[Patient's suicide: Emotional impact on healthcare professionals and changes in their behavior]. / Impacto emocional y cambios en la conducta profesional a causa del suicidio de pacientes.

The objective of the study was to assess the emotional impact on healthcare professionals and changes in their behavior as a result of patients' suicide in Argentina. An anonymous survey was e-mailed to healthcare professionals registered in CEMIC University Institute Department of Psychiatry database. A total of 250 responses were obtained. Among respondents, 50.6% had provided treatment to patients that committed suicide. The rate rose to 62.5% among psychiatrists. The professionals that gave an affirmative response were assessed with Horowitz Impact of Event Scale to determine the severity of trauma. The mean score for the sample was 19.6 (mild severity), with a higher mean observed in women (21.2). A difference was found in the group of younger professionals (20-29 years), who revealed a higher impact of event, with moderate severity (29.0). This difference was numerical and failed to be statistically significant (chi2 (4)=8.2110 p=0.084). Only 11.5% of respondents referred to the need to undergo treatment as a result of a patient's suicide-related death. However, 41.5% experienced a negative impact on their physical or mental health. About 60% of professionals made changes in their clinical practice after a patient's suicide. About 80% of respondents admitted they had not received enough training about suicide. Acknowledging these difficulties and providing support to healthcare professionals is crucial to face these challenges.

[Use of scales in depression patients in clinical practice in Argentina]. / Uso de escalas en depresión en la práctica clínica en Argentina.

Although depression is a treatable cause of suffering, disability and death, its identifcation and treatment continue to be a challenge in clinical practice and a severe problem for global public health. The main objective of this study was to investigate the frequency with which mental health professionals use scales to assess depressive patients in Argentina and to determine the reasons that constrain such practice. Between July and September 2012 a national survey was conducted by e-mail. Professionals registered in the database of the Argentine Association of Psychiatrists were invited to participate in the survey. Responses were obtained from 243 professionals. Of the total respondents, only 8.7% said they always used scales to assess depressive patients. The reasons recorded by most respondents why scales were not used were: lack of time and the belief that they do not help in clinical practice. Despite the fact that treatment guidelines for depression recommend the use of scales to optimize the assessment and treatment of depressive disorders, this does not seem to be the usual behavior in clinical practice in our country.

[A survey on biomarkers and early diagnosis in Alzheimer's disease]. / Una encuesta sobre biomarcadores y diagnóstico precoz de la enfermedad de Alzheimer.

Given the potential use of biomarkers in the diagnosis of Alzheimer's disease (AD) in early stages, new ethical and communication dilemmas appear in everyday clinical practice. The aim of this study was to know the opinion of health professionals (HP) and general public (GP) on the implementation of early diagnostic techniques in AD and the use of biomarkers for this purpose. A survey with multiple choice answers was elaborated in two versions: one for HP and the other for GP. Respondents were invited to participate through a system of mass mailing e-mail; e-mail addresses were collected from CEMIC database. A total of 1503 answers were analyzed: 807 HP and 696 GP. Most respondents, 84.7%, preferred the option of early diagnosis of AD even knowing the lack of curative treatment. Forty five percent of GP and 26.8% of HP replied that there is no ethical dilemma in the use of biomarkers and that no communication or ethical dilemma is generated to physicians when informing the diagnosis of the disease. The HP group showed more divergence in the views than the GP group. These results may indicate a change in the physician-patient relationship, showing the GP group with an active and supportive position towards the use of biomarkers for early diagnosis of AD.

[QUICK INVENTORY OF DEPRESSIVE SYMPTOMATOLOGY SELF-REPORT IN THE CLINICAL PRACTICE OF DEPRESSIVE PATIENTS]. / Cuestionario breve de sintomatolog!a depresiva autoadministrado en la práctica clinica de pacientes depresivos.

