Abstract

Detecting and monitoring cognitive deficits in elderly populations are necessary, as they can impact individuals´ functionality. This integrative review aims to analyze the scientific production on the use of cognitive assessment instruments in Brazilian elderly individuals through articles published in the last five years, indexed in the Web of Science, Pubmed, Scopus and Bireme databases. Inclusion criteria were original articles published in English and Portuguese from 2012 to 2016, the age criterion to define elderly individuals and scores higher than 6 in the adapted CASP. The exclusion criterion was conference abstracts submitted for publication. The final sample consisted of 100 articles. Sixty-one cognitive assessment instruments were used in the studies, especially the Mini-Mental State Examination. This review features the use of cognitive instruments in the Brazilian literature, their different versions and domains evaluated. The literature includes a large number of instruments. The most used tests were the MMSE (version proposed by Brucki et al.), the Verbal Fluency Test (“animal” category) and the Digit Span Memory Test (forward span and backward span). The findings presented in this review are relevant not only for observational and experimental research but also for clinical practice.

Elderly; Geriatric assessment; Cognition

Introduction

Increasing life expectancy and aging of the Brazilian population, associated with their impacts, have been the focus of studies for years. According to the Brazilian Institute of Geography and Statistics (IBGE) census in 2010, older adults accounted for 11% of the Brazilian population and it is estimated that they will reach 13.4% by 2030¹1. Ervatti LG, Borges GM, Jardim AP. Mudança Demográfica no Brasil no início do século XXI: Subsídios para as projeções da população. Rio de Janeiro: IBGE; 2015..

Elderly people are exposed to functional losses due to aging (senescence) and/or age-related diseases (senility). In addition, some diseases have a higher prevalence in this age group, such as dementia. Alzheimer’s disease is the most common type of dementia, which is coupled with severe debilitating cognitive deficits²2. Freitas EV, Py L, Cançado FAX, Doll J, Gorzoni ML. Tratado de geriatria e gerontologia. Rio de Janeiro: Guanabara Koogan; 2013..

In order ensure reliable detection and monitoring of cognitive deficit, information from family members/caregivers should be provided, and patients’ follow up, identification of clinical history and standardized tests³3. Young J, Meagher D, MacLullich A. Cognitive assessment of older people. BMJ 2011; 343:d5042. should also be performed. These tests may include imaging tests, biochemical exams and/or assessment instruments. The selection of a cognitive assessment instrument should be based on its reliability and whether its score results reflect the actual status of the patient without the influence of other factors, such as depressive symptoms, delirium, low level education or hearing impairment³3. Young J, Meagher D, MacLullich A. Cognitive assessment of older people. BMJ 2011; 343:d5042..

With the objective of analyzing the recent scientific production on the use of cognitive assessment instruments in the Brazilian elderly population, the following question was addressed in this integrative review: Which instruments are currently used for cognitive assessment in the Brazilian elderly population? Based on the findings, the characteristics of the most used instruments were analyzed.

Method

After defining the guiding question, the instruments were assessed for eligibility according to the following steps: 1) specification of inclusion criteria (original articles published in English and Portuguese from 2012 to 2016, the age criterion to define elderly individuals and scores higher than 6 in the adapted CASP) and exclusion criteria (conference abstracts submitted for publication); 2) searches using the following Health Science Descriptors (DeCS) and Boolean operators: [“cognition” OR “dementia” AND “geriatric assessment”], in the Scopus, Bireme, Pubmed and Web of Science databases in November 2016; 3) pre-selection of articles by reading the titles and abstracts and excluding duplicates; 4) critical assessment of the articles after reading them in full; and 5) presentation and discussion of results. The screening process was conducted by two reviewers independently, and disagreements were resolved by a third reviewer.

Two instruments were used for the critical assessment of the articles: the adapted Critical Appraisal Skill Program (CASP), which classifies the quality of the article from 0 to 10, with a score ˃ 6 indicating good methodological quality and reduced bias; and the Agency for Healthcare and Research and Quality (AHRQ), which hierarchically ranks the level of evidence of the study in (I) systematic review or meta-analysis, (II) randomized clinical trials, (III) clinical trials without randomization, (IV) cohort and case-control studies, (V) systematic review of descriptive and qualitative studies and (VI) descriptive or qualitative study⁴4. Toledo MM. Vulnerabilidade de adolescentes ao HIV/AIDS: Revisão Integrativa [dissertação]. São Paulo: Universidade de São Paulo; 2008.,⁵5. Stillwell SB, Fineout-Overholt E, Melnyk BM, Williamson KM. Evidence-based practice: step by step. Am J Nurs 2010; 110(5):41-47..

Results

The screening process of articles from the Web of Science, Pubmed, Scopus and Bireme databases is summarized in Figure 1. The final sample consisted of 100 articles⁶6. Alencar MA, Dias JMD, Figueiredo LC, Dias RC. Frailty and cognitive impairment among community-dwelling elderly. Arq Neuropsiquiatr 2013; 71(6):362-367.

7. Alexandre TS, Corona LP, Nunes DP, Santos JLF, Duarte YAO, Lebrão ML. Disability in instrumental activities of daily living among older adults: gender differences. Rev Saude Publica 2014; 48(3):378-389.

8. Alexandre TS, Corona LP, Nunes DP, Santos JLF, Duarte YAO, Lebrão ML. Gender differences in incidence and determinants of disability in activities of daily living among elderly individuals: SABE study. Arch Gerontol Geriatr 2012; 55(2):431-437.

9. Alexandre TS, Duarte YAO, Santos JLF, Wong R, Lebrão ML. Prevalence and Associated Factors of Sarcopenia Among Elderly in Brazil: Findings from The Sabe Study. J Nutr Health Aging 2014; 18(3):284-290.

