Tapping into the unimpossible: Philosophical health in lives with spinal cord injury.

BACKGROUND: We investigated the personal philosophies of eight persons with a tetraplegic condition (four male, four female), all living in Sweden with a chronic spinal cord injury (SCI) and all reporting a good life. Our purpose was to discover if there is a philosophical mindset that may play a role in living a good life with a traumatic SCI. METHODS: Two rounds of in-depth qualitative interviews were performed by the same interviewer, a philosophical practitioner by training (de Miranda). The second round systematically covered the following elements: bodily sense, sense of self, sense of belonging, sense of the possible, sense of purpose and philosophical sense. This six-step method developed by de Miranda is called SMILE_PH, an acronym for Sense-Making Interviews Looking at Elements of Philosophical Health. RESULTS: All the interviewees, as a consequence of their trauma, reported having gone through a reinvention of themselves which implied questioning the meaning and purpose of their life in particular and life in general. A philosophical rather than realistic sense of the possible was abstracted toward teleological growth. All interviewees developed a sense of purpose based on self-interested altruism and solidarity with disabled peers. CONCLUSIONS: To reinvent a good life with SCI, in addition to physical training and willpower, one needs to consider philosophical questions about the self and life, what Kant called the cosmic interests of reason: What may I hope? What must I do? What can I know? Our results indicate that we should, in the future, explore what the philosophical health approach may bring to rehabilitation processes in the months or years that follow the trauma.

Philosophical health: Unveiling the patient's personal philosophy with a person-centred method of dialogue.

Grounded in ideas about sense-making and whole-person care with a long intellectual heritage, the movement for Philosophical Health-with its specific conceptions of philosophical care and counselling-is a relatively recent addition to the ongoing debate about understanding better the perspectives of patients to improve health practice. This article locates the development of this movement within the context of broader discussions of person-centred care (PCC), arguing that the approach advocated by defenders of philosophical health can provide a straightforward method for implementing PCC in actual cases. This claim is explained and defended with reference to the SMILE_PH method created by Luis de Miranda (Sense-Making Interviews Looking at Elements of Philosophical Health), an approach recently trialled convincingly with people living with traumatic spinal cord injury.

Memory complaints at primary care in a middle-income country: clinical and neuropsychological characterization.

There are different causes of memory complaints in the elderly, such as subjective cognitive decline (SCD), mild cognitive impairment (MCI) or dementia. OBJECTIVE: 1) To characterize individuals with memory complaints in a mid-sized city in Brazil, through clinical, cognitive and functional assessment; 2) to compare SCD individuals with MCI and dementia patients in terms of clinical and cognitive variables. METHODS: We consecutively included individuals aged ≥50 years, with memory complaints (spontaneous or inquired). Subjects who scored ≥25 on the Memory Complaint Questionnaire or who had spontaneous memory complaints were selected. Participants underwent a semi-structured interview, the Mini-Mental State Examination, Figure Memory Test for visual episodic memory, Clock Drawing Test, Category Fluency (Animals), Neuropsychiatric Inventory, and functional assessment. Individuals were classified as SCD, MCI or dementia. We did not include individuals with previous diagnosis of dementia. RESULTS: The final sample consisted of 91 subjects (73.6% women; mean age 67.6±9.8 years): 14.3% had spontaneous complaints and 85.7% had inquired complaints. The most common comorbidities were hypertension (69.2%), diabetes (36.3%), and dyslipidemia (24.2%). Low levels of vitamin B12 and hypothyroidism were found in 26.4 and 16.5%, respectively. Regarding cognitive diagnosis, 16.5% of the sample were classified as SCD, 49.4% as MCI and 34.1% as dementia. MCI and dementia were identified in five (38.5%) and seven (53.4%) patients with spontaneous complaint, respectively. CONCLUSIONS: MCI and dementia are frequently underdiagnosed. Potential reversible causes of cognitive decline are common. The diagnosis of dementia is highly frequent among individuals with spontaneous memory complaints.

