White-light emission from a structurally simple hydrazone

Two hydrazones featuring a unique excitation wavelength-dependent dual fluorescence emission have been developed.

Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management

OBJECTIVE

The task force of the International Conference of Frailty and Sarcopenia Research (ICFSR) developed these clinical practice guidelines to overview the current evidence-base and to provide recommendations for the identification and management of frailty in older adults.

METHODS

These recommendations were formed using the GRADE approach, which ranked the strength and certainty (quality) of the supporting evidence behind each recommendation. Where the evidence-base was limited or of low quality, Consensus Based Recommendations (CBRs) were formulated. The recommendations focus on the clinical and practical aspects of care for older people with frailty, and promote person-centred care. Recommendations for Screening and Assessment: The task force recommends that health practitioners case identify/screen all older adults for frailty using a validated instrument suitable for the specific setting or context (strong recommendation). Ideally, the screening instrument should exclude disability as part of the screening process. For individuals screened as positive for frailty, a more comprehensive clinical assessment should be performed to identify signs and underlying mechanisms of frailty (strong recommendation). Recommendations for Management: A comprehensive care plan for frailty should address polypharmacy (whether rational or nonrational), the management of sarcopenia, the treatable causes of weight loss, and the causes of exhaustion (depression, anaemia, hypotension, hypothyroidism, and B12 deficiency) (strong recommendation). All persons with frailty should receive social support as needed to address unmet needs and encourage adherence to a comprehensive care plan (strong recommendation). First-line therapy for the management of frailty should include a multi-component physical activity programme with a resistance-based training component (strong recommendation). Protein/caloric supplementation is recommended when weight loss or undernutrition are present (conditional recommendation). No recommendation was given for systematic additional therapies such as cognitive therapy, problem-solving therapy, vitamin D supplementation, and hormone-based treatment. Pharmacological treatment as presently available is not recommended therapy for the treatment of frailty.

Subthreshold Depression Needs A Prime Time In Old Age Psychiatry? A Narrative Review Of Current Evidence

This study aims to carry out a narrative review, aiming to update the literature on subsyndromic depression (SD), which is the most prevalent depressive disorder in older adults, and no formal guidelines or consensus are dedicated to this topic. We carried out an electronic search for articles on SD. Relevant articles were retrieved from Pubmed, EMBASE and Web of Science using the search terms "subthreshold depression," "prevalence," "treatment" and "older adults" in several combinations. Original articles in English were included from inception to 1st March 2019. No clear consensus exists in the literature on its nosologic classification, diagnostic tools, causes, course, outcomes or management. SD diagnosis should base in depressive symptoms scales and DSM criteria. Treatment relies mainly on collaborative care and psychotherapy. SD is relevant in clinical practice and research in geriatric psychiatry. Given the negative outcomes and potential benefits of treatment, we recommend brief psychotherapy as first-line treatment and use of psychotropic agents in cases with greater severity and/or functional impairment in association with psychotherapy. SD can precede major depressive disorder, but it also may consist of a primary depressive disorder in older adults. Furthermore, adequate treatment of SD can prevent or reduce negative outcomes associated with depressive symptoms such as worsening of clinical comorbidities, loss of functionality, increased demand for health services, and increased mortality.

Comparison of Two Models of Frailty for the Prediction of Mortality in Brazilian Community-Dwelling Older Adults: The FIBRA Study

BACKGROUND

Prevalence of frailty is significant in Latin America. However, no previous study evaluated mortality prediction using the two most used frailty models in Brazil.

OBJECTIVES

The aim of the present study was to compare the frailty phenotype and the frailty index with regard to accuracy in the prediction of mortality among community-dwelling older adults.

METHODS

A cohort study was conducted involving 674 older adults. Thirty-five variables (signs, symptoms, chronic diseases and disabilities) were used for the construction of the frailty index (FI). The frailty phenotype index (FPI) was defined based on the criteria proposed in the Cardiovascular Health Study. Periodic verifications were performed in the databank of the Mortality Information System. Cox regression was used to estimate the relative risk (RR) of mortality and Kaplan-Meier survival curves were used in the analysis.

RESULTS

The prevalence of frailty was greater based using the FI (16.3%) compared to the FPI (5.34%). Older adults classified as frail by the FPI had a greater risk of death (RR: 10.03; 95% CI: 4.43-22.74) that those classified as frail by the FI (RR: 0.87; 95% CI: 0.25-3.00). The lowest survival rate was found in the group of older adults classified as frail based on the FPI and classified as pre-frail and robust based on the FI.