10. Alexandre TS, Duarte YAO, Santos JLF, Wong R, Lebrão ML. Sarcopenia according to the European Working Group Sarcopenia in older people (EWGSOP) versus dynapenia as a risk factor for disability in the elderly. J Nutr Health Aging 2014; 18(5):547-553.

11. Andrade FCD, Corona LP, Lebrão ML, Duarte YAO. Life expectancy with and without cognitive impairment among Brazilian older adults. Arch Gerontol Geriatr 2014; 58(2):219-225.

12. Ansai JH, Aurichio TR, Rebelatto JR. Relationship between dual task walking, cognition, and depression in oldest old people. Int Psycho Geriatr 2016; 28(1):31-38.

13. Ansai JH, Rebelatto JR. Effect of two physical exercise protocols on cognition and depressive symptoms in oldest-old people: A randomized controlled trial. Geriatr Gerontol Int 2015; 15(9):1127-1134.

14. Aprahamian I, Ladeira RB, Diniz BS, Forlenza OV, Nunes PV. Cognitive impairment in euthymic older adults with bipolar disorder: a controlled study using cognitive screening tests. Am J Geriatr Psychiatry 2014; 22(4):389-397.

15. Aprahamian I, Radanovic M, Nunes PV, Ladeira RB, Forlenza OV. The use of the Clock Drawing Test in bipolar disorder with or without dementia of Alzheimer’s type. Arq Neuropsiquiatr 2014; 72(12):913-918.

16. Araujo NB, Moraes HS, Silveira H, Arcoverde C. Vasques PE, Barca ML, Knapskog A, Engedal K. Coutinho ESF, Deslandes AC, Laks J Impaired cognition in depression and Alzheimer (AD): a gradient from depression to depression in AD. Arq Neuropsiquiatr 2014; 72(9):671-679.

17. Argimon IL, Irigaray TQ, Stein LM. Cognitive Development across Different Age Ranges in Late Adulthood. Universitas Psychologica 2013; 13(1):253-264.

18. Avellar M, Scoriels L, Madeira C, Vargas-Lopes C, Marques P, Dantas C, Manhães AC, Leite H, Panizzutti R. The effect of D-serine administration on cognition and mood in older adults. Oncotarget 2016; 7(11):11881-11888.

19. Avelino-Silva TJ, Farfel JM, Curiati JAE, Amaral JRG, Campora F, Jacob-Filho W. Comprehensive geriatric assessment predicts mortality and adverse outcomes in hospitalized older adults. BMC Geriatrics 2014; 14(129):1-8.

20. Avila R, Lopes MA, Nakano EY, Bottino CMC. Normative data of Fuld Object Memory Evaluation test for brazilian elderly population. Arq Neuropsiquiatr 2016; 74(2):138-144.

21. Baierle M, Vencato PH, Oldenburg L, Bordignon S, Zibetti M, Clarissa MT, Duarte MMMF, Veit JC, Somacal S, Emanuelli T, Grune T, Breusing N, Garcia SC. Fatty Acid Status and Its Relationship to Cognitive Decline and Homocysteine Levels in the Elderly. Nutrients 2014; 6(9):3624-3640.

22. Banhato EFC, Leite ICG, Guedes DV, Chaoubah A. Cognition in Elderly People: Study of the Short Form 8 (SF8) of the Wechsler-III Scale. Psicologia: Reflexão e Crítica 2012; 25(1):96-104.

23. Barcelos-Ferreira R, Nakano EY, Steffens DC, Bottino CMC. Quality of life and physical activity associated to lower prevalence of depression in community-dwelling elderly subjects from Sao Paulo. J Affect Disord 2013; 150(2):616-622.

24. Bez JPO, Neri AL. Gait speed, grip strength and self-rated health among the elderly: data from the FIBRA Campinas network, São Paulo, Brazil. Cien Saude Colet 2014; 19(8):3343-3353.

25. Boscatto EC, Duarte MFS, Coqueiro RS, Barbosa AR. Nutritional status in the oldest elderly and associated factors. Rev Assoc Med Bras. 2013; 59(1):40-47.

26. Brito TRP, Pavarini SCI. Relação entre apoio social e capacidade funcional de idosos com alterações cognitivas. Rev. Latino-Am. Enfermagem 2012; 20(4):677-684.

27. Caixeta GCS, Doná F, Gazzola JM. Cognitive processing and body balance in elderly subjects with vestibular dysfunction. Braz J Otorhinolaryngol 2012; 78(2):87-95.

28. Caldas VVA, Zunzunegui MV, Freire ANF, Guerra RO. Translation, cultural adaptation and psychometric evaluation of the Leganés cognitive test in a low educated elderly Brazilian population. Arq Neuropsiquiatr 2012; 70(1):22-27.

29. Camargos EF, Louzada LL, Quintas JL, Naves JOS, Louzada FM, Nóbrega OT. Trazodone Improves Sleep Parameters in Alzheimer Disease Patients: A Randomized, Double-Blind, and Placebo-Controlled Study. Am J Geriatr Psychiatry 2014; 22(12):1565-1574.

30. Castro-Costa E, Dewey ME, Uchôa E, Firmo JOA, Lima-Costa MF, Stewart R. Construct validity of the mini mental state examination across time in a sample with low-education levels: 10-year follow-up of the Bambuí Cohort Study of Ageing. Int J Geriatr Psychiatry 2014; 29(12):1294-1303.

31. Cecato JF, Fiorese B, Montiel JM, Bartholomeu D, Martinelli JE. Clock Drawing Test in Elderly Individuals with Different Education Levels: Correlation with Clinical Dementia Rating. Am J Alzheimers Dis Other Demen 2012; 27(8):620-624.

