INTRODUCTION Alzheimer disease is related to several risk factors including aging, family history, high blood pressure and diabetes. Studies have shown specific regional cerebral perfusion changes in patients with Alzheimer disease. Some authors state that these changes could appear years before patient memory becomes impaired, enabling early diagnosis in high-risk persons who appear to be healthy.
OBJECTIVE Determine the usefulness of cerebral perfusion studies in Alzheimer patients and first-degree relatives for obtaining additional diagnostic information and detecting functional changes that may suggest elevated disease risk.
METHODS This study involved 128 persons (87 clinically diagnosed with Alzheimer disease and 41 of their first-degree relatives with normal cognition), all from Artemisa Province, Cuba. We performed clinical, laboratory, neuropsychological and genetic (apolipoprotein E—ApoE, e4 allele) tests, as well as cerebral perfusion studies using single photon emission computed tomography after administering 740–925 MBq of 99m Tc-ECD, following internationally standardized protocols.
RESULTS In the Alzheimer disease group, the cerebral single photon emission computed tomography showed a typical Alzheimer pattern (bilateral posterior temporal-parietal hypoperfusion) in 77% (67/87) of participants; 35.9% (28/67) in stage 1; 51.3% (40/67) in stage 2; and 12.8% (10/67) in stage 3 of the disease. In this group, 12.7% (11/87) had mild or unilateral cerebral perfusion changes; 5.7% (5/87) vascular dementia; 3.4% (3/87) frontal dementia; and 1.2% (1/87) normal cerebral perfusion. Of the patients, 28.7% (25/87) received a different classification of stage and disease diagnosis after cerebral perfusion results were considered. In the relative group, 14.6% (6/41) had cerebral perfusion abnormalities. Among these, 7.1% (3/41) were mild bilateral temporal–parietal hypoperfusion; 4.8% (2/41) mild unilateral temporal–parietal hypoperfusion; and 2.4% (1/41) had perfusion defecits in their right frontal lobes. Of patients with typical Alzheimer disease patterns in the cerebral single photon emission computed tomography, 76.6% (52/67) had positive ApoE e4. All relatives with perfusion abnormalities (6/6) had positive ApoE e4.
CONCLUSIONS Cerebral perfusion studies confirmed the Alzheimer disease diagnosis, classified disease stages, and differentiated between the types of dementia. The test showed perfusion changes in several asymptomatic first-degree relatives with positive ApoE e4, which could be predictors of disease. The technique was useful for evaluating patients and their relatives.
KEYWORDS Cerebrovascular circulation; tomography, emission-computed, single-photon; Alzheimer disease; Alzheimer’s disease; Cuba
INTRODUCTION Age-related cognitive disorders, including Alzheimer disease, are among the main causes of disability and dependence in older adults worldwide. High blood homocysteine levels (hyperhomocysteinemia) are a risk factor for diseases whose metabolism involves different B vitamins. Antioxidant vitamins provide a protective effect by mitigating oxidative stress generated by these diseases. Epidemiological studies have presented varying results on the relationships between blood levels of these vitamins and such cognitive disorders.
OBJECTIVE Evaluate the association of vitamin and homocysteine levels with mild cognitive impairment and Alzheimer disease in a group of Cuban older adults.
METHODS A cross-sectional study was conducted in Havana, Cuba, of 424 persons aged ≥65 years: 43 with Alzheimer disease, 131 with mild cognitive impairment, and 250 with no signs of cognitive impairment. Dementia was diagnosed using criteria of the International 10/66 Dementia Research Group and Diagnostic and Statistical Manual of Mental Disorders (DSM IV), and mild cognitive impairment was diagnosed using Petersen’s criteria. Blood levels of vitamins (thiamine, B-2, folate, B-12, C and A) and homocysteine were measured by standard procedures. Analysis of variance for continuous variables and percentage comparison tests for dichotomous variables were used to compare groups.
