This qualitative case study investigated the impact of sand tray on individuals diagnosed with Alzheimer’s and other forms of dementia. Four participants successfully completed the creation of sand trays while the researcher observed, interviewed, and documented the individual sand trays. The intervention established that sand tray allows the dementia patient to kinesthetically connect to their inner cognitions through the intentional symbolic expression offered by this unique therapeutic medium. Using a series of eight sand trays of varying thematic concepts, the participants were offered a modality to facilitate a synthesization of their continued individuation, presenting a possible neural pathway to connect and express thoughts, feelings, emotions, concerns, challenges, and fears. The findings of this study include the fact that all trays were classified as “empty” and that the majority of the participants placed objects almost exclusively on the right side of the tray, which is commonly associated with the concreteor conscious side. The use of sand tray allowed each individual the opportunity to create autobiographies in the sand and literally navigate through time – past, present, and future, confronting fears, expressing hope and possibilities. The results of the research study offer insight into the psychotherapeutic effects of using sand tray with dementia patients, as well as a better understanding of the cognitive and expressive abilities and limitations of an individual with impaired memory. The results also offer insight into the difficulties with short-term memory in this population and possibly indicate a potential means for monitoring cognitive decline. Keywords: Neurocognitive disorder, Alzheimer’s, dementia, sand tray, play therapy / Includes bibliography. / Dissertation (Ph.D.)--Florida Atlantic University, 2013.

Introdução: O Computer-Administered Neuropsychological Screen For Mild Cognitive Impairment (CANS-MCI) é um teste computadorizado para o rastreio do Comprometimento Cognitivo Leve (CCL). O CCL é considerado um estado transicional entre o envelhecimento normal e é uma condição de risco para o desenvolvimento de demências. Diante disso, sua detecção torna-se importante para a implementação de intervenções terapêuticas e preventivas. Objetivos: Avaliar as propriedades psicométricas do CANS-MCI e analisar sua acurácia diagnóstica para CCL em uma amostra clínica de idosos brasileiros. Métodos: Noventa e sete sujeitos foram avaliados e classificados em: controles normais (CN, n=41), comprometimento cognitivo leve (CCL, n=35) e doença de Alzheimer (DA, n=21). O diagnóstico foi previamente estabelecido por equipe multidisciplinar, com base em dados clínicos, neuropsicológicos e de neuroimagem. O desempenho dos pacientes no CANS-MCI foi comparado ao de outras provas já validadas para população brasileira. Resultados: os resultados indicaram que o CANS-MCI apresentou alta consistência interna (Alfa de Cronbach = 0,77). A confiabilidade do teste-reteste foi elevada (r = 0,875, p <0,001). Foi encontrada uma correlação moderada entre o escore total do CANS-MCI e o RAVLT (variável que avalia a capacidade de aprendizagem, com r=0,51 e p<0,001). O CANS-MCI foi capaz de discriminar controles de CCL (81% de sensibilidade e 73% especificidade) e Controles de DA (100% de sensibilidade e 97% especificidade), indicando alta acurácia. CONCLUSÃO: O CANS-MCI manteve suas características psicométricas originais, mostrou-se estável no reteste e foi capaz de diferenciar sujeitos controles daqueles diagnosticados com CCL e DA / Background: Computer-Administered Neuropsychological Screen for Mild CognitiveImpairment (CANS-MCI) is a computerized test screening battery for mild cognitive impairment (MCI). MCI is transitional state between normal aging and dementia. Therefore, its detection becomes important for the implementation of preventive and therapeutic interventions. Objectives: To evaluate the psychometric properties of the CANS-MCI and analyze its diagnostic accuracy for MCI in a clinical sample of elderly Brazilians. Methods: Ninety-seven subjects were evaluated and classified as: normal controls (NC, n = 41), mild cognitive impairment (MCI, n = 35) and Alzheimer\'s disease (AD, n = 21). The diagnosis was previously established by a multidisciplinary team, based on clinical, neuropsychological and neuroimaging data. The performance of patients in the CANS-MCI was compared to other tests which have been validated for the Brazilian population. Results: The results indicated that the CANS-MCI showed high internal consistency (Cronbach\'s alpha = 0.77) and that the test-retest reliability was high (r = 0.875, p <0.001). There was a moderate correlation between the CANS-MCI total score and the RAVLT (for learning ability) (r=0.51, p <0.001). The CANS-MCI was able to discriminate NC from MCI (81% of sensitivity and 73% of specificity) and MCI from AD (100% of sensitivity and 97% of specificity), with high accuracy. Conclusion: The CANS-MCI in its Brazilian version maintained its original psychometric properties, it was stable at retest and it was able to differentiate between unimpaired seniors from those diagnosed with MCI and AD. Results suggest this computerized battery can be used to screen for MCI among elderly Brazilian

