com Alzheimer. Há evidências de um efeito protetivo da ativação glial em reação ao acúmulo amiloide. Conclusão: Os marcadores gliais no geral têm pouca utilidade para o diagnóstico diferencial, mas podem auxiliar no prognóstico e como biomarcadores inespecíficos para doenças neurodegenerativas. (AU)

Introduction: Glial cell-associated neuroinflammation is a driving force for the pathological process of Alzheimer's disease (AD). This study is a systematic review aimed to analyze the following glial markers: chitinase-3-like protein 1 (YKL-40), triggering receptor expressed on myeloid cells 2 (TREM2), glial fibrillary acidic protein (GFAP) and S100 calcium-binding protein B (S100B). Methods: The PubMed, MEDLINE and CAPES Journals databases were searched for studies published until 2020 that addressed blood and/or cerebrospinal fluid (CSF) levels of YKL-40, TREM2, GFAP and S100B. Results: A total of 233 articles were retrieved, of which 60 were included in this study. All CSF ­ YKL-40 and soluble TREM2 (sTREM2) in preclinical stage ­ and blood biomarker levels were elevated for AD and were correlated to cognitive decline. None of the analyzed biomarkers showed promising results for differential diagnosis. Besides CSF sTREM2 levels, blood TREM2 mRNA levels were also altered in AD. Blood GFAP levels seem to be the best option for distinguishing controls from AD patients.' There is evidence of a protective role of glial activation in amyloid accumulation. Conclusion: Glial markers in general are of little use for differential diagnosis but can assist in prognosis and as nonspecific biomarkers of neurodegenerative diseases. (AU)

An Analysis on Prescribing Patterns of Alzheimer's Dementia Treatment and Choline Alfoscerate using HIRA Claims Data

BACKGROUND: Alzheimer's dementia is the most common dementia. However, recently, choline alfoscerate is prescribed for treating Alzheimer's dementia, although it is not a treatment for this disease. PURPOSE: To analyze the prescription patterns of choline alfoscerate as a dementia treatment for patients with Alzheimer's disease and to analyze, as well as the factors affecting choline alfoscerate prescription. METHOD: The 2016 HIRA-NPS data was used in this study. The code of Alzheimer's dementia is F00 in the ICD-10 disease classification code. We analyzed the demographic, clinical, and regional characteristics associated with donepezil, rivastigmine, galantamine, memantine, and choline alfoscerate prescriptions. All statistical and data analyse were conducted by SAS 9.4 and Excel. RESULTS: For patients with Alzheimer's disease, choline alfoscerate was the second most prescribed after donepezil. Analysis results showed that choline alfoscerate was more likely to be prescribed to men than to women, and more likely to be prescribed by local health centers than by medical institutions. Moreover, choline alfoscerate was highly likely to be prescribed at neurosurgical departments, among medical departments. CONCLUSION: This study confirmed that choline alfoscerate was prescribed considerably for patients with Alzheimer's dementia. Further studies valuating its clinical validity should be performed to clarify whether choline alfoscerate prescription is appropriate for treating Alzheimer's dementia.

Two Elderly Cases of Constipation with Irritability Diagnosed as Alzheimer's Dementia after Successfully Treated with Daijokito / 日本東洋医学雑誌

We report two cases of irritable bowel syndrome (IBS) with predominant constipation successfully treated with daijokito and then diagnosed as Alzheimer's dementia. [Case 1] An 82-year-old man. He had been treated for IBS with probiotic and purgative. However, the symptom of IBS did not get cured and he had suffered from digestive symptom with iracund mental condition. [Case 2] A 74-year-old man. He suffered from abdominal pain and constipation so he needed enema and stool extraction frequently. He sometimes angered if he could not get treatment without delay. In both cases, their bowel and mental condition improved after treatment with daijokito. After their conditions improved, we checked their cognitive function, and found the levels of their cognitive function were low. We diagnosed them as Alzheimer's dementia. The patients probably had felt the difficulty and gotten mental stress on usual days because of dementia, so the mental stress could complicate the symptoms of IBS. Daijokito probably improved the digestive symptom due to IBS and the mental stress from dementia of these patients, and after the treatment we could diagnose the dementia. Elderly patients with constipation and iracund mental condition might have dementia.

