Mortality from dementia in a community-dwelling Brazilian population

BACKGROUND: The influence of dementia on mortality has not yet been reported for a Latin American country. OBJECTIVES: To evaluate the influence of dementia on mortality of a community-dwelling elderly population in Brazil, and to verify the extent to which the diagnosis of dementia is reported on death certificates. METHODS: A cohort of 1,656 individuals, aged 65 and over, was screened for dementia at their domiciles, in 1997. The same population was re-evaluated in 2000, and information on deaths was obtained from relatives and from the municipal obituary service. Kaplan-Meier curves were used for the survival analysis, and the mortality risk ratio (MMR) was calculated using Cox proportional hazards models. RESULTS: We obtained data from 1,393 subjects, corresponding to 84.1% of the target population. The number of deaths was 58 (51.3%) among the patients with dementia and 163 (12.7%) among those without dementia in 1997 (p <0.0001). Dementia and Alzheimer's disease (AD) decreased survival, with hazards ratios of 5.16 [95% Confidence Interval (CI): 3.74-7.12] for dementia and 4.76 (95% CI: 3.16-7.18) for AD. The Cox proportional hazards model identified dementia (MMR=3.92, 95% CI: 2.80-5.48) as the most significant predictor of death, followed by age, history of stroke, complaints of visual impairment and heart failure and by severe arterial hypertension in the baseline evaluation. Dementia and/or AD were mentioned in only 12.5% of the death certificates of individuals with dementia. CONCLUSIONS: Dementia causes a significant decrease in survival, and the diagnosis of dementia is rarely reported on death certificates in Brazil.     

Epidemiologic survey of dementia in a community-dwelling Brazilian population

The authors report the prevalence of dementia in a community-dwelling Brazilian elderly population and correlate prevalence data with educational and socioeconomic levels. The study was conducted in Catanduva, Brazil. A total of 1,656 randomly selected subjects aged 65 years or more were submitted to a health questionnaire, the Mini-Mental State Examination (MMSE), and the Pfeffer Functional Activities Questionnaire (PFAQ). According to the PFAQ and MMSE scores, selected subjects were submitted to clinical, neurologic, and cognitive evaluations. The subjects diagnosed with dementia underwent laboratory tests and brain computed tomography (CT). Dementia was diagnosed in 118 subjects, corresponding to a prevalence of 7.1%. The main clinical diagnoses were Alzheimer disease (AD; 55.1%), vascular dementia (9.3%), and AD with cerebrovascular disease (14.4%). The prevalence increased with age and was higher in women. There was an inverse association with education (3.5% among persons with 8 or more years of schooling to 12.2% among those who were illiterate). Multivariate analysis disclosed significant association between these three variables and dementia. The prevalence of dementia in this Brazilian population was 7.1%, and AD was the most frequent diagnosis. Age, female gender, and low educational level were significantly associated with a higher prevalence of dementia.     

Incidence and lifetime risk of dementia and Alzheimer's disease in a Southern European population

Lobo A, Lopez‐Anton R, Santabárbara J, de‐la‐Cámara C, Ventura T, Quintanilla MA, Roy JF, Campayo AJ, Lobo E, Palomo T, Rodriguez‐Jimenez R, Saz P, Marcos G. Incidence and lifetime risk of dementia and Alzheimer’s disease in a Southern European population. Objective: To calculate both the incidence rates and the lifetime risk (LTR) of dementia and Alzheimer’s disease (AD). Methods: A two‐phase case‐finding procedure was implemented in a cohort of 4057 cognitively intact individuals 55+ years of age living in Zaragoza, Spain, and followed‐up at 2.5 and 4.5 years. Age‐ and sex‐specific incidence rates were calculated. A mortality‐adjusted, multivariate model was used to document LTRs. Results: The incidence rate of dementia continued to rise after the age of 90 years, but was slightly lower than in North and West European studies. Only a tendency for an increased LTR with age was observed. Thus, LTR was 19.7% for a 65‐year‐old woman and 20.4% at the age of 85 years, the corresponding figures for AD being 16.7% and 17.6%. The LTR of AD was higher in women and was about twice as high among illiterate individuals when compared with individuals with higher educational levels. Conclusions: The incidence rate of dementia in this Southern European city was slightly lower than in previous studies in North‐West Europe. LTR of dementia and AD seems to be slightly increased with age. The association of illiteracy with higher LTR of AD is intriguing.     