Introdução: Os Benzodiazepínicos estão entre as drogas mais prescritas no mundo. Possuem características ansiolíticas, hipnóticas, miorelaxantes e anticonvulsivantes. Estudos prévios evidenciam inadequações nas prescrições de benzodiazepínicos, como uso equivocado para quadros inespecíficos, tratamento prolongado e abuso por idosos. Benzodiazepínicos podem trazer sérios efeitos adversos, sobretudo em idosos, como sonolência diurna, deterioro da memória e funções cognitivas, desequilíbrio e quedas. Objetivos: Analisar a prevalência do uso de benzodiazepínicos nos pacientes do Centro de Atenção Psicossocial (CAPS) de Campo Bom-RS em um período de 24 meses (Junho de 2013 a Maio de 2015), faixa etária, frequência de dispensações, dosagens, CIDs e especialidades dos médicos prescritores; bem como possíveis relações com a função cognitiva, afetiva, e quedas em idosos. Métodos: Estudo transversal, com informações coletadas e tabuladas a partir dos prontuários e prescrições médicas do CAPS Campo Bom, bem como do seu sistema informatizado de gerenciamento (Software Multi 24 Horas). Foram obtidos dados como idade, gênero, identificação dos CIDs; bem como informações sobre prescrições de Benzodiazepínicos, como frequência, quantidade, tipo de medicamento, posologia, profissional prescritor e demais medicamentos utilizados. Critério de inclusão: utilização de qualquer benzodiazepínico disponível na rede SUS: Clonazepam 0,5mg, Clonazepam 2,5 mg/ml, Clonazepam 2mg e Diazepam 5mg. Foram aplicados os testes MEEM e GDS nos pacientes idosos, em entrevistas individuais, nas quais também se avaliou a escolaridade, ocorrência e frequência de quedas, além das comorbidades auto relatadas. Para construção do banco de dados foi utilizado o Software Microsoft® Office Excel® 2007, e para análise estatística o Software PASW V18 (SPSS®). Resultados: O número total de pacientes ativos identificados no CAPS foi de 855 indivíduos, sendo 543 (63,5%) mulheres e 84 idosos (9,8%). A prevalência de utilização de BZD nesta população representou 47,2% (n=404 indivíduos). Foram identificadas 12.680 prescrições médicas dispensadas e, deste total, a prevalência de prescrições de benzodiazepínicos foi de 21,7% (n=2.748). Dentre os pacientes que receberam BZD, 297 (73,5%) eram mulheres e 59 idosos (14,6%), dos quais 56 foram entrevistados. Dentre os idosos entrevistados, 42 (75,0%) possuíram significativa sintomatologia depressiva (GDS≥5) e 32 (57,1%) apresentaram duas ou mais quedas no período de 1 ano. Dezoito pacientes idosos demonstraram fazer uso de dois ou mais BZDs. Houve correlação linear negativa entre os escores do MEEM e do GDS (r = - ,416; p=,002). Houve também uma correlação linear negativa entre o escore do MEEM e número de quedas em idosos (r = -,327 p=,016). Conclusões: Os benzodiazepínicos corresponderam a 21,7 % do total de prescrições do CAPS e do total dos indivíduos 47,2% receberam benzodiazepínicos. Proporcionalmente aos homens, as mulheres tenderam a receber mais prescrições de benzodiazepínicos (p<.001). A prevalência de significativa sintomatologia depressiva nos idosos usuários do CAPS foi alta (75,0%), assim como a incidência de quedas, sendo que mais da metade dos idosos caiu 2 ou mais vezes no período. Identificou-se uma correlação linear negativa entre a função cognitiva como avaliada pelo MEEM e a sintomatologia depressiva avaliada pelo GDS; bem como houve uma correlação linear negativa entre o MEEM e o número de quedas em idosos. / Introduction: Benzodiazepines are among the most prescribed drugs in the world, they have characteristics such as anxiolytic, hypnotic, muscle relaxants and anticonvulsants. Studies have pointed out distortions in benzodiazepines’ prescriptions, such as misuse for unspecific cases, prolonged treatment and use by elderly. Such medications may cause serious damage, particularly in the elderly, and its continued use causes side effects such as daytime somnolence, imbalance, memory and cognitive function loss, increased incidence of falls. Objectives: To assess the prevalence of benzodiazepine use among patients of the Center for Psychosocial Care in Campo Bom-RS within the period of June 2013 to May 2015. The variables analyzed were: age, frequency of dispensations, dosages, ICDs and specialties of prescribing doctors; as well as possible correlations between cognitive function, emotional function and falls in the elderly. Methods: Cross-sectional study, with data collected and tabulated from medical records and prescriptions, as well as from the management system from CAPS (Software Multi 24 hours). Data obtained was age, gender, ICDs identification; as well as frequency of prescriptions, quantity and type of medication, dosage, prescribing professional, others used drugs. Inclusion criteria: Use of any benzodiazepine available in the Health Unic System: Clonazepam 0,5 mg, Clonazepam 2,5 mg/ml, Clonazepam 2 mg and Diazepam 5mg. MMSE and GDS tests have been applied in the elderly, through individual interviews, in which we found about educational level, occurrence and frequency of falls and other self-reported comorbidities. The software Microsoft® Excel® 2007 was used to build database, and for statistical analysis the software PASW V18 (SPSS) was used. Results: The total number of active patients identified at CAPS was 855 individuals, of these 543 were women (63.5%) and 84 elderly (9.8%). The prevalence of benzodiazepines’ use in this population was 47.2 % (n = 404). We have found 12.680 prescriptions dispensed and the prevalence of benzodiazepines’ prescriptions was 21.7 % (n = 2.748). Among patients who received benzodiazepines, 297 (73.5%) were women and 59 elderly (14.6%), of these 56 were interviewed. From the interviewed patients, 42 (75.0%) had significant depressive symptomatology (GDS≥5) and 32 (57.1%) have suffered two or more falls. Eighteen elderly patients demonstrated to use two or more benzodiazepines. There was a negative linear correlation between MMSE and GDS scores (r = -.416, p =.002). There was also a negative linear correlation between MMSE scores and number of falls in elderly (r = -.327 p =. 016). Conclusions: Benzodiazepines accounted for 21.7% of the total CAPS’ prescriptions, and 47.2% individuals treated at CAPS received benzodiazepines. Women tended to receive more prescriptions of benzodiazepines (p <.001) than men. The prevalence of significant depressive symptomatology in the elderly was very high (75.0%). As well as the incidence of falls, since more than half of the elderly patients presented two or more falls in the period. We identified a negative linear correlation between cognitive function as assessed by MMSE and depressive symptoms assessed by the GDS; and there was a negative linear correlation between MMSE and the number of falls in the elderly.

