Level of knowledge and misconceptions about brain concussion in Brazilian adults

BACKGROUND

Brain concussion (BC) is seen as a public health priority due to its high incidence and morbidity rate, among thousands of people around the world. There are needs for fast identification, accurate diagnosis and correct management in order to reduce the short and long-term problems relating to BC. Proper knowledge of BC in the population and among clinicians is a critical factor in achieving this.

OBJECTIVES

To evaluate the level of self-reported BC knowledge and gaps/misconceptions, and to identify variables correlated with this level.

METHODS

A cross-sectional descriptive survey was performed. A Brain Concussion Knowledge Questionnaire (BCKQ) that had been created to capture data was widely distributed. Total scores, domain partial scores and percentages of correct and incorrect answers were calculated to ascertain the level of knowledge relating to BC.

RESULTS

The sample was formed by 1,247 Brazilian adults (age: 41.7±11.8 years). Partial scores of the BCKQ revealed the existence of poor knowledge and misconceptions in all domains of the questionnaire, especially regarding questions about recovery from and management of BC. Moderate correlations between BCKQ scores and professions (p=0.312; P=0.00) or previous brain concussion knowledge (p=0.489; P=0.00) were observed. In a multiple linear regression model, age, profession and sports practice were predictors of BC knowledge.

CONCLUSION

This first study to analyze the level of BC knowledge in a sample of Brazilian adults suggests that poor knowledge and misconceptions are present. Thus, meaningful and useful information was provided by this study for developing health education programs about BC for the population in order to improve fast diagnosis and correct BC management.

Use of a Questionnaire to Measure Concussion Knowledge in Brazilian adults

Objective

We aimed to evaluate the self-reported concussion knowledge of the general population, to observe and describe any gaps in the knowledge and misconceptions, and to identify the variables that influence the concussion knowledge.

Background

Concussion represents 80–90% of Traumatic Brain Injury (TBI) causes and its higher incidence is related to sports. The United States Centers for Disease Control estimates a TBI annual incidence ranging from 1.6 to 3.8 million cases, including concussions related to sport. Thus, it is seen as a public health priority. Adequate general population knowledge is a critical issue to correct diagnosis and management of concussion.

Design/Methods

We conducted a cross-sectional descriptive survey. A Concussion knowledge Questionnaire (CKQ) was created to capture data on concussion identification and causes, concussion consequences, recovery and management, and sport-related concussion The number of the sample correct and incorrect answers was calculated to measure the percent of concussion knowledge by CKQ domain.

Results

The sample was formed by 1247 Brazilian adults with a mean age of 41.7 (±11.8) years and high level of schooling. The total score in the CKQ was a mean of 20 (±10) points, which corresponds to a rate of 41.6% of correct answers. Thus, there is poor knowledge in all domains of the CKQ. Only 35.5% of correct answers were registered regarding the main symptoms of a concussion. Similarly, the higher number of incorrect answers was related to questions about recovery and management of a concussion.

Conclusions

Our study is the first to examine the concussion knowledge in a sample of Brazilian adults and provide useful information for development of concussion education programs. Our findings suggest very poor concussion knowledge in sample studied. More larger and meaningful research is needed to investigate the concussion knowledge and the variables that may interfere in the knowledge of the Brazilian general.

Chronic traumatic encephalopathy – a study in Brazilian retired soccer players

Objective

Evaluate the neurological, neuopsychological and electroencephalogram (EEG) findings in a cohort of retired soccer players.

Background

Chronic traumatic encephalopathy (CTE) is considered to be a consequence of exposure to repeated head traumas, but evidence suggests that a single moderate or severe traumatic brain injury can also induce progressive neuropathological changes.

Design/Methods

Prospective observational study that evaluated 26 retired soccer players and 14 controls. The retired athletes and controls were submitted to neurological evaluation, neuropsychological evaluation and EEG.

Results

In general, the soccer players performed well in tests, within the normal range. 15 soccer players had a history of previous TBI/concussion. In the retired group the average age was 60.4 years (55.7 in the CG), average of 11.7 schooling years (13.7 in the CG). The average results in MMSE was 26.6 (29 in the CG), the average digit span in backwards was 3.1 (3.8 in the CG), the average verbal fluency for animals was 15.6 (24 in the CG) and the average clock-drawing test was 8.96 (9 in the CG). Visual EEG analysis showed a predominance of posterior alpha activity between 9.0 and 12.0 Hz (mean 10.3 Hz) in the soccer participants and 11 Hz in the control group (CG). The analysis wiht low resolution electromagnetic tomography (LORETA) showed that 11 soccer players had hippocampal asymmetry (5 had less activity in the right hippocampus and 6 had less activity in the left hippocampus).