RESULTS Persons with Alzheimer disease presented significantly lower levels of vitamins B-2, C and A than healthy participants (p <0.05). Homocysteine levels were significantly higher in those with Alzheimer disease and mild cognitive impairment than in participants with no cognitive impairment (p <0.05). Statistically, levels of thiamine, folic acid, and vitamin B-12 were not significantly different across groups. Compared with those without cognitive impairment, prevalence rates (PR) in the Alzheimer group were significantly higher for hyperhomocysteinemia (PR = 3.26; 1.84–5.80) and deficiency of all B vitamins: thiamine (PR = 1.89; 1.04–3.43), B-2 (PR = 2.85; 1.54–5.26), folate (PR = 3.02; 1.53–5.95), B-12 (PR = 2.21; 1.17–4.19), vitamin C (PR = 3.88; 2.12–7.10) and A (PR = 5.47; 3.26–9.17). In mild cognitive impairment, prevalence rates were significantly higher for hyperhomocysteinemia (PR = 1.42; 1.08–1.87), vitamin B-2 deficiency (PR = 1.70; 1.24–2.32) and vitamin A deficiency (PR =1.88; 1.05–3.38).
CONCLUSIONS Hyperhomocysteinemia and various vitamin deficiencies are related to Alzheimer disease and mild cognitive impairment. Longitudinal studies are needed to further elucidate the relationship between different nutritional biomarkers and dementia. A better understanding of this relationship could provide a basis for therapeutic and preventive strategies.
KEYWORDS Vitamins, homocysteine, geriatrics, Alzheimer disease, cognitive impairment, Cuba
INTRODUCTION Alzheimer disease is the main cause of dementia associated with aging in Cuba and the world. Development of methods for early diagnosis is vital to increasing intervention effectiveness and improving patient quality of life. Recent studies have shown associations between alterations in serum levels of antineuronal antibodies and Alzheimer disease pathology. However, the specific relationship between such antineuronal antibodies and Alzheimer pathogenesis remains unclear because of the great variety of antibodies identified and their heterogeneity among patients and nondemented controls.
OBJECTIVE Assess the association between serum levels of antibodies against neuronal antigens (total brain protein, aldolase and amyloid beta protein) and cognitive performance in older Cuban adults.
METHODS A cross-sectional pilot study was conducted of adults aged ≥65 years living in Havana’s Playa Municipality and Artemisa Province (southwest of Havana). A sociodemographic and risk factor questionnaire was administered, neuropsychological assessment conducted, and physical and neurological examinations performed. A relative or caregiver was also interviewed. Laboratory tests included: complete blood count, glycemia, lipid panel, and apolipoprotein E genotype. Of 143 individuals studied, 33 were cognitively normal, 52 had mild cognitive impairment, and 58, probable Alzheimer disease. Serum antibody levels were determined by ELISA and compared using covariance analysis with a significance level of 0.05. ELISA specificity, sensitivity and predictive value were assessed by analyzing their respective diagnostic performance curves.
RESULTS Patients with probable Alzheimer disease performed least well on the mini mental state examination (cognitively normal 28.8, SD 1.2; mild cognitive impairment 27.4, SD 2.2; probable Alzheimer disease 12.9, SD 6.5; ANOVA p <0.001). The percentage of Apo E4 carriers was seven times greater in the group with probable Alzheimer disease than in the cognitively normal group. Among the antibodies studied, only those against amyloid beta peptide had levels significantly higher in the Alzheimer disease group than in the cognitively normal group (p = 0.007) and the group with mild cognitive impairment (p = 0.002).
CONCLUSIONS Results support the presence of an autoimmune component in Alzheimer disease and suggest that serum anti–amyloid-beta could be used for its diagnosis.
KEYWORDS Dementia, Alzheimer disease, mild cognitive impairment, autoantibodies, E4 apolipoprotein, Apo E4, enzyme-linked immunosorbent assay, ELISA, immunoassay, immunosorbent techniques, amyloid beta protein, Cuba
Aging and Alzheimer is a prospective, longitudinal cohort study involving 2944 adults aged ≥65 years from selected areas in Cuba’s Havana and Matanzas Provinces. This door-to-door study, which began in 2003, includes periodic assessments of the cohort based on an interview; physical exam; anthropometric measurements; and diagnosis of dementia and its subtypes, other mental disorders, and other chronic non-communicable diseases and their risk factors. Information was gathered on sociodemographic characteristics; disability, dependency and frailty; use of health services; and characteristics of care and caregiver burden. The first assessment also included blood tests: complete blood count, blood glucose, kidney and liver function, lipid profile and ApoE4 genotype (a susceptibility marker). In 2007–2011, the second assessment was done of 2010 study subjects aged ≥65 years who were still alive. The study provides data on prevalence and incidence of dementia and its risk factors, and of related conditions that affect the health of older adults. It also contributes valuable experiences from field work and interactions with older adults and their families. Building on lessons learned, a third assessment to be done in 2016–2018 will incorporate a community intervention strategy to respond to diseases and conditions that predispose to dementia, frailty and dependency in older adults.
KEYWORDS Dementia, Alzheimer disease, chronic disease, aging, chronic illness, frailty, dependency, cohort studies, Cuba
Dementia is a great challenge to public health in Cuba due to its impact on society and families. Cuba’s National Intervention Strategy for Alzheimer Disease and Dementia Syndromes is designed to address this challenge. The Strategy includes working guidelines for primary and secondary care, education about rights of people with cognitive impairment, professional development, research, and health promotion and dementia prevention. An associated action plan, focused on primary care, includes proposals for creation of memory clinics, day centers and comprehensive rehabilitation services for cognitive stimulation. Short-term measures proposed include increasing early detection; creating a dementia morbidity and mortality registry; promoting professional training; providing support for families; and promoting basic and clinical research on dementia. Medium-term proposals aim to reduce dementia incidence and mortality by controlling risk factors and promoting healthy lifestyles, offering new treatment options and optimizing early detection. A set of indicators has been developed to evaluate strategy implementation. With this strategy, Cuba joins the small number of developing countries that have responded to WHO’s call to improve care for patients with dementia and alleviate its impact on society and families.
KEYWORDS Dementia, Alzheimer disease, aging, national health programs, social stigma, primary prevention, health promotion, civil rights, Cuba
A review/analysis of current literature on exemplary multicenter registries of clinical dementias was conducted as a comparative basis for a proposed Cuban registry on cognitive impairment and dementia.
The study of mental health disorders has been predominantly based on clinical concepts and criteria, and only in recent years a public health approach has been applied. Traditional epidemiological studies do not reveal patterns of cognitive impairment and behavioral disorders (particularly dementias) in routine clinical practice in a defined geographic area, which would provide essential information for long-term planning and allocation of health and social resources. Thus, multicenter clinical registries have become an important source of clinical and epidemiological data on dementias in recent decades. This article addresses the Cuban proposal for an automated national dementia registry, comparing it to others internationally. The registry would be housed in the Neurology and Neurosurgery Institute, and would include a duly protected surveillance network hosted on the Institute’s website.
Such a multicenter dementia registry based on epidemiological surveillance methods and limited to a defined area would provide new, valid, representative and current data on dementia occurrence patterns by subtype, flow of case identification and referral from primary care, as well as the main clinical features of patients at the time of their first contact with health services. This information would support development of health planning policies for implementation of programs aimed at improved distribution of social and health resources in the affected population, monitoring of the disorder’s natural evolution and identification of preventive measures. The scientific benefits would be equally important: production of new knowledge, generation of hypotheses for clinical research projects, standardization of diagnostic criteria, and promotion of multicenter research in both national and multinational centers.