Relationship between Body Composition and Cognitive Function : Using Bioelectrical Impedance Analysis

OBJECTIVE: Body composition is measured using bioelectrical impedance analysis (BIA), and correlation between the result of BIA and cognitive function is analyzed. METHODS: A total of 118 elderly (46 male, 72 female) were recruited. They were divided into three groups; normal (n=33), mild cognitive impairment (n=42), and Alzheimer's dementia (n=43) according to the diagnostic criteria. Skeletal muscle mass, body fat mass, and fat-free mass were measured using a BIA device, and were converted to the ratio of body weight. All participants underwent Korean version of Mini-Mental State Examination (MMSE-K). RESULTS: In pearson correlation analysis, skeletal muscle percentage (SMP) and fat-free mass percentage (FFMP) were positively correlated with MMSE-K score (r=0.309, p=0.001; r=0.245, p=0.008), and body fat percentage was negatively correlated (r=−0.258, p=0.005). In multiple regression analysis, SMP (β=2.012, t=4.457, p < 0.001) and FFMP (β=−1.733, t=−3.838, p < 0.001) were selected as the best predictors of changes in MMSE-K score (R2=0.198). CONCLUSION: Reduced skeletal muscle and increased body fat correlate with decreased cognitive function, suggesting the need for prevention of frailty and early diagnosis of cognitive impairment.

Particulate Matter and Cognitive Function / 신경정신의학

The term “particulate Matter (PM)” refers to the mixture of small-sized solid particles and liquid droplets floating in the air, and is referred to as PM₁₀ ( < 10 µm), PM(2.5) ( < 2.5 µm) and PM(1.0). Much PM is an anthropogenic substance generated by transportation or industrial activities, which is transformed into a second toxic substance by chemical reactions in the atmosphere. PM reaches the brain directly through olfactory transport, or through the blood-brain barrier during systemic circulation. PM that enters the local cerebral circulation causes neuroinflammation through microglial cells and endotoxins. According to previous studies, greater PM exposure results in lower brain volume, especially white matter. Among neurodevelopmental disorders, the correlation between the occurrence of autism spectrum disorder and exposure to PM is widely known. Other studies have found that exposure to PM was associated with low cognitive function and increased rate of cognitive aging. PM can also cause pathology of early Alzheimer's disease and increases the risk of Alzheimer's dementia and mild cognitive impairment.

Improvement of Cognitive Function after Computer-Based Cognitive Training in Early Stage of Alzheimer's Dementia

BACKGROUND AND PURPOSE: Cognitive training is known to be an effective tool in enhancing cognitive functioning. Research has also shown that playing video game improves certain aspects of visual attention and cognitive processing speed. The effect of computer-based cognitive training has not been demonstrated so far. This study therefore evaluated whether computer-based cognitive training improved the cognitive abilities in patients with early stage of Alzheimer's dementia. METHODS: Totally, 20 participants (early stage of Alzheimer's dementia) participated in this study. To test the effectiveness of computer-based cognitive training programs to cognition, all patients were randomly allocated to either an intervention group (n=10) or a control group (n=10). The intervention group regularly received 24 sessions of computer-based cognitive training, over a 12 week period. Neuropsychological examinations were conducted before and after this training period. RESULTS: After 12 weeks, the intervention group showed a significant change in language of Korean version of the Mini-Mental State Examination (K-MMSE), compared with the baseline cognitive examinations. Also, there was greater improvement in language, attention, calculation, verbal memory, and frontal function for the experimental group, as compared with controls. CONCLUSIONS: Computer-based cognitive training might have beneficial effects on the general cognitive functions in early stage of Alzheimer's dementia.