32. Cerutti-Kopplin D, Emami E, Hilgert JB, Hugo FN, Padilha DMP. Cognitive status of edentate elders wearing complete denture: Does quality of denture matter? J Dent 2015; 43(9):1071-1075.

33. Costa DS, Paula JJ, Rezende NA, Rodrigues LOC, Malloy-Diniz LF, Romano-Silva MA, Miranda DM. Neuropsychological impairments in elderly Neurofibromatosis type 1 patients. Eur J Med Genet 2014; 57(5):216-219.

34. Curcio C, Alvarado BE, Gomez F, Guerra F, Guralnik J, Zunzunegui MV. Life-Space Assessment scale to assess mobility: validation in Latin American older women and men. Aging Clin Exp Res 2013; 25(5):553-560.

35. Danielewicz AL, Wagner KJP, d’Orsi E, Boing AF. Is cognitive decline in the elderly associated with contextual income? Results of a population-based study in southern Brazil. Cad Saude Publica 2016; 32(5):1-11.

36. Diniz BS, Teixeira AL, Machado-Vieira R, Talib LL, Radanovic M, Gattaz WF, Forlenza OV. Reduced cerebrospinal fluid levels of brain-derived neurotrophic factor is associated with cognitive impairment in late-life major depression. J Gerontol B Psychol Sci. Soc. Sci. 2014; 69(6):845-851.

37. Fattori A, Oliveira IM, Alves RMA, Guariento ME. Cluster analysis to identify elderly people’s profiles: a healthcare strategy based on frailty characteristics. São Paulo Med J 2014; 132(4):224-230.

38. Fichman-Charchat H, Miranda CV, Fernandes CS, Mograbi D, Oliveira RM, Novaes R, Aguiar D. Brief Cognitive Screening Battery (BCSB) is a very useful tool for diagnosis of probable mild Alzheimer’s disease in a geriatric clinic. Arq Neuropsiquiatr 2016; 74(2):149-154.

39. Figueiredo CS, Assis MG, Silva SLA, Dias RC, Mancini MC. Functional and cognitive changes in community-dwelling elderly: Longitudinal study. Braz J Phys Ther 2013; 17(3):297-306.

40. Fraga VG, Guimarães HC, Teixeira AL, Barbosa MT, Mateo ECC, Carvalho MG, Caramelli P, Gomes KB. Genetic predisposition to higher production of interleukin-6 through -174 G > C polymorphism predicts global cognitive decline in oldest-old with cognitive impairment no dementia. Arq Neuropsiquiatr 2015; 73(11):899-902.

41. Fraga VG, Guimarães HC, Lara VP, Teixeira AL, Barbosa MT, Carvalho MG, Caramelli P, Gomes KB. TGF-_1 Codon 10 T>C Polymorphism Influences Short-Term Functional and Cognitive Decline in Healthy Oldest-Old Individuals: The Pietá Study. J Alzheimers Dis 2015; 48(4):1077-1081.

42. França VF, Barbosa AR, D’Orsi E. Cognition and Indicators of Dietary Habits in Older Adults from Southern Brazil. PLoS One 2016; 11(2):1-12.

43. Faria CA, Lourenço RA, Ribeiro PCC, Lopes CS. Desempenho cognitivo e fragilidade em idosos clientes de operadora de saúde. Rev Saude Publica 2013; 47(5):923-930.

44. Ferreira L, Tanaka K, Santos-Galduróz RF, Galduróz JCF. Respiratory training as strategy to prevent cognitive decline in aging: a randomized controlled trial. Clin Interv Aging 2015; 20(10):593-603.

45. Gomes MV, Toffoli LV, Arruda DW, Soldera LM, Pelosi GG, Neves-Souza RD, Freitas ER, Castro DT, Marquez AS. Age-Related Changes in the Global DNA Methylation Profile of Leukocytes Are Linked to Nutrition but Are Not Associated with the MTHFR C677T Genotype or to Functional Capacities. Plos One 2012; 7(12):1-8.

46. Gomes CS, Maciel ACC, Freire ANF, Moreira MA, Ribeiro MO, Guerra RO. Depressive symptoms and functional decline in an elderly sample of urban center in northeastern Brazil. Arch Gerontol Geriatr 2014; 58(2):214-218.

47. Gratao ACM, Talmelli LFS, Haas VJ, Marques S, Kusumota L, Rodrigues RAP. Assessment of caregiver burden with elderly having cognitive déficit. Acta Paul Enferm 2012; 25(6):908-913.

48. Horie NC, Serrao VT, Simon SS, Gascon MRP, Santos AX, Zambone MA, Freitas MMB, Cunha-Neto E, Marques EL, Halpern A, Melo ME, Mancini MC, Cercato C. Cognitive effects of intentional weight loss in elderly obese individuals with mild cognitive impairment. J Clin Endocrinol Metab 2016; 101(3):1104-1112.

49. Irigaray TQ, Gomes Filho I, Schneider RH. Efeitos de um Treino de Atenção, Memória e Funções Executivas na Cognição de Idosos Saudáveis. Psicologia: Reflexão e Crítica 2012; 25(1):188-202.

50. Leite MT, Hildebrandt LM, Kirchner RM, Winck MT, Silva LAA, Franco GP. Estado cognitivo e condições de saúde de idosos que participam de grupos de convivência. Rev Gaúcha Enferm 2012; 33(4):64-71.

51. Lempke-Scoralick NN, Barbosa AJG, Mota MMPE. Efeitos de um Processo de Alfabetização em Informática na Cognição de Idosos. Psicologia: Reflexão e Crítica 2012: 25(4):774-782.