INTRODUCTION: To determine the intensity of depressive disorder is helpful to make treatment decisions. The purpose of this study is to establish the correlation between the Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR16) and Montgomery Asberg Depression Rating Scale (MADRS), in order to measure the depression intensity in outpatients from two urban areas in Argentina. METHOD: Over an 18-month period, 67 outpatients from the current clinical practice were included in the study. They first presented with a diagnosis of nonpsychotic major depressive disorder, according to the DSM-IV-TR criteria. Both the QIDS-SR16 and MADRS were administered. RESULTS: The internal consistency of the QIDS-SR16 was acceptable, with the Cronbach's alpha being 0.74. Criterion validity was estimated through the correlation between both scales and was 0.84 (p<0.0001), while gamma statistics for the ordinal comparison of categories was 0.95, thus showing a high correlation. CONCLUSION: The study findings show that the correlation between the two analyzed questionnaires allows determining depression intensity in patients from our setting. These findings further allow analyzing the usefulness of the scale for several depressive subtypes. As far as training and administration, the QIDS-SR16 is less time-consuming.

[Ethical considerations regarding the communication of diagnosis of prodromal Alzheimer's disease]. / Consideraciones éticas de la comunicación diagnóstica en la enfermedad de Alzheimer prodrómica.

Population aging has increased age-related diseases such as dementia, Alzheimer's disease (AD) being the most common in older adults (50%-60%). It is one of the most feared conditions for its irreversible and incurable, by its chronicity and it consists of a long process of depersonalization. The clinical diagnosis is mainly based on DSM-IV and NINCDS-ADRDA. Definitive diagnosis is post-mortem, as it requires histopathological confirmation. However, there have been new diagnostic criteria based EA biomarkers, which can be done in life, anticipating the course of several years before dementia. Thus, physicians are increasingly exposed to AD patients in early stages, having to face the dilemma of communicating the diagnosis to a patient with cognitive failures and disease awareness, with the implications that generates about him and his family. The objectives of this paper will analyze the ethical problem of communication of clinical diagnosis of AD in prodromal stages (pre-dementia) in our country, based on the analysis of ethical principles (autonomy and non maleficence) involved in decision making.

Mild cognitive impairment: risk of dementia according to subtypes.

UNLABELLED: Mild cognitive impairment (MCI) has 3 clinical subtypes: amnestic (aMCI), multiple domains (mdMCI) and non-amnestic single domain (na-SD-MCI) whose evolutive possibility to dementia has not been profoundly studied. OBJECTIVE: This paper aims to determine the conversion to dementia of the different subtypes of MCI and determine risk factors associated to conversion to dementia. METHODS: A total of 127 patients diagnosed with MCI (age=70.21; SD=13.17) were evaluated with a neuropsychological and neuropsychiatric battery. They were classified into 3 groups: amnestic MCI (n=20), multiple-domain MCI (n=98), non-amnestic MCI (n=9). Seventeen normal subjects (age=74.59; SD=10.63) were included. RESULTS: Of those included, 27.1% developed Alzheimer's type dementia [average time for conversion to Alzheimer's dementia (AD) 11.12 months (SD=0.183)]. None of the controls developed dementia. Thirty-five percent (n=7) of amnestic MCI converted to AD: 20% (n=4) at 6 months and 15% (n=3) at 12 months); 11.1% (n=1) of the non-amnestic single domain MCI converted to AD at 6 months. It was found that 31.6% (n=31) of multiple domain MCI rotated to AD: 15.3% (n=15) at 6 months and 16.3% (n=16) at 12 months. Age (p<0.05, ß=1.03) increased the likelihood of rotation to AD. Multi-domain MCI subtype was the most frequent. However, the conversion to dementia in amnestic subtype was the highest, age and retirement being the variables that increased the likelihood of conversion to Dementia.

[Review of recommendations and new diagnosis criteria for mild cognitive impairment due to Alzheimer's disease]. / Revisión de los nuevos criterios y recomendaciones para el diagnóstico de Deterioro Cognitivo Leve debido a Enfermedad de Alzheimer.

The symptomatic predementia phase of Alzheimer's disease (AD), known as mild cognitive impairment (MCI) is a clinical and neuropsychological condition which defines the transitional state between normal aging and dementia, and is used as a clinical description of people at risk of developing AD. A review of the diagnostic criteria of MCI due to Alzheimer's disease was recently published by the Alzheimer's Association and the National Institute on Aging of the U.S. in order to ensure early diagnosis of the disease, useful for both clinical practice and clinical trials. The objectives of this paper are to review and analyze the revised diagnostic criteria for MCI due to Alzheimer's disease recently proposed, to compare with criteria for MCI available and to establish current strengths and limitations of the new proposal in clinical practice. The new diagnostic criteria for MCI due to AD have a radical importance since they are potentially applicable in the clinical or research protocols and in all clinical settings where such markers are available. They provide a useful, consistent and valuable tool to homogenize the subgroup of patients with MCI who already has AD in a predementia phase with inexorable progression to dementia by AD over the years.

