Evaluation of quality of life, physical, and mental aspects in longevous patients with chronic kidney disease.

PURPOSE: The diagnosis of chronic kidney disease (CKD) in elderly individuals has been increasing. The objective of this study was to evaluate physical, mental and social aspects in longevous elderly patients with CKD. METHODS: Eighty patients with CKD (stage 4 and 5, not on dialysis) and 60 longevous elderly (≥ 80 years) paired by gender and age living in the community were evaluated. Physical, cognitive, social and quality of life aspects were analyzed according to the following scales: Charlson comorbidity index, Medical Outcomes Study Short Form 36-Item (SF-36), Medical Outcomes Study, Boston Naming Test, verbal fluency test (animal naming), sit-to-stand test, gait speed, and the Mini-Mental state examination. RESULTS: Compared to the control group, the CKD group had a higher mean in the comorbidities index (3.5 ± 1.2 vs. 1.0 ± 1, respectively, p < 0.001). In the multivariate analysis, the CKD group presented worse performance in the SF-36 dimensions: 'physical functioning,' 'general health,' 'emotional functioning,' 'vitality,' and physical component summary. On the other hand, they presented better results for the 'mental health' dimension, in addition to lower  social support, worse verbal fluency and worse results on the sit-to-stand test. CONCLUSIONS: Longevous patients with stage 4 or 5 CKD presented worse evaluation in several domains of physical and emotional functioning, lower social support and evidence of worse cognitive performance. These aspects should be taken into account in order to improve the care provided to these patients, improve their quality of life and prevent their morbidity.

Functional magnetic resonance imaging response as an early biomarker of cognitive decline in elderly patients with metabolic syndrome.

OBJECTIVES: We assessed whether potential changes in brain activation patterns of elderly individuals with metabolic syndrome (MetS) who were cognitively healthy (without mild cognitive impairment or dementia) were associated with cognitive decline in executive function in the short-term. METHOD: We analyzed 43 individuals (23 MetS, 20 controls) using a global geriatric evaluation, a neuropsychological battery, and task-related (attention) fMRI exam. Correlation analysis between the fMRI signal at baseline and cognitive impairment after 1year was based on the voxel-based Pearson coefficient, corrected for multiple comparisons. RESULTS: At baseline, MetS patients showed reduced brain response in frontal and parietal regions compared to controls. After one year, the MetS group also showed a decline in verbal fluency performance. fMRI response in the right dorsolateral prefrontal cortex and bilateral parietal lobes was negatively correlated with verbal fluency decline in the MetS group. DISCUSSION: Our results provide an early biomarker of the possible development of cognitive impairment, particularly in the executive function, of elderly individuals suffering from MetS. These findings also point to an up or down regulation which could be interpreted as compensatory mechanism for possible brain tissue burden caused by MetS.

Estimation of glomerular filtration rate from serum creatinine and cystatin C in octogenarians and nonagenarians.

