Diagnosis and management of Parkinson’s disease dementia and dementia with Lewy bodies: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology

ABSTRACT Parkinson’s disease dementia (PDD) and dementia with Lewy bodies (DLB) represent the second most common type of degenerative dementia in patients aged 65 years and older, leading to progressive cognitive dysfunction and impaired quality of life. This study aims to provide a consensus based on a systematic Brazilian literature review and a comprehensive international review concerning PDD and DLB. Moreover, we sought to report on and give recommendations about the best diagnostic approaches focusing on primary and secondary care. Based on the available data, we recommend clinicians to apply at least one brief global cognitive instrument to assess PDD, such as the Mini-Mental State Examination and preferably the Montreal Cognitive Assessment and the Addenbrooke’s Cognitive Examination-Revised. Validated instruments to accurately assess functional abilities in Brazilian PD patients are still incipient. Further studies should focus on biomarkers with Brazilian cohorts.

Treatment of dementia: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology

ABSTRACT There is currently no cure for neurodegenerative or vascular dementias, but some pharmacological and non-pharmacological interventions may contribute to alleviate symptoms, slow disease progression and improve quality of life. Current treatment approaches are based on etiology, symptom profile and stage of dementia. This manuscript presents recommendations on pharmacological and non-pharmacological treatments of dementia due to Alzheimer’s disease, vascular cognitive impairment, frontotemporal dementia, Parkinson’s disease dementia, and dementia with Lewy bodies.

Tratamento da demência: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia

RESUMO Atualmente não há tratamento curativo para as demências neurodegenerativas ou para a demência vascular, mas algumas intervenções farmacológicas e não farmacológicas podem contribuir para aliviar os sintomas, retardar a progressão da doença e melhorar a qualidade de vida. As abordagens terapêuticas atuais são baseadas na etiologia, no perfil dos sintomas e no estágio da demência. Neste artigo apresentamos recomendações sobre os tratamentos farmacológicos e não farmacológicos da demência devida à doença de Alzheimer, comprometimento cognitivo vascular, demência frontotemporal, demência da doença de Parkinson e demência com corpos de Lewy.

Diagnóstico do comprometimento cognitivo vascular: recomendações do Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia

RESUMO Desde a publicação das últimas recomendações para o diagnóstico e tratamento da Demência Vascular pela Academia Brasileira de Neurologia em 2011, avanços significativos ocorreram na terminologia e critérios diagnósticos. O presente manuscrito é resultado do consenso entre especialistas indicados pelo Departamento Científico de Neurologia Cognitiva e do Envelhecimento da Academia Brasileira de Neurologia (2020-2022). O objetivo foi atualizar as recomendações práticas para a identificação, classificação e diagnóstico do Comprometimento Cognitivo Vascular (CCV). As buscas foram realizadas nas plataformas MEDLINE, Scopus, Scielo e LILACS. As recomendações buscam fornecer uma ampla revisão sobre o tema, então sintetizar as evidências para o diagnóstico do CCV não apenas para neurologistas, mas também para outros profissionais de saúde envolvidos na avaliação e nos cuidados ao paciente com CCV, considerando as diferentes realidades dos níveis de atenção à saúde (primário, secundário e terciário) no Brasil.

Diagnosis of Alzheimer's disease: recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology

This paper presents the consensus of the Scientific Department of Cognitive Neurology and Aging from the Brazilian Academy of Neurology on the diagnostic criteria for Alzheimer's disease (AD) in Brazil. The authors conducted a literature review regarding clinical and research criteria for AD diagnosis and proposed protocols for use at primary, secondary, and tertiary care levels. Within this clinical scenario, the diagnostic criteria for typical and atypical AD are presented as well as clinical, cognitive, and functional assessment tools and complementary propaedeutics with laboratory and neuroimaging tests. The use of biomarkers is also discussed for both clinical diagnosis (in specific conditions) and research.

Effects of group Acceptance and Commitment Therapy (ACT) on anxiety and depressive symptoms in adults: A meta-analysis

BACKGROUND

A comprehensive meta-analysis quantitatively examining the effects of group Acceptance and Commitment Therapy (ACT) on anxiety and depressive symptoms is required to advance our understanding of its efficacy and moderating factors.

