The Brain Health Diplomat's Toolkit: supporting brain health diplomacy leaders in Latin America and the Caribbean.

Maintaining and improving brain health, one of the most critical global challenges of this century, necessitates innovative, interdisciplinary, and collaborative strategies to address the growing challenges in Latin America and the Caribbean. This paper introduces Brain Health Diplomacy (BHD) as a pioneering approach to bridge disciplinary and geographic boundaries and mobilize resources to promote equitable brain health outcomes in the region. Our framework provides a toolkit for emerging brain health leaders, equipping them with essential concepts and practical resources to apply in their professional work and collaborations. By providing case studies, we highlight the importance of culturally sensitive, region-specific interventions to address unique needs of vulnerable populations. By encouraging dialogue, ideation, and cross-sector discussions, we aspire to develop new research, policy, and programmatic avenues. The novel BHD approach has the potential to revolutionize brain health across the region and beyond, ultimately contributing to a more equitable global cognitive health landscape.

Brief instrument for direct complex functionality assessment: a new ecological tool.

Background: The Direct Assessment of Functional Status (DAFS) is the only instrument validated in Brazil that assesses functionality directly with the patient. However, this clinical tool takes a long time to be administered. This limits its use in hospitals and outpatient clinics that require brief assessment instruments. Additionally, we need to count with a direct assessment because the number of older adults living alone is increasing and we thus lack reliable informants. Objective: This study aimed to present the development and content validity evidence of a direct complex functionality test for older adults, the Brief Instrument for Direct Functionality Assessment (BIDFA). Method: A total sample of 30 older adults and eight expert judges took part in the study stages. The BIDFA construction stages were: (1) literature review of functionality instruments; (2) development of seven ecological tasks to evaluate the performance of daily complex activities with the older adults; (3) content analysis by eight expert judges; (4) pilot study with 30 older adults; (5) the ecological analysis of items; (6) focus group analysis; and (7) final version of the BIDFA. Results: The BIDFA had evidence of content validity with an agreement index of 96.5%. The final version of BIDFA was left with six domains of complex functionality divided into semantic memory and time orientation; shopping skills; executive attention, math and finance skills; organization; planning and procedural memory; and problem-solving. The complex functionality score by BIDFA ranges from 0 to 100 points. Conclusion: The BIDFA was found to have good content validity by the expert judges and by the ecological analysis of the items by the older adults. The new instrument is expected to help assess the functional status of older adults, in an abbreviated context including complex functionality demands, with a wider range of total and subdomain scores.

Subjective cognitive decline, mild cognitive impairment, and dementia - syndromic approach: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology.

This consensus, performed by the Brazilian Academy of Neurology (BAN) will approach practically how to evaluate patients with cognitive complaints and how to clinically and etiologically diagnose the three clinical syndromes associated with the different stages of cognitive decline: subjective cognitive decline (SCD), mild cognitive impairment (MCI), and dementia. This BAN consensus discusses SCD diagnosis for the first time, updates MCI and dementia diagnoses, recommends the adequate cognitive tests and the relevant etiological work-up and care of patients with cognitive decline at different levels of care within the Brazilian Unified Health System. We also review the main assessment instruments used in Brazil and Latin America.

Este consenso realizado pela Academia Brasileira de Neurologia (ABN) abordará de maneira prática como avaliar pacientes com queixas cognitivas e como realizar o diagnóstico clínico e etiológico das três síndromes clínicas associadas aos estágios de declínio cognitivo: declínio cognitivo subjetivo (DCS), comprometimento cognitivo leve (CCL) e demência. O diagnóstico de DCS é discutido pela primeira vez em consenso da ABN e as atualizações para o diagnóstico de CCL e demência são abordadas, bem como a recomendação para o uso de testes cognitivos apropriados, investigação etiológica pertinente e cuidados aos pacientes com declínio cognitivo nos diferentes níveis de atenção do Sistema Único de Saúde. Foi realizada pesquisa dos principais instrumentos de avaliação utilizados em nosso meio e na América Latina.