BACKGROUND: Equations to estimate GFR have not been well validated in the elderly and may misclassify persons with chronic kidney disease (CKD). We measured GFR and compared the performance of the Modification of Diet in Renal Disease (MDRD), the Chronic Kidney Disease-Epidemiology Collaboration (CKD-Epi) and the Berlin Initiative Study (BIS) equations based on creatinine and/or cystatin C in octogenarians and nonagenarians. METHODS: Using cross-sectional analysis we assessed 95 very elderly persons (mean 85 years) living in the community. GFR was measured by iohexol (mGFR) and compared with estimates using six equations: MDRD, CKD-Epi_creatinine, CKD-Epi_cystatin, CKD-Epi_creatinine-cystatin, BIS_creatinine and BIS_creatinine-cystatin. RESULTS: Mean mGFR was 55 (range,19-86) ml/min/1.73 m(2). Bias was smaller with the CKD-Epi_creatinine-cystatin and the CKD-Epi_creatinine equations (-4.0 and 1.7 ml/min/1.73 m(2)). Accuracy (percentage of estimates within 30% of mGFR) was greater with the CKD-Epi_creatinine-cystatin, BIS_creatinine-cystatin and BIS_creatinine equations (85%, 83% and 80%, respectively). Among the creatinine-based equations, the BIS_creatinine had the greatest accuracy at mGFR < 60 ml/min/1.73 m(2) and the CKD-Epi_creatinine was superior at higher GFRs (79% and 90%, respectively). The CKD-Epi_creatinine-cystatin, BIS_creatinine-cystatin and CKD-Epi_cystatin equations yielded the greatest areas under the receiver operating characteristic curve at GFR threshold = 60 ml/min/1.73 m 2 (0.88, 0.88 and 0.87, respectively). In participants classified based on the BIS_creatinine, CKD-Epi_cystatin, or BIS_creatinine-cystatin equations, the CKD-Epi_creatinine-cystatin equation tended to improve CKD classification (net reclassification index: 12.7%, p = 0.18; 6.7%, p = 0.38; and 15.9%; p = 0.08, respectively). CONCLUSIONS: GFR-estimating equations CKD-Epi_creatinine-cystatin and BIS_creatinine-cystatin showed better accuracy than other equations using creatinine or cystatin C alone in very elderly persons. The CKD-Epi_creatinine-cystatin equation appears to be advantageous in CKD classification. If cystatin C is not available, both the BIS_cr equation and the CKD-Epi_cr equation could be used, although at mGFR < 60 ml/min/1.73 m(2), the BIS_cr equation seems to be the best alternative.

Assessment of undergraduate clinical reasoning in geriatric medicine: application of a script concordance test.

A challenging aspect of geriatric practice is that it often requires decision-making under conditions of uncertainty. The Script Concordance Test (SCT) is an assessment tool designed to measure clinical data interpretation, an important element of clinical reasoning under uncertainty. The purpose of this study was to develop and analyze the validity of results of an SCT administered to undergraduate students in geriatric medicine. An SCT consisting of 13 cases and 104 items covering a spectrum of common geriatric problems was designed and administered to 41 undergraduate medical students at a medical school in São Paulo, Brazil. A reference panel of 21 practicing geriatricians contributed to the test's score key. The responses were analyzed, and the psychometric properties of the tool were investigated. The test's internal consistency and discriminative capacity to distinguish students from experienced geriatricians supported construct validity. The Cronbach alpha for the test was 0.84, and mean scores for the experts were found to be significantly higher than those of the students (80.0 and 70.7, respectively; P < .001). This study demonstrated robust evidence of reliability and validity of an SCT developed for use in geriatric medicine for assessing clinical reasoning skills under conditions of uncertainty in undergraduate medical students. These findings will be of interest to those involved in assessing clinical competence in geriatrics and will have important potential application in medical school examinations.

Influências da vitamina K em pacientes cardiopatas usuários de anticoagulantes orais e o gene CYP2C9 / Influence of vitamin K in cardiac patients taking oral anticoagulants and CYP2C9

As orientações nutricionais são restritivas quanto aos alimentos ricos em vitamina K com intuito de um controle adequado do International Normalized Ratio (INR). Avaliamos o consumo de alimentos ricos em vitamina K, sua relação com o nível sérico dessa vitamina e o INR de 66 pacientes cardiopatas usuários de varfarina. A idade média foi de 61 anos (DP = 11,71). O consumo de vitamina K foi abaixo do recomendado em 74% dos pacientes no RGA 7 dias. No QFA, o consumo de verduras e legumes verdes escuros era abaixo de três vezes por semana. Não encontramos relação no tipo de óleo consumido com os níveis séricos de vitamina K. A vitamina K plasmática observada foiu em média de 0,54 ng/mL. Não houve correlação entre a ingestão de vitamina K e o INR desses pacientes, assim como não houve diferença na ingestão ou dos níveis séricos em relação à idade. A orientação nutricional restritiva a alimentos ricos em vitamina K estava relacionada a níveis séricos abaixo dessa vitamina, sendo importante estabelecer a consequência dessa condição sobre outros aspectos da saúde desses pacientes. As variações observadas no INR desses pacientes foram independentes dos níveis séricos de vitamina K, sugerindo uma supervalorização da dieta como um fator desestabilizador. Confirmamos, no nosso estudo, que a proporção de pacientes com genótipo CYP2C9 é a esperada para a população. Porém, não encontramos diferença significativa na dose atual diária dos pacientes nos genótipos variantes do CYP2C9, assim como no INR.