INTRODUÇÃO: O impacto na saúde pública dos transtornos neuropsiquiátricos como a demência e o comprometimento cognitivo tem aumentado com o aumento da população idosa de países em desenvolvimento como o Brasil. O diagnóstico destas entidades requer confirmação objetiva da presença de prejuízo cognitivo, para a qual recomenda-se o uso de testes neuropsicológicos. OBJETIVO: Comparar o perfil neuropsicológico de sujeitos com comprometimento cognitivo leve (CCL), com um grupo de sujeitos considerados normais, provenientes de uma amostra comunitária identificada em um estudo de prevalência de demência e comprometimento cognitivo na cidade de São Paulo. MÉTODO: A amostra total (1.563 sujeitos de 60 ou mais anos de idade) foi selecionada aleatóriamente em três áreas com diferentes perfis sócio-econômicos em São Paulo. Os sujeitos foram classificados como CCL amnéstico, utilizando critérios adaptados de Petersen et al. (1999) usando os seguintes instrumentos: um questionário de queixas de memória de 10-pontos, Mini Exame do Estado Mental (MEEM), FOME e a escala internacional de atividades da vida diária (ADL-IS). Em uma segunda fase, os sujeitos foram submetidos novamente ao MEEM, ADL- IS, questionário (SRQ 20) para identificar sintomas psiquiátricos, e uma bateria de testes neuropsicológicos para avaliar: atenção (Dígitos de WMS-R, Trail Making Test), memória (Memória Lógica e Reprodução Visual de WMS-R, Selective Reminding Test - Buschke), praxia (desenho do relógio, Cubos do WAIS-R), linguagem (Teste de Nomeação de Boston, fluência verbal - animais) e QI estimado (Vocabulário e Cubos do WAIS-R). RESULTADOS: trinta e sete indivíduos classificados como CCL amnéstico e trinta e um classificados como normais completaram a avaliação. Não foram encontradas diferenças significativas entre os grupos quanto a: idade, gênero, anos de escolaridade, estado civil, classe social ou pontuações no MEEM ou no SRQ-20. Houve diferenças significativas entre os dois grupos nos seguintes testes: Trail Making A, Memória Lógica (evocação imediata e tardia), Selective Reminding Test (aprendizagem total), Reprodução Visual (evocação Imediata e tardia), Nomeação de Boston (nomeação e paragnosias), Cubos e QI Estimado, sendo que os indivíduos com CCL tiveram pior desempenho que os controles. CONCLUSÕES: Os achados sugerem que submetidos a uma bateria neuropsicológica abrangente, os dois grupos estudados apresentam diferenças significativas no desempenho não somente da memória mas também em outros domínios como atenção, linguagem e praxia. Estes achados sugerem que o conceito de CCL múltiplos domínios pode ser mais útil que o conceito de CCL amnéstico, quando são avaliados idosos que pertencem a uma amostra comunitária / BACKGROUND: The impact on public health of neuropsychiatry disorders as dementia and mild cognitive impairment is growing as the population grows older in developing countries as Brazil. The diagnosis of these entities requires confirmation of cognitive impairment assessed by neuropsychological tests. OBJECTIVE: Compare the neuropsychological profile of Mild Cognitive Impairment (MCI) individuals and Normal subjects from a community sample identified in a Prevalence Study of Dementia and MCI in São Paulo. METHOD: The total sample (1.563 subjects over 60 years old) was randomly selected from three different social class areas of São Paulo. The subjects were classified as amnestic MCI following criteria adapted from Petersen et al. (1999) using the following instruments: 10-point questionnaire on memory complaints, Mini Mental State Examination (MMSE), Fuld Object Memory Evaluation, and Activities of Daily Living - International Scale (ADL-IS). In a second phase, patients were submitted to the MMSE, ADL- IS, Self Reporting Questionnaire (SRQ 20) to identify psychiatric symptom, and Neuropsychological test battery to evaluate: Attention (Digit Symbol from WMS-R, Trail Making Test), Memory (Logic Memory and Visual Reproduction from WMS-R, Selective Reminding Test - Buschke 1973), Praxis (Clock drawing, Block Design - WAIS-R), Language (Boston Naming Test and Verbal Fluency - animal) and Intelligence (Estimated Intellectual Quotient - Vocabulary and Block Design from WAISR). RESULTS: 37 subjects classified as amnestic MCI and 31 Normal controls completed the evaluation. We did not found significant differences between the two groups in age, gender, years of education, civil status, social class, MMSE and SRQ-20 scores. There were significant differences between MCI and controls in the following tests: Trail Making A, Logical Memory (Immediate and Delayed recall), Selective Reminding Test (total learning), Visual Reproduction (Immediate and delayed Recall), Boston Naming Test (Naming and Paragnosias), Block Design, and Estimated IQ in which MCI subjects had a worse performance than the elderly Controls. CONCLUSIONS: Our findings suggest that the two groups evaluated through an extensive neuropsychological battery present differences in memory performance but also in other cognitive functions as attention, language and praxis. Perhaps the MCI multiple-domain concept would be more useful than the amnestic MCI considering individuals coming from community samples