CONCLUSION

The FPI demonstrated greater accuracy in predicting the risk of mortality among Brazilian older adults than the FI. The validation of frailty measures is fundamental to the identification of older adults who are more vulnerable to adverse health events.

Cognitive screening test in primary care: cut points for low education

OBJECTIVE

To establish the diagnostic accuracy of the Brazilian version of the General Practitioner Assessment of Cognition (GPCOG-Br) compared to the Mini-Mental State Examination (MMSE) in individuals with low educational level.

METHODS

Ninety-three patients (≥ 60 years old) from Brazilian primary care units provided sociodemographic, cognitive, and functional data. Receiver operating characteristics, areas under the curve (AUC) and logistic regressions were conducted.

RESULTS

Sixty-eight patients with 0-4 years of education. Cases (n = 44) were older (p = 0.006) and performed worse than controls (n = 49) on all cognitive or functional measures (p < 0.001). The GPCOG-Br demonstrated similar diagnostic accuracy to the MMSE (AUC = 0.90 and 0.91, respectively) and similar positive and negative predictive values (PPV/NPV, respectively: 0.79/0.86 for GPCOG-Br and 0.79/0.81 for MMSE). Adjusted cut-points displayed high sensitivity (all 86%) and satisfactory specificity (65%-80%). Lower educational level predicted lower cognitive performance.

CONCLUSIONS

The GPCOG-Br is clinically well-suited for use in primary care.

Solution and Solid-State Emission Toggling of a Photochromic Hydrazone

The proliferation of light-activated switches in recent years has enabled their use in a broad range of applications encompassing an array of research fields and disciplines. All current systems, however, have limitations (e.g., from complicated synthesis to incompatibility in biologically relevant media and lack of switching in the solid-state) that can stifle their real-life application. Here we report on a system that packs most, if not all, the desired, targeted and sought-after traits from photochromic compounds (bistability, switching in various media ranging from serum to solid-state, while exhibiting ON/OFF fluorescence emission switching, and two-photon assisted near-infrared light toggling) in an easily accessible structure.

New molecular switch architectures

In this paper we elaborate on recently developed molecular switch architectures and how these new systems can help with the realization of new functions and advancement of artificial molecular machines. Progress in chemically and photoinduced switches and motors is summarized and contextualized such that the reader may gain an appreciation for the novel tools that have come about in the past decade. Many of these systems offer distinct advantages over commonly employed switches, including improved fidelity, addressability, and robustness. Thus, this paper serves as a jumping-off point for researchers seeking new switching motifs for specific applications, or ones that address the limitations of presently available systems.

Decision Making assessed by the Iowa Gambling Task and Major Depressive Disorder A systematic review

Major Depressive Disorder (MDD) can occur in parallel with cognitive impairment. The search for a neuropsychological profile of depression has been pursued in the last two decades. However, scant research has been done on executive functions and decision-making ability (DM).

Normative data for the Montreal Cognitive Assessment (MoCA) and the Memory Index Score (MoCA-MIS) in Brazil: Adjusting the nonlinear effects of education with fractional polynomials

OBJECTIVE

To provide age-corrected and education-corrected norms for the Montreal Cognitive Assessment (MoCA) and the Memory Index Score (MoCA-MIS) in Brazil.

METHODS

Community-dwelling outpatients were enrolled if they had no history of neurologic or psychiatric diseases and were not taking any drugs with effects on the central nervous system. Dementia has been excluded with the Functional Activities Questionnaire. The final sample consisted of 597 cognitively healthy Brazilians aged 50 to 90 years. To account for nonlinear relationships, we have used fractional polynomials that provide a flexible parameterization for continuous variables.

RESULTS

According to the original proposed cutoff (≤25 points), 87% of our sample would be considered impaired. Even using a more conservative suggestion (≤22 points), 67% of our normative sample would be regarded as impaired. These data reinforce the need of adjusting cutoffs for schooling in populations with heterogeneous educational backgrounds. MoCA scores presented a nonlinear positive association with education tending to a plateau at higher levels (P < 0.001). On the other hand, MoCA-MIS scores presented a nonlinear negative relationship with age, with an accelerated pattern at higher age levels (P < 0.001).

CONCLUSIONS

We presented normative data for the MoCA and the MoCA-MIS that will facilitate the use of the test in Brazil and, potentially, in other populations with substantial proportions of low-educated individuals. Moreover, we described a systematic approach for adjusting the effects of age and education using fractional polynomials and provided suggestions on how to account for the nonlinear relationship that is frequently encountered between demographic factors and measures of cognitive performance.

