Demographic and clinical characteristics of lithium-treated older adults with bipolar disorder.

OBJECTIVES: There is limited information on the characteristics of older adults with bipolar disorder (OABD) treated with lithium, along with safety concerns about its use by older adults. The aim of the present study is to describe the demographic and clinical characteristics of OABD receiving lithium therapy, using data from the Global Ageing & Geriatric Experiments in Bipolar Disorder (GAGE-BD). EXPERIMENTAL PROCEDURES: Cross-sectional analysis of the GAGE-BD dataset to determine differences and similarities between lithium users and non-users. We analysed data from 986 participants aged 50 years or older (mean age 63.5 years; 57.5% females) from 12 study sites. Two subgroups ('Lithium'; 'Non-lithium') were defined according to the current prescription of lithium. We compared several outcomes between these groups, controlling for age, gender, and study site. RESULTS: OABD treated with lithium had lower scores on depression rating scales and were less likely to be categorised as with moderate or severe depression. There was a lower proportion of lithium users than non-users among those with evidence of rapid cycling and non-bipolar psychiatric diagnoses. Assessment of global cognitive state and functionality indicated better performance among lithium users. The current use of antipsychotics was less frequent among lithium users, who also reported fewer cardiovascular comorbidities than non-users. CONCLUSION: We found several potentially relevant differences in the clinical profile of OABD treated with lithium compared with those treated with other mood stabilisers. However, the interpretation of the present results must take into account the methodological limitations inherent to the cross-sectional approach and data harmonisation.

In older men, higher plasma testosterone or dihydrotestosterone is an independent predictor for reduced incidence of stroke but not myocardial infarction.

CONTEXT: Older men have lower T levels, but whether differences in circulating T or its metabolites dihydrotestosterone (DHT) or estradiol (E2) contribute to cardiovascular disease remains controversial. OBJECTIVE: We tested the hypothesis that plasma T, DHT, and E2 are differentially associated with the incidence of myocardial infarction (MI) and stroke in older men. PARTICIPANTS AND METHODS: Plasma total T, DHT, and E2 were assayed using liquid chromatography-mass spectrometry in early-morning samples from 3690 community-dwelling men aged 70-89 years. Outcomes of the first hospital admission or death due to MI or stroke were ascertained by data linkage. RESULTS: Mean follow-up was 6.6 years. Incident MI occurred in 344, stroke in 300, and neither in 3046 men. In a multivariate analysis adjusting for age and other risk factors, T, DHT, and E2 were not associated with incident MI [fully adjusted hazard ratio (HR) for T in quartile (Q) 4 vs Q1: 0.92, 95% confidence interval (CI) 0.66-1.28; DHT: 0.83, 95% CI 0.59-1.15; E2: 0.84, 95% CI 0.62-1.15]. Higher T or DHT was associated with a lower incidence of stroke (T: Q4: Q1 fully adjusted HR 0.56, 95% CI 0.39-0.81, P = .002; DHT: 0.57, 95% CI 0.40-0.81, P = .002). E2 was not associated with stroke (HR 0.76, 95% CI 0.54-1.08, P = .123). CONCLUSIONS: Higher plasma T or DHT is a biomarker for reduced risk of stroke but not MI. Androgen exposure may influence outcomes after rather than the incidence of MI, whereas androgens but not E2 are independent predictors of stroke risk. Randomized clinical trials are needed to clarify the impact of modifying T or DHT on the risk of stroke in aging men.

The role of literacy, occupation and income in dementia prevention: the São Paulo Ageing & Health Study (SPAH).

BACKGROUND: Dementia is now a major public health issue in low- and middle-income countries, and strategies for primary prevention are needed. This study aimed to estimate the proportion of cases of dementia attributable to illiteracy, non-skilled occupation and low income, which are common, potentially modifiable social adversities that occur along the lifespan in low- and middle-income countries. METHODS: This report is based on data from the São Paulo Ageing & Health Study (SPAH) study (N = 2003). All individuals aged 65 years and older residing within pre-defined socially deprived areas of the city of São Paulo, Brazil, were included. The outcome of interest was prevalent dementia. Indicators of socioeconomic position (SEP) were literacy (distal indicator), highest occupational attainment (intermediate indicator), and monthly personal income (proximal indicator). We estimated the proportion of prevalent dementia attributable to each SEP indicator (illiteracy, non-skilled occupations and low income) by calculating their population attributable fractions (PAF). RESULTS: Dementia was more prevalent amongst participants who were illiterate, had non-skilled occupations and lower income. Illiteracy, poor occupational achievement and low income accounted for 22.0%, 38.5% and 38.5% of the cases of dementia, respectively. There was a cumulative effect of socioeconomic adversities during the lifespan, and nearly 50% of the prevalence of dementia could be potentially attributed to the combination of two or three of the socioeconomic adversities investigated. CONCLUSIONS: Public policies aimed at improving education, occupational skills and income could potentially have a role in primary prevention of dementia. Governments should address this issue in a purposeful and systematic way.

