Tania Correa de Toledo Ferraz Alves

O Departamento de Psicogeriatria, após análise crítica dos estudos pivotais e da literatura científica recente, emite as seguintes considerações sobre a aprovação e o uso clínico do donanemabe, anticorpo monoclonal direcionado à beta-amiloide, para indivíduos com comprometimento cognitivo leve (CCL) ou demência leve devido à doença de Alzheimer (DA).

Background: Psychogeriatric day hospitals best practices deliver integrated patient and family centered care by multidisciplinary teams, providing a safer transition between acute psychogeriatric units to rehabilitation services and outpatients clinical care. This reduces inpatient length of stay and rehospitalization rates, favoring a successful daily routine care at home. We implemented in 2022 an elderly day hospital service at the Institute of Psychiatry USP Medical School, Brazil. This case report illustrates how day hospitals can contribute to a better clinical outcome.Case report: 64 year‐old male patient with bipolar disorder (BD), recurrent readmissions in our psychogeriatric unit due to either complications from bipolar disorder or clinical conditions and family burden (2020 for 90 days due to rapid cycling BD and 2021 to treat clinical conditions 4 days). When he was at home his family reported increased burden and difficulty in daily care. They asked for readmissions in this period .The cognitive impairment and functional decline were associated with neuroprogression in BD.The lack of adequate treatment worsened psychiatric, cognitive symptoms and the capacity to maintain his activities of daily living (ADL).In 2022 he was admitted due to behavior symptoms (irritability and aggressivity) in our inpatient unit for 19 days. Transitioned to day hospital, he attended activities for two months, twice a week. The intervention provided cognitive and functional stimulation, caregivers training and psychoeducation. It was performed in groups and individually (patient and family).We observed improvement in cognition, basic daily life activities and social support. Admission and transition to outpatient care were CGI‐04‐04, MMSE 20‐23 and Katz 02‐04. We observed reduction in family burden and management of psychiatric and behavior symptoms.Conclusion: Patient and family needs were identified and cared for, and we achieved an improved health outcome by creating a safe transition, reducing length of stay and preventing readmission. This present intervention demonstrates a clinical example of the coordinated approach in order to provide transitional care and enable rehabilitation (cognition, basic daily life and bipolar symptoms).The benefits of the patient‐ family centered care provides consistent recovery and decreased length of hospital stay and risk of readmission.

Background: Patient and families/caregivers centered care programs reduce the negative impact of hospitalizations in old age and improve health outcomes. We started an individual‐centered multidisciplinary program that contemplated hospitalization and day‐hospital care at Institute of Psychiatry USP Medical School, Brazil in march 2022 .Our program involves specific goals for inpatients and family members / caregiver’s integrating pharmacology and a multidisciplinary approach.Method: Our program involves interventions during the hospitalization, day‐hospital and transition to outpatient care. Individual specific needs are assessed at the admission, and an individualized specific plan centered on patient and caregiver is designed and carried on. The therapeutic program provides patients cognitive and functional stimulation and caregivers training in order to adapt to behavior changes and together develop a successful daily routine care at home. The multidisciplinary team involves: medical team, nurse, psychologist, speech therapist, physiotherapist, occupational therapist, nutritionist and social worker. The intervention involves psychoeducation, cognitive and social stimulation/training for patients and/or caregivers/family in groups (60‐90 min), 5‐days a week, twice a day and individual sessions. Assessments include clinical and sociodemographic data, days of hospitalization, clinical global impression, MADRAS, MMSE and KATZ scales.Result: There were 61 consecutive admissions in the 10 months after the program implementation, main diagnosis at admission were depression and dementia . The mean age was 69,73, gender 40 female, 21 male, average hospital stay was 26,66 (inpatient unit), bed turnover 85,81%. Zero patient was readmitted in a period of 30 days after discharge. Admission mean: CGI 4,98, MADRAS 17,66,MMSSE 16,43 KATZ 3,98 and discharge: CGI 3,47,MADRAS 7,26. MMSSE 19,4.KATZ 4,36 .The reduction in CGI 31,3%, Madras 58,89% and improvement in MMSE 18%, KATZ 9,5%.Conclusion: Our findings demonstrated confirmed that a patient‐centered program results in improvement in cognition, basic activities of daily life and reduction of depressive symptoms. The present intervention provides consistent recovery of hospitalization. It is an important strategy to improve health quality and recovery for old age psychiatric patients.Descriptors: psychiatry; aging; multiprofessional intervention