Review of Decision-Making in Game Tasks in Elderly Participants with Alzheimer Disease and Mild Cognitive Impairment

BACKGROUND

Changes in decision-making (DM) have recently been investigated in patients with Alzheimer disease (AD) or mild cognitive impairment (MCI). DM is highly relevant to everyday functioning and autonomy. It relies on several cognitive abilities, such as semantic and episodic memory, as well as aspects of executive functioning. We conducted a systematic review of DM in older adults with MCI and AD.

SUMMARY

Only 5 studies whose main objective was to evaluate the DM performance were selected. The results extracted indicated that DM in ambiguity and in at-risk situations are both impaired in probable AD patients. MCI patients have difficulty making advantageous decisions under ambiguity and at risk, similar to patients with probable AD but they are less impaired. Key Messages: DM deficits may be a predictor of cognitive impairment and conversion to dementia and its potential clinical value should be further explored in longitudinal studies involving direct comparison between MCI and AD patients.

Polypharmacy but not Potential Inappropriate Prescription Was Associated with Frailty in Older Adults from a Middle-Income Country Outpatient Clinic

OBJECTIVES

the aims of the present study were: (1) investigate the prevalence and association of polypharmacy and pre-frailty or frailty in a middle-income country sample of older adults; and (2) evaluate the prevalence of potential inappropriate prescription (PIP) and its association with pre-frailty or frailty.

DESIGN

Cross-sectional observational study.

SETTING

Outpatient center at a university-based hospital in the state of São Paulo, Brazil.

PARTICIPANTS

629 older adults from both sexes evaluated between June 2014 and July 2016.

MEASUREMENTS

Frailty was identified through the FRAIL scale. All medications received were analyzed by research staff. Presence of PIP was evaluated according to the 2015 updated Beers list. Binary logistic regression tested the association between 4 definitions of polypharmacy (≥ 3, 4, 5, and 6 drugs), and presence of PIP, and the dependent variable pre-frailty and frailty.

RESULTS

15.7% of participants were frail. Polypharmacy was present in 219 (34.8%), and PIP was observed in 184 (29.3%) older adults. All definitions of polypharmacy were significantly associated with frailty (OR between 2.05 to 2.34, p < 0.001). Polypharmacy with 4 or 5 or more drugs were associated with pre-frailty (OR 1.53 and 1.47, respectively). PIP was not associated with frailty (OR 1.47, p = 0.149).

CONCLUSIONS

Several definitions of polypharmacy were associated with frailty, but only two were associated with pre-frailty. The presence of PIP was not associated with pre-frailty or frailty.

Frailty and cognitive status evaluation can better predict mortality in older adults?

OBJECTIVES

to evaluate the improvement in one-year mortality prediction after adding a 2-min cognitive screening to a simple 1-min frailty detection instrument. Secondary outcomes were new activities of daily living (ADL) disability and falls.

DESIGN

Prospective cohort study.

SETTING

A geriatric day-hospital for intermediate care.

PARTICIPANTS

A total of 701 older adults with an acute or decompensated disease (79.5 (8.3) years, 64% female).

MEASUREMENTS

A rapid and simple frailty evaluation was performed using the FRAIL questionnaire. The presence of cognitive impairment was defined by previous diagnosis of dementia or a score of five or less on an education-corrected 10-point cognitive screening tool.

RESULTS

Frail participants with normal (hazard risk [HR] 4.0, 95% confidence interval [CI], 1.73-9.25) and impaired cognition had a higher risk of death (HR 4.38, 95% CI, 1.95-9.87) than robust participants. The presence of cognitive impairment increased the risk of death in prefrail (HR 3.60, 95% CI, 1.55-8.34) and robust participants (HR 3.49, 95% CI, 1.22-9.96). Cognitive impairment was associated with an increased risk of incident ADL disability in all frailty categories. The presence of cognitive impairment was associated with a significantly higher risk of fall in robust seniors. The predictive accuracy of the FRAIL scale was lower than expected (between 0.58 and 0.69), and a small improvement was observed after adding the cognitive screening (between 0.61 and 0.72).

CONCLUSION

Despite of significant results in predicting relevant clinical events, the present combination of the FRAIL and 10-CS scales may not be ideal in clinical practice.

Performance of the Pentagon Drawing test for the screening of older adults with Alzheimer's dementia

The Pentagon Drawing Test (PDT) is a common cognitive screening test.

