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Schizophrenia is a psychiatric illness in which disorders of thought content are a prominent feature. The disruption of normal flow of thought, or “Formal Thought Disorder” (FTD), has been traditionally assessed through the content and form of patients’ speech, and speech abnormalities in schizophrenia were considered as a by-product of the disruption in conceptual structures and associative processes related to psychosis. This view has been changed due to increasing evidence that language per se is impaired in schizophrenia, especially its semantic, discursive, and pragmatic aspects. Schizophrenia is currently considered by some authors as a “language related human specific disease” or “logopathy”, and the neuroanatomical and genetic correlates of the language impairment in these patients are under investigation. Such efforts may lead to a better understanding about the pathophysiology of this devastating mental disease. We present some current concepts related to FTD as opposed to primary neurolinguistic abnormalities in schizophrenia. A esquizofrenia é uma doença psiquiátrica na qual as alterações do conteúdo do pensamento são uma característica marcante. A ruptura do fluxo normal de pensamentos, ou “Alteração Formal do Pensamento” (AFP) é acessada através da forma e conteúdo da fala do paciente. Alterações de fala e linguagem em esquizofrênicos eram consideradas como consequentes à ruptura de seus sistemas conceituais e processos associativos relacionados à psicose. Esta visão alterou-se pelo aumento nas evidências de comprometimento primário da linguagem na esquizofrenia, especialmente em seus aspectos semânticos, discursivos e pragmáticos. A esquizofrenia é atualmente considerada por alguns autores como uma “doença humana específica relacionada à linguagem”, ou “logopatia”. Os correlatos neuroanatômicos e genéticos do prejuízo linguístico nestes pacientes estão sendo investigados. Estes esforços podem levar à maior compreensão da fisiopatologia desta grave doença mental. Nesta revisão, apresentamos conceitos atuais sobre AFP e sua diferenciação das anormalidades linguísticas primárias na esquizofrenia.

Alzheimer's disease (AD) is a chronic neurodegenerative disease with well-defined pathophysiological mechanisms, mostly affecting medial temporal lobe and associative neocortical structures. Neuritic plaques and neurofibrillary tangles represent the pathological hallmarks of AD, and are respectively related to the accumulation of the amyloid-beta peptide (Aβ) in brain tissues, and to cytoskeletal changes that arise from the hyperphosphorylation of microtubule-associated Tau protein in neurons. According to the amyloid hypothesis of AD, the overproduction of Aβ is a consequence of the disruption of homeostatic processes that regulate the proteolytic cleavage of the amyloid precursor protein (APP). Genetic, age-related and environmental factors contribute to a metabolic shift favoring the amyloidogenic processing of APP in detriment of the physiological, secretory pathway. Aβ peptides are generated by the successive cleavage of APP by beta-secretase (BACE-1) and gamma-secretase, which has been recently characterized as part of the presenilin complex. Among several beta-amyloid isoforms that bear subtle differences depending on the number of C-terminal amino acids, Aβ (1-42) plays a pivotal role in the pathogenesis of AD. The neurotoxic potential of the Aβ peptide results from its biochemical properties that favor aggregation into insoluble oligomers and protofibrils. These further originate fibrillary Aβ species that accumulate into senile and neuritic plaques. These processes, along with a reduction of Aβ clearance from the brain, leads to the extracellular accumulation of Aβ, and the subsequent activation of neurotoxic cascades that ultimately lead to cytoskeletal changes, neuronal dysfunction and cellular death. Intracerebral amyloidosis develops in AD patients in an age-dependent manner, but recent evidence indicate that it may be observed in some subjects as early as in the third or fourth decades of life, with increasing magnitude in late middle age, and highest estimates in old age. According to recent propositions, three clinical phases of Alzheimer's disease may be defined: (i) pre-symptomatic (or pre-clinical) AD, which may last for several years or decades until the overproduction and accumulation of Aβ in the brain reaches a critical level that triggers the amyloid cascade; (ii) pre-dementia phase of AD (compatible with the definition of progressive, amnestic mild cognitive impairment), in which early-stage pathology is present, ranging from mild neuronal dystrophy to early-stage Braak pathology, and may last for several years according to individual resilience and brain reserve; (iii) clinically defined dementia phase of AD, in which cognitive and functional impairment is severe enough to surmount the dementia threshold; at this stage there is significant accumulation of neuritic plaques and neurofibrillary tangles in affected brain areas, bearing relationship with the magnitude of global impairment. New technologies based on structural and functional neuroimaging, and on the biochemical analysis of cerebrospinal fluid may depict correlates of intracerebral amyloidosis in individuals with mild, pre-dementia symptoms. These methods are commonly referred to as AD-related biomarkers, and the combination of clinical and biological information yields good diagnostic accuracy to identify individuals at high risk of AD. In other words, the characterization of pathogenic Aβ by means of biochemical analysis of biological fluids or by molecular neuroimaging are presented as diagnostic tools to help identify AD cases at the earliest stages of the disease process. The relevance of this early diagnosis of AD relies on the hypothesis that pharmacological interventions with disease-modifying compounds are more likely to produce clinically relevant benefits if started early enough in the continuum towards dementia. Therapies targeting the modification of amyloid-related cascades may be viewed as promising strategies to attenuate or even to prevent dementia. Therefore, the cumulative knowledge on the pathogenesis of AD derived from basic science models will hopefully be translated into clinical practice in the forthcoming years.

