ABSTRACT Introduction: Although the absence of memory impairment was considered among the Alzheimer's disease diagnostic criteria to differentiate Alzheimer's disease (AD) from Behavioural Variant of Frontotemporal dementia Frontotemporal Dementia (bvFTD), current and growingevidence indicates that a significant Neuropsychological assessment percentage of cases of bvFTD present with episodic memory deficits. In order to compare Memory the performance profile of the naming capacity and episodic memory in patients with AD and bvFTD the present study was designed. Methods: Cross-sectional and analytical study with control group (32 people). The study included 42 people with probable AD and 22 with probable bvFTD, all over 60 years old. Uniform Data Set instruments validated in Spanish were used: Multilingual Naming Test (MINT), Craft-21 history and Benson's complex figure, among others. Results: A higher average age was observed among the patients with AD. The naming capacity was much lower in patients with bvFTD compared to patients with AD, measured according to the MINT and the nouns/verbs naming coefficient. All patients with bvFTD, 73.81% of those with AD and only 31.25% of the control group failed to recognise Benson's complex figure. All differences were statistically significant (p < 0.001). Results:This study confirms the amnesic profile of patients with AD and reveals the decrease in naming capacity in patients with bvFTD, an area of language that is typically affected early on with executive functions, according to recent findings. Conclusions: Patients with AD perform worse in verbal and visual episodic memory tasks, while patients with bvFTD perform worse in naming tasks. These findings open the possibility of exploring the mechanisms of prefrontal participation in episodic memory, typically attributed to the hippocampus.

RESUMEN Introducción: Aunque la ausencia de deterioro de la memoria se consideró entre los criterios diagnósticos para diferenciar la enfermedad de Alzheimer (EA) de la demencia frontotemporal variante conductual (DFTvC), la evidencia actual, en aumento, sería la un importante porcentaje de casos de DFTvC con déficits de la memoria episódica. El presente estudio se diseñó con el fin de comparar el perfil de desempeño de la capacidad denominativa y de la memoria episódica de los pacientes con EA y DFTvC. Métodos: Estudio transversal y analítico con grupo de control (n = 32). Se incluyó a 42 sujetos con probable EA y 22 con probable DFTvC, todos mayores de 60 años. Se utilizaron instrumentos del Uniform Data Set validados en español: Multilingual Naming Test (MINT), historia de Craft-21 y Figura compleja de Benson, entre otros. Resultados: Se observó un mayor promedio de edad entre los pacientes con EA. La capacidad denominativa fue mucho menor en los pacientes con DFTvC que en aquellos con EA, medida según el MINT y el coeficiente de denominación sustantivos/verbos. Todos los pacientes con DFTvC, el 73,81% de aquellos con EAy solo el 31,25% de los controles no lograron reconocer la Figura compleja de Benson. Todas las diferencias fueron estadísticamente significativas (p< 0,001). Resultados: Este estudio confirma el perfil amnésico de los pacientes con EA y revela la disminución de la capacidad denominativa de los pacientes con DFTvC, un área del lenguaje que se afecta típica y tempranamente con las funciones ejecutivas, según recientes hallazgos. Conclusiones: Los pacientes con EA rinden peor en las tareas de memoria episódica verbal y visual, mientras que los pacientes con DFTvC rinden peor en tareas de denominación. Estos hallazgos abren la posibilidad de explorar los mecanismos de participación prefrontal en la memoria episódica, típicamente atribuida al hipocampo.

SUMMARY Frontotemporal dementia (FTD) was described by Arnold Pick more than a century ago. It is a type of dementia in which multiple clinical manifestations of behavior and language predominat. The first and most frequent subtype, called behavioral variant frontotemporal dementia (bvFTD), which, due to a variety of clinical presentations, can be confused with primary psychiatric conditions such as depression, bipolar disorder, obsessive-compulsive disorder, late-onset psychosis, impulse control disorders, and other pathologies. Recently, an important and promising stream of clinical, neurobiological, and genetic research offers fascinating insights into this disorder which, thus, becomes a paradigm of the intricate relationships between neurology and psychiatry. This review examines recent bibliography on bvFTD , with emphasis on aspects of its differential diagnosis.

RESUMEN La demencia frontotemporal (DFT) fue descrita por Arnold Pick hace más de un siglo. Se trata de un tipo de demencia en el que predominan múltiples manifestaciones clínicas de conducta y lenguaje. Un primer subtipo, denominado demencia frontotemporal variante conductual (DFTvc) es el más frecuente y, debido a sus variadas formas de presentación, puede ser confundido con cuadros psiquiátricos primarios como depresión, trastorno bipolar, trastorno obsesivo-compulsivo, psicosis de inicio tardío, trastornos de control de impulsos y otras patologías. En épocas recientes se ha desarrollado una importante y prometedora corriente de investigaciones clínicas, neurobiológicas y genéticas, que ofrecen fascinantes perspectivas acerca de este trastorno, el cual se constituye así, en un paradigma de las intrincadas relaciones entre neurología y psiquiatría. Esta revisión examina bibliografía reciente sobre la DFTvc, con énfasis en aspectos de su diagnóstico diferencial.