[Basis of treatment of dementia. Pros and cons of early versus delayed treatment. Rationale]. / Bases racionales del tratamiento de las demencias. Pro y contra del tratamiento temprano versus diferido.

The objective of this analysis was to review the clinical benefits of early treatment of Alzheimer's disease focusing on data on the use of inhibitors of acetylcholinesterase. A number of well-done clinical trials show that therapy is effective in dropping the progressive deterioration of cognition and behavior. They also reveal significant benefits to start treatment early. These benefits include behavioral stabilization preserving the independence, in addition to delay cognitive impairment. There is evidence that favors initiating treatment early in the course of dementia and reinforces the need to estimate the behavior and activities to precisely evaluate treatment response.

Validity and reliability of the SF-36 administered to caregivers of patients with alzheimer's disease: evidence from a south american sample.

BACKGROUND: Being a caregiver of a patient with Alzheimer's disease is associated with impaired health status and declines in health-related quality of life (HRQoL). This paper evaluates the reliability and validity of the Argentinean version of the Medical Outcomes Study Short-Form Health Survey (SF-36) among caregivers of patients with Alzheimer's disease. METHODS: Forty-eight caregivers of Alzheimer's disease patients completed the SF-36, the Zarit Burden Interview (ZBI) and the Neuropsychiatric Inventory (NPI). Patients were evaluated for dementia severity using the Clinical Dementia Rating (CDR) and for cognitive status using the Mini Mental State Examination (MMSE). RESULTS: The SF-36 scales demonstrated adequate-to-strong internal consistency (Cronbach's alpha range: 0.72 to 0.92). Correlations between the SF-36 scales and the ZBI were moderate to strong (range: -0.19 to -0.79, all p < 0.01 expect for physical function). Significant correlations between the SF-36 scales and the CDR, MMSE and NPI were lower (range: -0.30 to -0.40, p < 0.001) and strongest in mental health-related scales of the SF-36. The SF-36 demonstrated good factorial validity. CONCLUSIONS: The Argentinean translation of the SF-36 is reliable and valid for use to measure the HRQoL of caregivers of patients with Alzheimer's disease.

Cognitive, functional and behavioral factors associated with the burden of caring for geriatric patients with cognitive impairment or depression: evidence from a South American sample.

OBJECTIVE: To examine behavioral, cognitive and functional factors associated with psychosocial burden in caregivers of geriatric patients. METHODS: Primary caregivers assessed were included if the geriatric patient cared for had a cognitive impairment or dementia (degenerative, vascular or mixed) (Group 1) or depression and cerebrovascular disease (CVD) (Group 2). Caregivers completed the Zarit questionnaire, the Neuropsychiatric Inventory (NPI) and Instrumental Activities of Daily Living (IADL). Patients were evaluated for dementia severity using the Clinical Dementia Rating (CDR), Mini Mental State Examination (MMSE) and Beck Depression Inventory (BDI). Structural equation modelling (SEM) was used to assess measurement models and the factors associated with burden. RESULTS: Two hundred and fifty-eight caregiver-patient pairs were included. The best model fit was obtained with a model with two constructs: function-cognition (CDR, MMSE, and IADL) and behavior (neuropsychiatric symptoms from the NPI). In Group 1, both function (B = 0.32. T = 2.79) and behavior (B = 0.72, T = 7.84) were significantly correlated with caregiver burden, although the strength of association was more than two times higher for behavior. In Group 2, behavior was related to caregiver burden (B = 0.68, T = 6) but not function-cognition (B = 0.16, T = 1.36). CONCLUSION: These findings suggest that behavioral symptoms are an important factor associated with caregiver burden in patients with cognitive impairment, dementia, or depression, while functional and cognitive factors seem to also have an influence in patients with cognitive impairment.

Mild cognitive impairment: believe it or not?

