Diagnóstico de doença de Alzheimer no Brasil: critérios diagnósticos e exames complementares. Recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia

Este consenso teve o objetivo de recomendar condutas baseadas em evidências para o diagnóstico clínico de doença de Alzheimer (DA) em nosso meio. Foram avaliados sistematicamente consensos elaborados em outros países e artigos sobre o diagnóstico de DA no Brasil disponíveis no PUBMED ou LILACS. Concluiu-se que o diagnóstico de demência deve basear-se nos critérios do Manual de Diagnóstico e Estatística da Associação Psiquiátrica Americana (DSM) e o de DA, nos de McKhann et al. (NINCDS-ADRDA). Os exames complementares recomendados são: hemograma completo, concentrações séricas de uréia, creatinina, tiroxina livre, hormônio tíreo-estimulante, albumina, enzimas hepáticas, vitamina B12 e cálcio, reações sorológicas para sífilis e, em pacientes com idade inferior a 60 anos, sorologia para HIV. Exame do líquido cefalorraqueano está indicado em situações particulares. Tomografia computadorizada (ou preferentemente ressonância magnética, quando disponível) é exame obrigatório e tem a finalidade principal de excluir outras doenças. Cintilografia de perfusão (SPECT) e EEG são métodos opcionais.

Cross-cultural adaptation of the quality of life assessment scale on Alzheimer disease

OBJECTIVE: To present the internal validation of the quality of life (QOL) evaluation scale for patients with Alzheimer's disease (AD) and their caregivers/family members, proposed by Logsdon et al. METHOD: The scale was adapted through translation, back translation and equivalence evaluation. The Portuguese version was administered to a sample of 40 patients with mild to moderate AD according to NINCDS ADRDA and DSM-III-R criteria, and also to their respective caregivers/family members. RESULTS: The reliability of the instrument was excellent, both in the intra and the inter-examiner test-retest. The correlation coefficients for the intra-examiner assessment were 0.87/0.95/0.95 (p<0.001)) for the patient, family and caregiver versions, respectively. The correlation coefficients for the inter-examiner assessment were 0.76/0.96/0.93 (p<0.001) for the patients, family and caregiver versions, respectively. The reliability was excellent for both the patient and the relatives' versions in relation to the patient's QOL (alpha=0.81 and 0.85, respectively), and also in relation to the caregiver's QOL (alpha=0.84). CONCLUSION: The adapted version of the instrument proved to be straightforward and brief, presenting excellent stability and reliability. The Portuguese version can be obtained by contacting the first author.

Oxidative state in platelets and erythrocytes in aging and Alzheimer's disease

Several studies have shown involvement of peroxynitrite anion, a potent oxidative agent, in Alzheimer's disease (AD) neuropathology. Herein, we assessed in platelets and erythrocytes of AD patients, age-matched and young adults controls: thiobarbituric acid-reactive substances (TBARS) production; superoxide dismutase (SOD), nitric oxide synthase (NOS) and Na,K-ATPase activities; cyclic GMP (cGMP) content, both basal and after sodium nitroprusside (SNP) stimulation. Aging was associated with an increase in TBARS production and NOS activity, a decrease in basal cGMP content and no change in SOD and Na,K-ATPase activities. AD patients, compared to aged controls, have: increase in TBARS production and in NOS, SOD and Na,K-ATPase activities but no alteration in basal cGMP content. SNP increased cGMP platelets production in all groups. In conclusion, we demonstrated in platelets and erythrocytes a disruption in systemic modulation of oxidative stress in aging and with more intensity in AD.

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.

Estudo da coerência do eletrencefalograma na banda de frequência alfa em indivíduos adultos normais: resultados preliminares em 10 casos

A coerência espectral inter-hemisférica do eletrencefalograma da região occipital do escalpo (eletrodos O1 e O2) foi estimada usando a transformada rápida de Fourier. As médias de coerências na banda de freqüência alfa (alfa1 - 8,0 a 10,0 Hz e alfa2 -10,1 a 12,5 Hz) em indivíduos normais com mais de 50 anos foram comparadas com as obtidas em adultos jovens com idade inferior a 50 anos. Nossos resultados mostraram que não há diferença significativa dos níveis de coerência na banda alfa entre indivíduos em faixas etárias mais avançadas comparados aos adultos jovens.

Declínio da capacidade cognitiva durante o envelhecimento

O declínio da capacidade cognitiva (DCC) decorre dos processos fisiológicos do envelhecimento normal ou de um estágio de transição para as demências. Estudos epidemiológicos mostram que idosos com declínio da capacidade cognitiva apresentam maior risco de desenvolver Doença de Alzheimer (DA), em particular aqueles com déficit de memória episódica. A presente atualização mostra os principais critérios diagnósticos, achados neuropatológicos e neuropsicológicos do declínio da capacidade cognitiva durante o envelhecimento.