Language alterations in Huntington's disease (HD) are reported, but their nature and correlation with other cognitive impairments are still under investigation. This study aimed to characterize the language disturbances in HD and to correlate them to motor and cognitive aspects of the disease. We studied 23 HD patients and 23 controls, matched for age and schooling, using the Boston Diagnostic Aphasia Examination, Boston Naming Test, the Token Test, Animal fluency, Action fluency, FAS-COWA, the Symbol Digit Modalities Test, the Stroop Test and the Hooper Visual Organization Test (HVOT). HD patients performed poorer in verbal fluency (p

Scientific Department of Cognitive Neurology and Aging of ABN had a consensus meeting to write recommendations on treatment of vascular dementia, there was no previous issue. This disease has numerous particularities and can be considered a preventable dementia. Prevention treatment is primary care of vascular risk factors or a secondary prevention of factors that could cause recurrence of ischemic or hemorrhagic brain modifications. In these guidelines we suggested only symptomatic treatment, pharmacologic or non-pharmacologic. We have reviewed current publications on MEDLINE (PubMed), LILACS e Cochrane Library databases. Recommendations are concern to the following factors and their prevention evidences, association, or treatment of vascular dementia: physical activity, tobacco use, diet and food supplements, arterial hypertension, diabetes mellitus, obesity, statins, cardiac failure, atrial fibrillation, antithrombotics, sleep apnea, carotid revascularization, symptomatic pharmacological treatment. Resumo O DC de Neurologia Cognitiva e do Envelhecimento da ABN reuniu-se para escrever recomendações para o tratamento da demência vascular, uma vez que não havia nenhuma recomendação neste sentido. Esta doença tem inúmeras particularidades e pode ser considerada uma das demências que pode ser prevenida. O tratamento para sua prevenção é o de cuidados primários para os fatores de risco vasculares, ou a prevenção secundária dos fatores que levam a recorrência de alterações isquêmicas ou hemorrágicas cerebrais. Nestas recomendações sugerimos apenas o tratamento sintomático, medicamentoso ou não. Baseamo-nos nas evidências disponíveis, através da revisão das publicações nas bases MEDLINE (PubMed), LILACS e Cochrane Library. As recomendações dizem respeito aos seguintes fatores e suas evidências na prevenção, associação ou tratamento da demência vascular: atividade física, álcool, tabagismo, dieta e suplementos, hipertensão arterial, diabetes mellitus, obesidade, estatinas, insuficiência cardíaca, fibrilação atrial, antiagregantes, apneia do sono, revascularização carotídea e tratamento farmacológico sintomático.

Aphasia can be defined as an acquired deficit in language processing due to dysfunction in specific areas of the brain. The classic aphasias (Broca's, Wernicke's and Global) are representative of impairment in the very epicenters of language areas, thus inducing signs and symptoms that affect all levels of linguistic processing: phonological, syntactical, lexical, and semantic. However, there is a group of aphasias in which the lesion site spares the classic language areas, thus inducing more subtle signs and symptoms, and leading to a combination of linguistic symptoms mixed with those arising from other cognitive functions also affected by the same lesion. That is the case with the so called “transcortical aphasias” and “conduction aphasia”. Transcortical aphasias are classified as motor, sensory, and mixed. In transcortical motor aphasia (TCMA), the medial and the dorsolateral frontal lobes are compromised, interrupting the connections between these two systems and language areas; TCMA patients have impairment performance on tasks demanding speech generation (diminished fluency, impairment in narrative, and in the production of grammatically complex sentences), and a reduction in the motivation to engage in communication. In transcortical sensory aphasia (TCSA) there is a disorder in semantic processing, manifesting as comprehension and naming impairment, which indicates a disconnection between posterior language areas and semantic memory. In mixed transcortical aphasia (MTA) there is a combination of signs and symptoms of both TCMA and TCSA in varying degrees. Conduction aphasia, in which the core symptom is repetition deficit, represents a primary failure of the phonological loop.

The role of subcortical structures in language processing is a topic of intense debate in the literature. Language alterations resulting from subcortical damage, such as the basal ganglia and thalamus do not produce classical aphasia syndromes as those encountered in cortical lesions. Basal ganglia lesions (caudate nucleus, putamen, globus pallidus) produce a complex and varied symptomatology regarding language manifestations, being the more consistent an alteration in lexical selection processes. More recent theories implicate the striatum in sequential and computational aspects of language processing, combinatorial rule applications and procedural learning (which are related to morphology and syntax), as well as stuttering. Thalamic aphasias present a more homogeneous pattern, where anomia and semantic paraphasias predominate, pointing to the role of the thalamus in mechanisms of cortical engagement and semantic verification. There has been increasing evidence of the participation of the cerebellum in language processing. Among the language deficits found after cerebellar lesions are delay in language acquisition, deficits in speech initiation, and mutism. Other previously reported language alterations include deficits in speech production, such as short responses, difficulties in initiating a conversation, long latencies for answers, and word finding difficulties.

Language is the “most human” of all cognitive abilities. Hence, understanding how our brains process language has intrigued neuroscientists since the first description of an aphasic patient by Paul Broca at the end of the eighteenth century. Much of our knowledge about language processing derives from the observation of signs and symptoms caused by brain injury, but normal language is also a topic of investigation among researchers, from Psycholinguistics to Computational Sciences. However, the exact nature of linguistic processing is yet to be fully understood. Oral language comprehension seems to be based on the auditory discrimination of word subunits, which vary depending on the language considered: stress units (English), syllables (French), mora (Japanese), and so on. These subunits must then be grouped and a selection mechanism has to discriminate among similar words to avoid ambiguities. Grammatical rules contribute to organize words (in their morphosyntactic aspects), and, finally, context and prosody give their contribution so that the listener is able to understand the content of discourse, as in a conversation. Language production relies on the phylogenetic development of a specific supra-laryngeal articulation mechanism under neocortical control, and also of a social competence now described as Theory of Mind (ToM). Language production starts with the mental generation of a message to be conveyed; this message has to be translated into grammatically encoded words. Grammatical encoding includes lemma selection, morphosyntactic composition, morphophonological and phonetic encoding, in a complex process at the end of which the message (words) is uttered by the speaker.