Abstract not available

[Truncated abstract] Background: Dementia, largely due to Alzheimer's disease (AD), is a major public health problem. The early identification of disease is an important challenge for clinicians because treatment of AD is now available. A simple and accurate means of stratifying risk for AD and identifying early disease is needed so that risk factor modification and treatment can occur optimally. To date, despite many attempts, an accurate means of standardising an approach to the assessment of subtle cognitive symptoms has not been developed. A subjective complaint of poor memory has been identified as a possible marker for underlying brain disease. This study examines the utility of neuropsychological scores, homocysteine levels, APOE genotyping and brain imaging as predictors of cognitive decline in individuals with subjective memory complaint (SMC). Method Eighty subjects with SMC were recruited from memory clinics and the community (MC: 1). Forty-two control subjects were also examined (MC: 0). CAMDEX was used to describe baseline clinical features. The CAMCOG was used as a global test of cognition and was administered annually for four years. At baseline, neuropsychological testing was administered. Cranial CT scanning, measurement of plasma homocysteine and APOE genotyping were completed. Categorical variables were analysed using chi-square according to Pearson's method. Continuous data was analysed using Student's t-tests and Mann-Whitney tests. A logistic regression model was used to identify independent contributors to the presence of memory complaint. Participants were then matched for age, gender and time to follow-up (up for three years) to determine longitudinal predictors of cognitive decline. ... Baseline CAMCOG scores were greater in the control group (MC:0 = 98.3 ? 2.8, MC:1 94.2 ? 5.5, Z ?4.46, p 0.000). There were no differences in neuropsychological scores, concentration of total plasma homocysteine, APOE genotype or brain scan measurements. Using the Wald stepwise selection method, logistic regression could not be established due to non-convergence regardless of whether or not the continuous variables were re-coded into dichotomous variables. A matching process that created 32 pairs of controls/subjects allowed follow-up analysis. The controls showed significant improvement with time on the CAMCOG unlike subjects (mean ? SD, controls 1.5 ?-3.0, Z - 2.61, p 0.01, subjects 0.2 ? 3.2, Z ? 0.24, p 0.81). The logistic regression analysis showed that group membership could not be defined by any single independent variable. When group membership was abandoned and those with stable scores were compared to those who declined no clear meaningful independent predictors of decline apart from age were identified. Conclusions: Methodological issues such as small sample size and inadequate follow up duration were identified that may have precluded identification of predictive factors for cognitive decline. The results indicate that complaints of memory problems are not associated with established risk factors for Alzheimer's disease and fail to predict objective cognitive decline over three years. Future studies should continue trying to identify robust predictors of cognitive decline in later life.

