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Successful aging (SA) is a current positive aging-related perspective and it is important to determine the variables associated with this concept. Most longitudinal population-based studies on predictors of SA were carried out in developed countries. Objective: This investigation evaluated which baseline characteristics predicted successful aging in 16 years of follow-up in a southern Brazilian cohort - the Porto Alegre Longitudinal Aging study. Methods: At baseline, 345 community-dwelling healthy independent individuals aged 60 or older were assessed for medical and psychiatric conditions, memory, orientation, judgment and problem solving, functioning in the community and at home, and hobbies. SA, according to Rowe and Kahn’s definition, was the outcome assessed in the last evaluation at a maximum 16-year follow-up. All baseline variables were evaluated as potential predictors for the outcome SA. Results: Of the 345 individuals evaluated at baseline, 32 (9.3%) participants were classified as successful agers in the follow-up. Younger age (OR=0.926, 95%CI=0.863-0.994), female gender (OR=0.226, 95%CI=0.072-0.711) and higher MMSE (OR=1.220, 95%CI=1.031-1.444) were predictors of SA for the 16-year follow-up in a logistic regression model. Conclusion: In contrast with our previous hypothesis, the impact of the socioeconomic and socio-environmental characteristics was small, as was the baseline classification into successful and normal aging. RESUMO Envelhecimento bem sucedido (EBS) é uma perspectiva positiva sobre o envelhecimento, sendo importante determinar as variáveis associadas a esse conceito. A maioria dos estudos longitudinais de base populacional sobre preditores do EBS foi realizada em países desenvolvidos. Objetivo: Este estudo avaliou quais características da linha de base predisseram o envelhecimento bem sucedido em 16 anos de seguimento de uma coorte do sul-brasileira - o Estudo Longitudinal de envelhecimento de Porto Alegre (Porto Alegre Longitudinal Aging - PALA - study). Métodos: No início do estudo, 345 indivíduos da comunidade, saudáveis e independentes, com 60 anos ou mais foram avaliados para condições médicas e psiquiátricas, memória, orientação, julgamento e solução de problemas, funcionamento na comunidade, em casa e passatempos. EBS, segundo Rowe e Kahn, foi o desfecho obtido na última visita em um máximo de 16 anos de seguimento. Todas as variáveis da linha de base foram avaliadas como potenciais preditoras para o desfecho EBS. Resultados: Dos 345 indivíduos avaliados na linha de base, 32 participantes (9,3%) foram classificados como idosos com envelhecimento bem sucedidos em 16 anos de seguimento. No modelo de regressão logística, menor idade (OR=0,926; 95%CI=0,863-0,994), gênero feminino (OR=0,226; 95%CI=0,072-0,711) e MEEM mais elevado (OR=1,220; 95%CI=1,031-1,444) foram preditores de EBS para o seguimento de 16 anos. Conclusão: Em contraste com nossa hipótese prévia, o impacto das características socioeconômicas e socio-ambientais foi pequeno, bem como o da classificação inicial de envelhecimento normal e bem sucedido.

The definition of successful aging and identification of predictors have been extensively reviewed, less attention however, has been given to the role of this condition on mortality. Objective: To evaluate the effect of aging status (normal or successful) on mortality in a South Brazilian population-based cohort, adjusted for sociodemographic and clinical variables, and to report the mortality rate and causes of death in this population. Methods: The baseline sample comprised 345 community-dwelling, independent and healthy Southern Brazilian older individuals who were followed for 12 years. Clinical, socio-demographic, functional and cognitive variables were assessed at baseline and during the follow-up. At baseline, 214 participants fulfilled criteria for successful aging, and 131 for normal aging. The main outcome was death. Results: The Cox regression model showed an increased risk for mortality in subjects with normal aging (HR=1.9; p=0.003) adjusted by age (HR=1.1; p

Objectives:Since 2002, the treatment with cholinesterase inhibitors (CHEIs) for Alzheimer's disease (AD) has been paid for by the public health system of the Brazilian Ministry of Health for any patient that fulfills clinical criteria established by an evidence-based guideline developed and published by the Ministry. The aim of this study was to evaluate compliance of prescription patterns to the national guideline for use of CHEIs’ in the southern Brazilian state of Rio Grande do Sul.Methods:We created a regional expert-committee reference center to review all prescriptions of CHEIs and to send feedback to physicians whenever prescriptions without compliance to the guideline were noted. One thousand three hundred ninety-nine (1,399) CHEI prescriptions presented to the public health system from 2005 to 2007 were evaluated by an expert team of neurologists and psychiatrists. Clinical history, performance on mental status screening by Mini Mental State Examination (MMSE), Clinical Dementia Rating scale (CDR), laboratory results, and neuroimaging findings were evaluated in relation to the adherence to the national guideline's recommendations. If the prescription was rejected because of lack of adherence to the criteria of the guideline, a written response was sent by the expert committee to physicians concerning the request.Results:The majority of the requests (n= 1,044; 75 percent) did not meet the AD guideline's criteria, either for diagnosis or for treatment, and were not granted. A diagnostic mistake was evident in 64.3 percent of cases. Findings of vascular or Parkinson's dementia or severe AD were the main reasons for rejection. Rivastigmine was the most prescribed cholinesterase inhibitor, used in 86 percent of cases. Of note was the reduction in the number of CHEIs prescriptions in the years following this intervention.Conclusions:The public health strategy of using expert-review of prescriptions and their compliance to national guideline revealed a low rate of rational use of CHEIs for dementia. Such a strategy is relevant for protecting patients from unproven medical interventions and for reducing waste of resources.

Introduction. This study evaluates the progression of dementia and identifies prognostic risk factors for dementia.Methods. A group of 80 Brazilian community residents with dementia (34 with Alzheimer's disease and 46 with vascular dementia) was assessed over the course of 2 years. Data were analyzed with Cox regression survival analysis.Results. The data showed that education predicted cognitive decline (HR=1.2;P<.05) when analyzed without controlling for vascular risk factors. After the inclusion of vascular risk factors, education (HR=1.32;P<.05) and hypertension were predictive for cognitive decline (HR=38;P<.05), and Alzheimer's disease diagnosis was borderline predictive (P=.055).Conclusion.Vascular risk factors interacted with the diagnosis of vascular dementia. Education was a strong predictor of decline.

Cognitive dysfunction and dementia have recently been proven to be common (and underrecognized) complications of diabetes mellitus (DM). In fact, several studies have evidenced that phenotypes associated with obesity and/or alterations on insulin homeostasis are at increased risk for developing cognitive decline and dementia, including not only vascular dementia, but also Alzheimer's disease (AD). These phenotypes include prediabetes, diabetes, and the metabolic syndrome. Both types 1 and 2 diabetes are also important risk factors for decreased performance in several neuropsychological functions. Chronic hyperglycemia and hyperinsulinemia primarily stimulates the formation of Advanced Glucose Endproducts (AGEs), which leads to an overproduction of Reactive Oxygen Species (ROS). Protein glycation and increased oxidative stress are the two main mechanisms involved in biological aging, both being also probably related to the etiopathogeny of AD. AD patients were found to have lower than normal cerebrospinal fluid levels of insulin. Besides its traditional glucoregulatory importance, insulin has significant neurothrophic properties in the brain. How can clinical hyperinsulinism be a risk factor for AD whereas lab experiments evidence insulin to be an important neurothrophic factor? These two apparent paradoxal findings may be reconciliated by evoking the concept of insulin resistance. Whereas insulin is clearly neurothrophic at moderate concentrations, too much insulin in the brain may be associated with reduced amyloid-beta (Abeta) clearance due to competition for their common and main depurative mechanism - the Insulin-Degrading Enzyme (IDE). Since IDE is much more selective for insulin than for Abeta, brain hyperinsulinism may deprive Abeta of its main clearance mechanism. Hyperglycemia and hyperinsulinemia seems to accelerate brain aging also by inducing tau hyperphosphorylation and amyloid oligomerization, as well as by leading to widespread brain microangiopathy. In fact, diabetes subjects are more prone to develop extense and earlier-than-usual leukoaraiosis (White Matter High-Intensity Lesions - WMHL). WMHL are usually present at different degrees in brain scans of elderly people. People with more advanced WMHL are at increased risk for executive dysfunction, cognitive impairment and dementia. Clinical phenotypes associated with insulin resistance possibly represent true clinical models for brain and systemic aging.