Cognitive functions are intermingled and are known to depend upon each other for optimal efficiency. Linguistic performance depends on a series of cognitive domains known as “language supportive functions”. Among these are included attention, working memory, executive functions and visuospatial abilities. Attention plays a major role in several steps of linguistic processing, ranging from lexical selection to the comprehension of complex material (such as sentences and texts) and also writing. The phonological loop (the verbal component of working memory), which accounts for the transient manipulation of verbal material, is critical for adequate syntactic comprehension and vocabulary acquisition. Working memory deficits can interfere with the ability to comprehend texts, as well as discourse and conversation. Executive dysfunction interferes with the subject's ability to access semantic and lexical representations. Executive functions are also involved in sentence and discourse production, as they are necessary for planning how to express an idea. Visuospatial perception abilities may interfere with naming tasks, when subjects are unable to name an object because they cannot recognize it. Finally, it has been demonstrated that aphasia itself may hinder the subject's performance in several cognitive tasks, such as color-picture matching, picture ordering, calculation and drawing from memory. Moreover, the interface between language and other cognitive functions becomes evident in neuropsychological testing, as most tests require input and reasoning for verbally presented material (starting with test instructions), and frequently the output must also be verbal (oral or written), even when non-language functions are being tested.

Functional neuroimaging methods allow the study of healthy subjects and patients while they perform selected tasks, in a relatively non-invasive manner. PET and fMRI studies have greatly contributed to our understanding of language processing in the past decades. Regarding language comprehension, studies indicate that the posterior region of the left superior temporal gyrus, or Wernicke's area, is divided into several functional subareas which are involved in phonemic perception, access to lexical representations, and retrieval of words from the semantic store; the inferior temporal cortex, the medial and lateral portions of the temporal lobe, the angular gyrus and frontal association cortex in the left hemisphere (LH) are related to semantic processing, while the left frontal inferior cortex is involved in syntactic tasks. Comprehension of discourse and texts depends on the left frontal lobe, although the macrostructural and connotational aspects of discourse interpretation demand right hemisphere (RH) activation. Other aspects of language processing that have been extensively studied using functional neuroimaging methods are bilingualism, the effects of literacy in the organization of neural networks, and the impact of speech therapy in the recovery of linguistic abilities in patients with cerebral lesions or degenerative diseases. However, one of the challenges faced by researchers in this field is how to create activation experiments that mimic the natural use of language in a more ecological way.

OBJECTIVE: To identify predictors of the progression from pre-dementia stages of cognitive impairment in Alzheimer's disease is relevant to clinical management and to substantiate the decision of prescribing antidementia drugs. METHOD: Longitudinal study of a cohort of elderly adults with amnestic mild cognitive impairment and healthy controls, carried out to estimate the risk and characterize predictors of the progression to Alzheimer's disease. RESULTS: Patients with amnestic mild cognitive impairment had a higher risk to develop Alzheimer's disease during follow-up (odds ratio = 4.5, CI95% [1.3-13.6], p = 0.010). At baseline, older age, lower scores on memory tests and presence of the APOE*4 allele predicted the progression from amnestic mild cognitive impairment to Alzheimer's disease. In a sub sample of amnestic mild cognitive impairment patients, those who progressed to Alzheimer's disease had lower cerebrospinal fluid concentrations of amyloid-beta peptide (Aβ42, p = 0.020) and higher concentrations of total TAU (p = 0.030) and phosphorylated TAU (p = 0.010), as compared to non-converters. DISCUSSION: This is the first Brazilian study to report cerebrospinal fluid biomarkers in the prediction of the conversion from MCI to Alzheimer's disease. Our data are in accordance with those reported in other settings. The measurement of cerebrospinal fluid total-TAU, phospho-TAU and Aβ42 may help identify patients with mild cognitive impairment at higher risk for developing Alzheimer's disease. OBJETIVO: A identificação de preditores da conversão para a doença de Alzheimer em pacientes com comprometimento cognitivo leve é relevante para o manejo clínico e para decidir sobre a prescrição de drogas antidemência. MÉTODO: Estudo longitudinal em coorte de indivíduos idosos com comprometimento cognitivo leve amnéstico e controles saudáveis; estimativa do risco da progressão para doença de Alzheimer nos dois grupos; determinação das variáveis preditivas desse desfecho. RESULTADOS: Pacientes com comprometimento cognitivo leve amnéstico apresentaram maior risco de desenvolver doença de Alzheimer ao longo do seguimento (odds ratio = 4,5, CI95% [1,3-13,6], p = 0,012). Na avaliação inicial, idade mais avançada, escores mais baixos nos testes cognitivos e do alelo APOE*4 foram preditores da conversão do comprometimento cognitivo leve amnéstico para doença de Alzheimer. Em uma subamostra de pacientes com comprometimento cognitivo leve amnéstico, aqueles que progrediram para doença de Alzheimer tinham concentrações liquóricas mais baixas do peptídeo beta-amilóide (Aβ42, p = 0,020) e mais altas da proteína TAU total (p = 0,030) e TAU fosforilada (p = 0,010) do que os pacientes que não progrediram para doença de Alzheimer. DISCUSSÃO: Este é o primeiro estudo brasileiro com biomarcadores liquóricos a relatar preditores da conversão comprometimento cognitivo leve-doença de Alzheimer. Nossos dados biológicos (aumento de TAU total e fosfo-TAU; redução de Aβ42), e podem auxiliar na identificação dos pacientes com comprometimento cognitivo leve com maior risco de evolução para demência.