[Cognitive deficit: another complication of diabetes mellitus?]. / Déficit cognitivo: mais uma complicação do diabetes melito?

As the population getting older, the chronic diseases will be more prevalent as diabetes mellitus (DM) and diseases characterized by cognitive deficits, as dementia. Studies have already shown an association between DM and cardiovascular risk factors associated with cognitive impairment. Besides the vascular complications of DM, studies have proposed the role of hyperglycemia and advanced glycosilation end products (AGEP) causing oxidative stress and beta-amyloid protein brain deposition. Other factors have also been investigated, such as the role of insulinemia, genetic and IGF-1 (insulin-like growth factor-1). Some studies showed that good glucose control and intake of polyunsaturated fat, Omega-3 or anti-oxidative food can play a protector role against cognitive deficits. Improving knowledge about the association between DM and cognition and its physiopathology, can be essential for the prevention and treatment of cognitive impairment, leading to a beneficial impact on the quality of life of elderly patients with DM.

Déficit cognitivo: mais uma complicação do diabetes melito? / Cognitive deficit: another complication of diabetes mellitus?

Com o envelhecimento da população, as doenças crônicas serão mais prevalentes, como o diabetes melito (DM) e aquelas caracterizadas por disfunções cognitivas, como as demências. Alguns estudos mostraram associação do DM e outros fatores de risco cardiovascular associados a distúrbios cognitivos. Além das complicações vasculares, estudos sugerem ação da hiperglicemia e dos produtos avançados finais de glicação (PAFG) em estresse oxidativo e acúmulo de substância β-amilóide intracerebral. Outros fatores também vêm sendo investigados, como o papel da insulinemia, da genética e do IGF-1 (insulin-like growth factor-1). Estudos mostraram que o bom controle glicêmico e a ingestão de dieta rica em gordura poliinsaturada, ômega-3 ou alimentos antioxidantes podem ter papel protetor contra os déficits cognitivos. Esclarecimentos sobre a associação entre DM e cognição e sua fisiopatologia podem ser essenciais para a prevenção e o tratamento de déficits cognitivos, levando a impacto positivo sobre a qualidade de vida dos pacientes idosos com DM.

As the population getting older, the chronic diseases will be more prevalent as diabetes mellitus (DM) and diseases characterized by cognitive deficits, as dementia. Studies have already shown an association between DM and cardiovascular risk factors associated with cognitive impairment. Besides the vascular complications of DM, studies have proposed the role of hyperglycemia and advanced glycosilation end products (AGEP) causing oxidative stress and β-amiloid protein brain deposition. Other factors have also been investigated, such as the role of insulinemia, genetic and IGF-1 (insulin-like growth factor-1). Some studies showed that good glucose control and intake of poli-unsaturated fat, Ômega-3 or anti-oxidative food can play a protector role against cognitive deficits. Improving knowledge about the association between DM and cognition and its physiopathology, can be essential for the prevention and treatment of cognitive impairment, leading to a beneficial impact on the quality of life of elderly patients with DM.

Association of endothelial nitric oxide synthase gene intron 4 polymorphism with end-stage renal disease.

BACKGROUND: Nitric oxide (NO) released from endothelial cells is related to the maintenance of physiological vascular tone. The impairment of endothelial NO generation brought about by gene polymorphism is considered one of the deterioration factors in progressive renal disease. In the endothelial nitric oxide synthase (eNOS) intron 4 polymorphism, the presence of the aa genotype has been associated with cardiovascular and renal disease. The aim of this study was to investigate the presence of eNOS gene intron 4 polymorphism in patients with end-stage renal disease (ESRD). METHODS: A total of 114 patients and 94 controls were studied. DNA specimens were extracted from blood and amplified by polymerase chain reaction. The alleles were separated by agarose gel electrophoresis. Genotype distribution and allele frequencies were compared between groups using the chi-squared test. RESULTS: Statistical analysis revealed that the frequency of the eNOS4 genotype aa was significantly different in ESRD patients and in controls (P=0.016, OR=2.07, CI 95%: 1.14-3.74). There was also a statistically significant difference between ESRD patients and controls regarding allele carriers (P=0.004; OR=2.26; CI 95%: 1.29-3.96). When the frequencies of allele carriers in the diabetic nephropathy group and in the control group were compared, a significant difference was found (P=0.034, OR=2.28; CI 95%: 1.04-5.00). CONCLUSION: This study showed a strong correlation between eNOS4a polymorphism and end-stage renal disease.