Considerações sobre a repetição da linguagem no idoso com Alzheimer: uma perspectiva psicanalítica / Considerations for repeating the elderly with Alzheimer's: an psychoanalytical perspective / Consideraciones para la repetición del anciano con Alzheimer: una perspectiva psicoanalítica / Considérations pour répétition chez les personnes âgées atteintes d'Alzheimer: une perspective psychanalytique

O artigo propõe articular o fenômeno da repetição, em uma perspectiva psicanalítica, ao discurso repetitivo característico dos pacientes com doença de Alzheimer (DA), considerando os correlatos neurocognitivos desse processo. Trata-se de um estudo teórico exploratório. Metodologicamente, realizou-se uma busca de artigos nas bases de dados PsycINFO (APA), SciELO e PePSIC com os seguintes descritores: Alzheimer e Psicanálise; Alzheimer e Psicodinâmica; Alzheimer e repetição à compulsão; e também em inglês (Alzheimer and psychoanalysis; Alzheimer and pychodynamic; e Alzheimer and repetition compulsion). Encontrou-se apenas sete artigos que se aproximaram do tema deste trabalho dentro dos critérios de inclusão: artigos disponibilizados na íntegra e gratuitamente na base de dados, e artigos escritos nos idiomas português ou inglês. Não foram encontrados artigos em português. Foram ainda consultadas obras consagradas da Psicanálise, especialmente da corrente teórica freudiana. Uma interlocução entre a Psicanálise e as Neurociências é proposta, a fim de considerar a relação que o sujeito estabelece com sua doença, sem com isso negligenciar os aspectos fisiológicos e cognitivos caros ao processo de demenciação na DA. Entende-se que o discurso repetitivo do idoso pode servir-lhe como uma tentativa de manutenção da identidade subjetiva ao longo do tempo. Impõe-se o desafio da sustentação de uma escuta que favoreça a preservação do sujeito demenciado nas funções socializante e libertadora da linguagem. A restrição de estudos específicos sobre o fenômeno da repetição vinculada à discussão psicanalítica sobre o envelhecimento humano foi uma limitação para este estudo. Aponta-se a necessidade de elaborações teóricas mais profundas, ancoradas em ensaios clínicos mais amplos acerca do tema.

The article proposes to articulate the phenomenon of repetition, in a psychoanalytic perspective, to the characteristic repetitive discourse of patients with Alzheimer's Disease (AD), considering the neurocognitive correlates of this process. This is an exploratory theoretical study. Methodologically, a search of articles in the databases PsycINFO (APA), SciELO and PePSIC with the following descriptors: in Portuguese: Alzheimer e Psicanálise; Alzheimer e Psicodinâmica; Alzheimer e Repetição à compulsão; and in English Alzheimer and psychoanalysis; Alzheimer and psychodynamic; and Alzheimer's and repetition compulsion. There were only seven articles that approached the theme of this work, within the criteria of inclusion: articles available in full and free of charge in the database, and articles written in Portuguese or English. No articles were found in Portuguese. Also consecrated works of Psychoanalysis were consulted, especially the current Freudian theoretical. An interlocution between Psychoanalysis and Neurosciences is proposed in order to consider the relationship that the subject establishes with his illness, without neglecting the physiological and cognitive aspects that are dear to the process of dementia in AD. It is understood that the repetitive discourse of the elderly can serve as an attempt to maintain subjective identity over time. The challenge of sustaining a listening that favors the preservation of the demented subject in the socializing and liberating functions of language. The restriction of specific studies on the phenomenon of repetition linked to a psychoanalytic discussion about human aging was a limitation of this study. The need for deeper theoretical elaborations, anchored in broader clinical trials on the subject, is pointed out.