Resumo. Testes cognitivos breves (TCBs) são necessários para a detecção precoce do comprometimento cognitivo, particularmente nos serviços de atenção primária. Objetivo: Este artigo descreve uma revisão sistemática dos TCBs avaliados em populações peruanas. Métodos: Utilizamos técnicas de mapeamento sistemático para identificar artigos sobre testes de triagem para comprometimento cognitivo envolvendo indivíduos peruanos. Incluímos estudos publicados em inglês e espanhol até 2018. Revisamos 6 bancos de dados de referência na rede da Biblioteca Virtual em Saúde e no Web of Science; Scopus (MEDLINE) e banco de dados EMBASE. Resultados: Dez dos 447 artigos preencheram os critérios de inclusão. Os estudos incluíram amostras ambulatoriais (9) e comunitárias (2). Os critérios de elegibilidade entre os estudos foram semelhantes. Embora os diferentes protocolos tenham sido aplicados, os critérios diagnósticos foram padronizados. Para a discriminação entre demência e controles, INECO Frontal Screening (IFS) (AUC: 0.99), Addenbrooke’s Cognitive Examination (ACE) (AUC: 0.95 to 1.00) mostraram desempnho superior, assim como o Memory Alteration Test (M@T) (AUC: 1.00) o Desenho do relógio (CDT-Mv) (AUC: 0,94 a 1,00) para discriminação entre a doença de Alzheimer (DA) e os controles. Conclusão: As evidências disponíveis são limitadas. No entanto, nossa análise com dados nacionais sugere que o ACE pode ser uma boa opção sempre que possível com pacientes peruanos. Alternativamente, o M @ T e o IFS podem ser usados para rastrear pacientes com suspeita de DA ou DFT, respectivamente.

Abstract. Brief cognitive tests (BCTs) are necessary for early detection of cognitive impairment, particularly in primary care settings. Objective: This report describes a systematic review of BCTs evaluated in Peruvian populations. Methods: We used systematic mapping techniques to identify articles on screening tests for cognitive impairment involving Peruvian subjects. We included studies published in English and Spanish up to 2018. We reviewed 6 reference databases within the Virtual Health Library network, as well as the Web of Science, Scopus (MEDLINE), and EMBASE databases. Results: Ten out of 447 articles met the inclusion criteria. Studies included both outpatient (9) and community-based (2) samples. Eligibility criteria of the studies were similar. Although different protocols were applied, the diagnostic criteria were standardized. For discrimination between dementia and controls, IFS (AUC: 0.99) and ACE (AUC: 0.95 to 1.00) showed superior performance, as did the M@T (AUC: 1.00) and CDT-Mv (AUC: 0.94 to 1.00) for discriminating between Alzheimer’s disease (AD) and controls. Conclusion: The available evidence is limited. However, our analysis of national data suggests that the ACE may be a good choice whenever it can be applied to Peruvian patients. Alternatively, the M@T and IFS can be used for screening patients with suspected AD or FTD, respectively.

Frontotemporal dementia - behavioral variant (FTD-bv), is an important cause of disability in adults under 65 years of age. It is postulated as a neurological disease with predominantly psychiatric manifestations and, therefore, constitutes a frequent differential diagnosis in psychiatric pathologies of not early onset. Although traditionally the absence of memory impairment was considered among its diagnostic criteria - as opposed to Alzheimer’a disease (AD) -, several studies have found until 15% of prevalence of cases with frank mnemonic deterioration, as well as neuroimaging of one and the other can have overlap. Currently, the presence of "phenocopy syndromes" - clinical pictures similar to FTD-bv but without cognitive impairment- and cases of AD with disinhibition and behavioral symptoms, make the clinical diagnosis more complex and suggest the insufficiency of the established diagnostic criteria and the necessary adoption of paraclinical criteria. To this purpose, we present an illustrative case of FTD-bv with memory impairment and Alzheimer-like neuroimages, and we review the pertinent bibliography.

Resumen La Demencia frontotemporal – variable conductual (DFT-vc), es una importante causa de discapacidad en adultos menores de 65 años. Se postula como una enfermedad neurológica con manifestaciones predominantemente psiquiátricas y, por tanto, constituye un frecuente diagnóstico diferencial ante patologías psiquiátricas de inicio no temprano. Aunque tradicionalmente se consideraba entre sus criterios diagnósticos a la ausencia de deterioro de la memoria -como en la Enfermedad de Alzheimer (EA)-, diversos estudios registran hasta un 15% de prevalencia de casos con franco deterioro mnésico, igualmente las neuroimágenes de uno y otro cuadro demencial pueden tener un traslape. Actualmente la presencia de “síndromes de fenocopia” -cuadros clínicos semejantes a DFT-vc pero sin deterioro cognitivo- y casos de EA con síntomas de desinhibición y conductuales, tornan más complejo el diagnóstico clínico y sugieren la insuficiencia de los criterios establecidos para el diagnóstico y la necesaria adopción de criterios paraclínicos. Con ese fin presentamos un caso ilustrativo de DFT-vc con deterioro de la memoria, y revisamos la bibliografía pertinente.