Incidence of dementia in a community-dwelling Brazilian population

The authors report the incidence of dementia in a community-dwelling Brazilian population. In 1997, 1656 individuals aged 65 years or more, the majority being of very low educational level, were screened at their homes in Catanduva, Brazil, and dementia was diagnosed in 118 cases. The remaining 1538 individuals were rescreened 3.25 years later applying a health questionnaire, the Mini-Mental State Examination (MMSE) and the Pfeffer Functional Activities Questionnaire (PFAQ). According to 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. A total of 1119 individuals were rescreened and 50 incident cases of dementia (28 with Alzheimer disease [AD]) were identified. The incidence rate of dementia was 13.8 and of AD was 7.7 per 1000 person-years for individuals aged 65 years or older. The incidence rates of dementia almost doubled with every 5 years of age. There was no difference according to gender, but women had a higher incidence of dementia, predominantly AD, in very old age. There was a trend for higher incidence of dementia in illiterates (p = 0.07), but multivariate analysis disclosed significant association only between age and higher incidence of dementia. The incidence rates of dementia in this Brazilian community are comparable to those reported in Western and Asian studies.

Hyperphosphorylated tau protein in the cerebrospinal fluid of patients with Alzheimer's disease and other dementias: preliminary findings

Alzheimer's disease (AD) is pathologically characterized by the accumulation of amyloid plaques and tau-associated neurofibrillary tangles in the cerebral tissue. The search for antemortem biomarkers is intense including analysis of cerebrospinal fluid (CSF) beta-amyloid and tau proteins concentrations seeking for an accurate and early diagnosis. Levels of hyperphosphorylated tau at threonine 181 were measured in the CSF of 34 patients with AD (19 with senile AD - SAD and eight with presenile AD - PSAD) and seven with other dementias (OD). The levels of CSF phosphotau were significantly higher in the AD patients compared to OD (AUC 0.812), with no association with severity of dementia, age of onset, duration of the disease or scores in the Mini-Mental State Examination. There were no differences of phosphotau levels between SAD and PSAD patients. These findings corroborate some previous studies and indicate that CSF phosphotau may help to differentiate AD from other dementias.

Performance of illiterate and literate nondemented elderly subjects in two tests of long-term memory

Cognitive evaluation in developing countries is a difficult undertaking due to low levels of schooling and particularly the illiteracy still frequent in the elderly. This study was part of the epidemiologic evaluation of dementia in Catanduva, Brazil, and had the objective of comparing the performance of illiterate and literate nondemented elderly individuals in 2 tests of long-term memory-the delayed recall of a word list from the CERAD and the delayed recall of common objects presented as simple drawings from the Brief Cognitive Screening Battery (BCSB). Fifty-one elderly subjects (23 illiterates) were evaluated, and the performance of the illiterates and literates differed in the CERAD memory test, but not in the BCSB memory test. This test may be more suitable for the assessment of long-term memory in populations with a high frequency of illiterates, and therefore might prove to be a useful screening tool for the diagnosis of dementia.

Effects of galantamine on attention and memory in Alzheimer's disease measured by computerized neuropsychological tests: results of the Brazilian Multi-Center Galantamine Study (GAL-BRA-01)

OBJECTIVE: To investigate the effects of galantamine on the performance of patients with mild to moderate Alzheimer's disease (AD) in a computerized neuropsychological test battery (CNTB). METHOD: Thirty-three patients with probable AD were treated with galantamine for three months and evaluated in a prospective, open-label, multi-center study. The CNTB and the ADAS-Cog were administered at baseline and after 12 weeks. The CNTB includes reaction time tests to evaluate attention, implicit and episodic memory for faces and words. Statistical comparisons were performed between the results in week 12 versus baseline. Patients who did not reach the therapeutic doses were excluded from the efficacy analysis. RESULTS: Four patients (12.1%) were excluded from the analysis either because of treatment discontinuation (n=3) or because a therapeutic dose was not reached (n=1). The remaining 29 patients were treated with doses of 24 mg/day (n=22) and 16 mg/day (n=7). After 12 weeks, significant reductions in reaction time were seen in the test of episodic memory for faces (p=0.023) and in the test of two-choice reaction time (p=0.039) of the CNTB. CONCLUSION: Treatment with galantamine produced improvement in computerized tests of attention and episodic memory after 12 weeks, leading to statistically significant reduction in the reaction times.

Frontotemporal dementia with severe thalamic involvement: a clinical and neuropathological study

Frontotemporal dementia (FTD) is the third-leading cause of cortical dementia after Alzheimer's disease and Lewy body dementia, and is characterized by a dementia where behavioral disturbances are prominent and appear early in the course of the disease. We report the case of a 58 year-old man affected by dementia with behavioral disturbances, in addition to rigid-hypokinetic and a lower motor neuron syndrome that were present at later stages of the illness. Neuroimaging studies showed frontotemporal atrophy. Neuropathological studies revealed intense thalamic neuronal loss and astrocytic gliosis, as well as moderate frontotemporal neuronal loss, astrocytosis and spongiform degeneration. Thalamic degeneration has previously been described among the wide group of neuropathological features of FTD. The aim of the present study is to show the clinical and neuropathological aspects of thalamic degeneration in FTD, along with its role in behavioral disturbances, a common finding in this condition.

Prevalence of potentially reversible dementias in a dementia outpatient clinic of a tertiary university-affiliated hospital in Brazil

The importance of investigating the etiology for dementia lies in the possibility of treating potentially reversible dementias. The aims of this retrospective study are to determine the prevalence of potentially reversible dementias among 454 outpatients seen at the Cognitive and Behavioral Neurology Unit, Hospital das Clínicas, São Paulo University School of Medicine - Brazil, between the years of 1991 and 2001, and observe their evolution in follow-up. Among the initial 454 patients, 275 fulfilled the DSM-IV criteria for dementia. Alzheimer's disease was the most frequent diagnosis (164 cases; 59.6%). Twenty-two cases (8.0%) of potentially reversible dementia were observed, the most frequent diagnoses being neurosyphilis (nine cases) and hydrocephalus (six cases). Full recovery was observed in two patients and partial recovery in 10 patients. Two cases were not treated and eight cases were lost on follow-up. The prevalence found in the present study falls within the range reported in previous studies (0-30%).

[Suggestions for utilization of the mini-mental state examination in Brazil]

Mini-metal state examination (MMSE) is a screening test to detect cognitive impairment. The objectives of the present study are to describe some adaptations for use of MMSE in Brazil and to propose rules for its uniform application.

METHOD

We evaluated 433 healthy subjects using the MMSE and verified the possible influence of demographic variables on total scores.

RESULTS

Educational level was the main factor that influenced performance, demonstrated by ANOVA: F(4,425) = 100.45, p<0.0001. The median values for educational groups were: 20 for illiterates; 25 for 1 to 4 yrs; 26.5 for 5 to 8 yrs; 28 for 9 to 11 yrs and 29 for higher levels.

CONCLUSION

The MMSE is an excellent screening instrument and definitive rules are necessary for comparison purposes.

Brazilian version of the Mattis dementia rating scale: diagnosis of mild dementia in Alzheimer's disease

OBJECTIVES

To verify the diagnostic accuracy of the Brazilian version of the Mattis Dementia Rating Scale (DRS) in the diagnosis of patients with mild dementia in Alzheimer's disease (AD); to verify the interference of the variables age and schooling on the performance of the DRS.

METHOD

The DRS was administered to 41 patients with mild AD and to 60 controls. In order to analyze the effects of age and schooling on the performance of the tests, patients and controls were separated into three age groups and three levels of schooling.

RESULTS

The cutoff score of 122 showed a sensitivity of 91.7 % and specificity of 87.8 %. Age and schooling interfered in the DRS total score and in the scores of its subscales.

CONCLUSION

The DRS showed good diagnostic accuracy in the discrimination of patients with mild AD from the control individuals. In the sample examined, the effects of schooling were more marked than age.

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.

Como diagnosticar as quatro causas mais freqüentes de demência?

Doença de Alzheimer, demência vascular, demência com corpos de Lewy e demência frontotemporal são as quatro causas mais freqüentes de demência na prática clínica. O diagnóstico diferencial dessas condições se baseia na busca de perfis clínicos característicos por anamnese adequada, exame neurológico e avaliação neuropsicológica, além de investigação complementar pertinente, que consiste em exames laboratoriais e de neuroimagem. O presente artigo apresenta breve revisão das características principais de cada uma dessas formas de demência, com ênfase em aspectos relativos ao diagnóstico.

