Lifestyle and incident dementia: A COSMIC individual participant data meta­analysis.

INTRODUCTION: The LIfestyle for BRAin Health (LIBRA) index yields a dementia risk score based on modifiable lifestyle factors and is validated in Western samples. We investigated whether the association between LIBRA scores and incident dementia is moderated by geographical location or sociodemographic characteristics. METHODS: We combined data from 21 prospective cohorts across six continents (N = 31,680) and conducted cohort-specific Cox proportional hazard regression analyses in a two-step individual participant data meta-analysis. RESULTS: A one-standard-deviation increase in LIBRA score was associated with a 21% higher risk for dementia. The association was stronger for Asian cohorts compared to European cohorts, and for individuals aged ≤75 years (vs older), though only within the first 5 years of follow-up. No interactions with sex, education, or socioeconomic position were observed. DISCUSSION: Modifiable risk and protective factors appear relevant for dementia risk reduction across diverse geographical and sociodemographic groups. HIGHLIGHTS: A two-step individual participant data meta-analysis was conducted. This was done at a global scale using data from 21 ethno-regionally diverse cohorts. The association between a modifiable dementia risk score and dementia was examined. The association was modified by geographical region and age at baseline. Yet, modifiable dementia risk and protective factors appear relevant in all investigated groups and regions.

Dose-response relationship between late-life physical activity and incident dementia: A pooled analysis of 10 cohort studies of memory in an international consortium.

INTRODUCTION: Though consistent evidence suggests that physical activity may delay dementia onset, the duration and amount of activity required remains unclear. METHODS: We harmonized longitudinal data of 11,988 participants from 10 cohorts in eight countries to examine the dose-response relationship between late-life physical activity and incident dementia among older adults. RESULTS: Using no physical activity as a reference, dementia risk decreased with duration of physical activity up to 3.1 to 6.0 hours/week (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.67 to 1.15 for 0.1 to 3.0 hours/week; HR 0.68, 95% CI 0.52 to 0.89 for 3.1 to 6.0 hours/week), but plateaued with higher duration. For the amount of physical activity, a similar pattern of dose-response curve was observed, with an inflection point of 9.1 to 18.0 metabolic equivalent value (MET)-hours/week (HR 0.92, 95% CI 0.70 to 1.22 for 0.1 to 9.0 MET-hours/week; HR 0.70, 95% CI 0.53 to 0.93 for 9.1 to 18.0 MET-hours/week). DISCUSSION: This cross-national analysis suggests that performing 3.1 to 6.0 hours of physical activity and expending 9.1 to 18.0/MET-hours of energy per week may reduce dementia risk.

Social connections and risk of incident mild cognitive impairment, dementia, and mortality in 13 longitudinal cohort studies of ageing.

INTRODUCTION: Previous meta-analyses have linked social connections and mild cognitive impairment, dementia, and mortality. However, these used aggregate data from North America and Europe and examined a limited number of social connection markers. METHODS: We used individual participant data (N = 39271, Mage  = 70.67 (40-102), 58.86% female, Meducation  = 8.43 years, Mfollow-up  = 3.22 years) from 13 longitudinal ageing studies. A two-stage meta-analysis of Cox regression models examined the association between social connection markers with our primary outcomes. RESULTS: We found associations between good social connections structure and quality and lower risk of incident mild cognitive impairment (MCI); between social structure and function and lower risk of incident dementia and mortality. Only in Asian cohorts, being married/in a relationship was associated with reduced risk of dementia, and having a confidante was associated with reduced risk of dementia and mortality. DISCUSSION: Different aspects of social connections - structure, function, and quality - are associated with benefits for healthy aging internationally. HIGHLIGHTS: Social connection structure (being married/in a relationship, weekly community group engagement, weekly family/friend interactions) and quality (never lonely) were associated with lower risk of incident MCI. Social connection structure (monthly/weekly friend/family interactions) and function (having a confidante) were associated with lower risk of incident dementia. Social connection structure (living with others, yearly/monthly/weekly community group engagement) and function (having a confidante) were associated with lower risk of mortality. Evidence from 13 longitudinal cohort studies of ageing indicates that social connections are important targets for reducing risk of incident MCI, incident dementia, and mortality. Only in Asian cohorts, being married/in a relationship was associated with reduced risk of dementia, and having a confidante was associated with reduced risk of dementia and mortality.