KEYWORDS Dementia, Alzheimer disease, cognitive impairment, disease registries, public health, surveillance, Cuba
INTRODUCTION Population aging translates into more people with chronic non-communicable diseases, disability, frailty and dependency. The study of frailty—a clinical syndrome associated with an increased risk of falls, disability, hospitalization, institutionalization and death—is important to improve clinical practice and population health indicators. OBJECTIVES In a cohort of older adults in Havana and Matanzas provinces, Cuba, estimate prevalence of frailty and its risk factors; determine incidence of dependency; estimate mortality risk and identify mortality predictors. METHODS A prospective longitudinal study was conducted door to door, from June 2003 through July 2011, in a cohort of 2813 adults aged ≥65 years living in selected municipalities of Havana and Matanzas provinces; mean followup time was 4.1 years. Independent variables included demographics, behavioral risk factors and socioeconomic indicators, chronic non-communicable diseases (hypertension, stroke, dementia, depression, diabetes, anemia), number of comorbidities, and APOE ε4 genotype. Dependent variables were frailty, dependency and mortality. Criteria for frailty were slow walking speed, exhaustion, weight loss, low physical activity and cognitive decline. Prevalence and frailty risk were estimated by Poisson regression, while dependency and mortality risks and their predictors were determined using Cox regression. RESULTS Frailty syndrome prevalence was 21.6% (CI 17.9%–23.8%) at baseline; it was positively associated with advanced age, anemia and presence of comorbidities (stroke, dementia, depression, three or more physically debilitating diseases). Male sex, higher educational level, married or partnered status, and more household amenities were inversely associated with frailty prevalence. In followup, dependency incidence was 33.1 per 1000 person-years (CI 29.1–37.6) and mortality was 55.1 per 1000 person-years. Advanced age, male sex, lower occupational status during productive years, dependency, frailty, dementia, depression, cerebrovascular disease and diabetes were all associated with higher risk of death. CONCLUSIONS Given the challenge for developing countries presented by demographic and epidemiologic transition; the high prevalence in older adults of frailty syndrome, dependency and chronic non-communicable diseases; and the association of all these with higher mortality, attention should be targeted to older adults as a risk group. This should include greater social protection, age-appropriate health services, and modification and control of cardiovascular risk factors.
KEYWORDS Frail elderly, frail older adults, aged, elderly, dependency, mortality, chronic disease, dementia, Alzheimer disease, risk factors, Cuba
The following error has been corrected in all online versions of this article.
Page 24, Introduction, first paragraph, line 2, “600,000 to 2 billion” should read “600 million to 2 billion.”
Translated from the Spanish and reprinted with permission from the Revista Anales de la Academia de Ciencias de Cuba, [online] Vol. 2, No. 2, 2012. Original available at: http://www.revistaccuba.cu/index.php/acc/article/view/126
Dementia is a syndrome that has great repercussions for quality of life of patients and their families, as well as a high social cost. A [2009] systematic review of research evidence and consensus of expert opinions showed that 36 million people live with dementia worldwide, with 4.6 million new cases every year (similar to the global incidence of nonfatal stroke). The prevalence of dementia in older Cubans is high, with rates ranging from 6.4% to 10.2%, or about 130,000 persons (1.1% of the total population). This number is expected to rise to 260,000 by 2030. The age-standardized annual incidence of dementia is also high: 21 per 1000 population, with 28,750 new cases annually. Dementia is the leading cause of disability among older adults and is the main cause of dependency, financial burden and caregiver stress.
In this review, we highlight the importance of epidemiological research to obtain greater knowledge of the disease, improve health services, promote actions for prevention and early diagnosis, and implement a national strategy to address dementia in the Cuban population, itself now immersed in two processes: accelerated demographic aging and epidemiologic transition.
KEYWORDS Dementia, Alzheimer disease, epidemiology, risk factors, prevention, diagnosis, treatment