One of the major goals of cognitive neuroscience is to better understand the psychological and neural bases of human executive-attention. Executive or supervisory attention refers to a collection of higher-order cognitive functions whose primary contribution to behavior is to support controlled information processing and action. The capacity to control attention is essential for our adaptive interaction with the environment because it allows flexibility in our responses to ever changing situational contexts and demands. Executive-attention processes therefore play a unique role in shaping the human experience. Use of three-dimensional functional neuroimaging has fast become the empirical standard for investigating how executive-attention is implemented in the human brain. Most recently, emphasis has been placed on the use of these techniques to parse discrete components of a putative neural network relating to action-monitoring and cognitive control processes of the medial and lateral prefrontal cortex. This work has relied heavily on the use of popular experimental paradigms such as the Stroop task and their unique capacity to challenge such processes in humans. These tasks have also been especially useful for conceptualizing the nature of higher-cognitive dysfunction in complex brain disorders such as schizophrenia. The focus of this thesis concerns a novel application of the Stroop paradigm and functional imaging approach to examine executive-attention performance in healthy subjects and patients with schizophrenia and obsessive-compulsive disorder. On one hand, this work aimed to address current ideas on the nature of executive-control mechanisms and how they may be compromised in these two common psychiatric disorders. On the other hand, this work aimed to examine important conceptual and methodological issues associated with functional imaging approaches to the study of higher-cognition and cognitive psychopathology in humans. In line with connectionist models of executive-attention phenomena, the first study in this thesis investigated the effects of task practice on a larger-scale neurocognitive network associated with performance of the Stroop task in healthy subjects. This study involved the use of a novel methodological approach to model physiological covariances or ?functional connectivity? in PET data, which generated previously unseen and interesting insights into the neural basis of Stroop phenomena, whilst complimenting existing ideas on the role of the anterior cingulate and lateral prefrontal cortex in mediating executive-control functions. These findings were then extended to a comparative study of patients with schizophrenia and obsessive-compulsive disorder. This study largely corroborated previous reports of prefrontal executive dysfunction in schizophrenia, although patients also showed evidence for a compensatory strengthening of connectivity in a fronto-parietal network that accompanied task practice. This finding has important implications for existing models of higher-cognitive dysfunction and abnormal brain integration in schizophrenia. For patients with OCD compared to healthy subjects, performance of the Stroop task evoked a pattern of abnormal connectivity among predominantly corticostriatal regions, including a previously reported hyperfunction of the dorsal anterior cingulate cortex. While this latter result has been linked to a specific disturbance of action-monitoring in patients with OCD, the current study suggests that this may map onto a more extensive corticostriatal network abnormality in line with current theoretical models of this illness. One caveat raised in the first study of patients with schizophrenia concerned the effects of illnesschronicity and medication on functional imaging studies of higher-cognition and prefrontal function in schizophrenia. To address this, a second clinical study was undertaken in patients with a first-episode of schizophrenia (diagnosis confirmed at follow-up) who were examined before and after commencing antipsychotic treatment. Overall, the findings from this study support the idea of trait-like disturbances of prefrontal executive function in schizophrenia; however, they also suggested that aspects of this disturbance may be specific to the critical, early stage of illness - implicating progressive changes with illness chronicity and/or treatment intervention. These findings are discussed in relation to the developmental context of cognitive psychopathology in schizophrenia.

Thesis--University of Oklahoma. / Includes bibliographical references (leaves 51-58).

Thesis (Ph. D.)--University of North Texas, Aug., 2009. / Title from title page display. Includes bibliographical references.

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences