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A Síndrome de Pisa (SP), ou pleurotótono, é caracterizada por flexão lateral do corpo e da cabeça (encurvamento lateral) e discreta rotação axial do tronco1. Trata-se de uma síndrome distônica causada por neurolépticos atípicos, anti-eméticos e antidepressivos e inibidores de acetilcolinesterase (IAchE)5. Relatamos um caso de SP em uma paciente de 72 anos após uso de inibidores de acetilcolinesterase. Conclusão: Trata-se de uma síndrome com múltiplas etiologias, o que deve fazer com que o clínico fique atento a esta condição. Nesse caso, o fato da interrupção do uso de IAchE levar a reversão da SP, sugere relação de causa e efeito. Mais estudos são necessários sobre esse assunto, pois o pleurotótono pode ter consequências importantes no equilíbrio e motricidade do idoso.

A Sindrome de Diogenes (SD) e um transtorno comportamental que afeta principalmente idosos, levando a comportamentos de autonegligencia extrema, isolamento social e acumulacao4. Relatamos um caso de uma paciente com diagnostico de demencia frontotemporal e Sindrome de Diogenes secundaria. Alem de trazer riscos a saude do paciente, a SD pode prejudicar as pessoas que convivem com o portador da sindrome. Entender que ela pode ser secundaria a algum transtorno psiquiatrico pode ajudar no diagnostico precoce do paciente, reduzindo a taxa de morbimortalidade.

A doença de Huntington (DH) é uma condição neurodegenerativa, com herança autossômica dominante. Embora seja dada mais ênfase na detecção dos sintomas cognitivos e motores, as manifestações psiquiátricas podem preceder os outros sintomas. O objetivo deste relato foi descrever o caso de um paciente com Doença de Huntington diagnosticado tardiamente devido aos sintomas psiquiátricos. Conclusão: geralmente, a DH é associada a anormalidades de motricidade, porém é comum que as manifestações psiquiátricas e cognitivas antecedam os distúrbios motores. Isso pode gerar confusão diagnóstica, dificultando a identificação precoce da doença. É importante que o teste genético seja pedido quando houver suspeita de DH.

Atualizacao das Diretrizes em Cardiogeriatria da Sociedade Brasileira de Cardiologia – 2019

Pacientes com Transtorno Bipolar (TB) costumam apresentar déficits cognitivos ao envelhecer. No entanto, a correlação com síndromes demenciais é inconclusiva, apesar da similaridade com a variante comportamental da demência frontotemporal (bvFTD). Nós relatamos uma paciente de 78 anos de idade com TB tipo 1 desde a adolescência. Seus sintomas variavam de apatia a mania psicótica. A paciente passou por 3 internações, sendo a última há 10 anos, seguida de estabilização clínica. No entanto, nos últimos 2 anos, ela apresentou sintomas diferentes, como irritabilidade expressada por agressões verbal e física, comprometimento cognitivo, padrão repetitivo de comportamento, perambulação, delírios persecutórios, desorientação e hiporexia. O tratamento com anticolinesterásicos ou estabilizadores de humor não revelou melhora. Apresentou 17/30 pontos no miniexame do estado mental, a avaliação neuropsicológica sugeriu déficit de função executiva, atenção e memória. Os exames de neuroimagem demonstraram atrofia e hipoperfusão fronto-temporal. Abordagens diagnósticas e terapêuticas para este tipo de paciente representam um desafio significativo para os clínicos. Patients with Bipolar Disorder (BD) usually display cognitive deficits with aging. However, the correlation between BD and dementia syndromes is inconclusive, despite the similarity with behavioral variant frontotemporal dementia. We report a 78-year-old female patient who had bipolar type 1 disorder since adolescence. Her symptoms ranged from apathy to psychotic mania. She had had three hospitalizations, and since her last stay 10 years ago, her symptoms had remained stable. However, in the past 2 years, she displayed different symptoms, such as irritability manifested as verbal and physical aggression, cognitive impairment, repetitive pattern of behavior, perambulation, persecutory delusions, disorientation, and hyporexia. Treatment with anticholinesterases or mood stabilizers promoted no improvement. She scored 17/30 points on the Mini-Mental State Examination. Neuropsychological assessment suggested deficits in executive function, attention, and memory. Neuroimaging tests revealed frontotemporal degeneration and hypoperfusion. Diagnostic and therapeutic approaches for this type of patient represent a significant challenge for clinicians.

Aim: Alzheimer’s disease affects several nervous structures involved with the autonomic nervous system. Therefore, the still scarce evaluation of the cardiac autonomic function in this disease is of great functional, clinical, prognostic and therapeutic relevance. Methods: Time- and frequency-domain variability of 5-min R-R interval series in supine and standing positions was comparatively evaluated in 22 Alzheimer’s disease subjects, aged 60–87 years (mean 1 standard error of the mean, 79.6 1 1.4) with variable cognitive impairment, and 24 healthy individuals, aged 60–91 years (68.6 1 1.6). The Student’s t-test was used to compare the variability indices between the groups and logistic regression excluded the effects on these indices in the Alzheimer’s group of confounding variables different from the control group (age, physical activity and caffeinated intake), at a significance level of P 2 0.05. Results: No difference was observed between the groups (P = 0.12–0.72) for each timedomain mean indices and for the frequency-domain indices of overall and absolute sympathetic modulation in both positions (P = 0.21–0.78). Absolute parasympathetic modulation showed borderline decrease in supine position (P = 0.07) and was reduced in the standing (P = 0.05). The sympathovagal balance was altered (P = 0.05) toward relative parasympathetic borderline depression (P = 0.07) and sympathetic exacerbation (P = 0.04) only in the supine posture. Conclusion: Data indicate that Alzheimer’s disease subjects with mild-to-severe cognitive dysfunction showed subtle, absolute and relative parasympathetic depression and relative sympathetic exacerbation, which may even so contribute to distinctive functional and cognitive disturbances.

Although nervous structures affected in Alzheimer’s disease are also implicated in autonomic nervous system function, the relationship between autonomic and cognitive functions was not still investigated. The cardiac autonomic modulation of 5-min heart interval variability evaluated by time- and frequency-domain indexes, in supine and standing positions, of 22 Alzheimer’s disease patients (90.9% women) aged 79.6 ± 1.4 years (mean ± SE) was correlated with mild to severe cognitive impairment scored by the CAMCOG and MMSE subset tests, by the Spearman’s correlation analysis. Age and level of education were not correlated with the heart interval variability indexes and the cognitive scores. Significantly positive (r s = 0.43–0.47, P = 0.03–0.04) or trend (r s = 0.36–0.40, P = 0.06–0.10) correlation was observed in both positions between the cognitive performance and pNN50%, rMSSD and absolute and normalised high-frequency power, considered to express parasympathetic modulation. Negative trend correlation (r s = −0.35 to −0.39, P = 0.07–0.10) was observed between absolute sympathetic modulation (low-frequency power and low-to-high frequency power ratio) in supine posture. The cognitive status and the cardiac sympathovagal modulation appear to be correlated and hypothetically may influence one another in mild to severe Alzheimer’s disease. Individuals with more severe cognitive deficiency showed suggestive lower cardiac parasympathetic modulation and trend for higher cardiac sympathetic modulation.

The treatments of choice in Alzheimer's disease (AD) are cholinesterase inhibitors and NMDA-receptor antagonists, although doubts remain about the therapeutic effectiveness of these drugs. Herbal medicine products have been used in the treatment of Behavioral and Psychological Symptoms of Dementia (BPSD) but with various responses. The objective of this article was to review evidences from controlled studies in order to determine whether herbs can be useful in the treatment of cognitive disorders in the elderly. Randomized controlled studies assessing AD in individuals older than 65 years were identified through searches of MEDLINE, LILACS, Cochrane Library, dissertation Abstract (USA), ADEAR (Alzheimer's Disease Clinical Trials Database), National Research Register, Current Controlled trials, Centerwatch Trials Database and PsychINFO Journal Articles. The search combined the terms Alzheimer disease, dementia, cognition disorders, Herbal, Phytotherapy. The crossover results were evaluated by the Jadad's measurement scale. The systematic review identified two herbs and herbal formulations with therapeutic effects for the treatment of AD:Melissa officinalis,Salvia officinalisand Yi-Gan San and BDW (Ba Wei Di Huang Wan).Ginkgo bilobawas identified in a meta-analysis study. All five herbs are useful for cognitive impairment of AD.M. officinalisand Yi-Gan San are also useful in agitation, for they have sedative effects. These herbs and formulations have demonstrated good therapeutic effectiveness but these results need to be compared with those of traditional drugs. Further large multicenter studies should be conducted in order to test the cost-effectiveness of these herbs for AD and the impact in the control of cognitive deterioration.