Mild and moderate cognitive impairment and mortality among Brazilian older adults in long-term follow-up: The bambui health aging study

Objective: To compare mortality in older adults with and without mild or moderate cognitive impairment over 15 years of follow-up in a middle-income country, where little information on this subject is available. Methods: A total of 1,281 community-dwelling older adults were followed-up for a median of 13.3 years. We evaluated their cognitive impairment using the Mini-Mental State Examination, categorizing it as none (1.0 SD above cutoff means), mild (1.0 SD below cutoff means) or moderate (2.0 SD below cutoff means). The date of death was determined by reviewing death certificates. Cox's proportional hazards models were used to evaluate the risk of mortality in participants with cognitive impairment. Results: Participants with mild or moderate cognitive impairment had a higher mortality risk than those without it in the unadjusted model, but these associations did not remain in the final model. After sex stratification, only men with moderate cognitive impairment had a higher mortality risk in the final model. Conclusion: The findings suggest an association between moderate cognitive impairment and all-cause mortality in men in a large Brazilian cohort of older adults.

Mild and moderate cognitive impairment and mortality among Brazilian older adults in long-term follow-up: The Bambui Health Aging Study.

OBJECTIVE: To compare mortality in older adults with and without mild or moderate cognitive impairment over 15 years of follow-up in a middle-income country, where little information on this subject is available. METHODS: A total of 1,281 community-dwelling older adults were followed-up for a median of 13.3 years. We evaluated their cognitive impairment using the Mini-Mental State Examination, categorizing it as none (1.0 SD above cutoff means), mild (1.0 SD below cutoff means) or moderate (2.0 SD below cutoff means). The date of death was determined by reviewing death certificates. Cox's proportional hazards models were used to evaluate the risk of mortality in participants with cognitive impairment. RESULTS: Participants with mild or moderate cognitive impairment had a higher mortality risk than those without it in the unadjusted model, but these associations did not remain in the final model. After sex stratification, only men with moderate cognitive impairment had a higher mortality risk in the final model. CONCLUSION: The findings suggest an association between moderate cognitive impairment and all-cause mortality in men in a large Brazilian cohort of older adults.

Diabetes, depressive symptoms, and mortality risk in old age: The role of inflammation.

BACKGROUND: Both diabetes and depression increase the mortality risk in the elderly. In this study, we evaluated mortality risk associated with the comorbidity between depression and diabetes. We also assessed the moderating role of inflammation in the mortality risk in this population. METHODS: We included a total of 1,183 community-dwelling older adults, divided into four groups: "neither diabetes nor depression"; "diabetes only"; "depression only," and "both diabetes and depression," and followed-up for a median of 13.5 years. We evaluated the inflammatory status by the high-sensitivity C-reactive protein (hs-CRP) levels. Date of death was computed by reviewing death certificates. We used Cox's proportional hazards models and additive interactions to evaluate the risk of mortality in the subject groups and the moderating effect of hs-CRP. RESULTS: Participants with both diabetes and depression had higher death risk (hazard ratio [HR]: 2.33; 95% confidence interval [CI]: 1.59-3.42) than those with each condition alone (HR diabetes: 2.08 95% CI: 1.56-2.76 HR depression: 1.26; 95% CI: 1.03-1.54). High level of hs-CRP, indicative of high inflammatory status, significantly moderated the risk of mortality in subjects with both diabetes and depression (Bonferroni-adjusted p = 0.0116). CONCLUSIONS: The coexistence of diabetes and depression symptoms is associated with the highest death risk in this population. This risk is moderated by inflammatory status.

Use of mental health services by community-resident adults with DSM-IV anxiety and mood disorders in a violence-prone area: São Paulo, Brazil.

