Diagnosis of Alzheimer's dementia and vehicle driving restriction: a scoping review.

There are doubts about vehicle driving restriction for patients with Alzheimer's disease. A scoping review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-ScR) methodology. Relevant databases were searched for articles published between 2000 and 2022 in English, Spanish, or Portuguese. Articles were included if they specifically addressed driving, risk of accidents, permission or licence to drive a motor vehicle in a context of important cognitive decline, or if addressed traffic legislation on driving and dementia. Twenty-three articles were selected for full reading, six of which were observational studies and only one with an interventionist method. All articles were carried out in high-income countries such as the UK, the US, and Australia. As a conclusion, there is no psychometric test in the literature sensitive enough to assess vehicle driving competence in older adults with cognitive deficits. Based on selected studies, there is no robust evidence to make recommendation for or against the cessation of vehicular driving for patients with mild cognitive decline or with mild dementia. In some situations, vehicle driving cessation can impact patients and their families. In addition, legal regulations regarding vehicle driving for older adults and people with dementia are scarce worldwide. Despite the scarcity of studies addressing the theme of vehicle driving in the context of dementia, there is some level of consensual reasoning that patients with moderate to severe dementia should halt driving activities, but the same does not apply for patients with mild levels of cognitive impairment, including mild dementia.

Neuropsychological domains and fitness to drive in mild cognitive impairment or Alzheimer's disease.

Cognitive deficits associated with mild cognitive impairment (MCI) or Alzheimer's disease (AD) can impact driving. This integrative review investigated which cognitive domains were associated with poor driving performance or unfitness to drive in studies with outcomes measured in simulator or on-road driving in patients with MCI or AD. The review was conducted by searching for articles published between 2001 and 2020 in the MEDLINE (via PubMed), EMBASE, and SCOPUS databases. Studies addressing patients with other dementias (e.g., vascular or mixed dementia, Lewy body dementia, Parkinson's disease) were excluded. Of 404 articles initially selected, 17 met the eligibility criteria for this review. Based on the findings of this integrative review, attentional capacity, processing speed, executive functions and visuospatial skills were the functions whose declines were most frequently reported in a context of unsafe driving by older adults with MCI or AD. Reports were remarkably heterogeneous in methodological aspects whereas quite limited in cross-cultural coverage and in sample recruited, what prompts for further trials in the field.

Cerebellar cognitive affective syndrome due to cerebellar atrophy: case report / Síndrome cerebelar cognitivo-afetiva secundária à atrofia cerebelar: relato de caso

Cerebellar atrophy is a rare and challenging disease with few descriptions in the medical literature. Motor impairment is mild, but behavioral and linguistic alterations stand out, in what is known as the cerebellar cognitive affective syndrome secondary to cerebellar atrophy. We report the case of an older woman with early-onset (age 45) signs and symptoms of this syndrome, including impairment of executive functions and visuospatial cognition, personality changes, and language deficits, who was followed at a geriatric medical center for 14 years. Neuropsychological, imaging, and behavioral aspects during this period are discussed in light of scientific evidence. This case report contributes to the scientific literature by describing the progression of the signs and symptoms of cerebellar atrophy over the years, which can help guide medical management and support advice for patients and their families.

A atrofia cerebelar é uma doença rara, desafiadora e com poucas descrições na literatura médica. O prejuízo motor é discreto, mas as alterações comportamentais e de linguagem se destacam, caracterizando a síndrome cognitivo-afetiva cerebelar secundária à atrofia cerebelar. Apresentamos o relato de caso de uma paciente idosa, que apresentou sinais e sintomas dessa síndrome precocemente (aos 45 anos de idade) ­ tais como déficits na função executiva, prejuízo visuoespacial, alterações de personalidade e déficits de linguagem ­ e foi acompanhada em um centro médico geriátrico por um período de 14 anos. Aspectos neuropsicológicos, de imagem e comportamentais durante esse período são comentados à luz das evidências científicas. O caso relatado contribui com a literatura científica ao descrever a evolução dos sinais e sintomas da atrofia cerebelar ao longo dos anos, balizando as condutas médicas e amparando as orientações ao paciente e seus familiares.

Older drivers are at increased risk of fatal crash involvement: Results of a systematic review and meta-analysis.

Older adults have become a larger part of the driving population, but whether they are at increased risk of being involved in fatal crashes remains unclear. METHODS: We performed a systematic review of studies investigating fatal crash involvement of older vs non-older drivers by searching the following databases: PubMed, Cochrane Library, Embase, LILACS, SciELO, Web of Science, and ProQuest. Studies that used fatal crash involvement rates per distance driven as a measure of frequency were selected for meta-analysis. RESULTS: We analyzed 14 studies published between 2001 and 2018. Of these, 12 reported a higher rate of fatal crashes involving older drivers than non-older drivers; 9 of them used involvement rates per distance driven, which is considered the most appropriate metric. The meta-analysis revealed high heterogeneity between studies. The meta-regression attributed 40% of the heterogeneity to age (older vs non-older drivers) (p<0.005). CONCLUSION: Age appears to be associated with higher driver involvement rates for fatal crashes among older persons.