Limitations of the Mini-Mental State Examination for screening dementia in a community with low socioeconomic status: results from the Sao Paulo Ageing & Health Study.

BACKGROUND: The Mini-Mental State Examination (MMSE) is the most widely used instrument for the screening of cognitive impairment worldwide, but its ability to produce valid estimates of dementia in populations of low socioeconomic status and minimal literacy skills has not been adequately established. The authors investigated the psychometric properties of the MMSE in a community-based sample of older Brazilians. METHOD: Cross-sectional one-phase population-based study of all residents of pre-defined areas of the city of Sao Paulo, aged 65 years or over. The Brazilian version of the MMSE was compared with DSM-IV diagnosis of dementia assessed with a harmonized one-phase procedure developed by the 10/66 Dementia Research Group. RESULTS: Analyses were performed with 1,933 participants of the SPAH study. Receiver operating characteristic analysis showed that the MMSE cut-point of 14/15 was associated with 78.7% sensitivity and 77.8% specificity for the diagnosis of dementia amongst participants with no formal education, and the cut-point 17/18 with 91.9% sensitivity and 89.5% specificity for those with at least 1 year of formal education (areas under the curves 0.87 and 0.94, respectively; P = 0.03). Even with these best fitting cut-points, the MMSE estimate of the prevalence of dementia was four times higher than determined by the DSM-IV criteria. Education, age, sex and income influenced MMSE scores, independently of dementia caseness. CONCLUSION: The MMSE is an adequate tool for screening dementia in older adults with minimum literacy skills, but misclassification is unacceptably high for older adults who are illiterate, which has serious consequences for research and clinical practice in low and middle income countries, where the proportion of illiteracy among older adults is high.

Risk factors across the life course and dementia in a Brazilian population: results from the Sao Paulo Ageing & Health Study (SPAH).

BACKGROUND: Several mechanisms have been suggested to explain the association between adversities across life and dementia. This study aimed to investigate the association between indicators of socioeconomic disadvantages throughout the life-course and dementia among older adults in Sao Paulo, Brazil and to explore possible causal pathways. METHODS: We used baseline data from the SPAH study which involved participants aged 65 years and older (n = 2005). The outcome of interest was prevalent dementia. Exposures included in the analyses were socioeconomic position (SEP) indicators in childhood (place of birth and literacy) and adulthood (occupation and income), anthropometric measurements as markers of intrauterine and childhood environment (head circumference and leg length), smoking, diabetes and hypertension. Logistic regression models were used to test the hypothesized pathways and to assess whether there was an association between cumulative adversities across the life course and prevalent dementia. RESULTS: Indicators of socioeconomic disadvantage in early life were associated with increased prevalence of dementia. This association was partially mediated through adulthood SEP. Head circumference and leg length were also clearly associated with dementia but there was no evidence that this association was mediated by early life socioeconomic disadvantage. There was an association between cumulative unfavourable conditions across the life course and dementia. CONCLUSIONS: Early life disadvantages seem to operate through biological mechanisms associated with passive brain reserve and opportunities in life representing active cognitive reserve. Prevention of dementia should start early in life and continue through life span as seen with many other chronic diseases.

High prevalence of dementia among older adults from poor socioeconomic backgrounds in São Paulo, Brazil.

BACKGROUND: The aim of this study was to determine the prevalence of dementia in a socioeconomically disadvantaged population of older adults living in the city of São Paulo, Brazil. METHODS: A cross-sectional one-phase population-based study was carried out among all residents aged > or = 65 in defined census sectors of an economically disadvantaged area of São Paulo. Identification of cases of dementia followed the protocol developed by the 10/66 Dementia Research Group. RESULTS: Of 2072 individuals in the study, 105 met the criteria for a diagnosis of dementia, yielding a prevalence of 5.1%. Prevalence increased with age for both men and women after age 75 years, but was stable from 65 to 74 years. Low education and income were associated with increased risk of dementia. CONCLUSIONS: The prevalence of dementia among older adults from low socioeconomic backgrounds is high. This may be partly due to adverse socioeconomic conditions and consequent failure to compress morbidity into the latter stages of life. The increasing survival of poorer older adults with dementia living in developing countries may lead to a rapid increase in the prevalence of dementia worldwide.

[Bipolar disorder with late onset: an organic variety of mood disorder?]. / Transtorno bipolar de início tardio: uma variedade orgânica do transtorno de humor?

Bipolar disorder (BD) is commonly associated with late adolescence or early adulthood, although a substantial proportion of patients develops the condition in later life. The results of early clinical investigations suggested that cases of bipolar disorder with onset in later life were more often associated with 'organic causes', and could potentially justify the distinction between early and late onset bipolar disorder. This paper reviews currently available evidence in support of the organic hypothesis for late onset bipolar disorder. It concludes that the split of bipolar disorder according to age at onset is artificial, and lacks clinical significance and epidemiological support.

Transtorno bipolar de início tardio: uma variedade orgânica do transtorno de humor? / Bipolar disorder with late onset: an organic variety of mood disorder?

Transtorno bipolar (TB) é comumente associado à fase final da adolescência ou idade adulta jovem, embora em uma proporção substancial dos pacientes a doença comece em fases mais tardias da vida. Os resultados de várias investigações clínicas sugerem que casos de transtorno bipolar com início tardio têm, mais freqüentemente, uma "causa orgânica" e que isso justificaria a subdivisão do transtorno bipolar entre "início precoce" e "início tardio". Este artigo revê a literatura sobre a hipótese orgânica do transtorno bipolar de início tardio e conclui que essa subdivisão é artificial e carece de suporte clínico e epidemiológico.

A voxel-based morphometry study of temporal lobe gray matter reductions in Alzheimer's disease.

Several MRI studies have reported reductions in temporal lobe volumes in Alzheimer's disease (AD). Measures have been usually obtained with regions-of-interest (ROI) drawn manually on selected medial and lateral portions of the temporal lobes, with variable choices of anatomical borders across different studies. We used the fully automated voxel-based morphometry (VBM) approach to investigate gray matter abnormalities over the entire extension of the temporal lobe in 14 AD patients (MMSE 14-25) and 14 healthy controls. Foci of significantly reduced gray matter volume in AD patients were detected in both medial and lateral temporal regions, most significantly in the right and left posterior parahippocampal gyri and the left posterior inferior temporal gyrus/fusiform gyrus (P<0.05, corrected for multiple comparisons). At a more flexible statistical threshold (P<0.001, uncorrected for multiple comparisons), circumscribed foci of significant gray matter reduction were also detected in the right amygdala/enthorinal cortex, the anterior and posterior borders of the superior temporal gyrus bilaterally, and the anterior portion of the left middle temporal gyrus. These VBM results confirm previous findings of temporal lobe atrophic changes in AD, and suggest that these abnormalities may be confined to specific sites within that lobe, rather than showing a widespread distribution.

Caregiver burden in an elderly population with depression in São Paulo, Brazil.

BACKGROUND: Mental disorders are among the most prevalent chronic conditions in old age, depression being the most widespread. The aim of this study was to examine the burden and distress reported by carers of elderly patients with depression. METHOD: Patients aged 60 or over starting outpatient treatment for depression and their relatives were included. Patients were assessed for the severity of depressive symptoms, behaviour and mood disturbance, and abilities of daily living. Relatives were assessed for burden and emotional distress. RESULTS: Eighty-two patients and their relatives were included. Levels of carers' burden were high. Multiple linear regression showed that patients' behaviour and mood disturbance and relatives's emotional distress scores were independently associated with relatives' burden. CONCLUSIONS: Levels of burden were similar to those found in studies with carers of elderly people with dementia, indicating that depressive symptoms can be considered an important source of distress for caregivers.

Delirium: além do diagnóstico clínico / Delirium: moving beyond the clinical diagnosis

Delirium é um transtorno mental comum que tem sido associado a permanência hospitalar prolongada, aumento nos custos com cuidados médicos e maior morbidade e mortalidade entre idosos. De forma geral, o manejo de pacientes tem se limitado ao tratamento das complicações advindas do episódio agudo e dos distúrbios comportamentais e psicológicos associados ao delirium, embora isto pareça ter um impacto desprezível sobre o curso da doença e o prognóstico dos pacientes no longo prazo. Este artigo revisa o desenvolvimento de estratégias desenhadas com o objetivo de reduzir a incidência e as complicações clínicas do delirium e propöe que um tratamento efetivo de pacientes com delirium deve sempre incluir medidas básicas de prevençäo primária, secundária e terciária

Congestive heart failure and cognitive functioning amongst older adults

BACKGROUND: Congestive heart failure is associated with decline in quality of life and, possibly, cognitive functions such as memory and attention. AIMS: The present study was designed to investigate the presence of cognitive impairment amongst patients with congestive heart failure (CHF). We hypothesised that CHF patients would have lower scores than elderly controls on general measures of cognitive functioning. METHODS AND RESULTS: We examined a sample of 50 consecutive patients admitted to hospital with CHF functional class III/IV and a convenience sample of 30 older adults assessed at the outpatient service of geriatric medicine of a teaching hospital in Säo Paulo, Brazil. All subjects were interviewed with the Cambridge Examination for Mental Disorders of the Elderly (CAMDEX), as well as the neuropsychological battery of the CAMDEX (CAMCOG), Mini-Mental State Examination (MMSE), Trail Making A and B, Digit Span, Digit Symbol, and Letter Cancellation Test. All CHF patients had left ventricular ejection fraction (EF) below 45 percent and all controls above 65 percent. The cognitive performance of CHF patients was significantly worse than controls for all cognitive assessments. Twenty-seven of 50 CHF patients had a MMSE total score lower than 24, compared with only 10/30 controls (p=0.073). Similarly, 36/49 and 9/30 CHF subjects and controls respectively had CAMCOG scores below 80 (p<0.001). Cognitive scores were significantly associated with EF, which was the most robust predictor of cognitive impairment according to the CAMCOG in a logistic regression model. CONCLUSION: Our results indicate that CHF is associated with significant levels of cognitive impairment and show that mental performance is, at least partly, a consequence of EF. Physicians should be prepared to assess the mental state of patients, as poor cognitive functioning may interfere with treatment compliance and management plan

Percepção dos déficits cognitivos e alterações do comportamento em pacientes com doença de Alzheimer / Awareness of cognitive deficits and behavioural abnormalities amongst patients with Alzheimer's disease

A doença de Alzheimer (DA) está associada a deterioração das habilidades intelectuais e, com frequência, do comportamento do paciente. O paciente, porém, tem percepção limitada da gravidade e qualidade dessas alterações. Nós desenhamos este estudo para investigar a concordância entre pacientes e cuidadores na avaliação de dificuldades cognitivas e alterações do comportamento associadas à DA. Trinta pacientes com diagnóstico de DA (DSM-IV) atendidos consecutivamente no ambulatório de saúde mental da Santa Casa de São Paulo foram recrutados para inclusão no estudo. Um cuidador foi também selecionado para cada paciente. A concordância entre pacientes e cuidadores quanto às dificuldades cognitivas e alterações comportamentais foi avaliada através da versão ampliada do questionário para demência-anosognosia (QD). As habilidades cognitivas de pacientes e cuidadores foi avaliada através do mini exame do estado mental (MMSE). A idade média dos pacientes e cuidadores era 71,38 (IC=68,23 a 74,53) e 52,48 anos (IC=47,11 a 57,86) respectivamente. Sessenta por cento e 73,3 por cento dos pacientes e cuidadores eram do sexo feminino. O escore médio dos pacientes no MMSE foi 14,93 (IC=12,68 a 17,18). A concordância entre pacientes e cuidadores para os escores de itens individuais do QD, de acordo com o índice Kappa ponderado, variou de 0 a 0,67, embora valores menores do que 0,40 fossem observados para 39 dos 42 itens. O escore total dos pacientes na seção do QD que avalia habilidades cognitivas (QD-A) foi significativamente menor do que para os cuidadores (t-pareado = -4,07, p<0,001). O mesmo padrão de resposta foi observado na seção do questionário que avalia comportamento (QD-B).(t-pareado= -2,27, p=0,032). A correlação de Spearman entre os escores do QD-A e MMSE de acordo com o paciente e cuidador foi -0,39 e -0,57 respectivamente. Anosognosia cognitiva (diferença entre o QD-A de cuidadores e pacientes) não se correlacionou de forma significativa com o escore do MMSE (rho= -0,14) ou presença de depressão entre os pacientes (t= -0,40, p= 0,698). Estes resultados indicam que os pacientes têm percepção limitada dos déficits cognitivos e alterações de comportamento associadas à DA. Além disso, eles sugerem que a baixa auto-crítica dos pacientes não é influenciada de forma importante pela gravidade do quadro demencial ou presença de sintomas depressivos.