Mild cognitive impairment (MCI) was previously defined as a transitional state that can precede dementia, but the condition and the rates of conversion remain controversial. MCI is now the focus of natural history studies, along with Alzheimer's disease (AD) prevention. The objective of our review will be to consider the question of whether MCI is a well enough established entity that it can be a diagnosis in medical practice and a valid target of Alzheimer's prevention therapy. MCI was originally defined by Petersen et al. (1999) as progressive memory loss, prodrome of Alzheimer's disease. More recently MCI has been expanded to other cognitive domains with other potential causes like normal aging, fronto-temporal dementia, and vascular dementia. Despite many consensus conferences, experts cannot agree on critical aspects of the MCI, particularly with respect to its clinical utility. Based on neuropsychological studies, a hippocampal memory profile has been proposed for MCI as prodromal AD. Further research is needed to advance these criteria. We have no doubt, however, that in the future, the diagnosis of AD as disease (not only a dementia syndrome) will be made in the early pre-dementia stage and will be drawn from a combination of neuropsychological, neuro-imaging and CSF biomarkers.

[Behavioural and psychological signs in dementia. Clinical features. Pharmacological and non-pharmacological treatment strategies]. / Trastornos psicóticos y de conducta en las demencias: clínica y estrategias terapéuticas farmacológicas y no farmacológicas.

In first term, we define the current concepts in regard to psychosis (delirium and hallucinations) and abnormal behaviours (aggression, depression and mood changes such as mania, apathy, anxiety, agitation and desinhibition) in dementia. We also review the most used drugs in order to control these symptoms (typical and atypical antipsychotics, anti-epileptic drugs, benzodiazepines, SSRI, memantine and AcheI). As well, we take in consideration pharmacokinetic and pharmacodynamic characteristics, relationship to aging and interactions of these medications. Finally, we briefly describe the management of non-pharmacological of the most common behavioural symptoms: disruptive conducts such as exaggerated responses to minimal stimuli, catastrophic reaction, violence, anger and hostility, wandering and sundowning. As well, we discuss how to manage sleep disturbances, sexual aggression, incontinence and dressing apraxia. Management of these conditions involves, in first term, a comprehensive understanding of the whole situation and identification of underlying possible causes will make possible to evaluate results. This approach will lead to a more rationale proposal of psychotherapeutic and behavioural techniques, and milieu modifications. Finaly, we consider safety patient's in the community as well as the risk of abuse originated in a non-healthy patient-caregiver relationship.

Risk of Conversion to Dementia in a Mild Behavioral Impairment Group Compared to a Psychiatric Group and to a Mild Cognitive Impairment Group.

BACKGROUND: There is insufficient available information on behavioral changes in the absence of cognitive impairment as factors increasing the risk of conversion to dementia. OBJECTIVE: To observe and analyze patients with mild behavioral impairment (MBI), mild cognitive impairment (MCI), and a psychiatry group (PG) to compare the risk of progression to dementia. METHODS: From 677 initially assessed ≥60-year-old patients, a series of 348 patients was studied for a five-year period until censoring or conversion to dementia: 96 with MBI, 87 with MCI, and 165 with general psychiatry disorders, including 4 subgroups: Anxiety, Depression, Psychosis and Others. All patients were assessed with clinical, psychiatric, neurological, neuropsychological, and neuroimaging studies. RESULTS: From 348 patients, 126 evolved to dementia (36.2%). Conversion was significantly higher in MBI (71.5%), followed by the MCI-MBI overlap (59.6%) and MCI (37.8%) groups, compared to PG (13.9%) (Log-rank p < 0.001). MCI patients mostly converted to Alzheimer's dementia, while MBI converted to frontotemporal dementia and Lewy body dementia. Patients in PG converted to Lewy body dementia and frontotemporal dementia. CONCLUSION: Conversion to dementia is significantly higher in patients with neuropsychiatric symptoms. The MBI concept generates a new milestone in the refining of diagnosis of neurodegenerative diseases and the possibility of creating neuropsychiatric profiles. Its earlier identification will allow new possibilities for therapeutic intervention.

[Mild cognitive impairment. Survey of attitudes of specialists and general physicians. mild]. / Deterioro cognitivo leve. Encuesta sobre actitudes de medicos especialistas y generalistas.