Executive processing clusters in school-age children with ADHD

Este estudo buscou grupos de processamento executivo em crianças com diagnóstico de Transtorno de Déficit de Atenção/Hiperatividade (TDAH). Para tal, foram utilizadas medidas de flexibilidade cognitiva (FC), inibição (IN) e memória de trabalho (MT) e conduzidas análises de clusters hierárquicos e MANCOVA (p=0.05). Foram identificados três subgrupos com os seguintes perfis de processamento executivo: 1) déficits em FC e IN; 2) déficits em IN; 3) déficits em FC e MT. Esses resultados indicaram a presença de diferentes perfis de déficits em componentes executivos entre crianças com diagnóstico de TDAH. Esses achados podem contribuir para a elaboração de estratégias de intervenção e de programas de psicoeducação para estudantes com diagnóstico de TDAH em contextos clínicos e educacionais.(AU)

OBJECTIVE: This study aimed to characterize executive processing subgroups among children with Attention Deficit Hyperactivity Disorder (ADHD). METHOD: Sixty-one children with ADHD, with ages from six to twelve years old, were examined using instruments that evaluate the executive components of cognitive flexibility (CF), inhibition (IN) and working memory (WM). Analysis of hierarchical clusters and MANCOVA (p≤0.05) were conducted. RESULTS: Participants were divided in three clusters: 1) deficits in CF and in IN; 2) deficits in IN; 3) deficits in CF and in WM. CONCLUSIONS: the results indicated different neuropsychological profiles among children with ADHD, with different cognitive strengths and weaknesses. Clusters did not differ with respect to biological, clinical, and sociocultural factors. The findings may be useful for educational and health institutions, supporting psychoeducation programs and intervention strategies for students with ADHD.(AU)

Este estudio investigó grupos de procesamiento ejecutivo en niños diagnosticados con trastorno por déficit de atención e hiperactividad (TDAH). Para ello, se utilizaron medidas de flexibilidad cognitiva (FC), inhibición (IN) y memoria de trabajo (MT) y se realizaron análisis de conglomerados jerárquicos y MANCOVA (p=0.05). Se identificaron tres subgrupos con los siguientes perfiles de procesamiento ejecutivo: 1) déficits en FC e IN; 2) déficits en IN; 3) déficits en FC y MT. Estos resultados indicaron la presencia de diferentes perfiles de déficit en los componentes ejecutivos entre los niños diagnosticados con TDAH. Estos datos pueden contribuir al desarrollo de estrategias de intervención y programas de psicoeducación para estudiantes diagnosticados con TDAH en contextos clínicos y educativos.(AU)

Declínio cognitivo subjetivo, comprometimento cognitivo leve e demência - diagnóstico sindrômico: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia / Subjective cognitive decline, mild cognitive impairment, and dementia - syndromic approach: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology

RESUMO Este consenso realizado pela Academia Brasileira de Neurologia (ABN) abordará de maneira prática como avaliar pacientes com queixas cognitivas e como realizar o diagnóstico clínico e etiológico das três síndromes clínicas associadas aos estágios de declínio cognitivo: declínio cognitivo subjetivo (DCS), comprometimento cognitivo leve (CCL) e demência. O diagnóstico de DCS é discutido pela primeira vez em consenso da ABN e as atualizações para o diagnóstico de CCL e demência são abordadas, bem como a recomendação para o uso de testes cognitivos apropriados, investigação etiológica pertinente e cuidados aos pacientes com declínio cognitivo nos diferentes níveis de atenção do Sistema Único de Saúde. Foi realizada pesquisa dos principais instrumentos de avaliação utilizados em nosso meio e na América Latina.

ABSTRACT This consensus, performed by the Brazilian Academy of Neurology (BAN) will approach practically how to evaluate patients with cognitive complaints and how to clinically and etiologically diagnose the three clinical syndromes associated with the different stages of cognitive decline: subjective cognitive decline (SCD), mild cognitive impairment (MCI), and dementia. This BAN consensus discusses SCD diagnosis for the first time, updates MCI and dementia diagnoses, recommends the adequate cognitive tests and the relevant etiological work-up and care of patients with cognitive decline at different levels of care within the Brazilian Unified Health System. We also review the main assessment instruments used in Brazil and Latin America.

Mechanism of a Flexible ICU Visiting Policy for Anxiety Symptoms Among Family Members in Brazil: A Path Mediation Analysis in a Cluster-Randomized Clinical Trial.