Involuntary hand levitation associated with parietal damage: another alien hand syndrome

The alien hand syndrome (AHS) usually consists of an autonomous motor activity perceived as an involuntary and purposeful movement, with a feeling of foreignness of the involved limb, commonly associated with a failure to recognise ownership of the limb in the absence of visual clues. It has been described in association to lesions of the frontal lobes and corpus callosum. However, parietal damage can promote an involuntary, but purposeless, hand levitation, which, sometimes, resembles AHS. In the present study, four patients (cortico-basal ganglionic degeneration - n=2; Alzheimer's disease - n=1 and parietal stroke - n=1) who developed alien hand motor behaviour and whose CT, MRI and/or SPECT have disclosed a major contralateral parietal damage or dysfunction are described. These results reinforce the idea that parietal lobe lesions may also play a role in some patients with purposeless involuntary limb levitation, which is different from the classic forms of AHS.

Primary progressive aphasia: analisys of 16 cases

Primary progressive aphasia (PPA) is an intriguing syndrome, showing some peculiar aspects that differentiate it from classical aphasic pictures caused by focal cerebral lesions or dementia. The slow and progressive deterioration of language occurring in these cases provides an interesting model to better understand the mechanisms involved in the linguistic process. We describe clinical and neuroimaging aspects found in 16 cases of PPA. Our patients underwent language and neuropsychological evaluation, magnetic resonance imaging (MRI) and single photon emission computerized tomography (SPECT). We observed a clear distinction in oral expression patterns; patients were classified as fluent and nonfluent. Anomia was the earliest and most evident symptom in both groups. Neuroimaging pointed to SPECT as a valuable instrument in guiding the differential diagnosis, as well as in making useful clinical and anatomical correlations. This report and a comparison to literature are an attempt to contribute to a better understanding of PPA.

Elderly Japanese emigrants to Brazil before World War II: I. Clinical profiles based on specific historical background

OBJECTIVE

To research the demographic and clinical profiles of elderly Japanese emigrants, who arrived in Brazil before World War II, in order to give them appropriate psychogeriatric care.

DESIGN

Elderly Japanese immigrants aged 65 years and over, belonging to the Miyagi Association in the São Paulo Metropolitan Area, were targeted. They emigrated from Miyagi Prefecture to Brazil and are now living in the area. We were able to interview 166 respondents. All data were gathered using standardized interview methods covering (a) free interview about the immigration history, (b) demographics, and (c) physical status.

RESULTS

Through the free interview, we found their immigration histories, which affected their clinical profiles. The mean age and educational level were 77.5 years and 6.3 years, respectively. Sixty per cent of them immigrated when they were younger than 14. Ninety-four per cent of them still keep Japanese nationality. Fifty-seven per cent of them usually use Japanese, while 10% of them use Portuguese. Although their emigration histories were hard, 76% of them perceived their health as being excellent or relatively good. The percentages of subjects with histories of disease were hypertension, 52.5%; cardiac disease, 20.8%; diabetes mellitus, 24.2%; and hyperlipidemia, 25.0%, which were affected by the Brazilian environment.

CONCLUSION

The elderly Japanese who emigrated to Brazil before World War II have a unique historical and demographic background. Their clinical profiles cannot be fully understood without knowing their histories. They definitely need high quality international psychogeriatric care.

Elderly Japanese emigrants to Brazil before World War II: II. Prevalence of senile dementia

BACKGROUND

We previously showed the prevalence of dementia in the town of Tajiri (Miyagi Prefecture, Japan), and found it to be 8.0%. The first population-based study on dementia in Brazil (Catanduva) disclosed the prevalence as being 7.1%. To evaluate the effects of environment on development of dementia, elderly Japanese immigrants living in Brazil were examined. Brazil is the country with the largest number of Japanese immigrants.

METHODS

All immigrants aged 65 years and over from Miyagi Prefecture, living in the four cities of the São Paulo Metropolitan area were targeted (n = 192). We were able to examine 166 subjects (86.5%). The diagnosis of dementia was based on the DSM-IV with the severity assessed by the CDR (clinical dementia rating) scales. The cognitive ability screening instrument (CASI) was used for neuropsychological assessment.

RESULTS

Thirteen subjects were diagnosed with dementia, CDR 1-3, the prevalence being 7.8%. Older subjects suffered more from dementia, and, paradoxically, the more highly educated subjects also suffered more. All the CASI items, except for long-term memory and visual construction, significantly deteriorated in the CDR 0.5 group compared with the CDR 0 group.

COMMENTS

The prevalence of dementia was not thought to be affected by environmental factors. A paradoxically higher rate of dementia in the more educated subjects was probably due to the historical problems of the immigrants. Intact CASI item long-term memory in the CDR 0.5 group indicated that suspected dementia patients could maintain this function. This is the first epidemiological study on dementia in elderly Japanese immigrants in Brazil.