El artículo propone articular el fenómeno de la repetición, en una perspectiva psicoanalítica, al discurso repetitivo característico de los pacientes con Alzheimer (DA), considerando los correlatos neurocognitivos de este proceso. Se refiere a una investigación teórico-exploratoria. Metodológicamente fue realizada una búsqueda de artículos en las bases de datos PsycINFO (APA), SciELO y PePSIC con los siguiente descriptores: Alzheimer y Psicoanálisis; Alzheimer y Psicodinámica; Alzheimer y Repetición a la compulsión; y en inglés Alzheimer and psychoanalysis; Alzheimer and pychodynamic; y Alzheimer and repetition compulsion. Fue encontrado solo siete artículos que se acercaron al tema de este trabajo, dentro de los criterios de inclusión: artículos disponibles en la íntegra y gratis en las bases de datos, y artículos escritos en los idiomas portugués o inglés. Artículos en portugués no fueron encontrados. Fueron consultadas aún obras importantes del psicoanálisis, especialmente de la corriente freudiana. Es propuesta una interlocución entre el Psicoanálisis y las Neurociencias con la finalidad de considerar la relación que el sujeto establece con su enfermedad, sin que se pase por alto los aspectos fisiológicos y cognitivos caros al proceso de demencia en la DA. Se entiende que el discurso repetitivo del anciano puede servirle como intento de manutención de la identidad subjetiva a lo largo del tiempo. Se impone el reto del apoyo de una escucha que favorezca la preservación del sujeto demenciado en las funciones socializante y libertadora del lenguaje. La restricción de investigaciones específicas sobre el fenómeno de la repetición relacionada a una discusión psicoanalítica sobre el envejecimiento humano fue una limitación para este trabajo. Se indica la necesidad de elaborar teorías más profundas, ancladas en ensayos clínicos más amplios a cerca del tema.

L'article propose articuler le phénomène de la répétition, dans une perspective de la psychanalyse, avec le discours répétitif caractéristique des patients atteint de la maladie d'Alzheimer (MA), en considérant les correlations neurocognitives de ce processus. Il s'agit d'une étude théorique exploratoire. Sur le plan méthodologique, il y a eu une recherche d'articles dans les bases de données PsycINFO (APA), SciELO et PePSIC avec les mots clés suivants : Alzheimer et psychanalyse; Alzheimer et psychodynamique; Alzheimer et la compulsion de répétition; et en anglais: Alzheimer and psychoanalysis; Alzheimer and psychodynamic; et Alzheimer and repetition compulsion . Nous avons trouvé seulement sept articles qui abordent le thème de ce travail, dans les critères d'inclusion: articles disponibles dans son intégralité et gratuitement dans la base de données et des articles rédigés en langues portugaise ou anglaise. Nous n'avons pas trouvés des articles en Portugais. Des oeuvres consacrées de la psychanalyse ont été consultées, surtout de la théorique freudienne. Un dialogue entre la psychanalyse et les neurosciences est proposé, afin d'examiner la relation que le sujet établit avec sa maladie, sans pour autant négliger les aspects physiologiques et cognitives, chères au processus de demence chez la MA. Il est entendu que le discours répétitif des personnes âgées peut servir comme une tentative de maintenir l'identité subjective au fil du temps. S'impose le défi de la sustentation d'une écoute qui favorise la préservation du sujet dément chez les fonctions de socialisation et de libération langagièr. La restriction des études spécifiques sur le phénomène de la répétition liée à une discussion psychanalytique sur le vieillissement humain a été un frein à cette étude. Il faut souligner la nécessité d'élaborations théoriques plus profondes, ancrées dans des essais cliniques plus vastes sur le sujet.

Clinical Implications of Transcranial Magnetic Stimulation in Alzheimer's Dementia / 신경정신의학

The objective is this study is to provide a comprehensive understanding of the clinical implication of transcranial magnetic stimulation (TMS) in Alzheimer's dementia (AD). We collected studies using TMS in patients with AD and reviewed 41 identified articles. Thirty five articles were about measures of cortical reactivity, plasticity, connectivity, and six articles were about the enhancement of cognitive function in AD. Reduced short-latency afferent inhibition and resting motor threshold which reflect cholinergic dysfunction and enhanced cortical excitability respectively are consistent findings of altered cortical reactivity in AD. In addition, cortical plasticity and connectivity have shown impaired results in AD compared with healthy controls. Repetitively delivered TMS can improve several domains of cognitive function impaired in AD. Although the evidence is still preliminary, TMS has a clinical implication as a diagnostic and therapeutic method in AD. Thorough investigation of factors that can affect the results of TMS and further studies to clarify the results are needed.