BACKGROUND: While under-use of mental health services by adults with anxiety and/or depression is well established, use in a violence-prone area, and as a function of diagnosis and personality characteristics such resilience, is little known. We examine the sociodemographic and personality characteristics (specifically resilience), associated with use of mental health services in a violence-prone city by those with anxiety, depression, and their comorbidity. METHODS: The structured Composite International Diagnostic Interview was used to identify 12-month DSM-IV- and ICD-10-defined anxiety and depression in a cross-sectional, representative, community-resident sample age 15-75y (N = 2536) in São Paulo, Brazil, and their use of mental health services. Resilience was determined by the Wagnild and Young scale. Analyses, using weighted, design-corrected statistical tests, included frequency measures and multivariable logistic regression. RESULTS: Mental health services were used by 10% with only anxiety, 22% with only depression, and 34% with comorbidity, with odds of use in controlled analyses doubling from anxiety to depression to comorbidity. Use was significantly higher among those who were white, older (age >30 years, with substantial social support, low resilience, living in low homicide rate areas; use was not affected by experience of traumatic events. Psychiatrists, general practitioners, and psychologists were the primary providers. LIMITATIONS: Cross-sectional design CONCLUSIONS: Contrary to expectation, use was greater among residents of lower homicide areas, and was not associated with personal traumatic experience. This may reflect increased immunity to violence in higher homicidal rate areas, lower resilience, and poorer access to services. Increased access to mental health services is needed.

12-month prevalence and concomitants of DSM-IV depression and anxiety disorders in two violence-prone cities in Brazil.

BACKGROUND: Estimating 12-month prevalence of depression, anxiety, and comorbid anxiety/depression in noninstitutionalized adults (age 15-75) in two violence-prone cities. METHODS: The Composite International Diagnostic Interview v2.1 (Portuguese), administered in population-representative surveys (age 15-75) in São Paulo (N = 2536) and Rio de Janeiro (N = 1208), yielded 12-month prevalence of violent events experienced, and DSM-IV diagnoses of depression and anxiety, which were classified into mutually exclusive groups: 1) no anxiety/depression; 2) anxiety only; 3) depression only; 4) comorbid anxiety/depression. Weighted analyses estimated 12-month prevalence, multinomial logistic regression compared the demographic characteristics of the diagnosis groups, and association with experienced violence. RESULTS: Twelve-month prevalence of anxiety alone, depression alone, and comorbid anxiety/depression was 12.7% (of whom 24.9% were also depressed), 4.9% (of whom 46.2% had anxiety), and 4.2% respectively for São Paulo; and 12.1% (18.2% of whom were depressed), 4.6% (37.0% with anxiety), and 2.7% respectively for Rio de Janeiro. All conditions were approximately twice as prevalent in women than in men in both cities. In São Paulo, comorbidity was associated with age under 60, depression alone was more prevalent among 30-59 year olds, but in 23-29 year-olds in Rio de Janeiro. Exposure to violence increased the odds of anxiety, depression, and their comorbidity. With rare exception, marital status, education, and race/ethnicity were not associated with anxiety, depression, or their comorbidity. LIMITATIONS: Cross-sectional design. CONCLUSIONS: Prevalence rates for all conditions were high, and particularly associated with exposure to violence. Means to ameliorate violence, and its mental health effects, particularly for women, are needed.

Prevalence and Correlates of Elder Abuse in São Paulo and Rio de Janeiro.