Associations between social connections and cognition: a global collaborative individual participant data meta-analysis.

BACKGROUND: Poor social connections (eg, small networks, infrequent interactions, and loneliness) are modifiable risk factors for cognitive decline. Existing meta-analyses are limited by reporting aggregate responses, a focus on global cognition, and combining social measures into single constructs. We aimed to investigate the association between social connection markers and the rate of annual change in cognition (ie, global and domain-specific), as well as sex differences, using an individual participant data meta-analysis. METHODS: We harmonised data from 13 longitudinal cohort studies of ageing in North America, South America, Europe, Africa, Asia, and Australia. Studies were eligible for inclusion if they had baseline data for social connection markers and at least two waves of cognitive scores. Follow-up periods ranged from 0 years to 15 years across cohorts. We included participants with cognitive data for at least two waves and social connection data for at least one wave. We then identified and excluded people with dementia at baseline. Primary outcomes were annual rates of change in global cognition and cognitive domain scores over time until final follow-up within each cohort study analysed by use of an individual participant data meta-analysis. Linear mixed models within cohorts used baseline social connection markers as predictors of the primary outcomes. Effects were pooled in two stages using random-effects meta-analyses. We assessed the primary outcomes in the main (partially adjusted) and fully adjusted models. Partially adjusted models controlled for age, sex, and education; fully adjusted models additionally controlled for diabetes, hypertension, smoking, cardiovascular risk, and depression. FINDINGS: Of the 40 006 participants in the 13 cohort studies, we excluded 1392 people with dementia at baseline. 38 614 individual participants were included in our analyses. For the main models, being in a relationship or married predicted slower global cognitive decline (b=0·010, 95% CI 0·000-0·019) than did being single or never married; living with others predicted slower global cognitive (b=0·007, 0·002-0·012), memory (b=0·017, 0·006-0·028), and language (b=0·008, 0·000-0·015) decline than did living alone; and weekly interactions with family and friends (b=0·016, 0·006-0·026) and weekly community group engagement (b=0·030, 0·007-0·052) predicted slower memory decline than did no interactions and no engagement. Never feeling lonely predicted slower global cognitive (b=0·047, 95% CI 0·018-0·075) and executive function (b=0·047, 0·017-0·077) decline than did often feeling lonely. Degree of social support, having a confidante, and relationship satisfaction did not predict cognitive decline across global cognition or cognitive domains. Heterogeneity was low (I2=0·00-15·11%) for all but two of the significant findings (association between slower memory decline and living with others [I2=58·33%] and community group engagement, I2=37·54-72·19%), suggesting robust results across studies. INTERPRETATION: Good social connections (ie, living with others, weekly community group engagement, interacting weekly with family and friends, and never feeling lonely) are associated with slower cognitive decline. FUNDING: EU Joint Programme-Neurodegenerative Disease Research grant, funded by the National Health and Medical Research Council Australia, and the US National Institute on Aging of the US National Institutes of Health.

Public stigma: the community's tolerance of Alzheimer disease.

OBJECTIVES: To investigate public stigma relating to Alzheimer disease (AD) and variables correlated with this outcome. DESIGN: Cross-sectional study. SETTING: City of São Paulo, Brazil. PARTICIPANTS: A representative sample of 500 individuals aged 18-65 years, living within the community. MEASUREMENTS: Subjects were interviewed to assess three dimensions of stigma (stereotypes, prejudice, and discrimination). Stigma was considered present in this study when all three domains were simultaneously fulfilled. RESULTS: The 41.6% of the participants expressed stereotypes; 43.4% prejudice; and 35.5% discrimination. Among the whole sample, 14.8% endorsed the stigma definition criterion adopted for this study. Those with fewer years of education were 2.32 times as likely to stigmatize persons carrying AD. Stigma was unaffected by other sociodemographic variables, experience of mental illness, emotional reactions, or general information about AD. CONCLUSIONS: Dimensions of stigma were highly prevalent in relation to AD. Interventions are needed to reduce the negative effects of stigma.