METHODS

Four electronic databases were searched in August 2018. An update search was conducted in November 2021. Forty-eight randomised controlled trials (RCTs) were included in this review (3292 participants: anxiety = 34 RCTs, depression = 40 RCTs).

RESULTS

The overall effect size for anxiety symptoms was medium-to-large (g = 0.52, p < 0.001; 95% CI = 0.30-0.73), while the overall effect size was small-to-medium for depressive symptoms (g = 0.47, p < 0.001; 95% CI = 0.31-0.64). Subgroup analyses demonstrated that group ACT was significantly superior to non-active controls (e.g., waiting list) in reducing anxiety and depressive symptoms. Group ACT was only significantly superior to active controls (e.g., CBT) in reducing depressive symptoms. Subgroup analyses also demonstrated that the effect size can vary depending on the number of sessions provided and the primary condition of participants recruited.

LIMITATIONS

The number of studies included in each category of subgroup analyses was small and the risk of bias varied across studies. There was high heterogeneity among the included studies, and this might have affected the results.

CONCLUSION

The current evidence suggests that group ACT may be effective in treating anxiety and depressive symptoms, perhaps more so for depressive symptoms when compared to other well-established treatments. The intensity of treatment and the targeted population may need to be considered when delivering group ACT.

A Novel Panel of Plasma Proteins Predicts Progression in Prodromal Alzheimer's Disease

BACKGROUND

A cheap and minimum-invasive method for early identification of Alzheimer's disease (AD) pathogenesis is key to disease management and the success of emerging treatments targeting the prodromal phases of the disease.

OBJECTIVE

To develop a machine learning-based blood panel to predict the progression from mild cognitive impairment (MCI) to dementia due to AD within a four-year time-to-conversion horizon.

METHODS

We created over one billion models to predict the probability of conversion from MCI to dementia due to AD and chose the best-performing one. We used Alzheimer's Disease Neuroimaging Initiative (ADNI) data of 379 MCI individuals in the baseline visit, from which 176 converted to AD dementia.

RESULTS

We developed a machine learning-based panel composed of 12 plasma proteins (ApoB, Calcitonin, C-peptide, CRP, IGFBP-2, Interleukin-3, Interleukin-8, PARC, Serotransferrin, THP, TLSP 1-309, and TN-C), and which yielded an AUC of 0.91, accuracy of 0.91, sensitivity of 0.84, and specificity of 0.98 for predicting the risk of MCI patients converting to dementia due to AD in a horizon of up to four years.

CONCLUSION

The proposed machine learning model was able to accurately predict the risk of MCI patients converting to dementia due to AD in a horizon of up to four years, suggesting that this model could be used as a minimum-invasive tool for clinical decision support. Further studies are needed to better clarify the possible pathophysiological links with the reported proteins.

Sentence Comprehension in Primary Progressive Aphasia: A Study of the Application of the Brazilian Version of the Test for the Reception of Grammar (TROG2-Br)

Sentence-comprehension deficits have been described in patients with primary progressive aphasia (PPA). However, most instruments to address this domain in more detail and in a clinical context have not been adapted and translated into several languages, posing limitations to clinical practice and cross-language research.

Objectives

The study aimed to (1) test the applicability of the Brazilian version of the Test for Reception of Grammar (TROG2-Br) to detect morphosyntactic deficits in patients with PPA; (2) investigate the association between performance in the test and sociodemographic and clinical variables (age, years of formal education, and disease duration); (3) characterize the performance of individuals presenting with the three more common variants of PPA (non-fluent, semantic, and logopenic) and mixed PPA (PPA-Mx) and analyze whether TROG-2 may assist in the distinction of these clinical profiles.

Methods

A total of 74 cognitively healthy participants and 34 individuals diagnosed with PPA were assessed with TROG2-Br. Overall scores (correct items, passed blocks), types, and categories of errors were analyzed.