OBJECTIVES: To investigate whether the effect of a flexible ICU visiting policy that includes flexible visitation plus visitor education on anxiety symptoms of family members is mediated by satisfaction and involvement in patient care. DESIGN: We embedded a multivariable path mediation analysis within a cluster-randomized crossover trial as a secondary analysis of The ICU Visits Study (ClinicalTrials.gov number: NCT02932358). SETTING: Thirty-six medical-surgical ICUs in Brazil. PATIENTS: Closest relatives of adult ICU patients. INTERVENTIONS: Flexible visitation (12 hr/d) supported by family education or usual restricted visitation (median, 1.5 hr/d). MEASUREMENTS AND MAIN RESULTS: Overall, 863 family members were assessed (mean age, 44.7 yr; women, 70.1%). Compared with the restricted visitation (n = 436), flexible visitation (n = 427) resulted in better mean anxiety scores (6.1 vs 7.8; mean difference, -1.78 [95% CI, -2.31 to -1.22]), as well as higher standardized scores of satisfaction (67% [95% CI, 55-79]) and involvement in patient care (77% [95% CI, 64-89]). The mediated effect of flexible visitation on mean anxiety scores through each incremental sd of satisfaction and involvement in patient care were -0.47 (95% CI, -0.68 to -0.24) and 0.29 (95% CI, 0.04-0.54), respectively. Upon exploratory analyses, emotional support, helping the ICU staff to understand patient needs, helping the patient to interpret ICU staff instructions, and patient reorientation were the domains of involvement in patient care associated with increased anxiety. CONCLUSIONS: A flexible ICU visiting policy reduces anxiety symptoms among family members and appears to work by increasing satisfaction. However, increased participation in some activities of patient care as a result of flexible visitation was associated with higher severity of anxiety symptoms.

Dementia in Latin America: Paving the way toward a regional action plan.

Across Latin American and Caribbean countries (LACs), the fight against dementia faces pressing challenges, such as heterogeneity, diversity, political instability, and socioeconomic disparities. These can be addressed more effectively in a collaborative setting that fosters open exchange of knowledge. In this work, the Latin American and Caribbean Consortium on Dementia (LAC-CD) proposes an agenda for integration to deliver a Knowledge to Action Framework (KtAF). First, we summarize evidence-based strategies (epidemiology, genetics, biomarkers, clinical trials, nonpharmacological interventions, networking, and translational research) and align them to current global strategies to translate regional knowledge into transformative actions. Then we characterize key sources of complexity (genetic isolates, admixture in populations, environmental factors, and barriers to effective interventions), map them to the above challenges, and provide the basic mosaics of knowledge toward a KtAF. Finally, we describe strategies supporting the knowledge creation stage that underpins the translational impact of KtAF.

The Burden of Mental Illness Among Survivors of Critical Care-Risk Factors and Impact on Quality of Life: A Multicenter Prospective Cohort Study.

BACKGROUND: Survivors of critical care may demonstrate mental health disorders in the months after discharge. RESEARCH QUESTION: What are risk factors for mental health disorders after ICU discharge and is there an association between the burden of mental illness and health-related quality of life (HRQoL)? STUDY DESIGN AND METHODS: Multicenter prospective cohort study that included 579 adult ICU survivors with an ICU stay of > 72 h in 10 ICUs. RESULTS: The outcomes were anxiety and depression assessed by the Hospital Anxiety and Depression Scale, posttraumatic stress disorder (PTSD) assessed by the Impact Event Scale 6, and HRQoL assessed by the Short Form 12 version 2. The 6-month prevalences of any mental health disorder were 36.2% (the prevalences of anxiety, depression, and PTSD were 24.2%, 20.9%, and 15.4%, respectively). ICU survivors with mental health disorders showed worse HRQoL scores in both physical and mental dimensions than those without. The higher the number of psychiatric syndromes manifested, the worse the mental dimension of HRQoL. Age of < 65 years (P = .009), history of depression (P = .009), anxiety (P = .003) and depression (P = .02) symptoms at ICU discharge, physical dependence (P = .01), and decreased physical functional status (P = .04) at 6 months were associated with anxiety. History of depression (P = .001), depression symptoms at ICU discharge (P < .001), and decreased physical functional status at 6 months (P = .01) were associated with depression. Depression symptoms at ICU discharge (P = .01), physical dependence (P = .01), and decreased physical functional status (P = .02) at 6 months were associated with PTSD. INTERPRETATION: The network of potential risk factors for mental illness among patients discharged from an ICU is complex and involves multiple factors (age, premorbid mental health, acute emotional stress, and physical impairment after ICU stay). The negative impact of the burden of mental illness on HRQoL among critical care survivors is of concern.

Patient Competency Rating Scale-Brazilian Revised Version (PCRS-R-BR): Normative and Psychometric Data in 154 Healthy Individuals.

Background Patient Competency Rating Scale (PCRS-R-BR) is a clinical tool to evaluate the degree of competence in cognitive skills perceived by patients with brain injuries. However, no studies have investigated the influence of sociodemographic variables on self-report and self-awareness of healthy individuals.Aim This study aimed to (1) present normative data from the PCRS-R-BR in a healthy adult Brazilian sample; and (2) investigate psychometric properties of the scaleMethod One hundred and fifty-four adults that were divided in three age groups and two education groups and their informants completed the PCRS-R-BR.Results Score on the PCRS-R-BR Patient's Form differed as a function of age with younger adults reporting less competency than older individuals. An education effect was found on Attention/Working memory Factor on the Informant's PCRS-R-BR with informants of higher education adults reporting better competency than lower education individuals. A gender effect was observed on the Informant's Form. The Informant's Form scores of informants of women were higher than the scores provided by the informants of men. PCRS-R-BR showed adequate consistency coefficients and six factors.Conclusion PCRS-R-BR scores showed acceptable validity evidence and provides information regarding how age and gender effects may influence ratings in a Brazilian sample.