By the middle of the 19th Century the concept of Dementia, as an irreversible entity associated with the aging process, came into focus thanks to the work of Esquirol, who was one of the first to propose a descriptive approach to the clinical picture, and Bayle, who was the first to suggest that Dementia was an illness attributable to injuries of the Central Nervous System. Around 1900, Alois Alzheimer described the pathology of the injuries of two distinct entities, the first described by him, and the second by Arnold Pick (known today as Alzheimer´s Disease and Frontotemporal Dementia respectively). The advances in brain-imaging techniques and studies of cerebrospinal fluid led to improvements of the clinical diagnostic criteria for the diverse types of dementia, with a clinical- biological focus. Nevertheless, the most recent recommendations suggest Alzheimer´s disease to be approached from a purely biological focus.

A mediados del siglo XIX se empezó a enfocar el concepto de Demencia, como una entidad irreversible asociada a la edad, Esquirol fue uno de los primeros en plantear una aproximación descriptiva del cuadro clínico, y Bayle el primero en proponer Demencia como una enfermedad atribuible a lesiones en el sistema nervioso central. Fue alrededor del año 1900, que Alois Alzheimer precisó las lesiones patológicas de dos entidades clínicas distintas, la primera descrita por él mismo, y la segunda por Arnold Pick (conocidas hoy como enfermedad de Alzheimer y demencia frontotemporal respectivamente). Conforme progresaron las técnicas de imágenes cerebrales y estudios de líquido cefalo-raquídeo fueron mejorando los criterios de diagnóstico para los diversos tipos de demencia, con un enfoque clínico-biológico. Las recomendaciones más recientes, sin embargo proponen un enfoque exclusivamente biológico de la enfermedad de Alzheimer.

Multiple sclerosis is an inflammatory, autoimmune and neurodegenerative central nervous system disease characterized by motor and sensitive function loss; it is considered to be one of the principal causes of disability in young adults. Recently, cognitive impairment has gain considerable attention because it is a frequent symptom that causes disability. Cognitive impairment it is present in 40 to 65% of patients and affectsspeed of information processing, complex attention, working memory, visual and verbal memory, verbal fluency and executive functions. It may be present in radiologically isolated syndrome, clinically isolated síndrome and in the different stages of the disease; it is responsible for patient’s dependence and for the difficulties to maintain or get an employment. Cognitive impairment is associated to thalamic atrophy and a correlation with brain atrophy and cerebral lesional volume has been observed. Different evaluation tools are available, there are 5 minutes short screening tests and comprehensive 90 minutes batteries. Regarding cognitive impairment treatment, there is not a specific pharmacological treatment, nevertheless, disease modifying therapies could have a favorable influence on cognitive function because of their effects in the reduction of inflammatory activity and brain atrophy. There are no conclusive data about the efficacy of cognitive stimulation because of the diverse techniques employed and the different measures used to evaluate the results of the interventions.

La esclerosis múltiple es una enfermedad inflamatoria, autoinmune y neurodegenerativa del sistema nervioso central caracterizada por pérdida de la función motora y sensitiva; es considerada una de las principales causas de discapacidad en el adulto joven. Recientemente, se le ha dado gran importancia al deterioro cognitivo, por ser un síntoma frecuente y discapacitante. Este deterioro está presente en un 40 a 65% de los pacientes y afecta la velocidad de procesamiento de información, atención compleja, memoria de trabajo, memoria visual y verbal, fluencia verbal y funciones ejecutivas. Se puede presentar en el síndrome radiológico aislado, en el síndrome clínico aislado y en las diferentes fases de la enfermedad; además, es el responsable de la dependencia de algunos pacientes y de las dificultades para mantener o conseguir empleo. Este déficit cognitivo se asocia a atrofia del tálamo y se ha observado una correlación con las medidas de atrofia y con el volumen lesional cerebral. Existen diferentes herramientas para su evaluación; hay pruebas de cribado breves de 5 minutos de duración, hasta baterías extensas de 90 minutos. Respecto al tratamiento de las alteraciones cognitivas, no existe un tratamiento farmacológico específico; sin embargo, se considera que los fármacos modificadores de la enfermedad podrían tener una influencia favorable en la función cognitiva por sus efectos en la reducción de la actividad inflamatoria y la atrofia cerebral. En cuanto a la estimulación cognitiva, no existen datos concluyentes por las diferentes técnicas empleadas y las distintas medidas utilizadas para evaluar los resultados de las intervenciones.