Background: Higher mild cognitive impairment (MCI) prognostic variability has been related to sample characteristics (community-based or specialized clinic) and to diverse operationalization criteria. The aim of the study was to evaluate the trajectory of MCI of Alzheimer type in a population-based elderly cohort in Southern Brazil. We also estimated the risk for the development of probable Alzheimer's disease (AD) in comparison with healthy subjects.Methods: Data were derived from a population-based cohort (the PALA study). MCI outcomes were sub-classified into three categories: conversion, stabilization, and reconversion. The risk of progression to dementia was compared between MCI and normal participants. The analysis was based on 21 MCI subjects and 220 cognitively intact participants (N = 241).Results: Of the 21 MCI subjects, 38% developed dementia, 24% remained stable and 38% improved. The MCI annual conversion rate to AD was 8.5%. MCI was associated with significantly higher risk of conversion to AD (HR = 49.83, p = 0.004), after adjustment for age, education, sex and Mini-Mental State Examination score.Conclusions: Independent of the heterogeneity of the outcomes, MCI of the Alzheimer type participants showed significantly higher risk of developing probable AD, demonstrating the impact of the use of these MCI criteria that emphasize long-term episodic memory impairment.

and to assess the influence of other variables such as gender, age, education, manual activities and reading habits in this sample. Methods: The sample consisted of 520 individuals of both sexes from three different health care institutions (School Hospital, Center for Living and Unit-Family Health). All participants received a questionnaire and the standard Mini Mental State Examination (MMSE), which is an auxiliary method of treatment of possible cognitive deficits in individuals at risk, such as the elderly. The cutoff used was 13 points for illiterates, 18 for primary and secondary education and 26 for high school graduates (Bertolucci, 1994). Results: The mean age was 66.3 years. The mean score of MMSE in the total sample was 24.8 points.19.6% of the total sample had scores suggestive of dementia, with similar distribution between the sexes. Frequency of manual activity and reading are inversely related to the frequency of cognitive impairment. Conclusions: It was observed that the prevalence rates suggesting dementia were lower in the Center for Living, which may be correlated with the frequent practice of physical and social activities, and possibly greater interpersonal contact. Individuals from the primary unit and tertiary care displayed similar prevalence.

The association of successful aging with demographic, socioeconomic, and medical characteristics in healthy community-dwelling Brazilian individuals aged 60 years and older (N = 345) was investigated. Participants were classified as successful (n = 214, 62%) or normal (n = 131, 38%) agers. Successful agers participated in significantly more leisure activities (34%) than did normal agers (21%). Multivariate logistic regression analysis revealed that the number of living children was a risk factor, whereas confidants and family income were protective factors for successful aging. Copyright 2009, Oxford University Press.