Efficacy of Galantamine on Cognition in Mild-to-Moderate Alzheimer's Dementia after Failure to Respond to Donepezil

OBJECTIVE: This study compares the efficacy of the cholinesterase inhibitor (ChEI) galantamine on cognition in patients with mild-to-moderate Alzheimer's dementia (AD) who were either naïve to ChEI drugs or who had failed a trial of the ChEI donepezil. METHODS: Outpatients with AD were sequentially referred for screening and enrollment. Current outpatients who had taken donepezil for at least 6 months without demonstrated efficacy on cognition were switched to galantamine (switched group). New outpatients with no ChEI prescription history were classified as the naïve group and were given galantamine. The primary outcome measures for the between-group comparison were response rate on cognition at 26 and 52 weeks (categorical) and change on the Korean version of the Alzheimer's Disease Assessment Scale-cognitive subscale (dimensional). Secondary cognitive outcomes were measured using the subset of frontal executive function and the Korean Mini-Mental State Examination. RESULTS: Seventy outpatients were enrolled and 66 were analyzed by Intent-to-treat (ITT). There were 42 cases in the naïve group and 24 in the switched group. Response rates did not differ at 26 weeks (71.4% naïve vs. 58.3% switched; p=0.277) or at 52 weeks (59.5% naïve vs. 41.6% switched; p=0.162). No significant differences were observed in the pattern of change over the 52 weeks on the primary and secondary cognitive scales. CONCLUSION: As the efficacy of galantamine on cognition was not inferior in the switched group compared to that in the naïve group, switching ChEI drugs is clinically feasible for non-responding patients with mild-to-moderate AD.

Distinct Clinical Characteristics Depending on Cerebral Amyloid Positivity in Patients with Alzheimer Disease Dementia

OBJECTIVE: The present study investigated the clinical characteristics of Alzheimer's disease (AD) dementia with low brain amyloid-beta (Aβ-AD) burden comparing with AD dementia with high amyloid-beta burden (Aβ+AD). We also developed a prediction model for the amyloid positivity on ¹¹C-labelled Pittsburgh Compound B (PiB) positron emission tomography (PET) with distinct clinical variables in AD dementia patients. METHODS: Fifty-nine clinically defined AD dementia individuals, who participated in the Korean Brain Aging Study for Early diagnosis and prediction of AD (KBASE) study, were included. All the subjects received comprehensive clinical evaluations and PiB-PET. Based on cerebral PiB retention, all subjects were divided into Aβ+AD (n=47) and Aβ-AD (n=12) subgroups. To develop a prediction model for amyloid positivity, stepwise multiple logistic regression analysis was conducted. RESULTS: When compared to Aβ+AD, Aβ-AD showed older age, later age-at-onset, and lower education. In regard of risk factors for dementia, Aβ-AD had higher frequency of hypertension and diabetes mellitus as well as lower frequency of apolipoprotein E (APOE) ε4 allele. Although there was no between group difference in Clinical Dementia Rating (CDR) or CDR sum-of-boxes scores, mini-mental state examination and constructional recall scores were higher for Aβ-AD than Aβ+AD. The final amyloid positivity prediction model included APOE4 genotype, hypertension, and diabetes mellitus. CONCLUSION: The findings from this study indicated that clinically diagnosed AD dementia may have high possibility of not being pathological AD if they have older age and higher vascular risks, and did not have APOE4 genotype.

Translation, cross-cultural adaptation and applicability of the Brazilian version of the Frontotemporal Dementia Rating Scale (FTD-FRS) / Tradução, adaptação transcultural e aplicabilidade da Escala de Estadiamento e Progressão da Degeneração Lobar Frontotemporal

ABSTRACT Background: Staging scales for dementia have been devised for grading Alzheimer's disease (AD) but do not include the specific symptoms of frontotemporal lobar degeneration (FTLD). Objective: To translate and adapt the Frontotemporal Dementia Rating Scale (FTD-FRS) to Brazilian Portuguese. Methods: The cross-cultural adaptation process consisted of the following steps: translation, back-translation (prepared by independent translators), discussion with specialists, and development of a final version after minor adjustments. A pilot application was carried out with 12 patients diagnosed with bvFTD and 11 with AD, matched for disease severity (CDR=1.0). The evaluation protocol included: Addenbrooke's Cognitive Examination-Revised (ACE-R), Mini-Mental State Examination (MMSE), Executive Interview (EXIT-25), Neuropsychiatric Inventory (NPI), Frontotemporal Dementia Rating Scale (FTD-FRS) and Clinical Dementia Rating scale (CDR). Results: The Brazilian version of the FTD-FRS seemed appropriate for use in this country. Preliminary results revealed greater levels of disability in bvFTD than in AD patients (bvFTD: 25% mild, 50% moderate and 25% severe; AD: 36.36% mild, 63.64% moderate). It appears that the CDR underrates disease severity in bvFTD since a relevant proportion of patients rated as having mild dementia (CDR=1.0) in fact had moderate or severe levels of disability according to the FTD-FRS. Conclusion: The Brazilian version of the FTD-FRS seems suitable to aid staging and determining disease progression.