Resumo O diagnóstico e tratamento da depressão em pacientes com doença de Parkinson (DP) é inadequado, frequentemente contribuindo para a redução da qualidade de vida, progressão rápida da doença, maior comprometimento cognitivo e aumento da carga de cuidado aos familiares de pacientes com DP. Objetivo: Determinar os fatores associados à depressão na DP e examinar a frequência de sintomas depressivos entre pacientes com DP. Métodos: Este estudo foi um estudo observacional, analítico, multicêntrico, de uma coorte transversal conduzida entre julho de 2016 e maio de 2017. Os pacientes com DP foram recrutados em clínicas de neurologia em Lima, Peru. Todas as análises estatísticas foram realizadas por meio de estatística descritiva. Análises de regressão logística bivariada e multivariada foram calculadas usando STATA. Resultados: Dos 124 pacientes (idade média: 68,7 anos; 58% homens) incluídos no estudo, 60,5% (75/124) apresentaram sintomas de depressão; apenas 20% (25/124) receberam antidepressivos. Os fatores associados à depressão na DP incluíram: desemprego, quedas, congelamento da marcha, movimentos involuntários micrografia, postura inclinada, hiposmia, distúrbios do movimento no sono, progressão rápida da doença e uso de inibidores da MAO. Além disso, houve diferenças estatisticamente significativas encontradas em: duração da doença, escores nas escalas UPDRS e MMSE, estágio Hoehn e Yahr (HY) e tempo de duração da L-dopa entre os pacientes com DP, entre aqueles com e sem sintomas depressivos. Conclusão: Fatores associados a sintomas depressivos em pacientes com DP foram hiposmia, rápida progressão da doença, uso de L-dopa e uso de IMAOs. A frequência de sintomas depressivos em pacientes com DP é alta; o diagnóstico precoce e o tratamento imediato são necessários para melhorar a qualidade de vida e o ambiente familiar.

Abstract The diagnosis and treatment of depression in patients with Parkinson’s disease (PD) is inadequate, often contributing to a reduced quality of life, rapid disease progression, higher cognitive impairment, and an increased burden of care for family members of patients with PD. Objective: To determine the factors associated with depression in PD and to examine the frequency of depressive symptoms among patients with PD. Methods: This study was an observational, analytical, multicenter study of a cross-sectional cohort, conducted between July 2016 and May 2017. PD patients were recruited from neurology clinics in Lima, Peru. All statistical analyses were performed using descriptive statistics. Bivariate and multivariate logistic regression analyses were calculated using STATA. Results: Out of 124 patients (average age: 68.7 years; 58% males) included in the study 60.5% (75/124) presented with symptoms of depression; only 20% (25/124) received antidepressants. Factors associated with depression in PD included: unemployment, falls, freezing of gait, involuntary movements micrographia, stooped posture, hyposmia, movement disorders in sleep, rapid disease progression, and the use of MAOIs. Furthermore, statistically significant differences were found in disease duration, UPDRS and MMSE scores, Hoehn and Yahr (HY) stage, and length of time taking L-dopa between PD patients with and without depressive symptoms. Conclusion: Factors associated with depressive symptoms in patients with PD were hyposmia, rapid progression of the disease, the use of L-dopa, and use of MAOIs. The frequency of depressive symptoms in patients with PD is high; early diagnosis and prompt treatment are needed to improve their quality of life and the family environment.

Physicians with specialty in geriatrics, psychiatry and neurology have not received training about the differential diagnosis of dementia, particularly regarding fronto-temporal dementia (FTD). Objective: To assess the level of knowledge of physicians about FTD. Material and Method: The survey was carried out during symposiums and scientific congresses from January 2016 to July 2017. Inclusion criteria: being a general practitioner or specialist in Geriatrics, Neurology and psychiatry whose training process as a physician and specialist has been carried out in Peruvian universities. We analyzed 217 surveys of which 13 were eliminated. The survey was divided into three parts, the first about general data of doctors, the second part was about the diagnosis of dementia; and the third on specific data of FTD. STATA version 12 was used for the statistical analysis. Results: 90% of the doctors surveyed were specialists in: Psychiatry (41.3%), Geriatrics (31.3%) and Neurology (15.4%). The 98.5% of physicians surveyed claimed to diagnose dementia. The medical specialists performed better when identifying the tests used. 72.1% of the doctors surveyed could not recognize any type of FTD, while 27.9% recognized at least 1 type of FTD. 43.8% of physicians surveyed identified 5 or more of the symptoms presented in FTD. Conclusions: The level of knowledge among medical specialists surveyed about the diagnosis of dementia is acceptable, however it is deficient when it is specifically about the diagnosis of FTD.