52. Lima-Silva TB, Yassuda MS. Treino Cognitivo e Intervenção Psicoeducativa para Indivíduos Hipertensos: Efeitos na Cognição. Psicologia: Reflexão e Crítica 2012; 25(1):30-40.

53. Lopes MA, Ferrioli E, Nakano EY, Litvoc J, Bottino CMC. High Prevalence of Dementia in a Community-Based Survey of Older People from Brazil: Association with Intellectual Activity Rather than Education. J Alzheimers Dis 2012; 32(2):307-316.

54. Macedo AML, Cerchiari EAN, Alvarenga MRM, Faccenda O, Oliveira MAC. Avaliação funcional de idosos com déficit cognitivo. Acta Paul Enferm 2012; 25(3):358-363.

55. Macedo LDD, Oliveira TCG, Soares FC, Bento-Torres J, Bento-Torres NVO, Anthony DC, Picanço-Diniz CW. Beneficial effects of multisensory and cognitive stimulation in institutionalized elderly: 12-months follow-up. Clin Interv Aging 2015; 19(10):1351-1359.

56. Macuco CRM, Batistoni SST, Lopes A, Cachioni M, Falcão DVS, Neri AL Yassuda MS. Mini-Mental State Examination performance in frail, pre-frail, and non-frail community dwelling older adults in Ermelino Matarazzo, São Paulo, Brazil. Int Psychogeriatr 2012; 24(11):1725-1731.

57. Martinez BP, Gomes IB, Oliveira CS, Ramos IR, Rocha MD, Forgiarini Júnior LA, Camelier FW, Camelier AA. Accuracy of the Timed Up and Go test for predicting sarcopenia in elderly hospitalized patients. Clinics (São Paulo) 2015; 70(5):369-372.

58. Martinho KO, Dantas EH, Longo GZ, Ribeiro AQ, Pereira ET, Franco FS, Gonçalves MR, Morais KB, Martins MV, Danesio J, Tinôco AL. Comparison of functional autonomy with associated sociodemographic factors, lifestyle, chronic diseases (CD) and neuropsychiatric factors in elderly patients with or without the metabolic syndrome (MS). Arch Gerontol Geriatr 2013; 57(2):151-155

59. Matoso JMD, Santos WB, Moreira IFH, Lourenço RA, Correia MLG. Idosos Hipertensos Apresentam Menor Desempenho Cognitivo do que Idosos Normotensos. Arq Bras Cardiol 2013; 100(5):444-451.

60. Mattos IE, do Carmo CN, Santiago LM, Luz LL. Factors associated with functional incapacity in elders living in long stay institutions in Brazil: a cross-sectional study. BMC Geriatr 2014; 14(47):1-9.

61. Memória CM, Yassuda MS, Nakano EY, Forlenza OV. Brief screening for mild cognitive impairment: validation of the Brazilian version of the Montreal cognitive assessment. Int J Geriatr Psychiatry 2012; 28(1):34-40.

62. Memória CM, Yassuda MS, Nakano EY, Forlenza OV. Contributions of the Computer-Administered Neuropsychological Screen for Mild Cognitive Impairment (CANS-MCI) for the diagnosis of MCI in Brazil. Int Psychogeriatr 2014; 26(9):1483-1491.

63. Miranda LP, Silveira MF, Oliveira TL, Alves SF, Júnior HM, Batista AU, Bonan PR. Cognitive impairment, the Mini-Mental State Examination and socio-demographic and dental variables in the elderly in Brazil. Gerodontology 2012; 29(2):34-40.

64. Miranda EC, Pinheiro MM, Pereira LD, Iorio MCM. Correlation of the P300 evoked potential in depressive and cognitive aspects of aging. Braz J Otorhinolaryngol 2012; 78(5):83-89.

65. Montaño MBM, Andreoni S, Ramos LR. Clinical Dementia Rating independently predicted conversion to dementia in a cohort of urban elderly in Brazil. Int Psychogeriatr 2013; 25(2):245-251.

66. Moreira RO, Soldera AL, Cury B, Meireles C, Kupfer R. Is cognitive impairment associated with the presence and severity of peripheral neuropathy in patients with type 2 diabetes mellitus? Diabetol Metab Syndr 2015; 7(51):1-4.

67. Moreira BS, Dos Anjos DMC, Pereira DS, Sampaio RF, Pereira LSM, Dias RC, Kirwood RN. The geriatric depression scale and the timed up and go test predict fear of falling in community-dwelling elderly women with type 2 diabetes mellitus: a cross-sectional study. BMC Geriatr 2016; 16(56):1-10.

68. Moreira VG, Lourenço RA. Prevalence and factors associated with frailty in an older population from the city of Rio de Janeiro, Brazil: the FIBRA-RJ Study. Clinics (São Paulo). 2013; 68(7):979-985.

69. Nascimento CM, Pereira JR, Andrade LP, Garuffi M, Talib LL, Forlenza OV, Cancela JM, Cominetti MR, Stella F. Physical exercise in MCI elderly promotes reduction of pro-inflammatory cytokines and improvements on cognition and BDNF peripheral levels. Curr Alzheimer Res 2014; 11(8):799-805.

70. Nascimento CM, Pereira JR, Andrade LP, Garuffi M, Ayan C, Kerr DS, Talib LL, Cominetti MR, Stella F. Physical Exercise Improves Peripheral BDNF Levels and Cognitive Functions in Elderly Mild Cognitive Impairment Individuals with Different BDNF Val66Met Genotypes. J Alzheimers Dis 2015; 43(1):81-91.

71. Neri AL, Yassuda MS, Araújo LF, Eulálio MC, Cabral BE, Siqueira MEC, Santos GA, Moura JGA. Metodologia e perfil sociodemográfico, cognitivo e de fragilidade de idosos comunitários de sete cidades brasileiras: Estudo FIBRA. Cad Saude Publica 2013; 29(4):778-792.