Objective To identify the CAMCOG sub-items that best contribute for the identification of patients with mild cognitive impairment (MCI) and incipient Alzheimer's disease (AD) in clinical practice. Methods Cross-sectional assessment of 272 older adults (98 MCI, 82 AD, and 92 controls) with a standardized neuropsychological battery and the CAMCOG schedule. Backward logistic regression analysis with diagnosis (MCI and controls) as dependent variable and the sub-items of the CAMCOG as independent variable was carried out to determine the CAMCOG sub-items that predicted the diagnosis of MCI. Results Lower scores on Language, Memory, Praxis, and Calculation CAMCOG sub-items were significantly associated with the diagnosis of MCI. A composite score obtained by the sum of these scores significantly discriminated MCI patients from comparison groups. This reduced version of the CAMCOG showed similar diagnostic accuracy than the original schedule for the identification of patients with MCI as compared to controls (AUC = 0.80 ± 0.03 for the reduced CAMCOG; AUC = 0.79 ± 0.03 for the original CAMCOG). Conclusion This reduced version of the CAMCOG had similar diagnostic properties as the original CAMCOG and was faster and easier to administer, rendering it more suitable for the screening of subtle cognitive deficits in general clinical practice. Copyright © 2010 John Wiley & Sons, Ltd.

BACKGROUND: The theory of retrogenesis refers to changes in psychomotor abilities that occur in the reverse order in which they are acquired in normal psychomotor development. Such changes occur along the aging process and are also illustrated by the degenerative changes that occur in Alzheimer's disease (AD). OBJECTIVES: To review the concept of retrogenesis in aging and in AD and to discuss the articles published on the subject in the last ten years. METHODS: A search was conducted in the databases PubMed (MEDLINE), Lilacs, Cochrane and SciELO with the keywords "retrogenesis", "elderly" and "Alzheimer's disease". RESULTS: The literature search resulted in six articles, two of which recently published. We conducted a descriptive analysis of them. We observed that the study of retrogenesis in old age has been done primarily on the basis of AD, mainly through literature reviews and theoretical explorations. These works correlate events observed in AD with some physiological changes, following the opposite direction to the normal development of human beings. DISCUSSION: Based on available literature, we support the notion that functional retrogenesis model illustrate the changes that occur in patients with AD. This notion is supported by experimental models using diffusion tensor imaging and addressing white-matter changes that occur along the aging and the disease processes. CONTEXTO: A teoria da retrogênese refere-se às mudanças nas habilidades psicomotoras que ocorrem de forma inversa à aquisição do desenvolvimento motor normal. Tais mudanças ocorrem ao longo do processo de envelhecimento e também são ilustradas por mudanças degenerativas ocorridas na doença de Alzheimer (DA). OBJETIVOS: Revisar o conceito de retrogênese no envelhecimento e na DA e discutir os artigos publicados sobre o assunto nos últimos 10 anos. MÉTODOS: Foi realizada uma pesquisa nas bases de dados PubMed (MEDLINE), Lilacs, Cochrane e Sci SciELO com as palavras-chave "retrogenesis" (retrogênese), "elderly" (idoso) e "Alzheimer's disease" (doença de Alzheimer). RESULTADOS: A busca bibliográfica resultou em seis artigos, dois dos quais publicados nos primeiros meses de 2009, sendo realizadas análise descritiva e interpretação crítica deles. Foi possível observar que o estudo da retrogênese na velhice tem sido feito fundamentalmente com base na DA, principalmente por meio de revisões bibliográficas e explorações teóricas. Esses trabalhos correlacionam manifestações observadas na DA com determinadas alterações fisiológicas, seguindo o sentido oposto ao do desenvolvimento normal do ser humano. CONCLUSÃO: A partir da revisão realizada, destacou-se o modelo da retrogênese funcional que ilustra as alterações involutivas que ocorrem em pacientes acometidos em pacientes com DA. Modelos experimentais utilizando-se de técnicas de ressonância magnética com medidas de anisotropia, identificando alterações de substância branca, têm sido apresentados para testar as hipóteses teóricas da retrogênese.

OBJECTIVE: To describe the neuropsychological profile of mild cognitive impairment subtypes (amnestic, non-amnestic and multiple-domain) of a clinical sample. We further address the diagnostic properties of the Mini-Mental State Examination and the Cambridge Cognitive Examination for the identification of the different mild cognitive impairment subtypes in clinical practice. METHOD: Cross-sectional clinical and neuropsychological evaluation of 249 elderly patients attending a memory clinic at a university hospital in Sao Paulo, Brazil. RESULTS: The performance of patients with mild cognitive impairment was heterogeneous across the different subtests of the neuropsychological battery, with a trend towards an overall worse performance for amnestic (particularly multiple domain) mild cognitive impairment as compared to non-amnestic subtypes. Screening tests for dementia (Mini-Mental State Examination and Cambridge Cognitive Examination) adequately discriminated cases of mild Alzheimer's disease from controls, but they were not accurate to discriminate patients with mild cognitive impairment (all subtypes) from control subjects. CONCLUSIONS: The discrimination of mild cognitive impairment subtypes was possible only with the aid of a comprehensive neuropsychological assessment. It is necessary to develop new strategies for mild cognitive impairment screening in clinical practice. OBJETIVO: Descrever o perfil neuropsicológico dos subtipos de comprometimento cognitivo leve, amnéstico, não-amnéstico e múltiplos domínios, de uma amostra clínica. Além disto, avaliou-se as propriedades diagnósticas do Mini-exame do Estado Mental e do Cambridge Cognitive Examination na identificação dos diferentes subtipos de comprometimento cognitivo leve na prática clínica. MÉTODO: Avaliação clínica e neuropsicológica transversal de 249 idosos em uma clínica de memória de um hospital universitário em São Paulo, Brasil. RESULTADOS: Testes de rastreio para demência (Mini-exame do Estado Mental e Cambridge Cognitive Examination) identificam corretamente casos de doença de Alzheimer leve, mas não apresentam boa acurácia para diferenciar os diversos subtipos de comprometimento cognitivo leve. A performance dos sujeitos portadores de comprometimento cognitivo leve foi heterogênea nos diferentes testes da bateria neuropsicológica, com uma tendência a uma pior performance global nos pacientes com o subtipo amnéstico (especialmente os com envolvimento de múltiplos domínios cognitivos) em relação ao comprometimento cognitivo leve não-amnéstico. CONCLUSÕES: A discriminação dos diferentes subtipos de comprometimento cognitivo leve foi possível somente a partir de uma avaliação neuropsicológica detalhada. Desta maneira, é necessário o desenvolvimento de novas estratégias de rastreio para esta condição na prática clínica.