Resumen Médicos especialistas en geriatría, psiquiatría y neurología no han recibido entrenamiento respecto al diagnóstico diferencial de demencia, en particular acerca de demencia frontotemporal (DFT). Objetivo: Evaluar el nivel de conocimiento de los médicos sobre DFT. Material y Método: La encuesta se llevó a cabo durante simposios y congresos científicos desde enero de 2016 hasta julio de 2017. Los criterios de inclusión fueron: ser médico general o especialista en Geriatría, Neurología y Psiquiatría cuyo proceso de formación como médico y especialista haya sido realizado en universidades peruanas. Se analizaron 217 encuestas de las cuales 13 fueron eliminadas. La encuesta estuvo dividida en tres partes: la primera sobre datos generales de los médicos, la segunda parte fue acerca del diagnóstico de demencia y la tercera sobre datos específicos de DFT. Para el análisis estadístico se utilizó STATA versión 12. Resultados: El 90% de los médicos encuestados fueron médicos especialistas en: Psiquiatría (41,3%), Geriatría (31,3%) y Neurología (15,4%). El 98,5% de médicos encuestados afirmó diagnosticar demencia. Los médicos especialistas tuvieron un mejor desempeño al momento de identificar las pruebas empleadas. El 72,1% de médicos encuestados no pudo reconocer ningún tipo de DFT, mientras que el 27,9% reconoció al menos 1 tipo de DFT. El 43,8% de médicos encuestados identificó correctamente 5 o más de los síntomas presentados en DFT. Conclusiones: El nivel de conocimientos entre médicos especialistas encuestados acerca del diagnóstico de demencia es aceptable, sin embargo es deficiente cuando se trata específicamente acerca del diagnóstico de DFT.

The evaluation of apathy in neuropsychiatric pathology is very important in research and in clinical practice. Many times their symptoms are underdiagnosed as part of depression and other conditions. The present review addresses the scales most used in recent decades for the assessment of apathy and offers recommendations and general assessments of their use and utility based on the available literature. Apart from the differences between scales, the task of standardizing the diagnosis of apathy in clinical practice and national research is a need that should not be postponed by having sufficient and appropriate tools to date that have evolved from the definition of Marin to the Dimensional Apathy Scale (DAS). It is suggested that studies validate and culturally adapt these tools to our population environment and put into practice the quantitative measurement of apathy in the clinical environment.

La evaluación de la apatía en patología neuro-psiquiátrica es muy importante en la investigación y en la práctica clínica. Muchas veces sus síntomas son sub-diagnosticados o diagnosticados como depresión y otras condiciones. La presente revisión aborda las escalas más utilizadas las últimas décadas para la valoración de apatía y ofrece recomendaciones y apreciaciones generales sobre su uso y utilidad basada en la bibliografía disponible. Al margen de las diferencias entre escalas la tarea de estandarizar el diagnóstico de apatía en la práctica clínica y la investigación nacionales una necesidad que no debe postergarse al contar con herramientas suficientes y adecuadas a la fecha que han evolucionado desde la definición de Marin hasta la escala Dimensional Apathy Scale (DAS). Se sugiere estudios que validen y adapten culturalmente estas herramientas a nuestro entorno poblacional y pongan en práctica la medición cuantitativa de la apatía en la consulta clínica

Many diseases require surgery as a treatment, either emergency or elective. Surgeries can have various complications; However, the possible postoperative cognitive alterations are not considered: delirium of anesthetic awakening, postoperative delirium and postoperative cognitive dysfunction (PCDP). DCPO is a clinical syndrome characterized by alterations in memory, concentration, attention, understanding of language and social integration after the use of anesthesia and surgery that persists after three months; although some reports consider that it would not be an individual clinical entity. Its incidence varies from 5.1 to 52.5% depending on the population studied, type of surgery, time of evaluation from surgery and neuropsychological battery used. The risk factors for DCPO are: advanced age, previous cognitive impairment, severity of coexisting diseases, severity of the surgery, duration and type of anesthesia, occurrence of complications and educational level; It is essential to carry out a neuropsychological evaluation before and after the surgery for its diagnosis. The proposed etiopathogenic mechanisms are: age, changes in cerebral perfusion, sleep disturbances, inflammation, effects of anesthetic agents, and fundamentally neuroinflammation. The DCPO is a frequent and rarely suspected entity, although its diagnosis is controversial. It is suggested that patients who will undergo major elective surgeries, especially cardiac and cerebral surgeries, undergo previous neuropsychological evaluation at 3 months, and intraoperative electroencephalographic monitoring to reduce the incidence of DCPO.