Conclusions

Although the performance of the athletes in the tests was within the normal range, the means were always inferior to those of the controls. Almost half of the players presented asymmetry in the analysis by LORETA, although visual EEG analysis was normal. This may indicate that EEG changes may be earlier and more sensitive than clinical changes. These data are preliminary and further analysis are needed.

Differential diagnosis between dementia and psychiatric disorders: Diagnostic criteria and supplementary exams. Recommendations of the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology

In 2005, the Scientific Department of Cognitive Neurology and Aging of the Brazilian Academy of Neurology published recommendations for the diagnosis of Alzheimer's disease These recommendations were updated following a review of evidence retrieved from national and international studies held on PUBMED, SCIELO and LILACS medical databases. The main aims of this review article are as follows:

1) to present the evidence found on Brazilian (LILACS, SCIELO) and International (MEDLINE) databases from articles published up to May 2011, on the differential diagnosis of these psychiatric disorders and dementia, with special focus on Dementia due to Alzheimer's and vascular dementia, including a review of supplementary exams which may facilitate the diagnostic process; and

2) to propose recommendations for use by clinicians and researchers involved in diagnosing patients with dementia.

Differential diagnosis between dementia and other neuropsychiatric disorders should always include assessments for depression, delirium, and use of psychoactive substances, as well as investigate the use of benzodiazepines, anti-epileptics and pattern of alcohol consumption.

Cognition and chronic hypoxia in pulmonary diseases

Lung disease with chronic hypoxia has been associated with cognitive impairment of the subcortical type.

Performance of a Brazilian population on the test of functional health literacy in adults

OBJECTIVE

To analyze the scoring obtained by an instrument, which evaluates the ability to read and understand items in the health care setting, according to education and age.

METHODS

The short version of the Test of Functional Health Literacy in Adults was administered to 312 healthy participants of different ages and years of schooling. The study was conducted between 2006 and 2007, in the city of São Paulo, Southeastern Brazil. The test includes actual materials such as pill bottles and appointment slips and measures reading comprehension, assessing the ability to read and correctly pronounce a list of words and understand both prose passages and numerical information. Pearson partial correlations and a multiple regression model were used to verify the association between its scores and education and age.

RESULTS

The mean age of the sample was 47.3 years(sd=16.8) and the mean education was 9.7 years(sd=5; range: 1 - 17). A total of 32.4% of the sample showed literacy/numeracy deficits, scoring in the inadequate and marginal functional health literacy ranges. Among the elderly (65 years or older) this rate increased to 51.6%. There was a positive correlation between schooling and scores (r=0.74; p<0.01) and a negative correlation between age and the scores (r=-0.259; p<0.01). The correlation between the scores and age was not significant when the effects of education were held constant (rp=-0.031, p=0.584). A significant association (B=3.877, Beta =0.733; p<0.001) was found between schooling and scores. Age was not a significant predictor in this model (B=-0.035, Beta=-0.22; p=0.584).

CONCLUSIONS

The short version of the Test of Functional Health Literacy in Adults was a suitable tool to assess health literacy in the study population. The high number of individuals classified as functional illiterates in this test highlights the importance of special assistance to help them properly understand directions for healthcare.

[Cross-cultural adaptation of the Disability Assessment for Dementia (DAD)]

The original version of the Disability Assessment for Dementia (DAD) was translated into Portuguese and back translated to English. The divergences of translation were identified and discussed, resulting in a version that was used in a preliminary investigation for cross-cultural adaptation. The final version was administered to 29 patients with mild to moderate probable Alzheimer's disease. The correlation coefficients of DAD were 0.929 and 0.932 for the inter-examiner and test-retest evaluations respectively. The reliability indexes were also high (Kappa 0.72 p<0.001 inter-examiners and 0.85 p<0.001 test-retest). The Brazilian version of DAD was easy to administer and had good reliability to assess the functional status of demented patients. It will contribute to the follow-up of these patients in our population. Moreover, it can be used in transcultural studies on functional abilities in dementia.

[Brazilian version of the Cornell depression scale in dementia]

OBJECTIVE

Translating and adapting the Cornell scale for depression in dementia to the Portuguese language and verifying the interrater and test-retest reliability of the translated and adapted version.

METHOD

The Cornell scale was translated into Portuguese and back translated into English. Divergences of translation were identified and discussed, resulting in a version which was submitted to a pre-test for cross-cultural adaptation. The final version was administered to a sample of 29 patients with probable AD and to their caregivers.

RESULTS

The Cornell Scale presented good interrater (Kappa=0,77; p<0,001) and test-retest reliability (Kappa=0,76; p<0,001). The final version was easy to administer and well understood by the caregivers.

CONCLUSION

The Brazilian version of the Cornell Scale is an instrument with good reliability to evaluate depression in patients with dementia. This tool will contribute to the evaluation and follow-up of depressed patients with dementia in our population and may also be used in multicentric studies with Brazilian population.