Development and content validity of the CENEES program - psychoeducation for health staff on neuropsychology of aging.

Worldwide life expectancy has increased dramatically in recent years. Also on the rise are incidents of pathologies related to aging, such as Mild Cognitive Impairment (MCI) or Alzheimer's Disease (AD). An inaccurate diagnosis impairs the well-being and the quality of life of patients and their relatives, as well as being a financial burden on the health system. Continued education pertaining to the neuropsychological field is uncommon for health workers involved in general practice. This article aims to present the process of development and content validity of the "CENEES Program - Psychoeducation for Health Staff on The Neuropsychology of Aging". The CENEES Program was developed in six steps which include: literature review, first draft, focal group, adjustments after focal group, judgment analysis (n = 4), and finally the last version. The inter-rater reliability index after judgment analysis was 0.785. The final version of the CENEES Program contains eight meetings, divided into 4 modules: 1) Fundamentals of Neuroscience; 2) Memory; 3) Executive Functions; and 4) Communication. The final meeting was called "Review". The CENEES Program is a new resource to help professionals who work within the general practice field, especially community health workers. As far as we know, there is no psychoeducation program on aging which contains the four subjects that are covered in the CENEES Program. The CENEES Program could assist the workers' daily activities and make them comfortable to offer and build actions in the community. A pilot and follow-up studies are suggested.

Protocol for a randomized clinical trial: telephone-based psychoeducation and support for female informal caregivers of patients with dementia / Protocolo para ensaio clínico randomizado: psicoeducação por telefone e apoio para cuidadoras informais femininas de pacientes com demência

OBJECTIVE: The burden felt by informal caregivers of patients with dementia is a source of physical, emotional, and financial problems. Face-to-face interventions for caregivers have accessibility limitations that may prevent them from receiving adequate care. Telehealth tools can be a solution to this problem. We will compare a telephone psychoeducational and support intervention protocol to usual care for informal female caregivers of patients with dementia treated at Brazilian specialized outpatient clinics. METHODS: In this single-blind randomized clinical trial, the intervention group will receive one weekly call for 8 weeks that addresses issues such as disease education, communication with the patient, and problematic behaviors. The control group will receive printed material on problematic behaviors in dementia. The primary outcome will be the difference in caregiver burden between baseline and 8 weeks, which will be assessed by blinded investigators through the Zarit Burden Interview scale. Caregiver burden at 16 weeks after baseline, depression, anxiety, and quality of life at 8 and 16 weeks are secondary outcomes. CONCLUSIONS: We expect the intervention to reduce caregiver burden. These results could lead to public health programs for improving dementia care in lower-middle-income countries. Ethics and dissemination: This trial was approved by an independent ethics committee. The results will be published in an international peer-reviewed medical journal. Trial registration number: NCT03260608

OBJETIVO: A sobrecarga sentida por cuidadores informais de pacientes com demência é uma fonte de problemas físicos, emocionais e financeiros. As intervenções face a face para cuidadores apresentam limitações de acessibilidade que podem impedilos de receber cuidados adequados. As ferramentas de telessaúde podem ser uma solução para esse problema. Comparamos um protocolo de intervenção psicoeducacional e de apoio por telefone ao tratamento usual para cuidadoras informais de pacientes com demência tratados em ambulatórios especializados. METODOLOGIA: Será realizado um ensaio clínico randomizado simples-cego. Durante 8 semanas, o grupo de intervenção receberá uma ligação semanal abordando questões como educação sobre a doença, comunicação com o paciente e comportamentos problemáticos. O grupo controle receberá material impresso sobre comportamentos problemáticos na demência. O resultado primário será a diferença na sobrecarga da cuidadora entre o ponto de partida e oito semanas, que será avaliada por pesquisadores cegos com a escala Zarit Burden Interview. Sobrecarga da cuidadora em dezesseis semanas após o início do estudo, depressão, ansiedade e qualidade de vida após oito e dezesseis semanas são resultados secundários. CONCLUSÕES: Esperamos que a intervenção reduza a sobrecarga da cuidadora. Esses resultados podem levar a programas de saúde pública para melhorar o tratamento da demência em países de renda médiabaixa. Ética e divulgação: Este estudo foi aprovado por um comitê de ética independente. Os resultados serão publicados em uma revista médica internacional revisada por pares. Número de registro do teste: NCT03260608.