Alternative statistical approaches to identifying dementia in a community-dwelling sample

Little attention has been paid to examining the extent to which alternative statistical models may facilitate identification of persons with dementia. Using a sub-sample of the Duke Established Populations for Epidemiologic Studies of the Elderly, two analytical approaches were compared: logistic regression (which focuses on identifying specific characteristics predictive here of dementia), and recursive partitioning methods using tree-based models (which permit identification of the characteristics of those groups with high dementing disorder). In the stepwise multiple logistic regression model which included as potential predictors, gender, age, history of chronic health conditions, scales of basic and instrumental activities of daily living (IADL), and cognitive status, only IADL and cognitive status were significant predictors, with cognitive status the single most important factor. The classification tree approach, which permits identification of the characteristics of those groups with particularly high dementia rates, identified cognitive status as the most important criterion for dementia (as did logistic regression analysis). Among those without cognitive impairment, older age was a risk factor, confirming findings consistently reported in the literature. Among the cognitively impaired, IADL was an important risk factor. Those with five or more IADL problems were further classified into two risk groups, based on number of ADL problems. While classification tree analysis encourages identification of groups at risk, logistic regression encourages targeting of specific characteristics.     

Bereavement-related cognitive impairment in an oldest-old community-dwelling Brazilian sample

As it is already known that depression can cause a demonstrable impact on cognition in elderly subjects, the objective of this study was to determine whether also the mourning process is associated with any cognitive impairment in this age range. A random and representative sample (a sample with 77 subjects/total county population of oldest-old with 219 subjects = 35%) aged 80 years or more was selected from the county of Veranópolis in the Brazilian rural southern region. Of this group, the cognitive function of subjects without grief and of subjects with the presence of grief were compared. Five neuropsychological tests (the Buschke-Fuld Selective Reminding Test, the word-list from the CERAD battery, the Verbal Fluency Test, and two subtests of the Wechsler memory scale), the Mini-Mental State Examination (MMSE) and two self-perceived memory impairment questionnaires were used. Presence of depressive symptomatology was identified by the Yesavage Geriatric Depression Scale (GDS). The prevalence rates of some psychiatric diagnoses (syndromic general anxiety disorder, major and minor depression) were compared between the bereaved group and the control group. There was not a statistically significant difference between the scores of controls and subjects with grief in the GDS. The frequency of affective disorders in both groups did not differ. However, the recently bereaved elderly subjects presented a mild cognitive impairment when evaluated with the MMSE, with the digit span test and with Word-list neuropsychological memory test. Likewise these bereaved octogenarian subjects presented more frequently a diagnosis of 'aging-associated cognitive decline' when compared with non-bereaved oldest-old. These results suggest that the normal sadness and/or the chronic stress of the grieving process, even without the presence of an identifiable syndromal-level depression, are associated with memory and cognitive differences among the bereaved oldest-old. Cause-effect relationships, however, cannot be established from this cross-sectional correlational study: Grief may influence cognitive functioning in the elderly, but mildly cognitively compromised elderly persons may be more likely to experience strong grief reactions after loss.     

Epidemiology of dementia in a Finnish population

An epidemiological study of dementia was carried out in the city of Turku (population 164,568) in Finland. A total of 421 patients with moderate to severe dementia were found. Degenerative dementia, i.e. presenile and senile dementia, was present in 218 patients (51.8 %), and in 152 patients (36.1 %) the dementia was associated with arteriosclerosis, including multi-infarct and combined dementia. The prevalence rate of dementia, all types, was 256 per 100,000 population, and 1,961 per 100,000 population over 65 years old. The age-specific prevalence rates of dementia increased with advancing age from 0.1 % in the age group 55–64 years to 11 % in the age group over 85 years. The peak annual incidence rate for all types of dementia was 58 per 100,000 population, and 447 per 100,000 population over 65 years old. Both prevalence and incidence figures suggested a female preponderance in dementia of degenerative origin and in dementia with associated arteriosclerosis.     

Screening of dementia in community-dwelling elderly through informant report

Screening tools for cognitive decline still have low accuracy for dementia, mainly in cases of mild dementia. All of them are affected by factors such as age, sex, educational level, sensory deficits and several mental disorders. The information provided by a proxy close to the patient has been used during recent years in dementia diagnosis. Therefore, new questionnaires, which use standardized information from relatives, have been developed. The aim of this study was to validate a Spanish version (S-IQCODE) of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), a dementia screening questionnaire in Spanish population-based samples. A validity study of the screening tool was carried out in two population-based samples of community-dwelling elderly with different sociodemographic characteristics (urban and rural samples). Dementia diagnosis was performed by neurologists according to DSM-III-R criteria. The S-IQCODE showed a higher accuracy than the MMSE in both samples: sensitivity of 82% and 83% vs 73% and 83%, specificity of 90% and 83% vs 78% and 74%, accuracy of 89% and 83% vs 77% and 75%. Moreover, while the S-IQCODE did not have associations with any extraneous factors, the MMSE showed significant correlations with age (−0.51), educational level (0.62), mental health (−0.40), premorbid intelligence (0.67) and intellectual level (0.75). The results obtained with the S-IQCODE show that it could possibly be applied in screening for dementia in community-dwelling elderly. © 1997 John Wiley & Sons, Ltd.     