Background The CAMCOG is a brief neuropsychological battery designed to assess global cognitive function and ascertain the impairments that are required for the diagnosis of dementia. To date, the cut-off scores for mild cognitive impairment (MCI) have not been determined. Given the need for an earlier diagnosis of mild dementia, new cut-off values are also necessary, taking into account cultural and educational effects. Methods One hundred and fifty-seven older adults (mean age: 69.6 ± 7.4 years) with 8 or more years of formal education (mean years of schooling 14.2 ± 3.8) attending a memory clinic at the Institute of Psychiatry University of Sao Paulo were included. Subjects were divided into three groups according to their cognitive status, established through clinical and neuropsychological assessment: normal controls, n = 62; MCI, n = 65; and mild or moderate dementia, n = 30. ROC curve analyses were performed for dementia vs controls, MCI vs controls and MCI vs dementia. Results The cut-off values were: 92/93 for dementia vs controls (AUC = 0.99: sensitivity: 100%, specificity: 95%); 95/96 for MCI vs controls (AUC = 0.83, sensitivity: 64%, specificity: 88%), and 85/86 for MCI vs dementia (AUC = 0.91, sensitivity: 81%, specificity: 88%). The total CAMCOG score was more accurate than its subtests Mini-mental State Examination, Verbal Fluency Test and Clock Drawing Test when used separately. Conclusions The CAMCOG discriminated controls and MCI from demented patients, but was less accurate to discriminate MCI from controls. The best cut-off value to differentiate controls and demented was higher than suggested in the original publication, probably because only cases of mild to moderate dementia were included. This is important given the need for a diagnostic at earlier stages of Alzheimer's disease. Copyright © 2008 John Wiley & Sons, Ltd.

Parkinson's disease (PD) patients with dementia have impairment of syntactic comprehension. Non-demented PD patients also experience difficulties in sentence comprehension and can be particularly impaired in the processing of grammatical characteristics of syntactically complex sentences. Objective: The aim of this study was to verify the performance of PD patients without dementia in a syntactic comprehension task compared with normal elderly. Methods: We studied oral sentence comprehension in fourteen patients with idiopathic PD together with fourteen controls matched for age and education, using the Token Test and Schmitt's Syntactic Comprehension Test (developed in Brazilian Portuguese). Results: For the Token Test, there was no statistically significant difference between the PD group and the control group, whereas on the Syntactic Comprehension Test there was a slight statistically significant difference between the groups only for relatives in subject clauses (p=0.0407). Conclusions: PD patients differed from controls in the oral comprehension for relatives subject sentences alone. These results did not strictly reproduce those previously reported in the literature, and therefore point to the need for creating tests with diverse syntactic constructions in Portuguese able to produce consistent data regarding language behavior of Brazilian subjects with PD in comprehension tasks. Resumo Pacientes com doença de Parkinson (DP) e demência apresentam prejuízo da compreensão sintática. Pacientes com DP sem demência também apresentam dificuldades na compreensão de sentenças e podem estar particularmente comprometidos na habilidade de processar as características gramaticais de sentenças sintaticamente complexas. Objetivo: O objetivo deste estudo foi verificar o desempenho de pacientes com DP sem demência em tarefas de compreensão sintática, comparados a idosos normais. Métodos: Foram estudados quatorze pacientes com DP idiopática e quatorze controles emparelhados por idade e escolaridade, usando o Teste Token e o Teste de Compreensão Sintática de Schmitt (desenvolvido em português do Brasil). Resultados: No Teste Token, não houve diferenças estatisticamente significantes entre os pacientes com DP e o grupo controle. No Teste de Compreensão Sintática, foi encontrada diferença estatisticamente significante entre os grupos apenas nas sentenças relativas de sujeito (p=0.0407). Conclusão: Os pacientes com DP diferenciam-se do grupo controle apenas na compreensão oral de sentenças relativas de sujeito. Tendo em vista estes resultados, que não reproduzem de forma estrita o que é descrito na literatura, torna-se evidente a necessidade da criação de testes de linguagem com diferentes construções sintáticas em português do Brasil, a fim de obtermos dados consistentes a respeito do comportamento de pacientes brasileiros com DP em tarefas de compreensão sintática.

O termo comprometimento cognitivo leve (CCL) designa um quadro clínico em que ocorre declínio em um ou mais domínios cognitivos, o que pode levar a um relativo prejuízo da capacidade de realização de atividades mais complexas (por exemplo, atividades no campo profissional), sem que o indivíduo preencha critérios diagnósticos para demência. O CCL pode ter diversas etiologias, incluindo doenças clínicas mal controladas, polimedicação, depressão, etc; no entanto, em muitos casos corresponde a um estágio ainda incipiente de alguma forma de demência, como a doença de Alzheimer ou demência vascular. Indivíduos com CCL podem apresentar melhora do quadro, estabilização, ou progressão para demência, de acordo com a causa subjacente. O diagnóstico de CCL é baseado em critérios clínicos, e os exames subsidiários tem por objetivo identificar causas tratáveis e tentar identificar os indivíduos com maior risco de conversão para demência. O tratamento é orientado para a doença subjacente ao quadro, quando esta pode ser identificada. Reabilitação cognitiva pode apresentar resultados favoráveis no tratamento de déficits específicos, como os de atenção e memória.