The effect of intentionality on verbal memory assessment over days.

BACKGROUND: Intentionality to remember is associated with better performances in episodic memory retrieval. The practice effect has better performance in memory retrieval. However, little is known about the effect of intentionality on memory over days and the influence of age, gender, and level of education on it as well as on practice effect. OBJECTIVES: To verify the effect of intentionality and practice effect on memory performance over days, using an ecological approach. METHODS: One hundred and twenty subjects from 18 to 81 years of age and free of psychiatric and neurological disorders were evaluated. They were randomized into a "testing effect group" and a "intentionality group" and then were asked to read a text on the FIFA World Cup. The "intentionality group" was instructed to pay careful attention to the text because they would answer a questionnaire with 10 factual items from the text after 2 and 7 days. The "testing effect group" had the same procedure at the same time as the first group but were not instructed about the intentionality, and answered the questionnaire immediately after reading the text. RESULTS: Memory performance was better 2 days after the exposure session than 7 days later in the "intentionality group". On the other hand, there was no difference in memory performance from the "testing effect group" 2 and 7 days later. CONCLUSIONS: Intention to recall may enhance memory over a short period of days, while retaining similar amount of information over days to what was acquired immediately after text exposure.

INTRODUÇÃO: A intencionalidade de lembrar associa-se a melhores desempenhos na recuperação da memória episódica. O efeito da prática também apresenta melhores desempenhos na recuperação da memória. Entretanto, pouco se sabe sobre a intencionalidade na memória ao longo dos dias sob influência da idade, sexo e escolaridade, assim como sob efeito da prática. OBJETIVOS: Verificar o efeito da intencionalidade e de testes no desempenho da memória ao longo dos dias, utilizando abordagem ecológica. MÉTODOS: Foram avaliados 120 sujeitos (idade 18-81 anos) e a ausência de distúrbios psiquiátricos e neurológicos. Eles foram randomizados para o "grupo de efeito de testes" ou para o "grupo de intencionalidade" e expostos ao texto da Copa do Mundo de Futebol. O "grupo de intencionalidade" foi instruído a prestar muita atenção ao texto, pois seria aplicado um questionário com 10 itens factuais do texto 2 e 7 dias depois. O "grupo de efeito de testes" realizou o mesmo procedimento no mesmo tempo que o primeiro grupo, mas não foi instruído em relação à intencionalidade e responderam ao questionário imediatamente após a leitura do texto. RESULTADOS: O desempenho da memória foi melhor 2 dias após a exposição do que 7 dias depois no "grupo de intencionalidade". Por outro lado, não houve diferença no desempenho de memória no "grupo de efeito de testes" 2 e 7 dias depois. CONCLUSÕES: A intenção de recordar pode melhorar a memória por um curto período de dias. Enquanto o efeito de teste pode reter ao longo de dias quantidade similar de informação que foi adquirida imediatamente após a exposição do texto.

The effect of intentionality on verbal memory assessment over days / O efeito da intencionalidade na avaliação da memória verbal ao longo de dias

ABSTRACT Background: Intentionality to remember is associated with better performances in episodic memory retrieval. The practice effect has better performance in memory retrieval. However, little is known about the effect of intentionality on memory over days and the influence of age, gender, and level of education on it as well as on practice effect. Objectives: To verify the effect of intentionality and practice effect on memory performance over days, using an ecological approach. Methods: One hundred and twenty subjects from 18 to 81 years of age and free of psychiatric and neurological disorders were evaluated. They were randomized into a "testing effect group" and a "intentionality group" and then were asked to read a text on the FIFA World Cup. The "intentionality group" was instructed to pay careful attention to the text because they would answer a questionnaire with 10 factual items from the text after 2 and 7 days. The "testing effect group" had the same procedure at the same time as the first group but were not instructed about the intentionality, and answered the questionnaire immediately after reading the text. Results: Memory performance was better 2 days after the exposure session than 7 days later in the "intentionality group". On the other hand, there was no difference in memory performance from the "testing effect group" 2 and 7 days later. Conclusions: Intention to recall may enhance memory over a short period of days, while retaining similar amount of information over days to what was acquired immediately after text exposure.