Associação entre depressão na perimenopausa e níveis séricos de estradiol e hormônio folículo-estimulante / Association between depression in the perimenopause and serum levels of estradiol (E2) and follicle-stimulating hormone (FSH)

Objetivos: A perimenopausa é frequentemente associada ao surgimento de alterações físicas e emocionais. Estudos prévios indicam uma associação entre variações dos hormônios folículo-estimulante (FSH), luteinizante (LH) bem como de estrógenos e o surgimento de transtornos do humor, particularmente depressão. Este estudo investigou a correlação entre mudanças nos níveis de estradiol (E2) e FSH e a sintomatologia depressiva em mulheres na perimenopausa. Métodos: Cinquenta mulheres foram recrutadas nos atendimentos de uma clínica de menopausa e de um serviço psiquiátrico para a realização de ensaio clínico com uso de 17 b-estradiol ou placebo. Selecionaram-se mulheres em perimenopausa (idade entre 40 e 55 anos, presença de alterações vasomotoras, irregularidade menstrual nos últimos 6 meses e/ou amenorréia há no máximo 12 meses, níveis de FSH>20UI/L) e com diagnóstico de transtorno depressivo pelo DSM-IV (transtorno depressivo maior, transtorno distímico ou transtorno depressivo sem outra especificação). Dosagens séricas iniciais e finais (semana 12) de FSH e E2, bem como avaliações da sintomatologia depressiva (escores da MADRS) foram analisadas e suas correlações investigadas. Resultados: As pacientes apresentaram mudanças (p<0,05) entre os níveis séricos de FSH e E2 colhidos pré e pós-intervenção (placebo ou 17 b-estradiol). Observou-se, também, mudança significativa na sintomatologia depressiva (p<0,05). Houve correlação significativa entre as mudanças na sintomatologia depressiva e as mudanças nos níveis de E2 (r de Pearson=0,436, p=0,003) e de FSH (r=0,554, p<0,001), independentemente do tipo de tratamento empregado. Conclusões: Embora limitado pelo tamanho da amostra e a subpopulação estudada, este estudo preliminar identificou uma correlação significativa entre sintomatologia depressiva e níveis séricos de FSH e E2. Seguimentos populacionais prospectivos poderão esclarecer o papel da variabilidade hormonal no surgimento/exacerbação dos transtornos depressivos na perimenopausa

Associacao entre depressao na perimenopausa e niveis sericos de estradiol e hormonio foliculo-estimulante

Objetivos: A perimenopausa e frequentemente associada ao surgimento de alteracoes fisicas e emocionais. Estudos previos indicam uma associacao entre variacoes dos hormonios foliculo-estimulante (FSH), luteinizante (LH) bem como de estrogenos e o surgimento de transtornos do humor, particularmente depressao. Este estudo investigou a correlacao entre mudancas dos niveis de estradiol (E2) e FSH e a sintomatologia depressiva em mulheres na perimenoupausa. Metodos: Cinquenta mulheres foram recrutadas nos atendimentos de uma clinica de menopausa e de um servico psquiatrico para realizacao de ensaio clinico com uso de 17 b-estradiol ou placebo. Selecionaram-se mulheres em perimenopausa (idade entre 40 e 55 anos), presenca de alteracoes vasomotoras, irregularidade menstrual nos ultimos seis meses e/ou amenorreia ha no maximo 12 meses, niveis de FSH>20 UI/L e com diagnostico de transtorno depressivo pelo DSM-IV (transtorno depressivo maior, transtorno distimico ou transtorno depressivo sem outra espcecificacao). Dosagens sericas iniciais e finais (semana 12) de FSH e E2, bem como avaliacoes da sintomatologia depressiva (escores da MADRS) foram analisadas e suas correlacoes investigadas. Resultados: As pacientes apresentaram mudancas (p<0,05) entre os niveis sericos de FSH e E2 colhidos pre e pos-intervencao (placebo ou 17 b-estradiol). Observou-se, tambem, mudanca significativa na sintomatologia depressiva (p<0,05). Houve correlacao significativa entre as mudancas na sintomatologia depressiva e as mudancas dos niveis E2 (r de Pearson=0,436, p=0,003) e de FSH (r=0,554, p-0,001), independentemente do tipo de tratamento empregado. Conclusoes: Embora limitado pelo tamanho da amostra e a subpopulacao estudada, este estudo preliminar identificou uma correlacao significativa entre sintomatologia depressiva e niveis sericos de FSH e E2. Seguimentos populacionais prospectivos poderao esclarecer o papel da variabilidade hormonal no surgimento/exacerbacao dos transtornos depressivos na perimenopausa.