Influência da escolaridade e da idade em testes cognitivos / Influence of schooling and age on cognitive tests

Objetivos: Identificar fatores que interferem no desempenho de testes cognitivos frequentemente utilizados na prática clínica em idosos não dementes. Método: Amostra composta por 213 indivíduos, com média de idade de 72,9 ± 6,1 anos. Foram aplicados os seguintes instrumentos de avaliação: Escala de Depressão Geriátrica; Miniexame do Estado Mental (MEEM); Teste de Pares Associados I e II da Escala Wechsler de Memória; Teste de Dígitos ordem direta e inversa da Escala de Inteligência Wechsler para Adultos (WAIS-III); Teste de Tempo de Reação Simples (TEVA); e Torre de Hanói. Utilizou-se um modelo de regressão linear múltiplo para verificar interação entre variáveis dependentes e independentes. Resultados: Em sua maioria, os testes não sofreram influência significativa quando controlados para sexo, estado civil, sintomas depressivos ou uso de drogas psicotrópicas. Observou-se significativa interferência da escolaridade e da idade sobre o desempenho nos testes cognitivos aplicados. Observou-se alta correlação entre escores no MEEM e escolaridade, com aumento de 1 ponto no valor obtido no teste para cada 4 anos de escolaridade (p < 0,0001). Resultados dos testes de memória de curto e longo prazos também sofreram significativa influência da escolaridade (respectivamente, p = 0,0001; p = 0,02). Baixa escolaridade influenciou negativamente o desempenho em atenção segundo o teste TEVA, aumentando significativamente o Tempo de Reação ­ TR (p = 0,002), a percentagem de erro (p = 0,01) e proporção de falsos alarmes (p = 0,01). Conclusão: Nosso estudo observou significativa influência da idade e da escolaridade na performance de idosos não dementes em testes cognitivos que avaliam desempenho global, memória de curto e longo prazos, atenção, flexibilidade cognitiva e velocidade de processamento.

Objectives: To identify factors that interfere with performance in cognitive tests frequently used for non-demented elderly in clinical practice. Method: Sample composed of 213 individuals, mean age 72.9 ± 6.1 years. The following assessment instruments were applied: Geriatric Depression Scale; Mini-Mental State Examination (MMSE); Verbal Paired Associates tests I and II (VPA) from the Wechsler Memory Scale (WMS); Direct and Reverse Order Wechsler Adult Intelligence Scale-III (WAIS-III); Simple Reaction Time (SRT), and Tower of Hanoi. A multiple linear regression model was used to verify interaction between dependent and independent variables. Results: For the most part, the tests were not significantly influenced when adjusted for gender, marital status, depressive symptoms or use of psychotropic drugs. Significant interference of schooling and age on performance in applied cognitive tests was pointed out. There was a high correlation between MMSE scores and schooling, with a 1-point increase in the value obtained in the test for every four years of schooling (p < 0.0001). Results of shortand long-term memory tests were also significantly influenced by schooling (p = 0.0001, p = 0.02, respectively). Low schooling had a negative influence on attention performance according to SRT, significantly increasing reaction time (p = 0.002), error percentage (p = 0.01) and proportion of false alarms (p = 0.01). Conclusion: Our study found out a significant influence of age and schooling on performance of non-demented elderly in cognitive tests assessing overall performance, short- and long­term memory, attention, cognitive flexibility, and processing speed.

Lack of association between apolipoprotein E genotypes and cognitive performance in the non-demented elderly.

AIM: The ε4 alelle of the apolipoprotein E gene is known to be a key genetic risk factor for Alzheimer's disease and possibly for other neurological disorders. Some evidence in the literature indicates that the ε4 allele interferes with human cognition independently of chronological age and diagnosis of Alzheimer's disease. The present study investigated the correlation of allelic variants of apolipoprotein E with the cognitive performance of elderly individuals without apparent cognitive impairment. METHODS: This was a cross-sectional analysis that included 213 non-demented elderly individuals (age ≥60 years) from the Brazilian Federal District. The analysis assessed the subjects for cognitive domains including short- and long-term episodic memory, processing speed, and attention and executive functions. Sociodemographic and other clinical characteristics were gathered and analyzed as covariates. RESULTS: Being sufficiently powered, the present study did not identify differential performance across apolipoprotein E genotypes. There was no influence of age, gender, marital status, schooling, depressive symptoms or use of central nervous system depressants when the analyses were controlled for such factors. CONCLUSIONS: Our findings suggest that the ε4 allele does not contribute to detectable cognitive decline within the context of non-dementia.