RESUMO Introdução: A intencionalidade de lembrar associa-se a melhores desempenhos na recuperação da memória episódica. O efeito da prática também apresenta melhores desempenhos na recuperação da memória. Entretanto, pouco se sabe sobre a intencionalidade na memória ao longo dos dias sob influência da idade, sexo e escolaridade, assim como sob efeito da prática. Objetivos: Verificar o efeito da intencionalidade e de testes no desempenho da memória ao longo dos dias, utilizando abordagem ecológica. Métodos: Foram avaliados 120 sujeitos (idade 18-81 anos) e a ausência de distúrbios psiquiátricos e neurológicos. Eles foram randomizados para o "grupo de efeito de testes" ou para o "grupo de intencionalidade" e expostos ao texto da Copa do Mundo de Futebol. O "grupo de intencionalidade" foi instruído a prestar muita atenção ao texto, pois seria aplicado um questionário com 10 itens factuais do texto 2 e 7 dias depois. O "grupo de efeito de testes" realizou o mesmo procedimento no mesmo tempo que o primeiro grupo, mas não foi instruído em relação à intencionalidade e responderam ao questionário imediatamente após a leitura do texto. Resultados: O desempenho da memória foi melhor 2 dias após a exposição do que 7 dias depois no "grupo de intencionalidade". Por outro lado, não houve diferença no desempenho de memória no "grupo de efeito de testes" 2 e 7 dias depois. Conclusões: A intenção de recordar pode melhorar a memória por um curto período de dias. Enquanto o efeito de teste pode reter ao longo de dias quantidade similar de informação que foi adquirida imediatamente após a exposição do texto.

Verbal fluency in Alzheimer's disease and mild cognitive impairment in individuals with low educational level and its relationship with reading and writing habits.

Verbal fluency (VF) has contributed to building cognitive maps as well as differentiating healthy populations from those with dementia. OBJECTIVES: To compare the performance of healthy controls and patients with mild cognitive impairment (MCI) and Alzheimer's disease (AD) in two semantic VF tasks (animals/clothes) and a phonemic VF task (letter P). Also, to analyze the relationship between the frequency of reading and writing habits (FRWH) and VF in individuals with low educational level. METHODS: Sixty-seven older adults aged 60-80 years and with 2-8 years of schooling were divided into three groups: controls (n=25), older adults with MCI (n=24), and older adults with AD (n=18). We analyzed the type, mean size, and number of clusters, switches, intersections, and returns. A post-hoc single-factor ANOVA analysis was conducted to verify differences between groups. RESULTS: Total words in the phonemic VF and the animal category discriminated the three groups. Regarding the animal category, AD patients performed worse than controls in the total number of words, taxonomic clusters, returns, and number of words remembered. We found a moderate correlation between FRWH and total number of words in the phonemic fluency. CONCLUSIONS: Semantic (animate) and phonemic (total words) VF differentiated controls and clinical groups from each other - the phonemic component was more related to FRWH than the semantic one. The phonemic VF seems to be more related to cognitive reserve. VF tasks, considering total words and cluster analyses, are a valuable tool to test healthy and cognitively impaired older adults who have a low educational level.

A tarefa de fluência verbal (FV) contribui para um mapeamento cognitivo e diferenciação entre populações saudáveis e com demência. OBJETIVOS: Comparar o desempenho em duas tarefas de FV semântica (animais/roupas) e uma fonêmica (letra P) entre controles saudáveis e pacientes com Comprometimento Cognitivo Leve (CCL) e Doença de Alzheimer (DA). Além disso, analisar a relação entre frequência de hábitos de leitura e escrita (FHLE) e a FV nesses grupos de baixa escolaridade. MÉTODOS: Sessenta e sete adultos idosos foram divididos em três grupos: controles (n=25), idosos com CCL (n=24) e idosos com DA (n=18), 60-80 anos de idade e 2-8 anos de escolaridade. Avaliaram-se tipo, tamanho médio e quantidade de agrupamentos, alternâncias, intersecções e retornos. Conduziu-se uma análise ANOVA de um fator com post hoc para verificar diferenças entre grupos. RESULTADOS: O total de palavras na FV fonêmica e a categoria animais discriminaram os três grupos. Na categoria animais, pacientes com DA demonstraram desempenho inferior ao dos controles no número total de palavras, agrupamentos taxonômicos, retornos e número de palavras evocadas. Houve correlação moderada entre FHLE e número total de palavras na FV fonêmica. CONCLUSÕES: O componente semântico (animado) e o fonêmico (total de palavras) da FV diferenciaram os controles e os grupos clínicos entre si; o fonêmico relacionou-se mais com a FHLE do que o semântico. A FV fonêmica parece ser mais relacionada à reserva cognitiva. Tarefas de FV, considerando o total de palavras e as análises de clusters, são ferramentas valiosas para testar adultos idosos saudáveis e com declínio cognitivo na baixa escolaridade.