OBJECTIVES: To assess the prevalence of elder abuse and to investigate potential sociodemographic, health behavior, and medical correlates. DESIGN: Cross-sectional data were collected in face-to-face assessments. SETTING: São Paulo and Rio de Janeiro, Brazil. PARTICIPANTS: Individuals aged 60 to 75. MEASUREMENTS: Information on elder abuse was obtained using the Brazil-adapted, nine-item Hwalek-Sengstock Elder Abuse Screening Test. Sampling design-adjusted descriptive statistics and logistic regression were used in analyses. RESULTS: The overall prevalence of abuse was 14.4% (n = 46/259, 95% confidence interval (CI) = 9.82-20.61) in São Paulo and 13.3% (n = 27/197, 95% CI = 8.76-19.74) in Rio de Janeiro. Unadjusted analyses indicated that poor education, low physical activity, unemployment, heart disease, and psychiatric problems were associated with abuse, but in adjusted analyses, self-reported elder abuse was significantly associated only with psychiatric problems (São Paulo: OR = 4.48, 95% CI = 1.75-11.45; Rio de Janeiro: OR = 21.61, 95% CI = 6.39-73.14). CONCLUSION: Elder abuse is prevalent in São Paulo and Rio de Janeiro, but whether concomitants of abuse are cause, effect, or both is unclear because this was a cross-sectional study. These findings highlight the importance of the problem, as well as the need to develop measures to increase awareness, facilitate prevention, and fight against abuse of elderly adults.

Public Stigma towards Older Adults with Depression: Findings from the São Paulo-Manaus Elderly in Primary Care Study.

This study investigates three domains of public stigma (perceived negative reactions, perceived discrimination, and dangerousness) against older adults with depression. The sample comprised of older adults registered with primary care clinics (n = 1,291) and primary health care professionals (n = 469) from São Paulo and Manaus, Brazil. Participants read a vignette describing a 70-year-old individual (Mary or John) with a depressive disorder and answered questions measuring stigma. The prevalence of the three stigma domains was between 30.2 and 37.6% among older participants from São Paulo and between 27.6 and 35.4% among older participants from Manaus. Older adults from both cities reported similar prevalence of perceived stigma. Key factors associated with stigmatizing beliefs among older participants were reporting depressive symptoms, having physical limitations, and identifying the case of the vignette as a case of mental disorder. Among health professionals, the prevalence of the three stigma domains was between 19.8 and 34.8% in São Paulo and 30.2 and 44.6% in Manaus. The key factor associated with stigma among primary health care professionals was city, with consistently higher risk in Manaus than in São Paulo. Findings confirm that public stigma against older adults in Brazil is common. It is important to educate the public and primary health care providers in Brazil on stigma related to mental illness in order to reduce barriers to adequate mental health treatment.

Differential characteristics of young and midlife adult users of psychotherapy, psychotropic medications, or both: information from a population representative sample in São Paulo, Brazil.

OBJECTIVE: While the personal characteristics of users of psychotherapy and/or psychotropic medications have been examined, direct user comparison of these treatment approaches appears to be rare. Our aim is to ascertain extent of receipt of these services, and identify basic distinguishing characteristics of users. METHODS: Information on demographics, lifetime and past 12 month use of mental health services, and presence of common mental disorders (CMD), was gathered in 2002 using a multi-stage sampling procedure that yielded a population-representative, community-resident sample (N = 2000, age 18-65) for São Paulo, Brazil. Analysis used descriptive statistics and logistic regression. RESULTS: Overall, 9.3% reported receiving psychotherapy and/or psychotropic medication, 54.3% of whom did not meet CMD criteria. Of those meeting criteria for CMD (n = 455, 22.8%), 2.9% reported only psychotherapy, 10.1% reported only psychotropic medication, and 5.7% reported both. CMD was associated with use of psychotropic medication (psychotropic medication alone, Odds Ratio (OR) 3.58, 95% CI 2.33-5.52; together with psychotherapy, OR 4.17, 95% CI 2.34-7.44). CMD was not associated with use of psychotherapy. Users' distinguishing characteristics were: psychotherapy only--not married; psychotropics only--increasing age, female, not married; using both--only CMD status. Neither education nor income was associated with use. CONCLUSIONS: Nearly 10% of all community residents age 18-65, but less than a fifth of the 23% with CMD, received psychotherapy and/or psychotropic medication. Non-married status increased odds of all treatment types, but CMD presence increased only odds of psychotropic and combined psychotherapy/psychotropic use, with odds of psychotropic only use increasing with age, and for women. Use was equitable with respect to education and income.