Use of psychotropic medications by caregivers of elderly patients with dementia: is this a sign of caregiver burden?

This study evaluated the consumption of psychotropic medications by caregivers of elderly patients with or without dementia. This was a cross-sectional study conducted at all geriatric units in Brasília, Brazil, during a two-month period. Structured interviews were performed with 311 caregivers of people with or without dementia and they completed questionnaires. Among the caregivers, 196 (63%) were caregivers of patients with dementia and 115 (37%) were caregivers of patients without dementia. Forty-four caregivers (14.1%) were taking psychotropic drugs (benzodiazepines or antidepressants), and this usage was more frequent among caregivers of patients with dementia (p<0.01). Twenty-two caregivers of patients with dementia (11.4%) had used sleeping pills after beginning care, compared with only five (4.3%) caregivers of patients without dementia (p<0.01). In conclusion, this study found that caregivers of patients with dementia took psychotropic drugs (benzodiazepines and antidepressants) more frequently than the ones of patients without dementia.

Use of psychotropic medications by caregivers of elderly patients with dementia: is this a sign of caregiver burden? / Uso de psicotrópicos por cuidadores de pacientes idosos com demência: isso é um sinal de sobrecarga do cuidador?

This study evaluated the consumption of psychotropic medications by caregivers of elderly patients with or without dementia. This was a cross-sectional study conducted at all geriatric units in Brasília, Brazil, during a two-month period. Structured interviews were performed with 311 caregivers of people with or without dementia and they completed questionnaires. Among the caregivers, 196 (63 percent) were caregivers of patients with dementia and 115 (37 percent) were caregivers of patients without dementia. Forty-four caregivers (14.1 percent) were taking psychotropic drugs (benzodiazepines or antidepressants), and this usage was more frequent among caregivers of patients with dementia (p<0.01). Twenty-two caregivers of patients with dementia (11.4 percent) had used sleeping pills after beginning care, compared with only five (4.3 percent) caregivers of patients without dementia (p<0.01). In conclusion, this study found that caregivers of patients with dementia took psychotropic drugs (benzodiazepines and antidepressants) more frequently than the ones of patients without dementia.

Este estudo avaliou o consumo de drogas psicotrópicas por cuidadores de idosos de pacientes com e sem demência. Este foi um estudo transversal conduzido em todas as unidades de atendimento geriátrico em Brasília, Brasil, durante dois meses. Foram realizadas entrevistas estruturadas e um questionário preenchido por 311 cuidadores de idosos, com e sem demência. Entre os cuidadores, 196 (63 por cento) eram cuidadores de pacientes com demência e 115 (37 por cento) de pacientes sem demência. Quarenta e quatro cuidadores (14,1 por cento) estavam utilizando drogas psicotrópicas (benzodiazepínicos ou antidepressivos). Esse uso foi mais frequente entre os cuidadores de pacientes com demência (p<0,01). Vinte e dois cuidadores de pacientes com demência (11,4 por cento) usaram medicamentos para dormir após iniciar o trabalho de cuidador, comparado com somente 5 (4,3 por cento) cuidadores de pacientes sem demência (p<0,01). Em conclusão, este estudo encontrou que cuidadores de pacientes com demência tomavam mais frequentemente drogas psicotrópicas (benzodiazepínicos ou antidepressivos) do que os de pacientes sem demência.

Trazodone for the treatment of sleep disorders in dementia: an open-label, observational and review study.

Sleep disorders (SD) in patients with dementia are very common in clinical practice. The use of antidepressants with hypnotic actions, such as trazodone, plays an important role in these cases. The aim of this study is to present a profile of the use of trazodone in demented patients with SD, as well as a review of trazodone hydrochloride in SD. We evaluated 178 elderly patients with Alzheimer's disease and other dementias, clinically presenting SD and treated with hypnosedative medications. In the one-year period comprising the study, 68 (38.2%) of the 178 had sleep disorders. Most patients (114; 64%) had a diagnosis of Alzheimer's disease. Approximately 85% of patients with SD used hypnosedative drugs. Trazodone was the most commonly used drug among patients (N = 35), with an effectiveness of 65.7%. Trazodone has been shown to be a good option for treatment of the elderly with dementia and associated SD.