Verbal fluency in Alzheimers disease and mild cognitive impairment in individuals with low educational level and its relationship with reading and writing habits / Fluência verbal na doença de Alzheimer e comprometimento cognitivo leve na baixa escolaridade e sua relação com hábitos de leitura e de escrita

ABSTRACT. Verbal fluency (VF) has contributed to building cognitive maps as well as differentiating healthy populations from those with dementia. Objectives: To compare the performance of healthy controls and patients with mild cognitive impairment (MCI) and Alzheimer's disease (AD) in two semantic VF tasks (animals/clothes) and a phonemic VF task (letter P). Also, to analyze the relationship between the frequency of reading and writing habits (FRWH) and VF in individuals with low educational level. Methods: Sixty-seven older adults aged 60-80 years and with 2-8 years of schooling were divided into three groups: controls (n=25), older adults with MCI (n=24), and older adults with AD (n=18). We analyzed the type, mean size, and number of clusters, switches, intersections, and returns. A post-hoc single-factor ANOVA analysis was conducted to verify differences between groups. Results: Total words in the phonemic VF and the animal category discriminated the three groups. Regarding the animal category, AD patients performed worse than controls in the total number of words, taxonomic clusters, returns, and number of words remembered. We found a moderate correlation between FRWH and total number of words in the phonemic fluency. Conclusions: Semantic (animate) and phonemic (total words) VF differentiated controls and clinical groups from each other - the phonemic component was more related to FRWH than the semantic one. The phonemic VF seems to be more related to cognitive reserve. VF tasks, considering total words and cluster analyses, are a valuable tool to test healthy and cognitively impaired older adults who have a low educational level.

RESUMO. A tarefa de fluência verbal (FV) contribui para um mapeamento cognitivo e diferenciação entre populações saudáveis e com demência. Objetivos: Comparar o desempenho em duas tarefas de FV semântica (animais/roupas) e uma fonêmica (letra P) entre controles saudáveis e pacientes com Comprometimento Cognitivo Leve (CCL) e Doença de Alzheimer (DA). Além disso, analisar a relação entre frequência de hábitos de leitura e escrita (FHLE) e a FV nesses grupos de baixa escolaridade. Métodos: Sessenta e sete adultos idosos foram divididos em três grupos: controles (n=25), idosos com CCL (n=24) e idosos com DA (n=18), 60-80 anos de idade e 2-8 anos de escolaridade. Avaliaram-se tipo, tamanho médio e quantidade de agrupamentos, alternâncias, intersecções e retornos. Conduziu-se uma análise ANOVA de um fator com post hoc para verificar diferenças entre grupos. Resultados: O total de palavras na FV fonêmica e a categoria animais discriminaram os três grupos. Na categoria animais, pacientes com DA demonstraram desempenho inferior ao dos controles no número total de palavras, agrupamentos taxonômicos, retornos e número de palavras evocadas. Houve correlação moderada entre FHLE e número total de palavras na FV fonêmica. Conclusões: O componente semântico (animado) e o fonêmico (total de palavras) da FV diferenciaram os controles e os grupos clínicos entre si; o fonêmico relacionou-se mais com a FHLE do que o semântico. A FV fonêmica parece ser mais relacionada à reserva cognitiva. Tarefas de FV, considerando o total de palavras e as análises de clusters, são ferramentas valiosas para testar adultos idosos saudáveis e com declínio cognitivo na baixa escolaridade.

A Cross-National Analysis of the Psychometric Properties of the Geriatric Anxiety Inventory.

OBJECTIVES: Assessing late-life anxiety using an instrument with sound psychometric properties including cross-cultural invariance is essential for cross-national aging research and clinical assessment. To date, no cross-national research studies have examined the psychometric properties of the frequently used Geriatric Anxiety Inventory (GAI) in depth. METHOD: Using data from 3,731 older adults from 10 national samples (Australia, Brazil, Canada, The Netherlands, Norway, Portugal, Spain, Singapore, Thailand, and United States), this study used bifactor modeling to analyze the dimensionality of the GAI. We evaluated the "fitness" of individual items based on the explained common variance for each item across all nations. In addition, a multigroup confirmatory factor analysis was applied, testing for measurement invariance across the samples. RESULTS: Across samples, the presence of a strong G factor provides support that a general factor is of primary importance, rather than subfactors. That is, the data support a primarily unidimensional representation of the GAI, still acknowledging the presence of multidimensional factors. A GAI score in one of the countries would be directly comparable to a GAI score in any of the other countries tested, perhaps with the exception of Singapore. DISCUSSION: Although several items demonstrated relatively weak common variance with the general factor, the unidimensional structure remained strong even with these items retained. Thus, it is recommended that the GAI be administered using all items.

Early and Late Mortality Following Discharge From the ICU: A Multicenter Prospective Cohort Study.