The Relationship of Built Environment to Health-Related Behaviors and Health Outcomes in Elderly Community Residents in a Middle Income Country.

BACKGROUND: Few studies have examined the impact of the built environment (BE) on health behaviours and health outcomes in middle income countries. This study examines associations between self-assessed characteristics of the home and neighbourhood environment and health-related behaviours and health outcomes in an elderly population in Brazil. DESIGN AND METHODS: In a community sample of 6963 community dwellers 60 years old and older living in the state of Rio Grande do Sul, Brazil, associations between self-reported BE conditions and health behaviours and health outcomes were assessed using a structured questionnaire. Multivariate analysis was conducted to investigate these associations while accounting for other relevant characteristics. RESULTS: We found significant positive associations between adverse BE conditions and pulmonary, urinary conditions, gastrointestinal, problems, headache and depression. There were mixed associations between adverse BE conditions and musculoskeletal and sensory conditions, inverse associations with metabolic disorders. and no associations with dermatologic problems and cancer. After accounting for health related behaviours, results suggest a modest association between adverse BE conditions and hypertension, with no significant associations with other indicators of cardiovascular conditions (heart problems, stroke, varicose veins). CONCLUSIONS: The findings in this study suggest links between adverse conditions in the BE and health related behaviours in the hypothesized direction. Associations with the health conditions examined here are mixed. We find the strongest evidence for effects of adverse BE conditions for pulmonary and infectious conditions. Significant associations between the adverse BE indicators and health outcomes persist after accounting for health related behaviours, suggesting that BE conditions are linked to health pathways above and beyond the health related behaviours assessed in this study. Significance for public healthThe health outcomes for which we found most consistent evidence of associations with the built environment index (BEI) included respiratory conditions (bronchitis, pneumonia), urinary and renal conditions, gastrointestinal problems, headache, visual impairment and stroke. These health outcomes in the elderly may reflect exposures in the household environment associated with inadequate housing, such as mold, dust and damp. They may also be influenced by poor sanitary conditions, reflected in the absence of indoor plumbing and inadequate waste disposal facilities. Poor vision, headache and depression may all be associated with chronic exposure to poverty and stress, for which the measures of the household and neighborhood environmental conditions used in the BEI may be indicators. Assuring that the elderly in Brazil have access to adequate housing located in neighborhoods with access to basic sanitary conditions, water and lighting, will be increasingly important as the average age of Brazilians continues to increase, and increasing proportions of the population experience the adverse health effects associated with these conditions.

Prevalence and correlates of physical inactivity among older adults in Rio Grande do Sul, Brazil.

BACKGROUND: Current information on the epidemiology of physical inactivity among older adults is lacking, making it difficult to target the inactive and to plan for interventions to ameliorate adverse effects. OBJECTIVES: To present statewide representative findings on the prevalence of physical inactivity among older community residents, its correlates and associated health service use. METHODS: A representative non-institutionalized random sample of 6963 individuals in Rio Grande do Sul, Brazil, aged ≥60 years, was interviewed face-to-face. Information was obtained on demographic characteristics, social resources, health conditions and behaviors, health service use, and physical inactivity. Controlled logistic regression was used to determine the association of physical inactivity with these characteristics. RESULTS: Overall, 62% reported no regular physical activity. Physical inactivity was significantly more prevalent among women, older persons, those with lower education and income, Afro-Brazilians (73%; White: 61%; "other": 64%), those no longer married, and was associated with multiple individual health conditions and impaired activities of daily living (ADL). In adjusted analyses, associations remained for sociodemographic characteristics, social participation, impaired self-rated health, ADL, vision, and depression (odds ratios (OR) 1.2-1.7). Physically inactive respondents were less likely to report outpatient visits (OR 0.81), but more likely to be hospitalized (OR 1.41). CONCLUSIONS: Physical inactivity is highly prevalent, particularly among Afro -Brazilians. It is associated with adverse sociodemographic characteristics; lack of social interaction; and poor self-rated health, ADL, vision, and depression; although not with other health conditions. Self-care may be neglected, resulting in hospitalization.