Background: Diagnosis of mild cognitive impairment (MCI) and its subtypes requires a detailed diagnostic assessment and so may be missed at routine primary-care appointments, since the ordinary dementia screening tests lack sensitivity owing to ceiling effects, especially in highly educated subjects.Methods: The study was undertaken using a cross-sectional assessment of 112 elderly subjects (mean age 67.96 ± 5.77 years, and mean education level of 12.8 ± 5.7 years) with a semi-structured interview and a neuropsychological battery.Results: MCI patients did not differ from controls on total MMSE scores (p = 0.212). Nevertheless, MCI patients showed worse performance than controls on the verbal memory task (p = 0.012), and “drawing a pentagon” (p = 0.03). Amnestic MCI patients performed worse only on the “three-word recall” task (p = 0.013); non-amnestic MCI patients performed worse on the “three-stage command” task (p = 0.001); and multiple-domain MCI patients performed worse on the “drawing a pentagon” task (p = 0.001) and had a trend toward performing poorly on the ‘three word recall’ task (p = 0.06).Conclusion: The analysis of MMSE subtest scores, in addition to MMSE total scores, may increase the sensitivity of the MMSE test in screening for MCI and its subtypes.

Diagnosis of dementia is a challenge in populations with heterogeneous educational background. OBJECTIVE: To compare the accuracies of two delayed recall tests for the diagnosis of dementia in a community with high proportion of illiterates. METHOD: The delayed recall of a word list from the CERAD battery (DR-CERAD) was compared with the delayed recall of objects presented as line drawings from the Brief Cognitive Screening Battery (DR-BCSB) using ROC curves. Illiterate (23 controls and 17 patients with dementia) and literate individuals (28 controls and 17 patients with dementia) were evaluated in a community-dwelling Brazilian population. RESULTS: The DR-BCSB showed higher accuracy than the DR-CERAD in the illiterate (p=0.029), similar accuracy in the literate individuals (p=0.527), and a trend for higher accuracy in the entire population (p=0.084). CONCLUSION: the DR-BCSB could be an alternative for the diagnosis of dementia in populations with high proportion of illiterates. O diagnóstico de demência é um desafio em populações com heterogeneidade educacional. OBJETIVO: Comparar as acurácias de dois testes de recordação tardia no diagnóstico de demência em comunidade com alta prevalência de analfabetos. MÉTODO: O teste de recordação tardia de lista de palavras da bateria CERAD (RT-CERAD) foi comparado com o de recordação tardia de figuras simples da bateria de testes neuropsicológicos breves (RT-BTNB), utilizando-se curvas ROC. Indivíduos analfabetos (23 controles e 17 pacientes com demência) e alfabetizados (28 controles e 17 pacientes com demência) foram avaliados em uma comunidade brasileira. RESULTADOS: O RT-BTNB demonstrou maior acurácia que a RT-CERAD entre os analfabetos (p=0,029), acurácia similar nos indivíduos alfabetizados (p=0,527), e tendência a maior acurácia na população inteira (p=0,084). CONCLUSÃO: A RT-BTNB pode ser uma alternativa para o diagnóstico de demência em populações com alta prevalência de analfabetos.

TEMA: O teste de nomeação Boston é amplamente utilizado para avaliação de alterações de nomeação. Os escores usados no Brasil têm sido os mesmos da versão americana. No caso de indivíduos pouco escolarizados com lesões cerebrais, situação freqüente em nosso país, corre-se o risco de considerar déficit o que na realidade é desconhecimento e privação cultural. OBJETIVO: avaliar a influência da idade e escolaridade na habilidade de nomeação de amostra de indivíduos normais, da cidade de São Paulo, em uma tarefa de confrontação visual. MÉTODO: 133 voluntários normais, com idades entre 28 e 70 anos. RESULTADOS: os escores em nomeação espontânea foram [média (DP)]: [39,4 (9,8)]; por idade: 28 - 50 anos [39,5 (10,5)], 51 - 70 [39,1 (9,1)]; por escolaridade: 1 - 4 anos [33,7 (9,6)], 5 - 8 anos [36,6 (7,9)], 9 ou mais [47,4 (6)]. A comparação de desempenho entre os dois grupos de idade, não revelou diferenças significantes. Já o nível educacional mais alto determinou melhor performance tanto para a nomeação espontânea quanto para as facilitações. Pistas do estímulo precisaram ser ativadas para que o sujeito recordasse o nome correto, especialmente no grupo com menor escolaridade. Pistas fonêmicas beneficiaram os indivíduos com mais de oito anos de instrução formal. A nota de corte sugerida para uso no Brasil, foi calculada pela análise da curva ROC e baseada na comparação entre sujeitos normais e afásicos. CONCLUSÃO: A escolaridade foi a variável que mais influenciou o desempenho. Embora o grau de dificuldade de alguns itens possa em certa medida, diferir na língua inglesa e portuguesa, a aplicação da versão traduzida do TNB sem adaptações, para a população brasileira, é possível, desde que o nível educacional seja levado em conta na interpretação dos resultados. BACKGROUND: The Boston Naming Test is frequently used to evaluate naming deficits. The scores usedin Brazil have been the same as those used in the American version. In the case of individuals with poorschooling associated to cerebral lesions, a frequent situation in our country, one runs the risk ofconsidering a poor performance as a deficit, what in fact is a consequence of lack of knowledge andcultural deprivation. AIM: to evaluate the influence of age and schooling in the naming ability ofnormal individuals, from São Paulo city, in a visual confrontation task. METHOD: 133 normal volunteers,aged between 28 and 70 years. RESULTS: the scores obtained in spontaneous naming were [mean (SD)]:[39.4 (9.8)]; per age group: 28 - 50 years [39.5 (10.5)], 51 - 70 years [39.1 (9.1)]; per schooling: 1 -4 years [33.7 (9.6)], 5 - 8 years [36.6 (7.9)], 9 or more [47.4 (6)]. The comparison between theperformances of the two age groups did not reveal any significant differences. Higher educational leveldetermined a better performance both in spontaneous and facilitated naming. Cues of stimuli werenecessary for the individuals to access the correct name, especially for the group with lower educationallevel. Phonemic cues, on the other hand, benefited individuals with more than eight years of formaleducation. The suggested cut-off score for the test to be use in Brazil was calculated by the ROC curveanalysis and based on the comparison between normal and aphasic individuals. CONCLUSION: schoolingwas the variable that had the greatest influence on performance. Although the level of difficulty of afew items may, to some extent, differ between English and Portuguese, the translated version of theBNT can be used without any adaptations for the Brazilian population, provided that the level ofeducation is taken in consideration when interpreting the results.