Mild cognitive impairment (MCI) refers to persons who are slightly cognitively impaired for age but do not meet the criteria for dementia. MCI has been related to a pre-dementia stage of Alzheimer's disease (AD). However, other possible diagnoses such as cerebro-vascular disease, frontotemporal dementia or normal aging have been considered. Diagnosis, etiology and conversion to dementia are a source of ambiguity in MCI. The aim was to evaluate the opinion of experts on dementia and of general practitioners concerning MCI. A total of 24 experts from Argentina and Brazil (16 neurologists and 8 psychiatrists) and 30 general practitioners agreed to reply to a questionnaire on MCI (adapted from Dubois inventory, 2003). Of these, 92% of experts considered MCI as an ambiguous entity, not necessarily as a "pre-dementia" stage; 63% confirmed a tendency to worsen over the time and 83% of experts decided to initiate treatment using cholinesterase inhibitors, memantine and vitamin E. The opinion on MCI was that a priori it is not only an Alzheimer disease pre-dementia stage, but most of them consider the treatment against AD. MCI is a heterogeneous entity that should be classified as an open category and making it necessary to standardize definitions and design diagnosis guides to better understand Alzheimer disease pre-dementia stage.

[Cognitive performance in schizophrenia (paranoid vs residual subtype)]. / Estudio de los rendimientos cognitivos en pacientes esquizofrénicos (forma paranoide vs residual).

INTRODUCTION: Several studies refer to the relationship between schizophrenia and cognitive dysfunctions. The most frequent disturbances accepted are the deficits in the executive, memory and verbal tests. However, there are few comparative data about the cognitive functioning of the different subtypes of schizophrenia. OBJECTIVE: Analyze and compare the neuropsychological disturbances present in patients with paranoid and residual schizophrenia. MATERIALS AND METHOD: Eleven patients with paranoid schizophrenia, eleven patients with residual schizophrenia (DSM-IV criteria), and thirty one normal subjects matched by age, educational level, and general cognitive level (Mini Mental State Examination (Folstein, 1975), were assessed with a semistructured psychiatric examination and an extensive neuropsychological battery. RESULTS: Significant differences were found in memory, language, and executive functions when schizophrenics were compared with normal subjects. Differences in similarities were found between paranoid and residual schizophrenics. Residual schizophrenics had more disturbances in neuropsychological tests in comparison with paranoid schizophrenics. CONCLUSION: Schizophrenics demonstrated disturbances in memory, language, executive functions and attention. Residual schizophrenics had more impairment in neuropsychological tests than paranoid schizophrenics.

[Neuropsychiatric symptoms in mild cognitive impairment]. / Trastornos conductuales en el deterioro cognitivo leve.

UNLABELLED: The mild cognitive impairment (MCI), has emerged as an identifiable condition and in many cases is an intermediate state preceding diagnosable Alzheimer disease (AD) characterized by acquired cognitive deficits, without significant decline in functional activities of daily living. The aim of this study was to determine both the presence and type of neuropsychiatric manifestations in MCI patients and to compare them with both those suffering from mild AD and normal controls. METHODS: 86 subjects were assessed, 27 were classified as having MCI, 39 as having presumable mild AD, and 20 normal controls matched by age and education. The Neuropsychiatric inventory (NPI-Q) was used to assess the neuropsychiatric manifestations. RESULTS: The most common symptoms in the MCI group were irritability (55%), dysphoria (44%), apathy (37%), and anxiety (37%). Statistically significant differences were observed between the MCI and control groups regarding the above mentioned symptoms (p0.05). However, the differences between the MCI and mild AD groups were not found to be statistically significant. CONCLUSION: MCI is associated with a high rate of neuropsychiatric symptoms (irritability, depression, anxiety and apathy). These symptoms have serious adverse consequences and should be considered in diagnosis criteria.

[Cognition in dysthymia]. / Cognición en distimia.