RESUMO Introdução: As escalas de estadiamento das demências, como a Clinical Dementia Rating (CDR), foram elaboradas para graduar a doença de Alzheimer (DA) e não incluem os sintomas específicos da degeneração lobar frontotemporal (DLFT). Objetivo: Realizar a tradução e adaptação cultural da Frontotemporal Dementia Rating Scale (FTD-FRS) para o contexto brasileiro e apresentar dados preliminares da sua aplicabilidade. Métodos: O processo de adaptação transcultural consistiu em: tradução, retrotradução (realizadas por tradutores independentes), discussão com especialistas sobre a versão em português e equivalência com a versão original, desenvolvimento da versão final com pequenos ajustes. Foi feita uma aplicação piloto em 12 pacientes com diagnóstico de demência frontotemporal variante comportamental (DFTvc) e 11 com DA, pareados quanto à gravidade da demência (CDR=1). O protocolo de avaliação incluiu a Addenbrooke's Cognitive Examination-Revised (ACE-R), Mini Exame do Estado Mental (MEEM), Executive Interview (EXIT-25), Inventário Neuropsiquiátrico (INP) e a Escala de Avaliação Clínica da Demência (CDR). Resultados: A FTD-FRS na versão brasileira pareceu apropriada. Resultados preliminares revelaram maiores níveis de incapacidade na DFTvc do que em pacientes com DA (DFTvc: 25% leve, 50% moderado, 25% grave; AD: 36.36% leve, 63.64% moderado). A CDR parece subestimar a gravidade da demência na DFTvc, uma vez que uma relevante proporção dos pacientes classificados com leves (CDR=1) de fato apresentaram nível moderado ou grave de comprometimento na FTD-FRS. Conclusão: A versão brasileira da FTD-FRS pode se mostrar adequada para auxiliar no estadiamento e determinar a progressão da DLFT.

Cost of dementia care in India: Delusion or reality.

Context: In 2010, nearly 37 lakh Indians have been estimated to be suffering from dementia. Estimated costs of care in published literature do not reflect the actual expenses of individual households. Hence, a household budget approach was undertaken to arrive at the costs of dementia care in India. Materials and Methods: We identified and listed the different components of care, classified the applicability of care for the different components with respect to mild, moderate, and severe cases. This framework was utilized to assign costs of care and arrive at the household costs of care for a Person with Dementia (PwD) in both urban and rural areas. Results: The total expense was similar to that reported by individual households. The annual household cost of caring for a person with dementia in India, depending on the severity of the disease, ranged between INR 45,600 to INR 2,02,450 in urban areas and INR 20,300 to INR 66,025 in rural areas. Costs increased with increasing severity of the disease process. The costs of informal care contributed to nearly half of the total costs either in rural or urban area. With increasing severity, proportion of medical costs decreased while social cost increased. Medical costs in rural areas were nearly one-third of the total costs as against less than one-fifth in urban areas. Conclusion: The household budget model realistically estimated the household costs of care. It is hoped that the comprehensive and generic framework would prompt health professionals, researchers, and policy makers in India to catalyze geriatric health services, particularly for care for PwD.