Use of psychotherapy in a representative adult community sample in São Paulo, Brazil.

Little is known about the use of psychotherapy to treat common mental disorders in a major city in a middle-income country. Our data come from in-home interviews with a stratified random sample of 2000 community residents aged 18 to 65 years in the city of São Paulo, Brazil. The information obtained included sociodemographic characteristics; psychotropic drugs; mental status; and lifetime, previous 12 months, and current use of psychotherapy. Logistic regression was used to examine determinants of use of psychotherapy. Of the sample, 22.7% met General Health Questionnaire-12 criteria for common mental disorders. Lifetime, previous 12 months, and current use of psychotherapy were reported by 14.6%, 4.6%, and 2.3% of the sample, respectively. Users typically were women, were more educated, had higher income, were not married, were unemployed, and had common mental disorders. Further analysis found that 47% (with higher education and income) paid out-of-pocket, and 53% used psychotropic medication. Psychotherapy does not seem to be the preferred treatment of common mental disorders.

Factors associated with antidepressant, anxiolytic, and other psychotropic medication use to treat psychiatric symptoms in the city of São Paulo, Brazil.

The objective of this study was to examine the prevalence and characteristics of adult psychotropic medication use in São Paulo, Brazil. Information on lifetime and 12-month psychotropic medication use, and psychiatric status was obtained from a representative sample of 2000 adults aged 18-65 years in São Paulo, Brazil. Lifetime and 12-month use of psychotropic medications was 16.8 and 7.1%, respectively. Of the 22.8% of patients with current psychiatric problems, 29.5% reported lifetime use and 15.8% (5.6% of the sample) reported 12-month use (anxiolytics: 2.7%, antidepressants: 1.8%, alternative medicines: 0.9%, antipsychotics: 0.4%, mood stabilizers: 0.4%, hypnotics: 0.3%; multiple class use occurred). The most frequent prescribers were psychiatrists and general practitioners. Determinants of use included identification as a psychiatric case (four-fold increased odds), being female (three-fold increase), age (4-5% per additional year), and lower odds if married. Education, employment status, and birth in São Paulo were not associated with use. Income did not affect anxiolytic use, but antidepressant and alternative medicine use was associated with higher income. These results show that psychotropic drug use was comparatively low. Only 15.8% of patients with psychiatric problems reported recent psychotropic use. Comparable with other studies, use was greater among women and increased with age.

The association of health and income in the elderly: experience from a southern state of Brazil.

OBJECTIVES: In high income, developed countries, health status tends to improve as income increases, but primarily through the 50(th)-66(th) percentile of income. It is unclear whether the same limitation holds in middle income countries, and for both general assessments of health and specific conditions. METHODS: Data were obtained from Brazil, a middle income country. In-person interviews with a representative sample of community residents age ≥ 60 (N=6963), in the southern state of Rio Grande do Sul, obtained information on demographic characteristics including household income and number of persons supported, general health status (self-rated health, functional status), depression, and seven physician-diagnosed, self-reported health conditions. Analyses used household income (adjusted for number supported and economies of scale) together with higher order income terms, and controlled for demographics and comorbidities, to ascertain nonlinearity between income and general and specific health measures. RESULTS: In fully controlled analyses income was associated with general measures of health (linearly with self-rated health, nonlinearly with functional status). For specific health measures there was a consistent linear association with depression, pulmonary disorders, renal disorders, and sensory impairment. For musculoskeletal, cardiovascular (negative association), and gastrointestinal disorders this association no longer held when comorbidities were controlled. There was no association with diabetes. CONCLUSION: Contrary to findings in high income countries, the association of household-size-adjusted income with health was generally linear, sometimes negative, and sometimes absent when comorbidities were controlled.