Early-Onset Alzheimer Disease (EOAD) With Aphasia: A Case Report

Background: Alzheimer's disease (AD) is traditionally subdivided into early onset (EOAD) and late onset (LOAD). EOAD has an onset before age 65 years and accounts for 1-5% of all cases. Two main presentation types of AD are familial and sporadic. Case presentation: The authors present the case of a 68-year-old retired white man, with a college level educational background. At 55 years of age, the patient presented cognitive decline with short-term memory impairment and slowed, hesitant speech. At 57 years, he was unable to remember the way to work, exhibiting spatial disorientation. PET-CT: revealed hypometabolism and atrophy in the left temporal lobe and posterior region of the parietal lobes. Disease course: Evolving with difficulties in comprehension and sentence repetition over past 3 years and with global aphasia in past 6 months, beyond progressive memory impairment. Discussion: Possibly due to the young age and atypical presentation, and the diagnosis of EOAD is often delayed. To the best of our knowledge, this case can be classified as a sporadic EOAD with aphasia. Clinical variant and neuroimaging findings were crucial to the diagnosis and treatment of this atypical presentation of AD.

International Clinical Practice Guidelines for Sarcopenia (ICFSR): Screening, Diagnosis and Management

OBJECTIVES

Sarcopenia, defined as an age-associated loss of skeletal muscle function and muscle mass, occurs in approximately 6 - 22 % of older adults. This paper presents evidence-based clinical practice guidelines for screening, diagnosis and management of sarcopenia from the task force of the International Conference on Sarcopenia and Frailty Research (ICSFR).

METHODS

To develop the guidelines, we drew upon the best available evidence from two systematic reviews paired with consensus statements by international working groups on sarcopenia. Eight topics were selected for the recommendations: (i) defining sarcopenia; (ii) screening and diagnosis; (iii) physical activity prescription; (iv) protein supplementation; (v) vitamin D supplementation; (vi) anabolic hormone prescription; (vii) medications under development; and (viii) research. The ICSFR task force evaluated the evidence behind each topic including the quality of evidence, the benefit-harm balance of treatment, patient preferences/values, and cost-effectiveness. Recommendations were graded as either strong or conditional (weak) as per the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach. Consensus was achieved via one face-to-face workshop and a modified Delphi process.

RECOMMENDATIONS

We make a conditional recommendation for the use of an internationally accepted measurement tool for the diagnosis of sarcopenia including the EWGSOP and FNIH definitions, and advocate for rapid screening using gait speed or the SARC-F. To treat sarcopenia, we strongly recommend the prescription of resistance-based physical activity, and conditionally recommend protein supplementation/a protein-rich diet. No recommendation is given for Vitamin D supplementation or for anabolic hormone prescription. There is a lack of robust evidence to assess the strength of other treatment options.

Hypertension, diabetes and obesity are associated with lower cognitive performance in community-dwelling elderly: Data from the FIBRA study

Background

Systemic hypertension (SH), diabetes mellitus (DM) and abdominal obesity may negatively impact cognitive performance.

Objective

To evaluate the association between SH, DM and abdominal obesity and cognitive performance among cognitively unimpaired elderly.

Methods

A cross-sectional study of individuals aged 65+ from seven Brazilian cities was conducted. SH and DM diagnoses were self-reported and abdominal circumference was objectively measured. Individuals who scored below the education-adjusted cutoff scores on the Mini-Mental State Examination (MMSE) were excluded.

Results

Among 2,593 elderly, 321 (12.38%) had SH, DM and abdominal obesity concomitantly (Group I) and 421 (16.23%) had none of the three diseases (Group II). Group I had a higher proportion of individuals that were women, aged 70-74 years, illiterate and with lower income. Group I had a higher number of participants with low cognitive performance (28.04% vs. 17.58% in Group II). Variables associated with poor cognitive performance were: female gender (OR: 2.43, p < 0.001); and lower education (OR: 0.410, p < 0.001). The presence of the three diseases and age were not significant in the education-adjusted model.

Conclusion

There was an association between cognition and the presence of SH, DM and obesity. However, education seems to be decisive in determining cognitive performance in the presence of these three conditions.