Background: Structural brain changes in grey matter in late‐life depression (LLD) remains an intriguing area of research. Furthermore, late‐onset depression (LOD) has been frequently associated with general medical comorbidities, cognitive deficits and structural abnormalities of the brain. This magnetic resonance imaging (MRI) study compares the grey matter volume of elderly people with and without major depression (DSM‐IV‐TR criteria), as well LOD, early onset depression (EOD) and controls.Method: The sample consisted of elders with and without depression from community. Brain MRI scans were processed using statistical parametric mapping and voxel‐based morphometry.Result: Sixty three elders with depression and 24 controls were enrolled. Demographic characteristics were analyzed and sex showed a statistically significant difference (p = 0.001) between the groups, with males representing 17.5% of the patient sample and 54.2% of the control sample. Furthermore, MMSE and CAMCOG showed a statistically significant difference between groups (p<0.0001 for both tests), with the control group performing better. Although we excluded cases of patients with below‐expected performance according to the neuropsychological assessment, it is likely that this cognitive impairment presented by the patient group is secondary to major depressive disorder. We did not find a significant volumetric difference between depressed and control group (CG). We used the age of onset of depression as another way of classifying the patient sample and compared it with the control group regarding key demographic and clinical characteristics. Gender was statistically significant different between groups, however there were only 2 male subjects in the EOD group, making it not possible to control the analysis by gender. Compared to the CG (n = 24), the LOD group (n = 32) showed a statistically significant volumetric reduction with correction for multiple comparisons in the right thalamus (464 voxels; peak xyz coordinates = 14 ‐10 16; Z = 4, 62; p‐FWEcorr = 0.052) when using the whole brain for multiple comparisons.Conclusion: Our findings support the use of regional brain atrophy as a tool to better understand LOD.

The synthesis of mesoporous materials in macroscopic scale, as for example, the monoliths, has been of great interest in view of the wide range of applications that this material holds. Thus, this work consists of the production of silica monoliths for the purpose of they being used in the carbon dioxide (CO₂) adsorption process. The adsorbents were prepared in pure form and also with addition of heteroatoms: Al, Ti and Zr. The samples were then functionalized with pentaethylenehexamine (PEHA) by the wet impregnation method. The materials were characterized by the following techniques: X-ray diffraction (XRD), textural analysis, Fourier transform infrared spectroscopy (FTIR), Scanning electron microscopy (SEM) and Thermogravimetry (TG/DTG). The analyses indicated that the materials synthesized with heteroatom incorporation presented a disordered pore structure and high surface area (1387 m²/g for sample Ti/M1). In addition, they showed a significant increase in adsorption of CO₂ relative to their parent sample, a fact that is not much explored in the literature. The CO₂ adsorption performance tests were carried out at 30 ºC and atmospheric pressure. All functionalized materials demonstrated improved CO₂ adsorption capacity relative to their starting samples. Adsorption capacities up to 111.3 mg/g were found in this work, which makes the materials developed promising candidates for the capture of CO₂.

Background: Many cross-sectional voxel-based morphometry (VBM) investigations have shown significant inverse correlations between chronological age and gray matter (GM) volume in several brain regions in healthy humans. However, few VBM studies have documented GM decrements in the healthy elderly with repeated MRI measurements obtained in the same subjects. Also, the extent to which the APOE ɛ4 allele influences longitudinal findings of GM reduction in the healthy elderly is unclear. Objective: Verify whether regional GM changes are associated with significant decrements in cognitive performance taking in account the presence of the APOE ɛ4 allele. Methods: Using structural MRI datasets acquired in 55 cognitively intact elderly subjects at two time-points separated by approximately three years, we searched for voxels showing significant GM reductions taking into account differences in APOE genotype. Results: We found global GM reductions as well as regional GM decrements in the right thalamus and left parahippocampal gyrus ( p < 0.05, family-wise error corrected for multiple comparisons over the whole brain). These findings were not affected by APOE ɛ4. Conclusions: Irrespective of APOE ɛ4, longitudinal VBM analyses show that the hippocampal region and thalamus are critical sites where GM shrinkage is greater than the degree of global volume reduction in healthy elderly subjects.