Long term remission of anorexia nervosa: factors involved in the outcome of female patients.

BACKGROUND: Anorexia nervosa (AN) is usually marked by difficult recovery. OBJECTIVE: To elicit, describe and characterize factors involved in successful AN remission for at least five years and post-recovery life. METHODS: A qualitative study design using semi-structured interviews according to grounded theory methodology was used. An intentional sample of 15 information rich AN patients was selected using two sampling procedures: the criterion and "snowball" techniques. Qualitative interviews were audiotaped, transcribed, and entered into a content analysis. Researchers coded transcripts and developed themes. RESULTS: Four core parameters were found to be associated with remission: (i) 'motivation to change/stimuli'; (ii) 'empowerment/autonomy'; (iii) 'media related factors'; (iv) 'treatment factors'. Clinical remission can be associated with residual symptoms. CONCLUSIONS: The recovery model involves not only one, but rather a set of inter-active variables, each one can partially explain remission. Media factors can take a new role on recovery. Remission, however, can be followed by remnants of the disease and functional limitations.

Prevalence and concomitants of arthritis in the elderly in Rio Grande do Sul, Brazil.

OBJECTIVES: Information on the prevalence and concomitants of arthritis in developing countries is sparse. It is unclear whether they are comparable to findings in developed countries. To ascertain the prevalence, demographic characteristics, and health-related concomitants of arthritis in older persons in the southern state of Rio Grande do Sul, Brazil, a middle income country. METHODS: The state of Rio Grande do Sul, Brazil, was subdivided into nine regions. Stratified random sampling was used to identify 880 community residents age ≥60 years in each region. One region with suspect data was excluded. Of 7040 community residents contacted in eight regions, 6963 participated (1.1% refusal rate). In 1995, trained, monitored interviewers, using structured questionnaires, conducted in-home interviews gathering information on demographic characteristics (age, sex, race/ethnicity, education, income, living arrangements, employment status), health behaviors (physical activity, tobacco use, social activity), functional limitations, depression, and 15 self-reported health conditions, including arthritis. Data were analyzed using descriptive statistics and logistic regression. RESULTS: Arthritis, reported by 43% of the sample, was more prevalent in women, among the less educated, those with lower income, and higher age. Severity, but not prevalence, differed by race/ethnicity. Controlled analyses indicated significant association with female gender, lower education, and less social activity. Arthritis was associated with reduced odds of stroke, but increased odds of hypertension, varicosities, bronchitis, renal problems, headache, gastrointestinal disorders, and depression. Arthritis was not significantly associated with age or functional limitations, and associations did not differ by gender. CONCLUSIONS: The prevalence, demographic and health characteristics associated with self-reported arthritis in this southern state in Brazil are similar to findings elsewhere in Brazil, and in developed countries.

Anxiety disorders in old age.

PURPOSE OF REVIEW: This review highlights the key recent issues and novel findings on anxiety disorders in older adults. Studies of the epidemiology, medical and psychiatric comorbidity, neurobiology, and treatment of anxiety in the elderly are discussed. RECENT FINDINGS: Overall prevalence studies of anxiety symptoms or disorders in older adults indicate that, although less common than in younger adults, they are relatively common in late life. We examine the prevalence of specific anxiety disorders in the elderly, as mechanisms, outcomes, and treatment response may vary by type of anxiety disorder. Physical and psychiatric comorbidity are common. Certain anxiety disorders, such as generalized anxiety disorder, have demonstrated a positive impact following acute coronary syndrome. Regarding treatment, small effect sizes and incomplete response are typical, posing a challenge when treating this age group. SUMMARY: The epidemiology, neurobiology, and treatment of anxiety conditions in late life have recently received more attention in the medical literature. Areas in need of further investigation include neurobiology, clinical presentation, management, and treatment, as we do not know whether procedures indicated for younger cohorts hold for older adults.