Hypertension and frailty in older adults

The association between hypertension and frailty syndrome in older adults remains unclear. There is scarce information about the prevalence of hypertension among frail elderly patients or on its relationship with frailty. Up to one quarter of frail elderly patients present without comorbidity or disability, yet frailty is a leading cause of death. The knowledge and better control of frailty risk factors could influence prognosis. The present study evaluated: (1) the prevalence of hypertension in robust, prefrail, and frail elderly; and (2) factors that might be associated with frailty including hypertension. A cross-sectional study was conducted in 619 older adults at a university-based outpatient center. Study protocol included sociodemographic data, measures of blood pressure and body mass index, frailty screening according to the internationally validated FRAIL (fatigue, resistance, ambulation, illnesses, and loss of weight) scale, number of comorbidities, drug use assessment, physical activity, cognitive status, and activities of daily living. Ordinal logistic regression was used to evaluate factors associated with frailty. Prevalence of hypertension and frailty was 67.3% and 14.8%, respectively, in the total sample. Hypertension was more prevalent in the prefrail (72.5%) and frail (83%) groups than among controls (51.7%). Hypertension, physical activity, number of prescribed drugs, and cognitive performance were significantly associated with frailty status. Hypertension presented an odds ratio of 1.77 towards frailty (95% confidence interval, 1.21-2.60; P = .002). Hypertension was more prevalent in frail elderly patients and was significantly associated with frailty. Intensive control of hypertension could influence the trajectory of frailty, and this hypothesis should be explored in future prospective clinical trials.

Lithium, a Therapy for AD: Current Evidence from Clinical Trials of Neurodegenerative Disorders

BACKGROUND

Preclinical studies have shown that lithium modifies pathological cascades implicated in certain neurodegenerative disorders, such as Alzheimer's disease (AD), Huntigton`s disease (HD), multiple system atrophy (MSA) and amyotrophic lateral sclerosis (ALS). A critical question is whether these pharmacodynamic properties of lithium translate into neurodegenerative diseases modifying effects in human subjects.

METHODS

We reviewed all English controlled clinical trials published in PubMed, PsycINFO, Embase, SCOPUS, ISI-Web with the use of lithium for the treatment of neurodegenerative disorders between July 2004 and July 2014.

RESULTS

Lithium showed evidence for positive effects on cognitive functions and biomarkers in amnestic mild cognitive impairment (aMCI, 1 study) and AD (2 studies), even with doses lower than those used for mood stabilisation. Studies of Li in HD, MSA and CSI did not show benefits of lithium. However, due to methodological limitations and small sample size, these studies may be inconclusive. Studies in ALS showed consistently negative results and presented evidence against the use of lithium for the treatment of this disease.

CONCLUSION

In absence of disease modifying treatments for any neurodegenerative disorders, the fact that at least 3 studies supported the effect of lithium in aMCI/AD is noteworthy. Future studies should focus on defining the dose range necessary for neuroprotective effects to occur.

Caregiver burden in older adults with bipolar disorder: relationship to functionality and neuropsychiatric symptoms

BACKGROUND

There are few studies addressing caregivers of bipolar disorder (BD) patients, especially patients who are older adults with an increased need for care, often given by a relative. The aim of this study was to describe which factors increase caregiver burden among caregivers of elderly BD outpatients.

METHODS

Patients were older than 60 years and met the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, criteria for BD. They were evaluated for current mood, cognitive and other neuropsychiatric symptoms, functionality, medical comorbidities, quality of life, years since BD diagnosis, and number of psychiatric admissions. The caregiver who spent the greatest time with each patient was evaluated with the Zarit Caregiver Burden Interview. The caregivers' global health, mood symptoms, quality of life, and tasks performed for the patient were also assessed.

RESULTS

Thirty-six BD patients and their caregivers were assessed. The Zarit Caregiver Burden Interview was positively correlated with patients' neuropsychiatric symptoms (r = 0.508, P = 0.002) and functional impairment (r = 0.466, P = 0.004). The Zarit Caregiver Burden Interview was also correlated with caregivers' own depression (r = 0.576, P < 0.001), anxiety (r = 0.360, P = 0.031), quality of life (r = -0.406, P = 0.014), medical comorbidities (r = 0.387, P = 0.020), and number of tasks that they completed for the patient (r = 0.480, P = 0.003).

CONCLUSIONS

In this group of elderly BD patients, caregiver burden was more associated with symptoms frequently seen in others diseases as in dementia than with depressive, manic, or anxiety symptoms, which are often used as treatment outcomes measures goals in BD. Potential treatable and modifiable factors associated with caregiver burden could be caregivers' depression, anxiety, and medical comorbidities, as well as support for caregivers in terms of services and social relationships.

Pemphigus foliaceus as a differential diagnosis in vesicobullous lesions

Given the challenge of clinical diagnosis of bullous skin lesions, this report aimed to discuss the histological changes, the presentation and clinical reasoning for diagnosis of these lesions. At the same time, the importance of the pathology was reviewed to identify these clinical scenarios. In this case report, we highlighted the clinical progression of a case of pemphigus foliaceus.