Prevalence and characteristics of outpatient psychotherapy use: a systematic review.

Psychotherapy is an efficacious and long used type of care. However, information available in specialized literature shows that this area has been little studied. The objective of this study is to determine the prevalence of use of outpatient psychotherapy by adult population, their related factors, and funding sources through systematic review, including qualitative and quantitative analyses of original articles with cross-sectional design and population-based sampling. Between January 1970 and December 2007, 3 databases were searched. A total of 2240 articles were identified, and 6 studies fulfilled the inclusion criteria. These studies investigated the prevalence of use of outpatient psychotherapy either in the moment or for 12 months or throughout life. Some of them investigated sociodemographic and health characteristics of users, costs, and treatment-funding sources. Studies' restricted number and different characteristics did not enable a meta-analysis. Six studies on the prevalence of use of outpatient psychotherapy were identified, thus revealing lack of data on this issue.

Validity studies of quality of life instruments for eating disorders: systematic review of the literature.

To conduct a systematic review of studies that evaluated quality of life (QOL) among individuals with eating disorders, to analyze the characteristics of specific QOL instruments for eating disorders. Bibliographic searches were conducted in 6 databases and manual searches in 2 journals, covering the period from January 1975 to June 2008. The search strategies provided a total of 29,537 references. Out of the 41 studies that met the inclusion criteria for this review, 5 reported on the validation process for 4 specific instruments for eating disorders. Among the 4 specific QOL instruments for eating disorders, 3 presented adequate development procedures and psychometric properties. However, further research is needed to prove the validity and applicability of these instruments. Additional validation studies are needed, especially in relation to patients who deny that they have a disorder.

Cognitive-behavioral group therapy is an effective treatment for major depression in hemodialysis patients.

Depression is an important target of psychological assessment in patients with end-stage renal disease because it predicts their morbidity, mortality, and quality of life. We assessed the effectiveness of cognitive-behavioral therapy in chronic hemodialysis patients diagnosed with major depression by the Mini International Neuropsychiatric Interview (MINI). In a randomized trial conducted in Brazil, an intervention group of 41 patients was given 12 weekly sessions of cognitive-behavioral group therapy led by a trained psychologist over 3 months while a control group of 44 patients received the usual treatment offered in the dialysis unit. In both groups, the Beck Depression Inventory, the MINI, and the Kidney Disease and Quality of Life-Short Form questionnaires were administered at baseline, after 3 months of intervention or usual treatment, and after 9 months of follow-up. The intervention group had significant improvements, compared to the control group, in the average scores of the Beck Depression Inventory overall scale, MINI scores, and in quality-of-life dimensions that included the burden of renal disease, sleep, quality of social interaction, overall health, and the mental component summary. We conclude that cognitive-behavioral group therapy is an effective treatment of depression in chronic hemodialysis patients.

Anorexia nervosa treatment from the patient perspective: a metasynthesis of qualitative studies.

BACKGROUND: Anorexia nervosa is a complex condition that brings great challenges at each stage of treatment. This study aims to organize the body of information available in qualitative studies about the treatment of anorexia nervosa through a systematic literature review and metasynthesis. METHODS: Searches were carried out on the following databases for the years 1990 to 2005: PubMed, ISI, PsycINFO, EMBASE, LILACS, and SciELO from 1990 to 2005. A meta-ethnographic approach was used to synthesize the data through second-order and third-order interpretations. RESULTS: The search revealed 3415 studies, of which 16 were selected. Two concepts for second-order interpretation emerged from the process: (1) the process of change (phases of recovery, factors favoring recovery, factors limiting recovery) and (2) perception of the treatment modalities. From the second-order categories, a third-order category was derived--reconciliation, in which personal and environmental acceptance have a central role. CONCLUSIONS: Recovery from anorexia nervosa, as a very complex process, goes well beyond conventional treatment. Self-acceptance, determination, and spirituality are equally important elements.

Violence and post-traumatic stress disorder in Sao Paulo and Rio de Janeiro, Brazil: the protocol for an epidemiological and genetic survey.

BACKGROUND: violence is a public health major concern, and it is associated with post-traumatic stress disorder and other psychiatric outcomes. Brazil is one of the most violent countries in the world, and has an extreme social inequality. Research on the association between violence and mental health may support public health policy and thus reduce the burden of disease attributable to violence. The main objectives of this project were: to study the association between violence and mental disorders in the Brazilian population; to estimate the prevalence rates of exposure to violence, post-traumatic stress disorder, common metal disorder, and alcohol hazardous use and dependence: and to identify contextual and individual factors, including genetic factors, associated with the outcomes. METHODS/DESIGN: one phase cross-sectional survey carried out in Sao Paulo and Rio de Janeiro, Brazil. A multistage probability to size sampling scheme was performed in order to select the participants (3000 and 1500 respectively). The cities were stratified according to homicide rates, and in Sao Paulo the three most violent strata were oversampled. The measurements included exposure to traumatic events, psychiatric diagnoses (CIDI 2.1), contextual (homicide rates and social indicators), and individual factors, such as demographics, social capital, resilience, help seeking behaviours. The interviews were carried between June/2007 February/2008, by a team of lay interviewers. The statistical analyses will be weight-adjusted in order to take account of the design effects. Standardization will be used in order to compare the results between the two centres. Whole genome association analysis will be performed on the 1 million SNP (single nucleotide polymorphism) arrays, and additional association analysis will be performed on additional phenotypes. The Ethical Committee of the Federal University of Sao Paulo approved the study, and participants who matched diagnostic criteria have been offered a referral to outpatient clinics at the Federal University of Sao Paulo and Federal University of Rio de Janeiro.

Anorexia nervosa's meaning to patients: a qualitative synthesis.

BACKGROUND: We carried out a qualitative synthesis of international literature to provide insight into the patient's experience as a means to help clinicians recognize symptoms of anorexia nervosa. METHOD: International publications from 1990 to 2005 were searched for relevant qualitative investigations, and meta-ethnography was employed to identify common themes across studies. Databases included were PubMed, ISI, PsycINFO, EMBASE, LILACS and SciELO. RESULTS: 24 studies were included from a total of 3,415 papers. The second-order interpretation process using reciprocal translation allowed the identification of two concepts: (1) symptom identification (disease representation, self-concept, development of anorexia) and (2) disease interpretation (positive aspects, negative aspects, areas of life affected). Third-order constructs emerged revealing the disease as connected with identity and control. CONCLUSION: Knowledge of patients' efforts to interpret the illness as a part of their own identity and sense of control have a key role in physician understanding of the disorder by allowing physicians to bring structure to the patients' lives generally and to their help-seeking behavior specifically. The study has some limitations. Most of the results come from B-grade studies (as classified by the Critical Appraisal Skills Programme) that used qualitative methodology, implying the need for caution in data interpretation. Moreover, study populations were almost exclusively female, and no comparison was attempted concerning the severity of the condition between studies.

Public beliefs about the treatment of schizophrenia and depression in Brazil.

BACKGROUND: Little is known about public beliefs concerning the treatment of mental disorders in developing countries. AIMS: To assess preferences on sources of help and treatment and the perception of prognosis for schizophrenia and depression. METHOD: A household survey was carried out in 2002 with a probabilistic sample of 1000 individuals, residents of São Paulo city, Brazil, with ages ranging from 18-65. Vignettes in colloquial language describing individuals with schizophrenia and depression (according to DSM-IV and ICD-10) were presented, together with a structured questionnaire with questions about the vignette. RESULTS: Results indicated the same general tendencies for schizophrenia and depression. The public considered the help of lay people and psychologists the most useful. Medical professionals are viewed less favorably. The treatments and activities most recommended are psychotherapy and general activities, such as physical activities and attending church services. Medical treatments are seen as more harmful than helpful. The more important determinants were: identification as mental illness, religion, sex and years of school completed. Prognosis with treatment for both disorders is viewed as favorable. CONCLUSIONS: These results may indicate that the public need to receive more information on the full range of treatments options, especially those related to medical treatment.

The relationship between religiosity and tobacco, alcohol use, and depression in an elderly community population.