General psychiatric symptoms may interfere with the ability of individuals to take care of their health, to get involved with activities and develop social abilities, thereby increasing risk of death. Objective: To evaluate general psychiatric symptoms as predictive factors for mortality in a community elderly cohort in Southern Brazil. Methods: 345 healthy elderly, aged ³60 years, from the catchment area of Hospital de Clinicas de Porto Alegre were followed from 1996. Data for the present study were drawn from the period 1996-2004. General psychiatric symptoms (Self-Reporting Questionnaire - SRQ), depressive symptoms (Montgomery-Asberg depressive rating scale), and Mini Mental State Examination scores at baseline were included in the study. Socio-demographic, medical conditions, and functional capacity were also analyzed. The outcome was vital status at follow-up obtained from family members, hospital records and checked against official death registers. Results: Of the 345 baseline individuals, 246 were followed-up. The global mortality rate over the study period was 36.9% (N=90). Those who deceased during the period were older (73.5±7.5), more dependent overall, and more cognitively impaired than the living elderly (univariate analyses). In the logistic regression, only age (OR=0.93; p=0.003) and functional capacity (OR=0.22; p=0.007) remained significant in the final equation. Conclusion: Psychiatric symptoms presented no association with mortality in the present sample. Older age and functional incapacity were risk factors for mortality. Resumo Sintomas psiquiátricos gerais podem interferir com a capacidade do indivíduo cuidar de sua saúde, de envolver-se com outras atividades e desenvolver habilidades sociais, aumentando o risco de morte. Objetivo: Avaliar se os sintomas psiquiátricos são preditores de mortalidade em uma coorte de idosos de uma comunidade do sul do Brasil. Métodos: 345 idosos saudáveis, com idade igual ou superior a 60 anos, da área de abrangência de um hospital universitário de uma cidade do sul do Brasil foram acompanhados desde 1996. Os dados desse estudo representam o período de avaliação de 1996 a 2004. Os sintomas psiquiátricos na avaliação inicial foram medidos através do Self-Reporting Questionnaire (SRQ) e da Escala Montgomery-Asberg para sintomas depressivos (MADRS) e as variáveis independentes foram desempenho cognitivo no Mini Exame do Estado Mental (MEEM). Dados sócio-demográficos, questionário sobre condições sociais e de saúde, e capacidade funcional também foram analizados. O desfecho principal foi mortalidade durante o seguimento, obtida através de familiares e registros de óbito. Resultados: Dos 345 idosos "baseline", dados foram obtidos de 246 no seguimento. Taxa de mortalidade global no seguimento foi de 36.9% (N=90). Aqueles que faleceram durante o período de avaliação eram mais idosos (73,5±7,5), mais globalmente dependentes e comprometidos do ponto de vista cognitivo do que os idosos que permaneceram vivos (análises univariadas). Na regressão logística, apenas idade (RC=0,93; p=0,003) e capacidade funcional (RC=0,22; p=0,007) mantiveram significância na equação final. Conclusões: Sintomas psiquiátricos não mostraram efeito preditor para mortalidade na presente amostra. Maior idade e incapacitação foram fatores de risco para mortalidade.

Memory and other cognitive complaints are common in the elderly population. However, the clinical meaning of these complaints remains controversial. Objectives: The goal of this study was to investigate the association between cognitive complaints and performance on a mental state screening test in elderly patients attended for the first time at the Neurogeriatric and Dementia (NGA) Outpatient Clinic within a major University hospital. Methods: Two hundred patients referred to the NGA Clinic during 2005, 2006 and 2007 first semesters participated in the study. The variables of interest were: (a) source of and reason for referral; (b) whether or not they had previously been evaluated with the screening test (Mini Mental State Exam - MMSE) by their physicians before referral to our specialized clinic; (c) cognitive complaints; and (d) performance on the screening test (MMSE) at the NGA Clinic. Results: The main reason for referral to the NGA clinic was cognitive complaints 63% (N=126), where only 5% (N=10) of the referred patients had been previously evaluated by the cognitive screening test (MMSE or equivalent). Of the 135 patients who presented cognitive complaints during the first appointment, 52 (38%) presented MMSE scores below the education-adjusted cut-off. No association between cognitive complaint and performance on the MMSE during the first evaluation at the NGA Clinic was observed (c²=3.04, p=0.1). Conclusions: Although cognitive complaints among elders should not be disregarded, the mental state screening evaluation is crucial for the detection of clinically significant cognitive impairment. Resumo Memória e outras queixas cognitivas são comuns na população idosa. No entanto, o significado clínico destas queixas permanece controverso. Objetivo: O objetivo deste estudo foi investigar a associação entre queixa cognitiva e desempenho em um teste de rastreio do estado mental em pacientes idosos que consultavam pela primeira vez no Ambulatório de Neurogeriatria e Demência (NGA) de um grande hospital universitário. Métodos: Duzentos pacientes que foram encaminhados ao Ambulatório de Neurogeriatria durante os primeiros semestres de 2005, 2006 e 2007 participaram do estudo. As variáveis de interesse foram: (a) fonte e razão do encaminhamento; (b) existência de avaliação, com um teste de rastreio (Mini Exame do Estado Mental - MEEM), pelos seus médicos assistentes prévia ao encaminhamento ao NGA; (c) queixa cognitiva na consulta do NGA, e (d) desempenho no teste de rastreio (MEEM) no Ambulatório NGA. Resultados: O principal motivo de encaminhamento ao ambulatório de NGA foi queixa cognitiva 63% (N=126), somente 5% (N=10) dos pacientes encaminhados foram submetidos a algum teste de rastreio cognitivo prévio (MEEM ou equivalente). Dos 135 pacientes com queixa cognitiva durante a primeira avaliação, 52 (38%) apresentavam escores do MEEM abaixo do ponto de corte, ajustados para escolaridade. Nenhuma associação entre queixa cognitiva e desempenho no MEEM durante a primeira avaliação no ambulatório de NGA foi observada (c²=3.04, p=0.1). Conclusões: Embora, queixas cognitivas entre idosos não devem ser ignoradas, avaliação, através de rastreio do estado mental, é crucial para detecção de comprometimento cognitivo clinicamente significativo.

The serial position effect occurs when individuals are asked to recall a list of information that exceeds normal attention span. Alzheimer's disease (AD) patients show lower scores on word span recall tests when compared to healthy aging subjects, younger individuals or depressed patients. Objective: To evaluate the immediate free recall and the serial position effect of a 10-word list, emotionally neutral in tone, in Alzheimer's disease (AD) patients and two age-groups of healthy controls. Methods: The free word recall test was applied in a sample of 44 mild AD outpatients and 168 >50 year and 173 ≤50 year-old healthy controls. The span of recalled words and order of recollection of each item was recorded. Scores for serial position effect were analyzed. MMSE scores were recorded for all participants. Descriptive statistics and the ANOVA with Tukey test were performed. Results: The controls scored significantly better than AD patients on the MMSE and word span (p=0.0001). Older controls word span mean ±SD was 5.65±1.75, younger controls was 5.99±1.27, and AD patients was 2.86±1.42. The best recalled item in all groups was the first item of the list. Primacy was observed across the three groups, although AD patients presented lower scores. Recency was diminished among AD patients compared to control groups. Conclusions: Primacy effect was observed in AD patients as well as in both normal control groups. Recency effect was presented by the normal control groups but was extremely poor among AD patients. The first item was universally best retrieved. Resumo O efeito de posição de palavras numa lista (posição serial) ocorre quando o indivíduo é solicitado a recuperar informação que excede sua capacidade de atenção. Pacientes com doença de Alzheimer (DA) apresentam escores mais baixos nos testes de recuperação de palavras, quando comparados com idosos sadios ou pacientes com depressão. Objetivo: Avaliar a evocação imediata livre e o efeito da posição serial de uma lista de 10 palavras, de conteúdo emocional neutro, em pacientes com doença de Alzheimer (DA) e dois grupos etários de controles saudáveis. Métodos: O teste de evocação livre de palavras foi aplicado em uma amostra de 44 pacientes com DA leve ambulatoriais e 168 controles saudáveis com idade >50 anos e 173 com idade ≤50 anos. O escore da evocação de palavras e a ordem de evocacão de cada item foram registrados. Escores para o efeito da posição seriada foram analisados. O Mini Exame do Estado Mental foi também obtido de todos os participantes. Análise descritiva e ANOVA de uma via com teste de Tukey post hoc foram realizados. Resultados: Os controles obtiveram escores significativamente mais altos do DA no MEEM e span de palavras (p=0.0001). A extensão de palavras dos controles mais velhos mostrou uma média±DP 5,65±1,75, controls mais jovens foi 5,99±1,27, e pacientes com DA foi 2,86±1,42. O item melhor lembrado em todos os grupos foi o primeiro da lista. O efeito de primazia foi observado nos três grupos, ainda que pacientes com DA tenham apresentado os escores mais baixos. Recência mostrou-se reduzida entre os pacientes em relação aos grupos controles. Conclusões: O efeito de primazia foi observado nos pacientes com DA bem como nos dois grupos controles normais. O efeito de recência foi apresentado pelos grupos controles normais, mas de forma extremamente empobrecida pelos pacientes com Alzheimer. O primeiro item da lista foi universalmente melhor evocado.