Results

In controls, block scores were significantly correlated with years of formal education (Spearman's r = 0.33, p = 004) but not with age. In PPA, age, education, and disease duration were not significantly associated with performance in the test. Controls presented a significantly higher performance on TROG2-Br compared to PPA individuals and their errors pattern pointed to mild general cognitive processing difficulties (attention, working memory). PPA error types pointed to processing and morphosyntactic deficits in nonfluent or agrammatic PPA, (PPA-NF/A), logopenic PPA (PPA-L), and PPA-Mx. The semantic PPA (PPA-S) subgroup was qualitatively more similar to controls (processing difficulties and lower percentage of morphosyntactic errors). TROG2-Br presented good internal consistency and concurrent validity.

Discussion

Our results corroborate findings with TROG-2 in other populations. The performance of typical older adults with heterogeneous levels of education is discussed along with recommendations for clinical use of the test and future directions of research.

How to differentiate behavioral variant frontotemporal dementia from primary psychiatric disorders: practical aspects for the clinician

BACKGROUND

Due to the early and prominent behavioral changes which characterize behavioral variant frontotemporal dementia (bvFTD), patients are more likely to seek psychiatric help and are often initially diagnosed with a primary psychiatric disorder (PPD). Differentiating these conditions is critical because of the dramatically different outcomes, differences in patient management, family counseling and caregiver education.

OBJECTIVE

To propose a practical guide to distinguish between bvFTD and PDD.

METHODS

We conducted a non-systematic review of the published manuscripts in the field, including some previous investigations from our own group and work on which we have collaborated, and summarized the main findings and proposals that may be useful for neurological practice.

RESULTS

The reviewed literature suggests that a comprehensive clinical history, brief cognitive and neuropsychological evaluations, detailed neurological examination with special attention to motor alterations related to bvFTD, structural and functional neuroimaging evaluation, genetic investigation in selected cases, and assistance from a multidisciplinary team, including a neurologist and a psychiatrist with expertise in bvFTD, are very helpful in differentiating these conditions.

CONCLUSIONS

Although the clinician may commonly face great difficulty in differentiating between bvFTD and PPD, the use of appropriate tools in a systematic way and the availability of a well-trained multidisciplinary group can significantly increase diagnostic accuracy.

Retest effects in a diverse sample: sociodemographic predictors and possible correction approaches

Repeated cognitive assessment in longitudinal studies favors the occurrence of retest effects, usually increasing the scores obtained at the follow-up assessments when compared to baseline. Therefore, retest effects can compromise the evaluation of cognitive decline in older adults.

Association Between Adherence to the MIND Diet and Cognitive Performance is Affected by Income: The ELSA-Brasil Study

BACKGROUND

The relationship between the Mediterranean-DASH Diet Intervention for Neurodegenerative Delay (MIND) diet and cognition has not been widely investigated in low- to middle-income countries. We investigated the relationship between MIND diet and cognition in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) baseline data.

METHODS

We included 11,788 participants. MIND diet adherence was based on the intake of 15 components according to a food frequency questionnaire. We analyzed the association between MIND diet adherence and global cognition, memory, and executive function using adjusted linear regression. We examined the interaction between income and MIND diet adherence on cognition and presented income stratified analyses.

RESULTS

MIND diet adherence was not associated with cognition in the whole sample. Income was an effect modifier of MIND adherence on global cognition (P=0.03) and executive function (P<0.001). For participants with high income, greater adherence was associated with better executive function [β=0.015, 95% confidence interval (CI)=0.002; 0.028, P=0.025]; while for participants with low income, greater adherence was associated with lower global cognition (β=-0.020, 95% CI=-0.036; -0.005, P=0.010) and executive function (β=-0.023, 95% CI=-0.039; -0.007, P=0.004). Adherence to the MIND diet was higher among participants with high income (P<0.001).

CONCLUSION

For high-income participants, greater adherence was associated with better cognitive performance; for low-income participants, greater adherence was associated with lower cognitive performance.

Do patients with Progressive Supranuclear Palsy have episodic memory impairment? A systematic review

Background

Progressive supranuclear palsy (PSP) is the most common atypical parkinsonism and has executive dysfunction as a core feature. The magnitude of episodic memory disturbance in PSP is yet to be clarified.

Objectives

To investigate how impaired is episodic memory in PSP compared to healthy controls and other neuropsychiatric disorders. Also, we sought to identify the brain correlates underlying these memory disturbances.