We analyzed the performance of 162 normal subjects, subdivided into groups according to age and schooling, in the oral comprehension tasks of the Boston Diagnostic Aphasia Examination translated and adapted to Brazilian Portuguese to obtain a profile of performance for the Brazilian population, as well as cut-off scores for each task, and to determine the best combination of tasks that distinguish normal from aphasic subjects, as a guide for clinicians. The normal subjects were compared to 69 aphasics. Age alone influenced the performance in the designation of actions (subjects above 70 years showing the worst performance); schooling alone influenced the comprehension of forms, colors and numbers (subjects with less than four years of education showing a poorer performance). Both age and schooling influenced the performance in Body Part Identification (BPI) and Complex Ideational Material (CIM) with mean values of 70.5 +/- 3.3 (Word Discrimination, WD), 18.9 +/- 1.4 (BPI), 14.7 +/- 0.9 (Commands), and 10.3 +/- 1.7 (CIM) for the whole sample; the cut-off scores obtained were 65 (WD), 17.5 (BPI), 14 (Commands), and 9.5 (CIM) for the whole sample. Logistic regression showed that the combination of BPI + Commands + CIM was the most efficient in differentiating normal subjects from aphasics, with 72.5% sensitivity and 97.6% specificity. However, for low-education subjects, BPI and Commands were sufficient for this differentiation (75.7% sensitivity and 84.7% specificity). The main contribution of this study was to provide reference values that are far more representative of our population to be used by health professionals in Brazil, taking into account cultural differences.

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%).

Brazilian researchers and health professionals often face the challenge of having to use tests developed in foreign languages and standardized for populations of other countries, especially in the fields of Neuropsychology and Neurolinguistics. This fact promotes a feeling that some scoring systems may be inadequate for our sociocultural reality. In the present study, we describe the performance of a Brazilian population sample submitted to a translated and adapted version of the Boston Diagnostic Aphasia Examination (BDAE). Sixty normal volunteers (21 men and 39 women), all Portuguese native speakers, ranging in age from 15 to 78 years (average 43.7) and with an educational level of 2 to 16 years (average 9.9), were tested using a translated and adapted Portuguese version of the BDAE. Cut-off scores are suggested for our population and the performance of the Brazilian sample is compared to that of American and Colombian samples, with the results being closely similar in all tasks. We also performed a correlation analysis between age, gender and educational level and the influence of these variables on the performance of the subjects. We found no statistically significant differences between genders. Educational level correlated positively with performance, especially in the subtests involving reading and writing. There was a negative correlation between age and performance in two subtests (Visual Confrontation Naming and Sentences to Dictation), but a coexisting effect of educational level could not be ruled out.

CONTEXT: Aphasia is a very disabling condition caused by neurological diseases. In Brazil, we have little data on the profile of aphasics treated in rehabilitation centers. OBJECTIVE: To present a descriptive study of 192 patients, providing a reference sample of speech and language disturbances among Brazilians. DESIGN: Retrospective study. SETTING: Speech Pathology Unit linked to the Neurology Division of the Hospital das Clínicas of the Faculdade de Medicina da Universidade de São Paulo. SAMPLE: All patients (192) referred to our Speech Pathology service from 1995 to 2000. PROCEDURES: We collected data relating to demographic variables, etiology, language evaluation (functional evaluation, Boston Diagnostic Aphasia Examination, Boston Naming and Token Test), and neuroimaging studies. MAIN MEASUREMENTS: The results obtained in language tests and the clinical and neuroimaging data were organized and classified. Seventy aphasics were chosen for constructing a profile. Fourteen subjects with left single-lobe dysfunction were analyzed in detail. Seventeen aphasics were compared with 17 normal subjects, all performing the Token Test. RESULTS: One hundred subjects (52%) were men and 92 (48%) women. Their education varied from 0 to 16 years (average: 6.5; standard deviation: 4.53). We identified the lesion sites in 104 patients: 89% in the left hemisphere and 58% due to stroke. The incidence of aphasia was 70%; dysarthria and apraxia, 6%; functional alterations in communication, 17%; and 7% were normal. Statistically significant differences appeared when comparing the subgroup to controls in the Token Test. CONCLUSIONS: We believe that this sample contributes to a better understanding of neurological patients with speech and language disturbances and may be useful as a reference for health professionals involved in the rehabilitation of such disorders. CONTEXTO: Afasia é uma seqüela muito incapacitante, causada por doenças neurológicas. No Brasil existem poucos dados sobre o perfil dos afásicos atendidos em centros de reabilitação. OBJETIVO: Apresentar um estudo descritivo de 192 pacientes, fornecendo amostra de referência de problemas de fala e linguagem em brasileiros. TIPO DE ESTUDO: Retrospectivo. LOCAL: Ambulatório de Fonoaudiologia da Clínica Neurológica do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. PARTICIPANTES: Todos os pacientes (192) consultados em nosso serviço de Fonoaudiologia entre 1995 e 2000. PROCEDIMENTO: Coletamos dados referentes às variáveis demográficas, etiologia, avaliação de linguagem (funcional, Testes Boston para Diagnóstico de Afasia, Nomeação de Boston e Token), e estudos de neuroimagem. VARIÁVEIS ESTUDADAS: Resultados obtidos nos testes de linguagem, dados clínicos e de neuroimagem foram organizados e classificados. Setenta afásicos foram escolhidos para compor um perfil. Quatorze sujeitos com lesão de um único lobo foram analisados detalhadamente. Dezessete afásicos foram comparados com 17 controles na execução do Teste Token. RESULTADOS: 100 sujeitos (52%) eram homens e 92 (48%), mulheres. O grau de escolaridade variou de 0 até 16 anos (média: 6,5; desvio-padrão: 4,53). Os locais de lesão foram identificados em 104 pacientes, 89% em hemisfério esquerdo, 58% devidos a doença cerebrovascular. A incidência de afasia foi de 70%; disartria e apraxia, 6%; alterações funcionais de comunicação, 17%; 7% eram normais. No subgrupo comparado a controles no Teste Token, houve diferenças estatisticamente significantes. CONCLUSÕES: Acreditamos que esta amostra contribua para uma melhor compreensão de pacientes neurológicos com alterações de fala e linguagem e pode ser útil como referência para profissionais de saúde envolvidos na reabilitação de tais desordens.

O vasoespasmo cerebral é responsável por aumento de morbidade e mortalidade em pacientes acometidos por hemorragia subaracnóide (HSA). Sua detecção de forma precoce e não-invasiva pelo método de Doppler transcraniano (DTC) pode contribuir para um melhor prognóstico destes doentes. OBJETIVO: Discutir o uso do método de DTC para diagnóstico do vasoespasmo cerebral secundário à HSA espontânea. MÉTODOS: Foram analisados os registros de velocidade de fluxo em artérias intracranianas por DTC em 31 pacientes com diagnóstico tomográfico de HSA, realizados seqüencialmente em conjunto com exame neurológico. Todos os pacientes (à exceção de um) eram portadores de aneurismas intracranianos. RESULTADOS: Vasoespasmo clínico foi constatado em 11 pacientes (36,6% do total), com correspondente vasoespasmo ultra-sonográfico presente em nove casos (82%). Em três casos (33,3%) as alterações de velocidade de fluxo precederam os sinais clínicos. Entre os 20 pacientes assintomáticos, 15 (75%) apresentaram medidas de velocidade normais, havendo evidência de vasoespasmo sonográfico sem repercussão clínica em cinco (25%). O índice de falso negativo na correlação entre exame clínico e DTC (sinais clínicos de vasoespasmo presentes, com velocidades de fluxo normais) foi de 18%. No entanto, houve correspondência entre os achados clínicos e ultra-sonográficos em 26 dos 31 pacientes (83,8%). Os valores de velocidades médias nas várias artérias e sua interpretação para cada subgrupo são discutidos com maiores detalhes. CONCLUSÃO: O método de DTC é um auxiliar valioso na detecção pré-sintomática do vasoespasmo secundário à HSA, permitindo uma intervenção terapêutica mais precoce. Os dados obtidos neste trabalho coadunam-se com os diversos estudos publicados na literatura. Cerebral vasospasm accounts for an increased morbidity and mortality in patients with spontaneous subarachnoid hemorhage (SAH). Its early and non invasive detection by transcranial Doppler (TCD) may contribute to a better prognosis in such cases. PURPOSE: To discuss the use of transcranial Doppler (TCD) in the detection of cerebral vasospasm secondary cerebral to spontaneous subarachnoid hemorrhage (SAH). METHODS: We analyzed the flow velocities registered by TCD in intracranial arteries in 31 patients with SAH, performed sequentially, associated with neurological examinations. All patients (except one) had intracranial aneurysms. RESULTS: Clinical vasospasm was found in 11 patients (36,6% from the total), with correspondent sonographic vasospasm present in 9 cases (82%). In 3 cases (33.3%) the flow velocity alterations preceded the clinical symptoms. Between the 20 asymptomatic patients, 15 (75%) had normal flow velocity, with evidence of sonographic vasospasm without clinical repercussion in 5 (25%). The index of false negatives in the correlation between clinical examination and TCD (symptomatic vasospasm with normal flow velocity records) was 18%. However, there was correspondence between clinical and ultrasonographic findings in 26 of the 31 patients (83.8%). The average flow velocity values in the various arteries and its interpretation for each subgroup are discussed with further details. CONCLUSION: TCD is a valuable auxiliary method in the detection of cerebral vasospasm (even pre-symptomatic) secondary to SAH, allowing a more precocious therapeutic intervention. Our results are similar to those described in the literature.

Interest in the function of subcortical structures in cognitive function has grown in the last decades. Such interest has increased after the advent of modern innovations in radiology techniques, which provide a better visualization of subcortical lesions, like computerized tomography (CT) and magnetic resonance imaging (MRI) […] DISTURBANCES OF SPEECH AND LANGUAGE IN SUBCORTICAL LESIONS (ABSTRACT).

The assessment of blood flow velocities in basal arteries through transcranial Doppler (TCD) has appeared as an extremely valuable method in the management of therapeutic measures applied to patients with subarachnoid hemorrhage, before and after surgery […] USE OF TRANSCRANIAL DOPPLER IN MONITORATION OF CEREBRAL VASOSPASM SECONDARY TO SUBARACHNOID HEMORRHAGE (ABSTRACT)