Há diferentes causas de queixas de memória nos idosos, como declínio cognitivo subjetivo (DCS), comprometimento cognitivo leve (CCL) ou demências. OBJETIVO: 1) Caracterizar indivíduos com queixa de memória em uma cidade de médio porte do Brasil, por meio de avaliação clínica, cognitiva e funcional; 2) comparar indivíduos com DCS, com CCL e pacientes com demência em termos de variáveis clínicas e cognitivas. MÉTODOS: Incluiu-se, de modo consecutivo, indivíduos com idade ≥50 anos, com queixas de memória (espontânea ou inquirida). Foram selecionados participantes que pontuaram ≥25 no Questionário de Queixa de Memória ou que apresentaram queixa de memória espontânea. Todos foram submetidos à entrevista semiestruturada, Miniexame do Estado Mental, Teste de Figuras (teste de memória episódica visual), Teste do Desenho do Relógio, Fluência Semântica (Animais), Inventário Neuropsiquiátrico e avaliação funcional. Os indivíduos foram classificados em declínio cognitivo subjetivo (DCS), CCL e demência. RESULTADOS: A amostra final foi composta por 91 indivíduos (73,6% mulheres; média de idade 67,6±9,8 anos); 14,3% apresentaram queixa espontânea e 85,7%, queixa inquirida. As comorbidades mais comuns foram hipertensão (69,2%), diabetes (36,3%) e dislipidemia (24,2%). Baixos níveis de vitamina B12 e hipotireoidismo foram encontrados em 26,4 e 16,5%, respectivamente. Quanto ao diagnóstico cognitivo, 16,5% foram classificados como DCS, 49,4% como CCL e 34,1% como demência. CCL e demência foram respectivamente identificados em cinco (38,5%) e sete (53,4%) pacientes com queixa espontânea de memória. CONCLUSÕES: CCL e demência são frequentemente subdiagnosticados. Causas potencialmente reversíveis de declínio cognitivo foram frequentes na amostra. O diagnóstico de demência foi muito frequente entre indivíduos com queixas espontâneas de memória.

Frequência de baixa adesão e fatores relacionados em idosos atendidos em ponto dos volantes, Vale do Jequitinhonha / Frequency of low adherence and related factors in older adults treated in Ponto dos Volantes, in the Jequitinhonha Valley

OBJETIVO: Avaliar a adesão ao tratamento medicamentoso e possíveis fatores associados em idosos entrevistados durante consultas realizadas em Unidades Básicas de Saúde. MÉTODO: Trata-se de um estudo transversal, de base populacional, com amostra de 57 pacientes com idade entre 60 e 99 anos, residentes do município de Ponto dos Volantes, Minas Gerais, incluindo as zonas rural e urbana. A coleta de dados se deu durante o ato da consulta médica, através de um roteiro eletrônico estruturado. A associação entre os parâmetros e o nível de adesão ao tratamento foi avaliada através do teste do χ2, com intervalo de confiança de 95%. RESULTADOS: Dos idosos entrevistados, 45 (78,9%) responderam sobre adesão ao tratamento. Desses, 11 (24,4%) foram enquadrados no grupo de baixa aderência. Dentre os parâmetros avaliados, nenhum apresentou associação estatística relevante com a classificação da adesão medicamentosa. CONCLUSÃO: O presente estudo identificou que um em cada quatro pacientes apresentava baixa adesão aos tratamentos medicamentosos. Dentre as variáveis estudadas, notadamente sexo, idade, escolaridade, número de comorbidades, número de medicações em uso e renda, não se observou relação estatisticamente significante.

OBJECTIVE: To evaluate adherence to medication treatment and possible associated factors in elderly patients interviewed during medical appointments in primary care units. METHOD: This was a cross-sectional, population-based study of 57 older patients aged 60 to 99 years living in the municipality of Ponto dos Volantes, state of Minas Gerais, including rural and urban areas. Data were collected during medical appointments, using a structured electronic script. The association between the parameters and the level of adherence to treatment was assessed using the χ2 test, with a 95% confidence interval. RESULTS: Among the elderly patients interviewed, 45 (78.9%) responded about adherence to treatment. Of these, 11 (24.4%) were included in the low adherence group. None " of the parameters evaluated showed a statistically significant association with the classification of drug adherence. CONCLUSION: The present study identified that 1 in every 4 patients had low adherence to drug treatment. Among the variables studied, notably sex, age, schooling, number of comorbidities, number of medications, and income, no statistically significant relationship was observed.