OBJECTIVE: The objective of this study is to examine the religious characteristics of older subjects and the associations of these characteristics to the use of tobacco, alcohol, and depression. METHODS: Data from a multistage random sample were used to examine associations between religiosity and health behaviors (tobacco use, alcohol) and depression among elderly house hold residents aged 60+ in Rio Grande do Sul, Brazil. Survey measures included sociodemographic characteristics, four aspects of religiosity, tobacco use, alcohol abuse and dependence, depression, life style, social context, functional status, and health conditions. RESULTS: After controlling for demographic, social connections, health behavior, functional status, and health conditions, evangelical affiliation reduced the odds of being a current tobacco user by 51%. Those reporting affiliation as Afro-Brazilian and not having a religion had, respectively, a 74% and 124% increased risk. All other religious domains protect against tobacco use. Not having a religion affiliation and the experience of a religious change increased the risk of alcohol misuse by 88% and 31%, respectively. In contrast, orienting-motivating force increased the odds of depression by 38%. Participating in social religious activities had reduced the risk of depression by 16%. CONCLUSION: Several aspects of religiosity reduced the odds of being a tobacco user. Not having a religion and the experience of a religious change increased the risk of alcohol misuse. However, the domain orienting-motivating force increased the odds, and participating in social religious activities had reduced the risk of a depressive state.

How should alcohol dependence be treated? The public view.

AIMS: The aim of this study was to assess public preferences on sources of help and treatment, and perception of prognosis for alcohol dependence. METHOD: A household survey was administered in 2002 to a probabilistic sample of 500 individuals, all residents of the city of São Paulo, Brazil, with ages ranging from 18 to 65. A vignette in colloquial language describing an individual with alcohol dependence (according to DSM-IV and ICD-10 criteria) was presented together with a structured questionnaire with questions about the vignette. RESULTS: The public considered the help of lay people, self-help groups and psychologists the most useful. Medical professionals were viewed less favourably. The treatments and activities most recommended were psychotherapy and general activities, such as physical activities, keeping the mind busy and attending church services. Medical treatments were seen as more harmful than helpful. The more important determinants were identification of alcohol dependence as mental illness, religion and number of years of school completed. Prognosis with treatment was viewed as favourable. CONCLUSION: These results may indicate that the public needs to receive more information on the full range of treatments options, especially those related to professional or formal treatment.

Antidepressants in short-term treatment of binge eating disorder: systematic review and meta-analysis.

OBJECTIVE: To evaluate the effects of antidepressant interventions for patients with Binge Eating Disorder (BED). METHOD: A systematic review and meta-analysis of available randomized controlled trials including a quality appraisal was conducted. Six databases: PUBMED, EMBASE, PSYINFO, LILACS, The Cochrane Collaboration Controlled Trials Register and The Cochrane Depression, Anxiety and Neurosis Group Database of Trials were searched using an electronic search strategy. Articles published during the period from January 1994 to December 2005 were included. RESULTS: From the 3357 articles initially identified, 19 full manuscripts were selected and analyzed and 7 studies fulfilled the inclusion criteria and were included in the final analysis. Data from the meta-analysis revealed that binge-eating remission rates were higher in patients receiving antidepressants when compared with placebo. No difference in body weight has been found as measured by short-term change in body mass index. Most studies were short-term trials (median duration: 8 weeks). The only 16-week duration study did not show superiority of antidepressants over placebo. CONCLUSION: Available data are not sufficient to formally recommend antidepressants as a single first line therapy for both short-term remission of binge-eating episodes and weight reduction in patients with BED. BED is a chronic condition and very short-term studies (8 weeks) may be of limited value.

[Public perception of depression in the city of São Paulo]. / Percepção da depressão pela população da cidade de São Paulo.