Methods

We performed a systematic search on PubMed and Scopus, combining the terms "progressive supranuclear palsy" AND "memory". The search was limited to papers published in English, French, Portuguese or Spanish, with no chronological filters. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

Results

The initial search returned 464 results. After extraction of duplicates, 356 records were screened, leading to inclusion of 38 studies. Most studies found that PSP patients had lower scores on episodic memory compared to healthy controls. In addition, the majority of studies suggest that PSP does not differ from Parkinson's disease and from atypical parkinsonism in terms of episodic memory performance. The same is seen for PSP and frontotemporal dementia. Conversely, episodic memory impairment seems to be greater in typical Alzheimer's disease compared to PSP. Neuroimaging findings indicate that striatofrontal structures may be involved in PSP episodic memory dysfunction, while no associations with mesial structures (including hippocampi) were found.

Conclusions

Episodic memory is impaired in PSP. Whether this amnesia refers to executive dysfunction is still controversial. More studies are warranted to clarify the neural basis of memory impairment in PSP.

Sex differences in the association between alcohol intake and cognitive decline over four years in a middle-aged cohort: the Brazilian Longitudinal Study of Adult Health

The association between alcohol intake and cognitive decline has been widely studied. Sex differences and cognitive domains affected by alcohol intake patterns make this topic overly complex.

OBJECTIVE

To investigate the effect of alcohol intake on cognition of middle-aged participants from ELSA-Brasil by sex during four-years of follow-up.

METHODS

7,595 participants (55% women) aged between 50 to 75 years at baseline were assessed. Semantic and phonemic fluency, memory, and executive functions were assessed at baseline (2008-2010) and repeated during Visit 2. Linear mixed models were used to investigate the association between cognition and current abstainers, never drinkers, light drinkers, moderate drinkers, and heavy drinkers.

RESULTS

Heavy alcohol intake accentuated the decline in executive functions for men (β = -0.01; p < 0.05), and in semantic fluency (β = -0.02; p < 0.05), and memory (β = -0.02; p < 0.05) for women. Never drinker's men also showed an accentuated decline in semantic fluency (β = -0.02; p < 0.01). Moderate alcohol intake slowed cognitive decline in phonemic fluency for men (β = 0.02, p < 0.01) and women (β = 0.01, p < 0.01) and in executive functions (β = 0.01, p < 0.05) for women.

CONCLUSIONS

Having more than 14 drinks per week can impact executive functions in men and memory in women. In addition, alcohol consumption of 7 to 14 drinks per week may have a protective effect on gender-specific cognitive functions. These findings should be considered in public health policies and guidelines on alcohol and cognitive aging.

Investigation of the Association Between History of Learning Disabilities and Primary Progressive Aphasia in Brazilian Portuguese Speakers

Primary Progressive Aphasia (PPA) is a neurological syndrome characterized by impaired language due to neurodegeneration. It is subdivided into three variants: semantic, agrammatic or nonfluent, and logopenic. Pieces of evidence have suggested that learning disabilities in childhood, such as dyslexia, might be susceptibility factors in the occurrence of PPA in adulthood. The objective of this study was to verify the existence of the relationship between PPA and the history of learning disabilities of patients and their children, compared to a control group of individuals with Alzheimer's disease (AD). A questionnaire was applied to investigate the presence of indicators of learning disabilities and difficulties in individuals with PPA and AD and their children. Twenty subjects with PPA and 16 with AD participated in the study. Our findings are presented and discussed in light of the current scientific evidence and the social, educational, and economic Brazilian scenario. Despite the challenges of doing research with individuals with PPA in Brazil, we present the first evidence about the investigation of association between the history of learning disabilities and difficulties and PPA in native Brazilian Portuguese speakers.

Alzheimer's disease diagnosis and management: Perspectives from around the world

Alzheimer's disease (AD) and other dementias are a global challenge. Early diagnosis is important to manage the disease. However, there are barriers to diagnosis that differ by region. Researchers from Brazil, China, Nigeria, Spain, and Sweden have identified key barriers to AD diagnosis in their countries. In Brazil, socioeconomic inequalities and poor recognition of dementia by physicians can prevent diagnosis. In China, a very large population and lack of physician training in dementia make diagnosis problematic. In Nigeria, socioeconomic inequalities and cultural stigma can stand in the way of diagnosis. In Spain, patient hesitancy and an overloaded health-care system are barriers to diagnosis. In Sweden, inconsistent use of biomarkers is a prominent barrier to diagnosis of AD. To support diagnosis, more focus is needed on education of patients and physicians, increased use of support services, and improved access to biomarkers to accurately diagnose AD.