OBJECTIVES: To identify the frequency, causes, and risk factors of early and late mortality among general adult patients discharged from ICUs. DESIGN: Multicenter, prospective cohort study. SETTING: ICUs of 10 tertiary hospitals in Brazil. PATIENTS: One-thousand five-hundred fifty-four adult ICU survivors with an ICU stay greater than 72 hours for medical and emergency surgical admissions or greater than 120 hours for elective surgical admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main outcomes were early (30 d) and late (31 to 365 d) mortality. Causes of death were extracted from death certificates and medical records. Twelve-month cumulative mortality was 28.2% (439 deaths). The frequency of early mortality was 7.9% (123 deaths), and the frequency of late mortality was 22.3% (316 deaths). Infections were the leading cause of death in both early (47.2%) and late (36.4%) periods. Multivariable analysis identified age greater than or equal to 65 years (hazard ratio, 1.65; p = 0.01), pre-ICU high comorbidity (hazard ratio, 1.59; p = 0.02), pre-ICU physical dependence (hazard ratio, 2.29; p < 0.001), risk of death at ICU admission (hazard ratio per 1% increase, 1.008; p = 0.03), ICU-acquired infections (hazard ratio, 2.25; p < 0.001), and ICU readmission (hazard ratio, 3.76; p < 0.001) as risk factors for early mortality. Age greater than or equal to 65 years (hazard ratio, 1.30; p = 0.03), pre-ICU high comorbidity (hazard ratio, 2.28; p < 0.001), pre-ICU physical dependence (hazard ratio, 2.00; p < 0.001), risk of death at ICU admission (hazard ratio per 1% increase, 1.010; p < 0.001), and ICU readmission (hazard ratios, 4.10, 4.17, and 1.82 for death between 31 and 60 days, 61 and 90 days, and greater than 90 days after ICU discharge, respectively; p < 0.001 for all comparisons) were associated with late mortality. CONCLUSIONS: Infections are the main cause of death after ICU discharge. Older age, pre-ICU comorbidities, pre-ICU physical dependence, severity of illness at ICU admission, and ICU readmission are associated with increased risk of early and late mortality, while ICU-acquired infections are associated with increased risk of early mortality.

Effect of Flexible Family Visitation on Delirium Among Patients in the Intensive Care Unit: The ICU Visits Randomized Clinical Trial.

Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain. Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation. Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium. Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.

Prevalence of post-traumatic stress disorder symptoms in adult critical care survivors: a systematic review and meta-analysis.

BACKGROUND: As more patients are surviving intensive care, mental health concerns in survivors have become a research priority. Among these, post-traumatic stress disorder (PTSD) can have an important impact on the quality of life of critical care survivors. However, data on its burden are conflicting. Therefore, this systematic review and meta-analysis aimed to evaluate the prevalence of PTSD symptoms in adult critical care patients after intensive care unit (ICU) discharge. METHODS: We searched MEDLINE, EMBASE, LILACS, Web of Science, PsycNET, and Scopus databases from inception to September 2018. We included observational studies assessing the prevalence of PTSD symptoms in adult critical care survivors. Two reviewers independently screened studies and extracted data. Studies were meta-analyzed using a random-effects model to estimate PTSD symptom prevalence at different time points, also estimating confidence and prediction intervals. Subgroup and meta-regression analyses were performed to explore heterogeneity. Risk of bias was assessed using the Joanna Briggs Institute tool and the GRADE approach. RESULTS: Of 13,267 studies retrieved, 48 were included in this review. Overall prevalence of PTSD symptoms was 19.83% (95% confidence interval [CI], 16.72-23.13; I2 = 90%, low quality of evidence). Prevalence varied widely across studies, with a wide range of expected prevalence (from 3.70 to 43.73% in 95% of settings). Point prevalence estimates were 15.93% (95% CI, 11.15-21.35; I2 = 90%; 17 studies), 16.80% (95% CI, 13.74-20.09; I2 = 66%; 13 studies), 18.96% (95% CI, 14.28-24.12; I2 = 92%; 13 studies), and 20.21% (95% CI, 13.79-27.44; I2 = 58%; 7 studies) at 3, 6, 12, and > 12 months after discharge, respectively. CONCLUSION: PTSD symptoms may affect 1 in every 5 adult critical care survivors, with a high expected prevalence 12 months after discharge. ICU survivors should be screened for PTSD symptoms and cared for accordingly, given the potential negative impact of PTSD on quality of life. In addition, action should be taken to further explore the causal relationship between ICU stay and PTSD, as well as to propose early measures to prevent PTSD in this population. TRIAL REGISTRATION: PROSPERO, CRD42017075124 , Registered 6 December 2017.