Numerosas enfermedades requieren como tratamiento una cirugía, ya sea de emergencia o electiva. Las cirugías pueden tener diversas complicaciones; sin embargo no se consideran las posibles alteraciones cognitivas postoperatorias: delirio del despertar anestésico, delirio postoperatorio y disfunción cognitiva postoperatoria (DCPO). La DCPO es un síndrome clínico caracterizado por alteraciones en la memoria, concentración, atención, comprensión del lenguaje e integración social posterior al uso de anestesia y cirugía que persiste después de tres meses; aunque algunos reportes consideran que no sería una entidad clínica individual. Su incidencia varía del 5,1 al 52,5% dependiendo de la población estudiada, tipo de cirugía, tiempo de la evaluación desde la cirugía y batería neuropsicológica empleada. Los factores de riesgo para DCPO son: edad avanzada, deterioro cognitivo previo, gravedad de enfermedades coexistentes, severidad de la cirugía, duración y tipo de la anestesia, ocurrencia de complicaciones y nivel educativo; siendo imprescindible la realización de una evaluación neuropsicológica antes y después de la cirugía para su diagnóstico. Los mecanismos etiopatogénicos propuestos son: la edad, cambios en la perfusión cerebral, disturbios del sueño, inflamación, efectos de los agentes anestésicos, y fundamentalmente la neuroinflamación. La DCPO es una entidad frecuente y escasamente sospechada, aunque su diagnóstico es controversial. Se sugiere que los pacientes que serán sometidos a cirugías electivas mayores, en especial las cardiacas y cerebrales, sean sometidos a evaluación neuropsicológica previa y a los 3 meses, así como a monitoreo electroencefalográfico intraoperatorio para disminuir la incidencia de DCPO.

RESUMO. Há evidências limitadas sobre a progressão do desempenho cognitivo durante o estágio pós- acidente vascular cerebral (AVC). Objetivo: Avaliar a evolução do desempenho cognitivo em pacientes com AVC sem comprometimento cognitivo vascular (SCCV), pacientes com comprometimento cognitivo leve vascular (CCL-V) e pacientes com demência vascular (DV). Métodos: Coorte prospectivo de pacientes ambulatoriais com AVC de dois centros médicos secundários de Lima, Peru. Realizamos avaliações padronizadas no diagnóstico definitivo (avaliação inicial) e controles aos 6 e 12 meses depois, incluindo um conjunto de testes cognitivos breves: Clinical Dementia Rating (CDR), Addenbrooke's Cognitive Examination (ACE), and INECO Frontal Screening (IFS). Resultados: Completaram o estudo 152 pacientes ambulatoriais, mostrando que as médias de pontuação da CDR apresentaram aumento progressivo (0,34 a 0,46), contrariamente ao observado com ACE e IFS (78,18 a 76,48 e 23,63 a 22,24). A soma das caixas do teste CDR mostrou que os pacientes com comprometimento cognitivo vascular (CCL-V e DV) apresentaram piora progressiva (0,79 a 0,16). Por outro lado, em indivíduos SCCV, essa tendência não foi observada. O gráfico box-plot para ACE e IFS mostrou que, para a maioria dos tipos de AVC observados, tanto os pacientes SCCV como aqueles com CCV apresentaram piora progressiva. Conclusão: De acordo com os resultados de ACE e IFS durante o acompanhamento de 1 ano, o desempenho cognitivo em pacientes com AVC piora, o que é particularmente consistente em pacientes com AVC tipo infarto.

ABSTRACT. There is limited evidence about the progression of cognitive performance during the post-stroke stage. Objective: To assess the evolution of cognitive performance in stroke patients without vascular cognitive impairment (VCI), patients with vascular mild cognitive impairment (MCI), and patients with vascular dementia (VD). Methods: A prospective cohort of stroke outpatients from two secondary medical centers in Lima, Peru was studied. We performed standardized evaluations at definitive diagnosis (baseline evaluation), and control follow-ups at 6 and 12 months, including a battery of short cognitive tests: Clinical Dementia Rating (CDR), Addenbrooke's Cognitive Examination (ACE), and INECO Frontal Screening (IFS). Results: 152 outpatients completed the follow-up, showing progressive increase in mean score on the CDR(0.34 to 0.46), contrary to the pattern observed on the ACE and IFS (78.18 to 76.48 and 23.63 to 22.24). The box plot for the CDR test showed that VCI patients had progressive worsening (0.79 to 0.16). Conversely, this trend was not observed in subjects without VCI. The box plot for the ACE and IFS showed that, for the majority of the differentiated stroke types, both non-VCI and VCI patients had progressive worsening. Conclusion: According to both ACE and IFS results during a 1-year follow-up, the cognitive performance of stroke patients worsened, a trend which was particularly consistent in infarction-type stroke patients.