Increased plasma levels of BDNF and inflammatory markers in Alzheimer's disease.

Alzheimer's disease (AD) is the most common cause of dementia in the elderly. Neurotrophic factors and inflammatory markers may play considerable roles in AD. In this study we measured, through Enzyme-Linked Immunosorbent Assay, the plasma levels of brain derived neurotrophic factor (BDNF), glial cell-derived neurotrophic factor (GDNF) and neuronal growth factor (NGF), as well as tumor necrosis factor-alpha soluble receptors, sTNFR1 and sTNFR2, and soluble intercellular adhesion molecule 1 (sICAM-1), in 50 AD patients, 37 patients with mild cognitive impairment (MCI) and 56 healthy elderly controls. BDNF levels, expressed as median and interquartile range, were higher for AD patients (2545.3, 1497.4-4153.4 pg/ml) compared to controls (1503.8, 802.3-2378.4 pg/ml), P < 0.001. sICAM-1 was also higher in AD patients. sTNFR1 levels were increased in AD when compared to controls and also to MCI. GDNF, NGF and sTNFR2 levels showed no significant differences among the studied groups. The increase in BDNF might reflect a compensatory mechanism against early neurodegeneration and seems to be related to inflammation. sTNFR1 appears to mark not only the inflammatory state but also differentiates between MCI and AD, which may be an additional tool for differentiating degrees of cognitive impairment.

Good rate of clinical response to cholinesterase inhibitors in mild and moderate Alzheimer's disease after three months of treatment: An open-label study.

Life expectancy in Brazil has increased markedly over the last 30 years. Hence, age-related disorders, such as Alzheimer's disease (AD), warrant special attention due to their high prevalence in the elderly. Pharmacologic treatment of AD is based on cholinesterase inhibitors (ChEI) and memantine, leading to modest clinical benefits both in the short and long-term. However, clinical response is heterogeneous and needs further investigation. OBJECTIVE: To investigate the rate of response to ChEI in AD after three months of treatment. METHODS: Patients with mild or moderate dementia due to probable AD or to AD associated with cerebrovascular disease were included in the study. The subjects were assessed at baseline and again after three months of ChEI treatment. Subjects were submitted to the Mini-Mental State Examination (MMSE), Mattis Dementia Rating Scale, Katz Basic Activities of Daily Living, Pfeffer Functional Activities Questionnaire, Neuropsychiatric Inventory and Cornell Scale for Depression in Dementia. Good response was defined by a gain of ≥2 points on the MMSE after three months of treatment in relation to baseline. RESULTS: Seventy-one patients, 66 (93%) with probable AD and five (7%) with AD associated with cerebrovascular disease, were evaluated. The good response rate at three months was 31.0%, being 37.2% and 21.4% in mild and moderate dementia, respectively. There were no significant differences on most tests, except for improvement in hallucinations, agitation and dysphoria in moderate dementia patients. CONCLUSION: The rate of good clinical response to ChEI was higher than usually reported. Specific behavioral features significantly improved in the subgroup of moderate dementia.

A expectativa de vida no Brasil aumentou significativamente nos últimos 30 anos. Desse modo, transtornos relacionados à idade, como a doença de Alzheimer (DA), merecem especial atenção, devido à elevada prevalência. O tratamento farmacológico da DA se baseia nos inibidores da colinesterase (IChE) e na memantina, com melhora modesta em curto e longo prazo. Entretanto, a resposta clínica é heterogênea e necessita maior investigação. OBJETIVO: Investigar a taxa de resposta aos IChE em pacientes com DA após três meses de tratamento. MÉTODOS: Pacientes com demência leve ou moderada devida à DA ou DA com doença cerebrovascular foram avaliados antes e após três meses de uso de IChE. Todos foram submetidos ao Mini-Exame do Estado Mental (MEEM), Escala de Demência Mattis, avaliação das atividades básicas de vida diária de Katz, Questionário de Pfeffer, Inventário Neuropsiquiátrico e Escala de Depressão de Cornell. Boa resposta foi definida pelo ganho de ≥2 pontos no MEEM em relação à primeira consulta, após três meses. RESULTADOS: Setenta e um pacientes, 66 (93%) com DA provável e cinco (7%) com DA associada à doença cerebrovascular, foram avaliados. A taxa de boa resposta clínica em três meses foi de 31.0%, sendo 37,2% e 21,4% na demência leve e moderada, respectivamente. Não houve diferença significativa na maioria dos testes, exceto para melhora de alucinação, agitação e depressão em pacientes com demência moderada. CONCLUSÃO: A taxa de boa resposta clínica aos IChE foi superior à encontrada na literatura. Observou-se melhora de alguns sintomas comportamentais em pacientes com DA moderada.

Factors influencing possible delay in the diagnosis of Alzheimer's disease: Findings from a tertiary Public University Hospital.

Alzheimer's disease (AD) is characterized by impairment in memory and autonomy, causing excessive pressure on family and an overburdened health care system. Early diagnosis, with the appropriate treatment, is important to reduce the pattern of disease progression. OBJECTIVE: The study sought to identify the most probable causes of delay in diagnosis. METHODS: A cross-sectional study involving AD patients followed at an Outpatient Geriatric Clinic from a tertiary public university hospital was conducted between June 2009 and February 2011. RESULTS: Ninety-four patients were evaluated (66% women), aged 77.76±6.8 years and with median educational level of 3 years (95% CI 2.7-3.80). Regarding severity of dementia, 51.8% of patients were classified as having mild dementia (CDR 1), 40% moderate dementia (CDR 2) and 8.2% severe dementia (CDR 3). Mean educational level of caregivers was 8.3±3.9 years. Among those who believed there was a delay, 36% stated that the "family thought that the changes were normal for the age of the patient" reporting average delay of 1.8 years (95% CI: 1.3-2.5) while 45.3% stated that the "doctor did not reach a diagnosis" reporting a median delay of 1.5 years (95% CI: 1.4-2.3). CONCLUSION: Based on these results, it can be concluded the time between onset of symptoms and diagnosis was excessive. This study may be useful to help increase awareness of issues not sufficiently discussed in the literature, such as diagnostic delay and influence of caregivers' educational level on treatment.

A doença de Alzheimer é caracterizada por comprometimento na memória e na autonomia, causando pressão excessiva em familiares e sobrecarregando o sistema público de saúde. O diagnóstico precoce, com o tratamento adequado, é importante para reduzir o padrão de evolução da doença. OBJETIVO: O estudo pretende identificar as causas mais prováveis de atraso no diagnóstico. MÉTODOS: Trata-se de um estudo transversal envolvendo pacientes com DA acompanhados em Ambulatório de Geriatria de um hospital terciário público entre junho de 2009 e fevereiro de 2011. RESULTADOS: Noventa e quatro pacientes foram avaliados (66% mulheres), com média de idade de 77,8±6,8 anos e com mediana de escolaridade de 3 anos (IC 95%: 2,7-3,8). Quanto à gravidade da doença, 51,8% foram classificados como demência leve (CDR 1), 40% como demência moderada (CDR 2) e 8,2% como demência grave (CDR 3). A escolaridade do cuidador foi de 8,3±3,9 anos. Entre aqueles que acreditavam que havia um atraso no diagnóstico, 36% responderam que "a família achava as alterações como normais para a idade do paciente", com média de 1,8 anos (IC 95%: 1,3-2,5) e 45,3% responderam que "o médico não fez o diagnóstico", com mediana de 1,5 anos (IC 95%: 1,4-2,3). Foi observado que o tempo entre o início dos sintomas e o diagnóstico foi maior do que deveria ser. CONCLUSÃO: Este estudo pode contribuir para aumentar o conhecimento sobre questões ainda pouco discutidas na literatura científica, como atraso no diagnóstico e influência da escolaridade do cuidador no tratamento.