Different patterns of gray matter atrophy in behavioral variant frontotemporal dementia with and without episodic memory impairment

BACKGROUND

Differentiating patients with behavioral variant frontotemporal dementia (bvFTD) from Alzheimer's disease (AD) is important as these two conditions have distinct treatment and prognosis. Using episodic impairment and medial temporal lobe atrophy as a tool to make this distinction has been debatable in the recent literature, as some patients with bvFTD can also have episodic memory impairment and medial temporal lobe atrophy early in the disease.

OBJECTIVES

To compare brain atrophy patterns of patients with bvFTD with and without episodic memory impairment to that of patients with AD.

METHODS

We analyzed 19 patients with bvFTD, 21 with AD and 21 controls, matched by age, sex, and years of education. They underwent brain MRI and the memory test from the Brief Cognitive Battery (BCB) to assess episodic memory. We then categorized the bvFTD group into amnestic (BCB delayed recall score <7) and non-amnestic.

RESULTS

The amnestic bvFTD group (n = 8) had significant gray matter atrophy in the left parahippocampal gyrus, right cingulate and precuneus regions compared with the nonamnestic group. Compared with AD, amnestic bvFTD had more atrophy in the left fusiform cortex, left insula, left inferior temporal gyrus and right temporal pole, whereas patients with AD had more atrophy in the left hippocampus, left frontal pole and left angular gyrus.

CONCLUSIONS

There is a group of amnestic bvFTD patients with episodic memory dysfunction and significant atrophy in medial temporal structures, which poses a challenge in considering only these features when differentiating bvFTD from AD clinically.

Accuracy of the Brief Cognitive Screening Battery for diagnosing Alzheimer's disease defined by cerebrospinal fluid biomarkers and AT(N) classification: a case-control study

BACKGROUND

Validation of cognitive instruments for detection of Alzheimer's disease (AD) based on correlation with diagnostic biomarkers allows more reliable identification of the disease.

OBJECTIVES

To investigate the accuracy of the Brief Cognitive Screening Battery (BCSB) in the differential diagnosis between AD, non-AD cognitive impairment (both defined by cerebrospinal fluid [CSF] biomarkers) and healthy cognition, and to correlate CSF biomarker results with cognitive performance.

METHODS

Overall, 117 individuals were evaluated: 45 patients with mild cognitive impairment (MCI) or mild dementia within the AD continuum defined by the AT(N) classification [A+T+/-(N)+/]; 27 non-AD patients with MCI or mild dementia [A-T+/-(N)+/-]; and 45 cognitively healthy individuals without CSF biomarker results. All participants underwent evaluation using the BCSB.

RESULTS

The total BCSB and delayed recall (DR) scores of the BCSB memory test showed high diagnostic accuracy, as indicated by areas under the ROC curve (AUC): 0.89 and 0.87, respectively, for discrimination between AD and non-AD versus cognitively healthy controls. Similarly, total BCSB and DR displayed high accuracy (AUC-ROC curves of 0.89 and 0.91, respectively) for differentiation between AD and controls. BCSB tests displayed low accuracy for differentiation between AD and non-AD. The CSF levels of biomarkers correlated significantly, though weakly, with DR.

CONCLUSIONS

Total BCSB and DR scores presented good accuracy for differentiation between patients with a biological AD diagnosis and cognitively healthy individuals, but low accuracy for differentiating AD from non-AD patients.

When My Child Has Alzheimer's Disease

The significant increment in life expectancy, associated to the existence of high-performing older adults, and the appropriate diagnosis of early dementias, lead to an uncommon scenario, of healthy parents accompanying their children with Alzheimer's disease or another dementia to medical consultations. Here, we reported three peculiar clinical vignettes of patients diagnosed with a dementia, who were accompanied by healthy parents. This is a modern situation that tends to become more frequent, and must be properly discussed, since multidisciplinary care and specific training are necessary.