APO A-V-1131T-->C polymorphism frequency and its association with morbidity in a Brazilian elderly population.

Identification of genetic polymorphisms as risk factors for complex diseases affecting older people can be relevant for their prevention, diagnosis and management. The -1131T-->C polymorphism of the apolipoprotein A-V gene (APO A-V) is tightly linked to lipid metabolism and has been associated with increased triglyceride levels and familial dyslipidemia. The aims of this study were to analyze the allele and genotype frequencies of this polymorphism in a Brazilian elderly population and to investigate any association between the polymorphism and major morbidities affecting elderly people. This polymorphism was investigated in 371 individuals, aged 66-97 years, in a Brazilian Elderly Longitudinal Population Study. Major morbidities investigated were: cerebrovascular diseases (CVD); myocardial infarction (MI); type 2 diabetes; hypertension; obesity; dementia; depression; and neoplasia. DNA was isolated and amplified by PCR and its products were digested with restriction enzyme Tru1I. T and C allele frequencies were 0.842 and 0.158, respectively. Our population showed allele frequencies that were similar to European and Afro-American and different from Asiatic populations. Genotype distributions were not within Hardy-Weinberg equilibrium only for the obesity subject sample. On the other hand, a significant association between the C allele and obesity in the presence of CVDxdepression interaction was observed. Logistic analysis showed no association of the polymorphism with each morbidity group. Therefore, the C allele in elderly Brazilian subjects may represent a risk factor for these morbidity interactions, which may lead to better comprehension of their pathophysiology.

Association of apo A-IV 360 (Gln --> His) polymorphism with plasma lipids and lipoproteins: the Framingham Offspring Study.

The effect of a common apolipoprotein (apo) A-IV polymorphism (substitution of histidine for glutamine at position 360) on plasma lipid, lipoprotein cholesterol and lipoprotein(a) (Lp(a)) levels, and on low-density lipoprotein (LDL) particle size was examined by genotyping in 2322 Caucasian men and women (mean age: 48.9+/-10.1 years) participating in the Framingham Offspring Study (FOS). The relative frequencies of the apo A-IV-Gln (apo A-IV-1) and the apo A-IV-His (apo A-IV-2) alleles were 0.932 and 0.068, respectively, and were in Hardy-Weinberg equilibrium. No effect of the apo A-IV-2 genotype was observed on plasma triglyceride, total and lipoprotein cholesterol, and LDL particle size in either men or women after adjustment for age and body mass index. To avoid a possible interaction between the apo E genotype and the apo A-IV genotype, subgroup analyses were undertaken in 1,414 male and female subjects with the apo E3/3 genotype. Among women in this group there was a significant effect of the apo A-IV-2 allele on triglyceride levels (p=0.046). This effect was no longer significant after adjustment for age and BMI (p=0.074). No significant allele effect on other lipoprotein levels, including Lp(a), was noted in apo E3/3 men or women. We have also conducted a meta-analysis of our own data and of other studies found in the literature, indicating a significant lowering effect of apo A-IV-2 on plasma triglycerides, but no effects on other parameters. In conclusion, the apo A-IV-2 allele is associated with a modest reduction in plasma triglyceride levels in the general population.

Role of beta2-glycoprotein I, LDL-, and antioxidant levels in hypercholesterolemic elderly subjects.