UNLABELLED: Depression is named as one of the most prevalent Mental Health problem, affecting almost 10 % of the population. According to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) different subtypes are included. Dysthymic Disorder is characterized by a depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. The aim of this study was to investigate the neuropsychological profile of dysthymic disorder. Ninety three patients fulfilling criteria for dysthymia were examined on a variety of cognitive tasks, neurological exam and a semi-structured psychiatric interview. Forty one non-depressed individuals served as controls. Significant differences between groups were found in digit span; immediate and delayed recall of a story; and semantic and phonologic fluency. Logic memory was worse than serial learning task, and has a correlation with attention deficit and depressive features. CONCLUSIONS: This results indicate that the neuropsychological performance of patients with dysthymic disorder exhibit impairments in attention and memory. Attentional deficits appear to be the key of cognitive deficits in dysthymia.

[Neuropsychological tools for the study of depression]. / Herramientas neuropsicológicas en el estudio de la depresión.

Depression is a common disorder, affecting approximately one in ten of the population at some time in their lives. The nature and extent of such changes, however, is less clear, and their specificity to mood disorder, their existence before the onset of affective symptoms, their etiology and their relation ship to underlying neuroanatomical abnormalities remain poorly understood. Our objective is to present a comprehensive review of the existing neuropsychological literature on bipolar affective disorder, mayor depression and the differential diagnosis between geriatric depression and the depression as early symptom of Alzheimer's disease. The most critical neuropsychological assessment to study this patients will be discussed. Depression is associated with dysexecutive syndrome which correlate with fronto subcortical diseases. Cognitive impairment include attention disorders, memory difficulties type forgetfulness and executive dysfunction (planning and executions of complex behaviors, monitoring of performance, feedback, decision making etc). Cortical neuropsychological profile in a depressive patients represent Alzheimer's disease associate. Neuropsychological assessment is useful to detect both different cognitive profiles (Cortical vs Subcortical).

[Neuropsychiatric symptoms in patients with Alzheimer disease]. / Trastornos neuropsiquiátricos en pacientes con Enfermedad de Alzheimer.

BACKGROUND: In the past decade neuropsychiatric symptoms are not recognized until moderate and late stages of Alzheimer Disease (AD). OBJECTIVES: To identify the neuropsychiatric symptoms in different stage of the disease. MATERIALS AND METHODS: 72 patients with probable AD (NINCDS ADRDA criteria) and 19 control subjects underwent an extensive neurologic, neuropsychologic, and neuropsychiatric evaluation including the brief questionnaire form of the Neuropsychiatric Inventory (NPI-Q). RESULTS: 87,5% developed neuropsychiatric symptoms, being apathy and irritability the most frequent. In those with CDR 0,5 such findings were already present in 66,6%. Patients with mild dementia (MMSE 21-30) showed more affective symptoms, those with moderate (MMSE 11-20) more psychotic symptoms and patients with severe impairment (MMSE 0-11) showed more expression of frontal deterioration. CONCLUSIONS: Neuropsychiatric symptoms are frequent manifestations of AD, and must be recognized and treated properly even in the early stages of the disease because they contribute to caregiver burden and often precipitate institutionalization in nursing home.

Geriatric depression and its relation with cognitive impairment and dementia.

Different subtypes of depressive syndromes exist in late life; many of them have cognitive impairment and sometimes it is difficult to differentiate them from dementia. This research aimed to investigate subtypes of geriatric depression associated with cognitive impairment, searched for differential variables and tried to propose a study model. A hundred and eighteen depressive patients and forty normal subjects matched by age and educational level were evaluated with an extensive neuropsychological battery, scales to evaluate neuropsychiatric symptoms and daily life activities (DLA). Depressive patients were classified in groups by SCAN 2.1: Major Depression Disorder (MDD) (n: 31), Dysthymia Disorder (DD) (n: 31), Subsyndromal Depression Disorder (SSD) (n: 29), Depression due to Dementia (n: 27) (DdD). Neuropsychological significant differences (p<0.05) were observed between depressive groups, demonstrating distinctive cognitive profiles. Moreover, significant differences (p<0.05) were found in DLA between DdD vs all groups and MDD vs controls and vs SSD. Age of onset varied in the different subtypes of depression. Beck Depression Inventory (BDI) and Mini Mental State Examination (MMSE) were significant variables that helped to differentiate depressive groups. Significant correlations between BDI and Neuropsychological tests were found in MDD and DD groups. Depressive symptoms and its relation with neuropsychological variables, MMSE, cognitive profiles, DLA and age of onset of depression should be taken into consideration for the study of subtypes of geriatric depression.