72. Neri AL, Ongaratto LL, Yassuda MS. Mini-Mental State Examination sentence writing among community-dwelling elderly adults in Brazil: text fluency and grammar complexity. Int Psychogeriatr 2012; 24(11):1732-1737.

73. Olchik MR, Faria J, Steibel N, Teixeira AR, Yassuda MS. Memory training (MT) in mild cognitive impairment (MCI) generates change in cognitive performance. Arch Gerontol Geriatr 2013; 56(3):442-447.

74. Silva SO, Chan IT, Lobo Santos MA, Cohen M, de La Roque PMA, Silva AJ, Simões A, Givigi HR, Vaisman M, Paixão Júnior CM, Teixeira PFS. Impact of thyroid status and age on comprehensive geriatric assessment. Endocrine 2014; 47(1):255-265.

75. Oliveira TCG, Soares FC, Macedo LDED, Diniz DLWP, Bento-Torres NVO, Picanço-Diniz CW. Beneficial effects of multisensory and cognitive stimulation on age-related cognitive decline in long-term-care institutions. Clin Interv Aging 2014; 9:309-321.

76. Oliveira MO, Nitrini R, Yassuda MS, Brucki SMD. Vocabulary Is an Appropriate Measure of Premorbid Intelligence in a Sample with Heterogeneous Educational Level in Brazil. Behav Neurol 2014; 2014:1-6.

77. Oliveira FF, Wajman JR, Bertolucci PHF, Chen ES, Smith MC. Correlations among cognitive and behavioural assessments inpatients with dementia due to Alzheimer’s disease. Clin Neurol Neurosurg 2015; 135:27-33.

78. Oliveira FF, Pivi GAK, Chen ES, Smith MC, Bertolucci PHF. Risk factors for cognitive and functional change in one year in patients with Alzheimer’s disease dementia from São Paulo, Brazil. J Neurol Sci 2015; 359(1-2):127-132.

79. Oliveira GM, Yokomizo JE, Vinholi e Silva LS, Saran LF, Bottino CMC, Yassuda MS. The applicability of the cognitive abilities screening instrument-short (CASI-S) in primary care in Brazil. Int Psychogeriatr 2016; 28(1):93-99.

80. Paradela EMP, Lourenço RA. Is the Cambridge Cognitive Examination – Revised a good tool for detection of dementia in illiterate Brazilian older adults? Geriatr Gerontol Int 2014; 14(4):763-768.

81. Pastor-Valero M, Furlan-Viebig R, Menezes PR, Silva SA, Vallada H, Scazufca M. Education and WHO Recommendations for Fruit and Vegetable Intake Are Associated with Better Cognitive Function in a Disadvantaged Brazilian Elderly Population: A Population-Based Cross-Sectional Study. PLoS One 2014; 9(4):1-10.

82. Paula JJ, Miranda DM, Moraes EM, Malloy-Diniz LF. Mapping the clockworks: what does the Clock Drawing Test assess in normal and pathological aging? Arq Neuropsiquiatr 2013; 71(10):763-768.

83. Paulo TRS, Tribess S, Sasaki JE, Meneguci J, Martins CA, Freitas Júnior IF, Romo-Perez, Virtuoso Júnior JS. A Cross-Sectional Study of the Relationship of Physical Activity with Depression and Cognitive Deficit in Older Adults. J Aging Phys Act 2016; 24(2):311-321.

84. Peres MA, Bastos JL, Watt RG, Xavier AJ, Barbato PR, D’Orsi E. Tooth loss is associated with severe cognitive impairment among older people: findings from a population-based study in Brazil. Aging & Ment Health 2015; 19(10):876-884.

85. Perez M, Lourenço RA. Rede FIBRA-RJ: fragilidade e risco de hospitalização em idosos da cidade do Rio de Janeiro, Brasil. Cad Saude Publica 2013; 29(7):1381-1391.

86. Petry DM, Nery S, Gonçalves CJS. Avaliação neuropsicológica de idosos praticantes de capoeira. Rev Bras Med Esporte 2014; 20(1):51-54

87. Pinto JM, Neri AL. Factors associated with low life life satisfaction in community-dwelling elderly: FIBRA Study. Cad Saude Publica 2013; 29(12):2447-2458.

88. Quintas JL, Souza VC, Henriques AD, Machado-Silva W, Toledo JO, Córdova C, Moraes CF, Camargos EF, Nóbrega OT. Lack of association between apolipoprotein E genotypes and cognitive performance in the non-demented elderly. Psychogeriatrics 2014; 14(1):11-16.

89. Radanovic M, Nunes PV, Forlenza OV, Ladeira RB, Gattaz WF. Cognitive-linguistic deficits in euthymic elderly patients with bipolar disorder. J Affect Disord 2013; 150(2):691-694.

90. Ribeiro PCC, Lopes CS, Lourenço RA. Prevalence of Dementia in Elderly Clients of a Private Health Care Plan: A Study of the FIBRA-RJ, Brazil. Dement Geriatr Cogn Disord 2013; 35(1-2):77-86.

91. Sanchez MAS, Lourenço RA. Screening for dementia: Brazilian version of the Informant Questionnaire on Cognitive Decline on the Elderly and its psychometric properties. Geriatr Gerontol Int 2013; 13(3):687-693.

92. Santos GD, Nunes PV, Stella F, Brum PS, Yassuda MS, Ueno LM, Gattaz WF, Forlenza OV. Multidisciplinary rehabilitation program: effects of a multimodal intervention for patients with Alzheimer’s disease and cognitive impairment without dementia. Arch Clin Psychiatry 2015; 42(6):153-156.