Prion disease resembling frontotemporal dementia and parkinsonism linked to chromosome 17

OBJECTIVE

To compare the clinical features of a familial prion disease with those of frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17).

BACKGROUND

Prion diseases are not usually considered in the differential diagnosis of FTDP-17, since familial Creutzfeldt-Jakob disease (CJD), the most common inherited prion disease, often manifests as a rapidly progressive dementia. Conversely, FTDP-17 usually has an insidious onset in the fifth decade, with abnormal behavior and parkinsonian features.

METHOD

We present the clinical features of 12 patients from a family with CJD associated with a point mutation at codon 183 of the prion protein gene.

RESULTS

The mean age at onset was 44.0 +/- 3.7; the duration of the symptoms until death ranged from two to nine years. Behavioral disturbances were the predominant presenting symptoms. Nine patients were first seen by psychiatrists. Eight patients manifested parkinsonian signs.

CONCLUSION

These clinical features bear a considerable resemblance to those described in FTDP-17.

Caracterização clínica da demência vascular: avaliação retrospectiva de uma amostra de pacientes ambulatoriais

OBJETIVO: analisar as características clínicas e as condições mórbidas (CM) associados em uma amostra de pacientes com demência vascular (DV). MÉTODOS: foram estudados retrospectivamente 25 pacientes com diagnóstico de DV, estabelecidos com base critérios do grupo State of California Alzheimer´s Disease Diagnostic and Treatment Centers (ADDTC). Os dados clínicos e de neuroimagem e os exames laboratoriais foram computados para caracterização da amostra. RESULTADOS: a média da faixa etária foi de 68,7 ± 14,6 anos (64,0% homens), com escolaridade média de 5,2 ± 4,4 anos. A instalação súbita do quadro foi observada em 48,0% dos pacientes e a evolução em degraus e o curso flutuante, em 4,0% e 16,0% dos casos, respectivamente. Apresentavam déficit neurológico focal como sintoma inicial 48,0%, sendo constatado déficit ao exame em 80,0%. As principais CM foram: hipertensão arterial sistêmica (92,0%); hipercolesterolemia (64,0%); insuficiência coronariana (40,0%); tabagismo (40,0%); hipertrigliceridemia (36,0%); diabete melito (32,0%); doença de Chagas (8,0%). CONCLUSÕES: observou-se forte correlação entre DV e hipertensão e hipercolesterolemia. A presença de dois pacientes com doença de Chagas sugere que esta doença possa constituir possível fator de risco regional.

Encoding process in delayed recall impairment and rate of forgetting in Alzheimer's disease

OBJECTIVE

To assess the role of impaired encoding in learning and in delayed recall disturbances, and to evaluate the rate of forgetting in AD.

METHOD

Fifteen AD patients with mild or moderate dementia and 15 normal matched controls were assessed with the Buschke Selective Reminding Test. Delayed recall was evaluated after 30 minutes and after 24 hours.

RESULTS

AD patients had a poorer performance across the six trials of the learning phase as well as in both delayed recall evaluations, with no difference between recall at 30 minutes and at 24 hours.

CONCLUSION

Performance in the learning phase was as specific and almost as sensitive as the performance in delayed recall for AD diagnosis. Encoding impairment was responsible for poorer learning and rapid displacement of previous learned material in the AD group. Finally, we did not find a higher rate of forgetting in AD patients.

[Clinical characterization of vascular dementia: retrospective evaluation of an outpatient sample]

OBJECTIVE

to analyze the clinical features and associated morbidity in a group of patients with vascular dementia (VD).

METHODS

we retrospectively evaluated 25 patients with diagnosis of VD, based on the State of California Alzheimers Disease Diagnostic and Treatment Centers (ADDTC) criteria. Clinical and neuroimaging data and laboratory test results were obtained for the characterization of the sample.

RESULTS

the mean age was 68.7 +/- 14.6 years (64.0% men), with mean educational level of 5.2 +/- 4.4 years. Sudden onset of symptoms was observed in 48.0% of patients and stepwise deteriorating and fluctuating courses being observed in 4.0% and 16% respectively. Focal neurologic deficits were the first symptom in 48.0%, with focal deficits being observed in 80% on examination. The main morbidity were: hypertension (92.0%); hypercholesterolemia (64.0%); coronary heart disease (40.0%); smoking (40.0%); hypertriglyceridemia (36.0%); diabetes mellitus (32.0%); Chagas' disease (8.0%).

CONCLUSIONS

we observed strong association between VD and hypertension and hypercholesterolemia. The observation of two patients presenting Chagas' disease suggests that this endemic condition may be considered a possible regional risk factor.