Trazodone for the treatment of sleep disorders in dementia: an open-label, observational and review study / Trazodona para o tratamento de distúrbios do sono em demência: um estudo aberto, observacional e de revisão

Sleep disorders (SD) in patients with dementia are very common in clinical practice. The use of antidepressants with hypnotic actions, such as trazodone, plays an important role in these cases. The aim of this study is to present a profile of the use of trazodone in demented patients with SD, as well as a review of trazodone hydrochloride in SD. We evaluated 178 elderly patients with Alzheimer's disease and other dementias, clinically presenting SD and treated with hypnosedative medications. In the one-year period comprising the study, 68 (38.2 percent) of the 178 had sleep disorders. Most patients (114; 64 percent) had a diagnosis of Alzheimer's disease. Approximately 85 percent of patients with SD used hypnosedative drugs. Trazodone was the most commonly used drug among patients (N = 35), with an effectiveness of 65.7 percent. Trazodone has been shown to be a good option for treatment of the elderly with dementia and associated SD.

Distúrbios do sono (DS) em pacientes com demência são muito comuns na prática clínica. O uso de antidepressivos com ação hipnótica, como a trazodona, tem um papel importante nesses casos. O objetivo desse estudo é apresentar um perfil do uso da trazodona em pacientes com demência e com DS, bem como revisar o cloridrato de trazodona no DS. Nós avaliamos 178 idosos com doença de Alzheimer (DA) e outras demências, clinicamente apresentando DS e que foram tratados com medicações hipnossedativas. No período de um ano de estudo, 68 (38,2 por cento) tiveram DS. A maioria (114; 64 por cento) tinham diagnóstico de DA. Aproximadamente 85 por cento usaram fármacos hipnossedativos. A trazodona foi a mais utilizada (N=35), com evidência de melhora de 65,7 por cento. A trazodona mostrou-se ser uma boa opção no tratamento de idosos com demência e DS associado.

Incidence of sleep disorders in patients with Alzheimer disease.

OBJECTIVE: To determine the incidence of sleep disorder at a follow-up examination from 1 to 4 years, in demented patients diagnosed at first visit, besides analyzing associated demographic and comorbidities characteristics. METHODS: A total of 122 elderly patients aged 60 years or older and diagnosed with dementia (Alzheimer and other) were followed in a reference geriatric center for dementia. The clinical protocols included interviews with patient and caregiver, complete physical examination, laboratory and imaging tests. Criteria for the diagnosis of sleep disorder included complain of insomnia from the patient or caregiver using the Neuropsychiatric Inventory nighttime. RESULTS: The incidence density of sleep disorder among dements was 18.7/100 person/years. The risk of developing sleep disorder within the frst and fourth years of follow-up was 9.8% and 50.9%, respectively. Multivariate Coxregression analysis revealed that educational level less than 8 years and report of aggressiveness at baseline were an independent predictor of sleep disorder, increased risk in 3.1 (95%CI: 1.30-9.22) and 2.1 times (95%CI: 1.16-4.17), respectively. CONCLUSION: The incidence of sleep disorder in demented patients was elevated, and was particularly associated to low educational level and aggressiveness at admission.

Apathy syndrome treated successfully with modafinil.

The treatment of apathy is often complicated and difficult. The authors present a case of apathy syndrome that was treated successfully with modafinil. An 87-year-old widowed Brazilian woman presented with loss of interest and pleasure in activities. Her level of apathy, as evaluated by the Brazilian care giver version of the apathy scale, was 25 (a score higher than 18 points is associated with an apathy syndrome). No diagnosis of depression or sleep disorder was noted. After 2 years with many different antidepressants, modafinil treatment was started at 100 mg/day. One month after the initiation of modafinil therapy, the patient reported feeling more motivation, and she also returned to her favorite physical activity, which was swimming (400 m/day). Apathy scale revealed an improvement (18 points). Actigraphic analysis was performed, and no sleep disturbances were noted before or after treatment. Modafinil may be a promising option in the treatment of apathy.

A 95-year-old woman with leucocytosis and eosinophilia: anaplastic carcinoma in an ectopic thyroid.

A 95-year-old woman had been treated over the past 8 years for progressive dysphagia. When her condition worsened, blood tests revealed the presence of leucocytosis and eosinophilia in the absence of anaemia or thrombocytopenia. Within 11 days of diagnosis, the patient died of respiratory failure. Necropsy showed normal thyroid tissue and an absence of infectious disease. However, an upper mediastinal tumour was found and was histopathologically diagnosed as a neoplastic transformation of the ectopic thyroid. Only 1% of endothoracic goitres present as ectopic or autonomous goitre with no parenchymal or vascular connection to the thyroid gland. This case represents a very rare situation in which a leukemoid reaction and peripheral hypereosinophilia were observed as a manifestation of an anaplastic thyroid carcinoma in an ectopic mass.