93. Silva HS, Duarte YAO, Andrade FB, Cerqueira ATAR, Santos JLF, Lebrão ML. Correlates of above-average cognitive performance among older adults: the SABE study. Cad Saude Publica 2014; 30(9):1977-1986.

94. Soares LM, Cachioni M, Falcão DVS, Batistoni SST, Lopes A, Neri AL, Yassuda MS. Determinants of cognitive performance among community dwelling older adults in an impoverished sub-district of Sao Paulo in Brazil. Arch Gerontol Geriatr 2012; 54(2):187-192.

95. De Souza DMS, Veiga DF, Santos IDAO, Abla LEF, Juliano Y, Ferreira LM. Health-Related Quality of Life in Elderly Patients With Pressure Ulcers in Different Care Settings. Wound Ostomy Continence Nurs 2015; 42(4):352-359.

96. Teixeira CVL, Gobbi S, Pereira JR, Vital TM, Hernandéz SSS, Shigematsu R, Gobbi LTB. Effects of square-stepping exercise on cognitive functions of older people. Psychogeriatrics 2013; 13:148-156.

97. Teixeira-Leite H, Manhães AC. Association between functional alterations of senescence and senility and disorders of gait and balance. Clinics (Sao Paulo) 2012; 67(7):719-729.

98. Verdan C, Casarsa D, Perrout MR, Santos M, Souza JA, Nascimento O, Coutinho ESF, Laks J Lower mortality rate in people with dementia is associated with better cognitive and functional performance in an outpatient cohort. Arq Neuropsiquiatr 2014; 72(4):278-282

99. Yassuda MS, Lopes A, Cachioni M, Falcão DVS, Batistoni SST, Guimarães VV, Neri AL. Frailty Criteria and Cognitive Performance Are Related: Data from The Fibra Study in Ermelino Matarazzo, Sao Paulo, Brazil. J Nutr Health Aging 2012; 16(1):55-61.

100. Ávila RRA, Murphy CFB, Schochat E. Efeitos do Treinamento Auditivo em Idosos com Comprometimento Cognitivo Leve. Psicologia Reflexão e Crítica 2014; 27(3):547-555.

101. Reis KMC, Jesus CAC. Coorte de idosos institucionalizados: fatores de risco para queda a partir do diagnóstico de enfermagem. Rev. Latino-Am. Enfermagem 2015; 23(5):1130-1138.

102. Ribeiro LHM, Neri AL. Exercícios físicos, força muscular e atividades de vida diária em mulheres idosas. Cien Saude Colet 2012; 17(8):2169-2180.

103. Santos AA, Mansano-Schlosser TCS, Ceolim MF, Pavarini SCI. Sono, fragilidade e cognição: estudo multicêntrico com idosos brasileiros. Rev Bras Enferm 2013; 66(3): 351-357.

104. Santos CA, Ribeiro AQ, Rosa COB, Ribeiro RCL. Depressão, déficit cognitivo e fatores associados à desnutrição em idosos com câncer. Cien Saude Colet 2015; 20(3):751-760.-¹⁰⁵105. Silva A, Faleiros HH, Shimizu WAL, Nogueira LM, Nhãn LL, Silva BMF, Otuyama PM. Prevalência de quedas e de fatores associados em idosos segundo etnia. Cien Saude Colet 2012; 17(8):2181-2190., 80% of which are in English and 20% in Portuguese, selected according to the established criteria and after critical assessment.

Most studies were conducted in the Southeast (72%) and the South (12%) of Brazil, with the highest publication frequency in 2014 (30%) and 2012 (23%). The predominant age criterion to define elderly individuals was ≥ 60 (64%). According to the AHRQ instrument, the level of evidence VI (68%) stood out, followed by level IV (16%).

Regarding the study design, the majority of the articles (84%) were observational, 68% of which were transversal, 14% were cohort and 2% were case-control. Of the clinical trials, 9% were non-randomized and 7% were randomized.

Sixty-one instruments were used for cognitive assessment of Brazilian elderly individuals in the last five years (Chart 1). Most tests were short, with application time of less than 20 minutes.

Most studies (90%) used at least the Mini-Mental State Examination (MMSE) for data collection. The most administered version was that proposed by Brucki et al. (2003) (34.4%), but twelve versions could also be observed during the analysis of the articles. The MMSE was followed by the Verbal Fluency Test (VFT) (24%), the Digit Span Memory Test (15%), the Cambridge Cognitive Examination- Revised (CAMCOG-R) (13%), the Clinical Dementia Rating (CDR) and the Clock-Drawing Test (CDT) (10%).

Chart 2 presents a summary of the cognitive domains evaluated and which tests evaluated them.

Of the 100 articles, 39 mentioned only the use of the MMSE with three objectives in the Method section: screening, sample selection and evaluation of associations. The cut-off points for the MMSE varied mainly according to the individual´s level of education. The most commonly used cut-off points are listed as follows:

Brucki et al. (2003): < 20 points for illiterates; 25 points for individuals with 1 to 4 years of schooling; 26.5 for 5 to 8 years of schooling; 28 for 9 to 11 years of schooling; and 29 for more than 11 years of schooling;

Bertolucci et al. (1994): < 13 for illiterates (sensitivity: 82.4%, specificity: 97.5%); 18 for 1 to 8 years of schooling (sensitivity: 75.6%, specificity: 96.6%); and 26 for 9 or more years of schooling (sensitivity: 80%, specificity: 95.6%);

Lourenço & Veras (2006): < 18/19 for illiterates (sensitivity: 73.5%, specificity: 73.9%) and < 23/24 for individuals with one or more years of schooling (sensitivity: 75%, specificity: 69.7%).