RESUMO. Demência mista é denominação usual para a coexistência da doença de Alzheimer e doença cerebrovascular (DCV) no mesmo paciente demente. Atualmente, seu diagnóstico e tratamento continuam sendo um desafio. Fornecer uma visão geral da epidemiologia, patogênese, história natural, diagnóstico e terapia da Demência Mista Alzheimer-Vascular (DMAV). Foi realizada revisão da literatura buscando por artigos publicados entre 1990 e 2016 usando palavras-chave relacionadas ao DMAV. Estudos neuropatológicos indicam que DMAV é um achado patológico muito comum em idosos, com uma prevalência de cerca de 22%. A distinção entre demência de Alzheimer e demência vascular (DV) é complexa porque suas apresentações clínicas podem se sobrepor. Existem critérios internacionais para o diagnóstico DMAV. A terapia farmacológica mostra benefícios clínicos modestos que são semelhantes para todos os medicamentos utilizados em pacientes com demência de Alzheimer e DV. A terapia não-farmacológica inclui o manejo rigoroso dos fatores de risco cardiovascular (especialmente a hipertensão) e a promoção de uma dieta saudável. O diagnóstico e o tratamento do DMAV não podem ser melhorados sem outros estudos. Os medicamentos atualmente disponíveis fornecem apenas benefícios clínicos modestos, depois que DMAV instalou-se. Em indivíduos em risco, a terapia anti-hipertensiva e uma dieta saudável devem ser recomendadas para prevenir ou retardar a progressão da DMAV.

ABSTRACT. Mixed dementia is the coexistence of Alzheimer's disease and cerebrovascular disease (CVD) in the same demented patient. Currently, its diagnosis and treatment remains a challenge for practitioners. To provide an overview of the epidemiology, pathogenesis, natural history, diagnosis, and therapy of Mixed Vascular-Alzheimer Dementia (MVAD). The literature was reviewed for articles published between 1990-2016 by using the keywords linked to MVAD. Neuropathological studies indicate that MVAD is a very common pathological finding in the elderly with a prevalence about of 22%. The distinction between Alzheimer's dementia and vascular dementia (VD) is complex because their clinical presentation can overlap. There are international criteria for the MVAD diagnosis. The pharmacologic therapy shows modest clinical benefits that are similar among all drugs used in patients with Alzheimer's dementia and VD. The non-pharmacologic therapy includes the rigorous management of cardiovascular risk factors (especially hypertension) and the promotion of a healthy diet. The diagnosis and treatment of MVAD cannot be improved without further studies. Currently available medications provide only modest clinical benefits once a patient has developed MVAD. In subjects at risk, the antihypertensive therapy and healthy diet should be recommend for preventing or slowing the progression of MVAD.

Resumen Objetivo : validar y evaluar el rendimiento de la Global Deteriorarion Scale (GDS) en una población que acude a una unidad especializada de Lima. Pacientes y métodos: investigación de tipo transversal con un diseño descriptivo comparativo. El estudio incluyó 215 individuos seleccionados de forma abierta, que acudieron a la unidad de diagnóstico de deterioro cognitivo y prevención de demencia. Se estudiaron tres grupos: 60 controles, 40 con diagnóstico de deterioro cognitivo leve y 115 con demencia. Los individuos fueron sometidos a evaluaciones sucesivas: cribado, diagnóstico y estadiaje de demencia y tipo de demencia. La validez y fiabilidad de la clasificación de severidad fue demostrada mediante la concordancia entre la medición del Global Deteriorarion Scale con el Clinical Dementia Rating (CDR). El rendimiento de Global Deteriorarion Scale se valoró mediante la obtención de los valores de sensibilidad y especificidad. Resultados : los promedios de edad fueron de 69, 70, y 74 años para los controles, los pacientes con deterioro cognitivo leve y los pacientes con demencia, respectivamente. La Global Deteriorarion Scale tuvo una buena correlación con Clinical Dementia Rating (r de Spearman =0,97; P=0,0001). La sensibilidad de la escala para establecer estadio de demencia fue de 79 %, con especificidad del 100 % para cualquier categoría de demencia según los criterios diagnósticos estándares y según Clinical Dementia Rating. Conclusiones : se encontró una correlación casi perfecta entre Global Deteriorarion Scale y Clinical Dementia Rating; sin embargo, la Global Deteriorarion Scale presenta una sensibilidad moderada para establecer el estadio de demencia con respecto a Clinical Dementia Rating, mostrando además ser utilidad en el diagnóstico de deterioro cognitivo leve.

Abstract Objective: To validate and evaluate diagnostic accuracy of the Global Deteriorarion Scale (GDS) in a population of a specialized unit of Lima. Patients and Methods: This research is a comparative cross-sectional descriptive design. The study included 215 individuals selected openly, who attending in the diagnostic unit of cognitive impairment and dementia prevention. Three groups were studied: 60 controls, 40 individuals diagnosed with mild cognitive impairment (MCI) and 115 with dementia diagnosis. They were assessments in three phases: screening, diagnosis and staging of dementia, and type of dementia. The validity and reliability of the classification of severity was demonstrated by measuring the correlation between the GDS with the CDR (Clinical Dementia Rating). The diagnostic accuracy of GDS was evaluated by obtaining the values of sensitivity and specificity. Results: The average age was 69, 70, and 74 years for controls, patients with MCI and patients with dementia respectively. GDS had a good correlation with CDR (Spearman r = 0.97, P = 0.0001). The sensitivity of the GDS to set stage of dementia for any category of dementia was 79 % and specificity of 100 % according to standard diagnostic criteria and according to CDR. Conclusions: We demonstrated an almost perfect correlation between GDS and CDR, however GDS has a moderate sensitivity to set the stage dementia regarding CDR also proving to be useful in the diagnosis of MCI.