Cardiovascular risk (CVR) factors may be associated with poor cognitive functioning in elderlies and impairments in brain structure. Using MRI and voxel-based morphometry (VBM), we assessed regional white matter (WM) volumes in a population-based sample of individuals aged 65-75 years (n=156), subdivided in three CVR subgroups using the Framingham Risk Score. Cognition was assessed using the Short Cognitive Performance Test. In high-risk subjects, we detected significantly reduced WM volume in the right juxtacortical dorsolateral prefrontal region compared to both low and intermediate CVR subgroups. Findings remained significant after accounting for the presence of the APOEε4 allele. Inhibitory control performance was negatively related to right prefrontal WM volume, proportionally to the degree of CVR. Significantly reduced deep parietal WM was also detected bilaterally in the high CVR subgroup. This is the first large study documenting the topography of CVR-related WM brain volume deficits. The significant association regarding poor response inhibition indicates that prefrontal WM deficits related to CVR are clinically meaningful, since inhibitory control is known to rely on prefrontal integrity.

Using magnetic resonance imaging, we aimed to assess the presence of silent brain vascular lesions in a sample of apparently healthy elderly individuals who were recruited from an economically disadvantaged urban region (São Paulo, Brazil). We also wished to investigate whether the findings were associated with worse cognitive performance. A sample of 250 elderly subjects (66-75 years) without dementia or neuropsychiatric disorders were recruited from predefined census sectors of an economically disadvantaged area of Sao Paulo and received structural magnetic resonance imaging scans and cognitive testing. A high proportion of individuals had very low levels of education (4 years or less, n=185; 21 with no formal education). The prevalence of at least one silent vascular-related cortical or subcortical lesion was 22.8% (95% confidence interval, 17.7-28.5), and the basal ganglia was the most frequently affected site (63.14% of cases). The subgroup with brain infarcts presented significantly lower levels of education than the subgroup with no brain lesions as well as significantly worse current performance in cognitive test domains, including memory and attention (p<0.002). Silent brain infarcts were present at a substantially high frequency in our elderly sample from an economically disadvantaged urban region and were significantly more prevalent in subjects with lower levels of education. Covert cerebrovascular disease significantly contributes to cognitive deficits, and in the absence of magnetic resonance imaging data, this cognitive impairment may be considered simply related to ageing. Emphatic attention should be paid to potentially deleterious effects of vascular brain lesions in poorly educated elderly individuals from economically disadvantaged environments.

Inter-subject variability in age-related brain changes may relate to educational attainment, as suggested by cognitive reserve theories. This voxel-based morphometry study investigated the impact of very low educational level on the relationship between regional gray matter (rGM) volumes and age in healthy elders. Magnetic resonance imaging data were acquired in elders with low educational attainment (less than 4 years) (n = 122) and high educational level (n = 66), pulling together individuals examined using either of three MRI scanners/acquisition protocols. Voxelwise group comparisons showed no rGM differences (p<0.05, family-wise error corrected for multiple comparisons). When within-group voxelwise patterns of linear correlation were compared between high and low education groups, there was one cluster of greater rGM loss with aging in low versus high education elders in the left anterior cingulate cortex (p<0.05, FWE-corrected), as well as a trend in the left dorsomedial prefrontal cortex (p<0.10). These results provide preliminary indication that education might exert subtle protective effects against age-related brain changes in healthy subjects. The anterior cingulate cortex, critical to inhibitory control processes, may be particularly sensitive to such effects, possibly given its involvement in cognitive stimulating activities at school or later throughout life.

Recent literature has presented evidence that cardiovascular risk factors (CVRF) play an important role on cognitive performance in elderly individuals, both those who are asymptomatic and those who suffer from symptoms of neurodegenerative disorders. Findings from studies applying neuroimaging methods have increasingly reinforced such notion. Studies addressing the impact of CVRF on brain anatomy changes have gained increasing importance, as recent papers have reported gray matter loss predominantly in regions traditionally affected in Alzheimer’s disease (AD) and vascular dementia in the presence of a high degree of cardiovascular risk. In the present paper, we explore the association between CVRF and brain changes using pattern recognition techniques applied to structural MRI and the Framingham score (a composite measure of cardiovascular risk largely used in epidemiological studies) in a sample of healthy elderly individuals. We aim to answer the following questions: Is it possible to decode (i.e., to learn information regarding cardiovascular risk from structural brain images) enabling individual predictions? Among clinical measures comprising the Framingham score, are there particular risk factors that stand as more predictable from patterns of brain changes? Our main findings are threefold: i) we verified that structural changes in spatially distributed patterns in the brain enable statistically significant prediction of Framingham scores. This result is still significant when controlling for the presence of the APOE 4 allele (an important genetic risk factor for both AD and cardiovascular disease). ii) When considering each risk factor singly, we found different levels of correlation between real and predicted factors; however, single factors were not significantly predictable from brain images when considering APOE4 allele presence as covariate. iii) We found important gender differences, and the possible causes of that finding are discussed.