Influence of age, gender and educational level on performance in the Brief Cognitive Battery-Edu

The Brief Cognitive Battery-Edu (BCB-Edu) contains nine tests, seven of which are related to the memory of drawings, and has good accuracy in the diagnosis of cognitive impairment.

OBJECTIVES

To evaluate the influence of age, gender and educational level on the performance in tests related to memory of drawings of the BCB-Edu in healthy subjects.

METHODS

Participants were adult volunteers; exclusion criteria were illiteracy, neurologic or psychiatric disorders, visual or hearing impairment, untreated chronic clinical conditions, alcoholism, use of drugs, and for those aged 65 or over, an informant report of cognitive or functional impairment. We evaluated 325 individuals (207 women), with a mean age of 47.1 (±16.8) years, ranging from 19 to 81, and a mean of 9.8 (±5.0) schooling-years. Univariate analyses, correlations and logistic regression were employed (α=0.05).

RESULTS

There were significant negative correlations between age and the scores in four of the seven tests. However, schooling-years were positively correlated to the scores, where schooling-years decreased with age in this sample (rho= -0.323; p<0.001). Logistic regression confirmed that gender influenced the learning of drawings, where women performed better, while age influenced incidental memory, immediate memory, learning and delayed recall of the drawings, and schooling-years influenced visual identification, immediate memory, learning, delayed recall and recognition of the drawings.

CONCLUSION

Gender, age and education influence the performance on the memory of drawings of the BCB-Edu, although the extent of these influences differs according to the nature of the test.

Dementia Pugilistica with clinical features of Alzheimer's disease

A 61-year-old ex-boxer presented with a three-year history of progressive memory decline. During a seven-year follow-up period, there was a continuous cognitive decline, very similar to that usually observed in Alzheimer's disease. Parkinsonian, pyramidal or cerebellar signs were conspicuously absent. Neuropathological examination revealed the typical features of dementia pugilistica: cavum septi pellucidi with multiple fenestrations, numerous neurofibrillary tangles in the cerebral isocortex and hippocampus (and rare senile plaques). Immunohistochemistry disclosed a high number of tau protein deposits and scarce beta-amyloid staining. This case shows that dementia pugilistica may present with clinical features practically undistinguishable from Alzheimer's disease.

The syndrome of progressive posterior cortical dysfunction: A multiple case study and review

Dementia presenting with prominent higher order visual symptoms may be observed in a range of neurodegenerative conditions and is often challenging to diagnose.

OBJECTIVES

To describe cases of progressive dementia presenting with prominent visual cortical symptoms.

METHODS

We conducted a retrospective search of cases of progressive dementia with predominant visual symptoms, seen at our dementia unit from 1996 to 2006.

RESULTS

Twelve patients (5 men, 7 women) were identified, with ages ranging from 49 to 67 years. At the first examination, the duration of the symptoms ranged from one to ten years and the Mini-Mental State Examination scores from 7 to 27. Eleven patients presented with predominant visuospatial symptoms (partial or complete Balint syndrome) and one with visuoperceptive impairment. Other reported manifestations were: constructional apraxia in 11 patients, partial or complete Gerstmann syndrome in ten, ideomotor apraxia in nine, hemineglect or extinction in four patients, alien hand phenomenon in three, and prosopagnosia in one patient. Memory loss was reported by ten patients, but was not the main complaint in any of these cases. Insight was relatively preserved in five patients even after a long period following the onset of symptoms. Six patients developed parkinsonism during evolution. Clinical diagnoses were possible or probable AD in seven patients, cortico-basal degeneration in four, and dementia with Lewy body in one.

CONCLUSIONS

Clinicians should consider this condition especially in presenile patients with slowly progressive higher-order visual symptoms. Although described in association with different conditions, it may also occur in Alzheimer disease.

Asymmetric cortical high signal on diffusion weighted-MRI in a case of Creutzfeldt-Jakob disease

High signal in the cerebral cortex and/or basal ganglia on diffusion-weighted magnetic resonance imaging (DW-MRI) has been described as a good diagnostic marker for sporadic Creutzfeldt-Jakob disease (sCJD). We report a case of sCJD with atypical clinical evolution and unusual DW-MRI findings. A 53-year-old man was seen with a 2-year history of a rapidly progressive dementia and cerebellar ataxia. Cerebrospinal fluid analysis, including the test for 14-3-3 protein, was normal. EEG did not show periodic activity. However, DW-MRI showed gyriform hyperintensity involving practically the entire cortical ribbon of the left hemisphere, whilst being limited to the posterior cingulate gyrus in the right hemisphere. DNA analysis showed no mutations or insertions in the prion protein gene, and homozigozity for methionine in codon 129. A subsequent brain biopsy confirmed the diagnosis of CJD. Thus, high signal on DW-MRI may be limited to the cerebral cortex and may present a very asymmetric distribution in sCJD.