Hypertension and incident dementia in community-dwelling elderly Yoruba Nigerians

Ogunniyi A, Lane KA, Baiyewu O, Gao S, Gureje O, Unverzagt FW, Murrell JR, Smith‐Gamble V, Hall KS, Hendrie HC. Hypertension and incident dementia in community‐dwelling elderly Yoruba Nigerians.
Acta Neurol Scand: 2011: 124: 396–402.
© 2011 John Wiley & Sons A/S. Objectives – To investigate the relationship between hypertension and dementia incidence in community‐dwelling elderly Yoruba (aged 70 years and above) because of sparse information on dementia and its risk factors in developing countries. Materials and Methods – Community‐based, prospective study of consenting elderly Yoruba using two‐stage design. Blood pressure was measured during the baseline evaluation at 2001 and hypertension was defined as BP ≥ 140/90 mmHg. Diagnosis of dementia and normal cognition was by consensus using standard criteria. Non‐demented subjects from the 2001 evaluation wave were re‐evaluated during the 2004 and 2007 waves for dementia. Logistic regression was used to examine the association of baseline hypertension and incident dementia, after adjusting for age, gender, education, and histories of stroke and smoking. P‐values <0.05 were considered significant. Results – During the 6‐year follow‐up, 120 individuals developed dementia, while 1633 remained non‐demented. The frequency of hypertension in the demented group was significantly higher than in the non‐demented (70.0% vs 60.2%, P = 0.034). Baseline hypertension was a significant risk factor for dementia (OR = 1.52; 95% CI 1.01–2.30). Higher systolic, diastolic or pulse pressure was associated with increased risk (P < 0.05). Participants with diastolic BP ≥ 90 mmHg were at a significantly greater risk than those with readings below 70 mmHg (OR = 1.65; 95% CI 1.01–2.69). Conclusions – Hypertension was associated with increased risk of dementia in elderly Yoruba and its appropriate treatment may lower the risk.     

Incidence of dementia after age 90 in a multiracial cohort

Introduction

Little is known about dementia incidence in diverse populations of oldest-old, the age group with highest dementia incidence.

Use of services by community-dwelling patients with dementia: a systematic review

Dementia is a complicated disease requiring medical, psychological, and social services. Services to address these needs include medical care (outpatient physician/specialist, inpatient, emergency) and community care (home health, day care, meal preparation, transportation, counseling, support groups, respite care, physical therapy). This systematic review of articles published in English from 1991 to the present examines studies of ambulatory, community-dwelling dementia patients with established dementia diagnoses. Searches of the Medline database using 13 combinations of search terms, plus searches of Embase and PsycINFO databases using 3 combinations of terms and examination of reference lists of related articles, resulted in identification of 15 studies dealing with healthcare utilization among community-dwelling dementia patients in both medical and community care settings. Patients with dementia frequently use the full spectrum of medical services. Community resources are used less frequently. Community healthcare services may be a valuable resource in alleviating some burden of dementia care for physicians.     

Mild parkinsonian signs in a community-dwelling elderly population sample in Japan

Mild parkinsonian signs (MPS) may represent the mild end of a disease spectrum that spans from normal aging to neurodegenerative diseases. We conducted a population-based study in a rural island town in western Japan, Ama-cho. Participants included 1129 subjects, aged 60 years and older, residing in the town. Participants were classified according to a modified Unified Parkinson's Disease Rating Scale (mUPDRS) score. MPS was determined to be present if any of the following conditions were met: (1) two or more mUPDRS ratings=1 [MPS-mild]; (2) one mUPDRS rating≥2; or (3) mUPDRS rest tremor rating≥1; [(2) and (3): MPS-severe]. Subjects wore a uniaxial accelerometer (Actiwatch), resulting in the measurement of actigraphic activity counts (AC). Of the 804 participants with complete data, 178 subjects (22.1%) were classified as demonstrating MPS. AC was significantly lower in the MPS-severe group compared with both the CTL and the MPS-mild groups. Diagnostic sensitivity for MPS-severe became 100% when we adopted a cutoff point of low physical activity, as measured by actigraphy, combined with the presence of subjective depression. We established the prevalence of MPS in a community-dwelling elderly population sample in Japan. Actigraphy may be a useful objective tool for screening MPS-severe.