Executive functions as predictors of functional performance in mild Alzheimer's dementia and mild cognitive impairment elderly / Funções executivas como preditores do desempenho funcional em idosos com demência de Alzheimer em fase inicial e comprometimento cognitivo leve

Cognitive impairment and depressive symptoms are associated with worse functionality phenotype in Alzheimer's disease (AD) and Mild Cognitive Impairment (MCI) elderly. The present study aims to investigate the association between the impairment of executive functions and episodic memory, the presence of depressive symptoms with the functionality of these patients. One hundred and eighteen participants diagnosed with AD or MCI who underwent neuropsychological examination covering various domains of episodic memory and executive functions and the answered the Geriatric Depression Scale. Caregivers answered a scale of Activities of Daily Living. The cognitive variables were reduced through factor analysis to three components (Executive Functions, Memory Episodic and Working Memory) and, along with depressive symptoms, used as predictors in a linear regression model, where only Executive Functions were related to functionality (R²= 0.30). The results suggest that executive functions are particularly relevant for functionality in these patients.

O comprometimento cognitivo e os sintomas depressivos são associados a um pior fenótipo funcional em idosos com Alzheimer (DA) e Comprometimento Cognitivo Leve (CCL). O presente estudo almeja investigar a associação entre o comprometimento das funções executivas, da memória episódica e a presença de sintomas depressivos com o desempenho funcional nesses pacientes. Cento e dezoito idosos com DA ou CCL realizaram exame neuropsicológico, contemplando diversos domínios das Funções Executivas e Memória episódica, além da Escala de Depressão Geriátrica. Os cuidadores responderam uma escala de atividades de vida diária. As variáveis cognitivas foram reduzidas por meio de análise fatorial a três componentes (Funções Executivas, Memória Episódica e Memória de Trabalho) e junto aos sintomas depressivos utilizados como preditores em um modelo de regressão linear, onde apenas as Funções Executivas se relacionaram à funcionalidade (R² = 0.30). Os resultados sugerem que as Funções Executivas são particularmente relevantes à funcionalidade desses pacientes.

Association between Insight and Neuropsychiatric Symptoms in Alzheimer's Dementia : A Clinical Research Center for Dementia of South Korea Study (CREDOS) / 신경정신의학

OBJECTIVES: The aim of this study was to identify the association between insight and neuropsychiatric symptoms in patients with Alzheimer's dementia (AD). METHODS: We examined 2607 patients with AD in the Clinical Research Center for Dementia of South Korea study and designed a cross-sectional study. Each patient underwent psychiatric, neurological, and medical examination, interview for caregivers, laboratory tests, neuropsychological tests, and brain MRI. Cognitive function was measured using the Korean version of the Mini-Mental State Examination, Global Deterioration Scale, and Clinical Dementia Rating. Behavioral and psychological symptoms were measured using the Korean version of the Neuropsychiatric Inventory. Daily Living was measured using the Barthel Index for daily living activities and Seoul-Instrumental Activities of Daily Living. Insight was classified according to 'with insight', 'partial insight', and 'without insight' by interview with caregivers. RESULTS: Among the 2607 patients, 990 were included in the 'with insight' group, 1191 were included in the 'Partial insight' group, and the 'without insight' group included 426 patients. The 'without insight' group had a significantly higher aggression level than the 'with insight' group, but not the 'partial insight' group [odds ratio (OR)=1.46, 95% confidence interval (CI) : 1,14-1.88]. A significantly lower prevalence of depression was observed in the 'Partial insight' group and the 'without insight' group, compared to the 'with insight' group (OR=0.51, 95% CI : 0.43-0.61/OR=0.61, 95% CI : 0.48-0.78). The 'partial insight' group showed a lower anxiety level than the 'with insight' group (OR=0.63, 95% CI : 0.53-0.75). CONCLUSION: Findings of this study confirmed that insight level was associated with aggression, depression, and anxiety in patients with Alzheimer' dementia.