The levels of electronegative low-density lipoprotein (LDL-), LDL cholesterol oxidability, and plasma levels of molecular antioxidants and of beta(2)-glycoprotein I (beta(2) GPI) were studied in a group of 10 hypercholesterolemic (HC) and 10 normocholesterolemic (NC) elderly subjects. HC subjects showed significantly higher levels of cholesterol, LDL cholesterol, LDL-, and beta(2)GPI than NC, whereas high-density lipoprotein cholesterol and alpha-tocopherol levels were lower in HC as compared with NC subjects. Correlations among LDL- levels, LDL oxidation lag time, beta(2)GPI, and antioxidant plasma levels were studied in 100 HC elderly subjects. Lag time for in vitro LDL oxidation positively correlated with ubiquinol-10 levels (p = 0.008), but not with other antioxidants studied or beta(2)GPI. LDL- and alpha-tocopherol levels showed an inverse and significant correlation (p = 0.018). beta(2)GPI and LDL cholesterol levels were correlated (p = 0.001), whereas no significance was found between LDL- and beta(2)GPI levels (p = 0.057). The physiological significance of alpha-tocopherol and ubiquinol-10 levels on LDL- levels, and the presence of high levels of beta(2)-GPI, are discussed in terms of protective mechanisms operating during the overall atherosclerosis process.

Two-year follow-up study of elderly residents in S. Paulo, Brazil: methodology and preliminary results

Estudos transversais recentes mostraram alta prevalência de doenças crônicas e incapacidades físicas entre idosos. Considerando o rápido processo de envelhecimento do Brasil e as conseqüências que esse aumento de idosos com doenças crônicas e incapacidades associadas acarretará para o sistema de saúde, fazia-se necessário estudo que pudesse superar as limitaçöes dos dados transversais, permitindo determinar quais os fatores determinantes de uma vida longa e livre de doenças incapacitantes, o chamado envelhecimento bem sucedido. É apresentada a metodologia do primeiro estudo epidemiológico longitudinal com idosos residentes na comunidade, no Brasil. O perfil do cohorte inicial é comparado com dados de estudos anteriores a com o perfil dos näo respondentes para avaliar a validade de análises longitudinais futuras. O projeto EPIDOSO (Epidemiologia do Idoso) seguiu por dois anos 1.667 idosos (65+), residentes em Säo Paulo. Consistiu de duas ondas, cada qual com três inquéritos: domiciliar, clínico e laboratorial. O perfil da populaçäo näo diferiu de estudos anteriores, mostrando maioria de mulheres, viúvas, vivendo em domicílios multigeracionais, com uma alta prevalência de doenças crônicas, distúrbios psiquiátricos e incapacidades físicas. A despeito de todas as dificuldades inerentes a um estudo longitudinal, o grupo de näo-respondentes ao segundo inquérito domiciliar näo diferiu significativamente dos respondentes, assegurando análises longitudinais livres desse tipo de viés. Em relaçäo aos inquéritos clínico e laboratorial, os näo-respondentes mostraram-se mais velhos e mais incapacitados que os respondentes, limitando o uso dos dados clínicos e laboratoriais a análises pertinentes a uma cohorte mais jovem e saudável. Sexo, educaçäo, apoio familiar e nível socioeconômico näo influenciaram de forma significativa a taxa de näo-resposta, ao contrário do que se costuma verificar

Avaliaçäo da eficácia e tolerabilidade do Bezafibrato Retard no tratamento das hiperlipidemias primárias / Evaluation of efficacy and tolerability of bezafibrate retard in the treatment of primary hyperlipidemia

Num estudo aberto, näo comparativo, foram avaliados 20 pacientes portadores de hiperproteinemia primária, com níveis de colesterol plasmático acima de 200mg/dl e/ou triglicérides acima de 250 mg/dl, após, pelo menos, 30 dias de orientaçäo dietética. Os pacientes foram tratados com bezafibrato retard, na posologia de um comprimido de 400 mg ao dia, durante três meses. Ao término do tratamento, houve uma reduçäo significativa dos níveis séricos de colesterol total (-14,6%), triglicérides (-39,7%), bem como aumento significativo dos níveis de HDL-colesterol (+ 19,6%). As provas de funçäo hepática e renal e o hemograma dos 20 pacientes avaliados permaneceram inalterados durante o transcorrer do estudo