Some authors conducted further analysis and adapted these cut-off points according to the design, studied population, objective, among others, which allowed differentiation of the studies and an increasing number of versions. The VFT and the Digit Span Memory Test were the second and third most used tests, respectively. The VFT was administered with several categories, and in this review, the semantic category of animals stood out. The Digit Span Memory Test has only one version and can be applied in forward span and backward span. The CDT was also addressed in six forms, and the versions proposed by Sunderland et al. (1989) and Shulman et al. (1993) were most commonly used.

The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), used in eight articles, does not directly assess the patient - it is completed by the caregiver or someone close to the patient. The Leganés Cognitive Test (LCT) can be pointed out, as it was used in the assessment of cognitive function only in one Brazilian state (Rio Grande do Norte).

Two studies mentioned the use of the Comprehensive Geriatric Assessment (CGA), one in hospitalized elderly patients, and the other with elderly patients attending a geriatric outpatient clinic. When administering the CGA, both studies used the MMSE, but one of them associated it with the IQCODE.

Discussion

A considerable number of studies were included in this review, which indicates that cognition in the elderly population has been extensively addressed in the Brazilian literature. Most of the articles (72%) were published in the Southeast region. The distribution of stricto sensu postgraduate courses in Brazil in 2015 showed that the Southeast region accounted for 45.6% of the courses, followed by the South, Northeast, Midwest and North with 21.4%, 19.9%, 8.1% and 5% respectively¹⁰⁶106. Coordenação De Aperfeiçoamento De Pessoal De Nível Superior (CAPES). GeoCapes. [acessado em março de 2017] Disponível em: http://geocapes.capes.gov.br
http://geocapes.capes.gov.br... . This shows how the existing regional inequality impacts the Brazilian scientific production.

Regarding the numerical criterion used for a definition of elderly individuals, the World Health Organization (WHO) has accepted the chronological age of ≥ 60 years to refer to the older population in developing countries or 65 years in developed countries¹⁰⁷107. Organização Mundial da Saúde (OMS). Relatório Mundial de envelhecimento e saúde. 2015. Disponível em: http://apps.who.int/iris/bitstream/10665/186468/6/WHO_FWC_ALC_15.01_por.pdf
http://apps.who.int/iris/bitstream/10665... . Most studies used the criterion ≥ 60 and the studies conducted in the Southeast, North and Northeast of the country used an older age for eligibility. Additionally, a pattern of use by region could not be observed.

A wide range of instruments could be identified, including brief tests and test batteries. The use of these instruments also ranged from screening to aid in diagnostic procedures. The administration of the instruments to monitor types of intervention (e.g., cognitive, motor, drug) provides data on the possible benefits of a specific physical stimulation for the cognition of elderly individuals.

In clinical practice, it is proposed that elderly individuals should be first evaluated with an instrument that provides a basic measure for cognitive function monitoring and/or an alert to the need for further investigation¹⁰⁸108. Cordell CB, Borson S, Boustani M, Chodosh J, Reuben D, Verghese J, Thies W, Fried LB. Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimer’s & Dementia 2013; 9:141-150.. Through a systematic review, the authors identified diagnostic errors rates of over 10% in 16 diseases prevalent in elderly patients, mainly in dementias. Underdiagnosis of dementia appears more prevalent in older patients with poor access to health care, lower socioeconomic status and lower levels of education¹⁰⁹109. Skinner TR, Scott IA, Martin JH. Diagnostic errors in older patients: a systematic review of incidence and potential causes in seven prevalent diseases. Int J Gen. Med 2016; 9:137-146.. A Brazilian study found that only one third of the elderly individuals diagnosed with dementia by specialists had previous diagnosis of moderate to severe dementia¹¹⁰110. Jacinto AF, Brucki S, Porto CS, Martins MA, Nitrini R. Detection of cognitive impairment in the elderly by general internists in Brazil. Clinics (São Paulo) 2011; 66(8):1379-1384.. The causes of low case detection were not indicated.

In relation to the area of research, choosing an adequate instrument and establishing a cut-off point are necessary to avoid mistakes due to false-positive and false-negative test results. Researchers are able to find a cut-off point that best suits their sample¹¹¹111. Melo DM, Barbosa AJG. O uso do Mini-Exame do Estado Mental em pesquisas com idosos no Brasil: uma revisão sistemática. Cien Saude Colet 2015; 20(12):3865-3876. by retrieving published studies with samples containing related profiles, also taking into account the specificity and sensitivity of the test.

The analysis of the most used test in the Brazilian studies with elderly individuals - the MMSE- still shows no standardized administration of the test. The different versions and cut-off points support this statement. These issues display the cultural, educational and age biases that influence the test score. Although these different cut-off points are created to minimize bias and establish criteria for normality for the Brazilian population, the level of education is a variable that influences the MMSE score, and may generate false-negative results in individuals with higher levels of education⁹⁴94. Soares LM, Cachioni M, Falcão DVS, Batistoni SST, Lopes A, Neri AL, Yassuda MS. Determinants of cognitive performance among community dwelling older adults in an impoverished sub-district of Sao Paulo in Brazil. Arch Gerontol Geriatr 2012; 54(2):187-192.,¹¹²112. Moraes C, Pinto JÁ Jr, Lopes MA, Litvoc J, Bottino CMC. Impact of sociodemographic and health variables on mini-mental state examination in a community-based sample of older people. Eur Arch Psychiatry Clin Neurosci 2010; 260:535-542..

It should be noted that, although the MMSE does not evaluate all cognitive domains, it is quick to administer and it is the most widely studied instrument for cognitive screening not only in Brazil but worldwide. The MMSE is also used as a gold standard and reference for validation of other assessment instruments. In Brazil, the first version was proposed almost 23 years ago¹⁰⁸108. Cordell CB, Borson S, Boustani M, Chodosh J, Reuben D, Verghese J, Thies W, Fried LB. Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimer’s & Dementia 2013; 9:141-150..

The Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) includes batteries of test covering all cognitive domains, but it was used in only one study. It requires longer administration time, which may be a negative factor for its use in research. Also, it does not have criteria for normality for the individuals´ level of education.

As for the other instruments more commonly used, the Verbal Fluency Test and Digit Span Memory Test do not assess global cognition and are more specific for certain functions. The VFT focuses on the evaluation of executive functions and consists in recalling the greatest number of words during a pre-established time - usually one minute. The score is calculated by counting the total of produced words. In the phonemic fluency test, the individuals are requested to produce words beginning with a certain letter, for example, “F”, “A”, “S”. The semantic fluency consists of naming words within a category, such as animals. Studies show that it is an instrument with good accuracy in the detection of cognitive deficits in the elderly population¹¹³113. Lim YY, Snyder PJ, Pietrzak RH, Ukiqi A, Villemagne VL, Ames D, Salvado O, Bourgeat P, Martins RN, Masters CL, Rowe CC, Maruff P. Sensitivity of composite scores to amyloid burden in preclinical Alzheimer’s disease: Introducing the Z-scores of Attention,Verbal fluency, and Episodic memory for Nondemented older adults composite score. Alzheimers Dement (Amst.) 2016; 2:19-26.

114. Demetriou E, Holtzer R. Mild Cognitive Impairments Moderate the Effect of Time on Verbal Fluency Performance. J Int Neuropsychol Soc 2017; 23(1):44-55.-¹¹⁵115. Mirandez RM, Aprahamian I, Talib LL, Forlenza OV, Radanovic M. Multiple category verbal fluency in mild cognitive impairment and correlation with CSF biomarkers for Alzheimer’s disease. Int Psychogeriatr 2017; 29(6):949-958..

In the articles here, the semantic verbal fluency test of animal category was the most common test in association with other instruments. The semantic task, in addition to evaluating executive functions and language, has the advantage of accessing declarative semantic memory. The cut-offs points for the Brazilian versions varied according to levels of education and age¹¹⁶116. Caramelli P, Carthery-Goulart MT, Porto CS, Charchat-Fichman H, Nitrini R. Category Fluency as a Screening Test for Alzheimer Disease in Illiterate and Literate Patients. Alzheimer Dis Assoc Disord 2007; 21(1):65-67.,¹¹⁷117. Machado TL, Charchat-Fichman H, Santos EL, Carvalho VA, Fialho PP, Koenig AM, Fernandes CS, Lourenço RA, Paradela EMP. Caramelli P. Normative data for healthy elderly on the phonemic verbal fluency task – FAS. Dement Neuropsychol 2009; 3(1):55-60..

The Digit Span Subtest of the Wechsler Adult Intelligence Scale (WAIS-III) consists of two tasks of repeating a sequence of numbers in forward span and backward span, especially used in the evaluation of attention. Although both tasks can be administered independently, the studies included in this review used both tasks. The backward version is also widely used to evaluate working memory. The cut-off point was not cited. The VFT and the Digit Span Memory Test can be used in association with the MMSE for an enhanced cognitive assessment, provided that it is the goal of the professional and/or researcher. The combined use of instruments may be beneficial to avoid false diagnosis in the elderly population¹¹⁸118. Montiel JM, Cecato JF, Bartholomeu D, Martinelli JE. Testes do desenho do relógio e de fluência verbal: contribuição diagnóstica para o Alzheimer. Psicologia: teoria e prática 2014, 16(1):169-180..

The CDT is a cognitive screening instrument used to evaluate executive function, praxis and visuospatial skills. It also presents several versions with different scores. In the most used version, the patient is asked to draw the face of a clock and place the hands to designate a specific time, e.g., 11h10min¹¹⁹119. Shulman KI. Clock-drawing: is it the ideal cognitive screening test? Int J Geriat Psychiatry 2000; 15(6):548-561.. Combined with the MMSE, the CDT has a sensitivity of 84.9% and specificity of 90.4% in the screening for cognitive impairment in elderly populations¹²⁰120. Yang L, Yan J, Jin X, Jin Y, Yu W, Xu S, Wu H. Screening for Dementia in Older Adults: Comparison of Mini-Mental State Examination, Mini-Cog, Clock Drawing Test and AD8. PLoS One 2016; 11(12):1-5.. But, individuals with symptoms such as tremor and motor coordination deficits may show lower scores, or even fail to perform a task due to these motor impairments.

As for the instrument administration time, frail or multimorbid elderly individuals may need more time to complete the evaluation. Individuals who require hearing aids, glasses and dental prostheses should be using them during the evaluation¹²¹121. Oresanya LB, Lyons WL, Finlayson E. Preoperative Assessment of the Older Patient: A Narrative Review. JAMA 2014; 311(20):2110-2120..

A limitation of the study lies in the fact that after the application of the eligibility criteria, the whole Brazilian literature was not evaluated, given that dissertations and theses were not included. This could have increased the variation of the instruments used.

Conclusion

The variability of cognitive deficits due to aging or associated pathological process points to the need to address the issue of how to identify these deficits earlier and whether this early identification influences the course of the disease and the quality of life of the individuals and their relatives.

This integrative review addresses the use of cognitive assessment instruments in the Brazilian literature, their different versions and domains evaluated. The recent literature includes a large number of instruments. The most used tests were the MMSE (version proposed by Brucki et al.), the Verbal Fluency Test (animal category) and the Digit Span Memory Test (forward span or backward span). The findings presented in this review are relevant not only for observational and experimental research but also for clinical practice.

References

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