Efeitos de um programa de atividade física sobre os sintomas depressivos e a qualidade de vida de idosos com demência de Alzheimer / Effects of a physical activity program on depressive symptoms and quality of life of elderly with Alzheimer's dementia / Efectos de un programa de actividad física en los síntomas depressivos y la calidad de vida del ancianos con demencia de Alzheimer

O objetivo do estudo foi analisar os efeitos de um programa de exercícios físicos sobre os sintomas depressivos e a percepção da Qualidade de vida (QV) de pacientes com Doença de Alzheimer (DA) e de seus cuidadores. Seis idosas realizaram um programa de exercícios físicos durante seis meses, outras seis compuseram o grupo controle. O Mini-Exame do Estado Mental, a Escala de Qualidade de Vida e a Escala de Depressão em Geriatria foram aplicados para avaliação das variáveis. Os dados foram analisados através de uma ANOVA "two-way" e correlação de Pearson, com nível de significância de 5% (p < 0,05).Os resultados mostraram que o programa proposto pode auxiliar na redução dos sintomas depressivos de pacientes com DA, mas não promoveu melhoras significativas na percepção da QV destes pacientes e nem de seus cuidadores. Entretanto menores comprometimentos da percepção da qualidade de vida foram observados em pacientes e cuidadores que eram fisicamente ativos.

The aim of the study was to analyze the effects of a physical exercises' program on depressive symptoms and quality of life (QL) in elderly with Alzheimer's Disease (AD) and QL of their caregivers. Six elderly women performed a physical exercises' program with six months of duration, and the other six composed the control group. The Mini-Mental State Examination, the Quality of Life Scale and the Geriatric Depression Scale were applied to evaluate the variables. Data were analyzed by Analyze of Variance (Two-way) and Pearson's correlations. The level of significance was set at 5% (p < 0.05). The results showed that the physical exercises' program proposed could aid on the reduction of depressive symptoms of AD patients. However less worsening was observed on QL of patients and caregivers from the physically active group.

El objetivo del estudio fue analizar los efectos de un programa de ejercicios en los síntomas depresivos y la percepción de calidad de vida (CV) de los pacientes con Demencia de Alzheimer (DA) y sus cuidadores. Seis personas ancianas realizaran un programa de ejercicio físico por un periodo del seis meses, otro grupo estaba formado por el grupo de control. El Mini Examen del Estado Mental, la Escala de Calidad de Vida y la Escala de Depresión Geriátrica fueran utilizados para evaluar las variables. Los datos fueron analizados por análisis de varianza de dos entradas (ANOVA de dos vías) y la correlación de Pearson, con un nivel de significancia de 5% (p < 0,05). Los resultados muestran que el programa propuesto puede ayudar en la reducción de los síntomas depresivos en pacientes con DA, pero no promove mejoras significativas en la percepción de la calidad de vida de estos pacientes ni sus cuidadores. Sin embargo menos daños de la percepción de calidad de vida se observaron en los pacientes y los cuidadores que eran físicamente activos.

Sobrecarga en cuidadores de pacientes con demencia tipo alzheimer / Overload in caregivers for patients with alzheimer dementia

Este estudio tuvo como objetivo determinar los niveles de sobrecarga que presenta una muestra de cuidadores de pacientes con demencia tipo Alzheimer. La muestra fue seleccionada por conveniencia, la cual debería tener como labor principal el cuidado y mantenimiento de algún familiar que padezca esta enfermedad. Se evaluaron 52 cuidadores, sin distinción de edad, género, raza o religión. La evaluación de la sobrecarga se hizo a partir de la Escala de Sobrecarga del Cuidador Test de Zarit, la cual busca identificar el nivel de sobrecarga. Simultáneamente se organizaron los datos sociodemográficos y se analizaron a través del programa estadístico SPSS versión 1.9. Los resultados arrojaron que el 65.4% no presenta sobrecarga, el 17.3% presenta sobrecarga leve y el mismo porcentaje presenta sobrecarga intensa. Se determinó que los datos sociodemográficos como el alto nivel de escolaridad, el elevado estrato socioeconómico y el parentesco están relacionados con la no sobrecarga.

This study's objective was to determine the overload levels of caretakers for patients with Alzheimer dementia. The sample was selected by convenience. The main task had to be the care and support of a relative with this disease. 52 caretakers were evaluated, without regard of age, gender, race or religion. The overload evaluation was done using the Overload Scale of Caretaker Zarit Test, which seeks to identify the level of overload. Social demographic data was simultaneously organised and analysed using the SPSS version 1.9 statistics program. Results show that 65.4% did not file overload, 17.3% presents mild overload and the same percentage presents severe overload. It was determined that social demographic data such as highly educated, high socioeconomic status and relationship are related to the overload.