The comprehensive treatment of a patient with dementia includes management of cognitive, psychological and behavioral symptoms, and the preservation of adequate levels of functionality. Pharmacological strategies have demonstrated a marginal benefit with adverse events that limit optimal doses, and decrease treatment adherence. Music therapy is a non-pharmacological strategy that could slightly improve some cognitive aspects such as autobiographical memory; further evidence indicates that it could also generate a modest decrement of concomitant anxiety, agitation and depression Additional studies are required, however, with larger patient samples and better methodological designs.

El tratamiento integral de un paciente con demencia incluye el manejo de síntomas cognitivos, psicológicos y conductuales y la preservación de un nivel adecuado de funcionalidad. Las estrategias farmacológicas han demostrado un beneficio marginal con eventos adversos que limitan las dosis óptimas y disminuyen la adherencia a los tratamientos. La terapia musical es una estrategia no farmacológica que podría mejorar levemente algunos aspectos cognitivos como la memoria autobiográfica; la evidencia existente indica que este enfoque podría generar también un modesto efecto de disminución de ansiedad, agitación y depresión concomitantes. Se requieren, sin embargo, estudios adicionales con muestras mayores de pacientes y mejoría de sus diseños metodológicos.

ABSTRACT Objectives. Evaluate the performance of clock drawing test- Manos versión (PDR-M) and Mini Mental State Examination -Peruvian version (MMSE) to detect dementia in a sample based on urban community of Lima, Peru. Materials and methods. This study is a secondary analysis database, observational, analytical and cross-sectional, the gold standard was the clinical and the neuropsychological evaluations together. Performance testing individually and in combination were evaluated.. Data were obtained from prevalence study conducted in 2008 in Cercado de Lima. Results. MMSE performance for evaluation of patients with dementia of any kind showed sensitivity of 64,1%, specificity of 84,1%, PPV of 24.4%, NPV of 96.7%, PLR of 4,03 and NLR of 0,43. PDR-M showed sensitivity of 89,3%, specificity of 98,1%, PPV of 79.3%, NPV of 99.1%, PLR of 47,79 and NLR of 0,11. When both tests were applied, and at least one of them was positive, they showed sensitivity 98.1%, specificity 84.1%, PPV of 33.1%, NPV of 99.8%, PLR of 6,17 and NLR of 0,02. When performing separate analysis of Alzheimer-type dementia and non- Alzheimer dementia, the values of the parameters do not differ substantially from those obtained for dementia of any kind. Conclussions. The combination of MMSE and PDR-M show good discriminative ability to detect moderate and severe dementia in population living in urban community in Lima.

RESUMEN Objetivos. Evaluar el rendimiento de la prueba de dibujo de reloj en versión de Manos (PDR-M) y Mini Mental State Examination (MMSE) en su versión peruana, para detectar demencia de cualquier tipo en adultos mayores residentes de una comunidad urbana de Lima, Perú. Materiales y métodos. Análisis secundario de base de datos, de tipo observacional, analítico y transversal; con diseño de prueba diagnóstica, teniendo como prueba estándar a las evaluaciones clínica y neuropsicológica en conjunto. Se evaluó el rendimiento de las pruebas individualmente, así como de forma combinada. Resultados. El rendimiento de MMSE para la evaluación de pacientes con demencia de cualquier tipo presentó sensibilidad de 64,1%, especificidad de 84,1%, VPP de 24,4%, VPN de 96,7%, LR (+) de 4,03 y LR (-) de 0,43. La PDR-M presentó sensibilidad de 89,3%, especificidad de 98,1%, VPP de 79,3%, VPN de 99,1%, LR (+) de 47,79 y LR (-) de 0,11. Cuando se aplicaron ambas pruebas, y al menos una de ellas fue positiva, presentaron sensibilidad de 98,1%, especificidad de 84,1%, VPP de 33,1%, VPN de 99,8%, LR (+) de 6,17 y LR (-) de 0,02. Al realizar el análisis, por separado, de demencia tipo alzhéimer y no alzhéimer, los valores de los parámetros no se diferencian sustancialmente de los obtenidos para demencias de cualquier tipo. Conclusiones. La combinación de MMSE y PDR-M demuestran un buen rendimiento para detectar demencia en estadios moderado y severo en población residente de una comunidad urbana de Lima.