OBJECTIVE: To assess how the population identifies symptoms of depression as well as its causes. METHODS: A household survey with a probabilistic sample of 500 individuals, residing in the city of São Paulo and aged between 18 and 65 years, was conducted in 2002. A structured questionnaire including sociodemographic data and a vignette presentation describing a person with depression, according to the Diagnostic and Statistical Manual of Mental Disorders-IV and the International Classification of Diseases-10 was used during the in-person interviews carried out by trained, qualified interviewers. Two questions about the vignette's symptom identification were subsequently asked. The results were analyzed by means of logistic regression and variance analysis. RESULTS: Symptoms presented were identified as "depression" by less than half of the sample. About 20% of respondents believed it was a mental illness. Low level of education was the only variable associated with identification as mental illness (OR=2.001, 95% CI: 1.275; 3.141, p=0.003). The most relevant causes were "unemployment" and "isolation". Biological, spiritual and moral causes were considered to be less relevant. Factors that most influenced the responses about causes were level of education, gender, personal experience with mental problems and identification as mental illness. CONCLUSIONS: The population of the city of São Paulo in general, especially those with a higher level of education, views depression in terms of a psychosocial model that somewhat differs from the biomedical model.

Public perception of alcohol dependence.

OBJECTIVE: To describe how the population of the city of São Paulo identifies alcohol dependence, which causes they attribute to this disorder and what is reported regarding stigma perception, risk of violence and emotional reactions. METHOD: Cross sectional study involving a probabilistic sample of 500 individuals in São Paulo aged 18 to 65 years. A structured questionnaire was used and started with a vignette describing an individual with alcohol dependence according to the DSM-IV and ICD-10, followed by a questionnaire divided into various sections examining the causes, stigma, risk of violence and emotional reactions to the case presented in the vignette. RESULTS: Less than 20% of the subjects reported to believe this was a mental illness. The causes considered most relevant were psychosocial ones, followed by moral causes. Alcohol dependence was associated with a high risk of violence and stigma by the part of others. In contrast, reactions declared by the subjects about their probable attitude were mostly positive. CONCLUSION: Alcohol dependence is seen as a psychosocial and moral problem. Negative images predominate regarding individuals with this disorder.

Quality of life of patients with nephrolithiasis and recurrent painful renal colic.

BACKGROUND: Quality of life (QoL) has not been a priority goal for patients with recurrent painful colic of renal lithiasis. AIM: To evaluate QoL in patients with recurrent painful symptoms due to renal colic. METHODS: In this case-control study, 194 subjects (97 cases/97 controls) were matched according to age and gender. Cases were patients at an outpatient clinic with a confirmed diagnosis of nephrolithiasis with recurrent painful renal colic. The control group consisted of patients seen at an ophthalmology outpatient clinic for refraction symptoms. MAIN OUTCOME MEASURES: QoL was measured using the SF-36. RESULTS: Average SF-36 dimension scores for cases and controls, respectively, were: physical function 70/95, role-emotional function 33.3/100, role limitations due to physical problems 25/100, bodily pain 41/84, general health status 52/82, vitality 45/80, social function 62.5/100 and mental health 52/84. All values were statistically different (p < 0.001). Using multiple linear regression, there was a statistically significant QoL drop in subjects with lithiasis. Low social and economic levels were associated with the following SF-36 domains: physical function, general health status, vitality and mental health. The influence of the diagnosis on role-physical and role-emotional domains. Analysis of the physical and mental components of the SF-36 Scale showed significantly lower averages between cases and controls: PCS (p < 0.001) and MCS (p < 0.001). CONCLUSION: The QoL of patients with painful recurrent symptoms due to renal colic was substantially impaired.

[Prevalence of elder abuse: a systematic review]. / Prevalência de maus-tratos na terceira idade: revisão sistemática.

OBJECTIVE: To identify prevalence studies of abuse among elderly and assess their quality. METHODS: A systematic literature review was performed through PubMed, LILACS, Embase, ISI, and PsycInfo, for the period between 1988 and 2005. Population-based studies were included and studies without clear methodological definition and with clinical and service samples were excluded. RESULTS: There were found 440 articles, but only 11 of them were selected. Most were cross-sectional designs and only two were longitudinal studies. These studies were conducted in various countries worldwide, mostly in US and Europe. They varied widely in terms of abuse definition. Prevalence of physical abuse ranged from 1.2% (Holland) to 18% (Finland). CONCLUSIONS: There is a considerable prevalence variation between sites. The most influential variables on prevalence seem to be culture-related. As the number of elderly is increasing worldwide, there is a need for studies to better understand this phenomenon.