背景: 香港和廣州市是華南兩大發達城市，都面臨著人口老化的嚴峻形勢。由於醫療水準的提高，癡呆成為一個非常嚴重的公共健康問題。由於缺乏有效的治療手段，早期發現和干預成為減少認知功能損害及癡呆發病的最有效的措施。研究怎樣保護長者的認知功能對於公眾健康具有越來越重要的意義。越來越多的證據表明休閒活動有益於認知功能。研究表明體育鍛煉，腦力活動以及社會活動有益於認知健康，可以減少癡呆發病的風險。然而由於概念上的差異和研究方法的不同，使得目前的研究結果很難進行比較。由於社會背景會顯著影響休閒活動的參與，研究社會背景怎樣影響休閒活動對於長者認知功能的作用具有重要的意義。香港和廣州為華南兩大城市，其人口種族，基因，健康狀況及人口學特徵相似。然而在過去的一百多年中，由於歷史發展的不同，兩城市有著不同的社會系統。以上這些因素對於研究不同設計背景下的認知功能的對照研究提供了方便。研究兩地認識休閒活動與認知功能的關係，有助於評價不同社會環境對於休閒活動影響認知功能的以及社會因素對認知功能的影響。 / 研究目的: 本研究對於兩地長者認知功能的特點以及休閒活動的參與情況進行了比較。研究的主要目的是評估休閒活動與認知功能的關係，以及兩個城市中休閒活動與認知功能的關係。 / 方法: 這是一個橫斷面研究。557名非癡呆住在社區的長者參與了研究，其中香港260名，廣州297名。兩組長者在年齡，性別以及教育程度上沒有差異。休閒活動分為體育活動，智力活動，社會活動以及消遣活動。休閒活動的參與通過三種方式進行評估：種類，次數以及每週參與的小時數。一組評估量表包括：簡短精神狀態量表，詞語記憶，延遲回憶，詞語流暢性測驗，連線測驗，數位劃消測驗及Stroop測驗，用於評估兩地長者的認知功能。 / 兩地長者的人口學特徵，認知功能以及休閒活動的參與進行了比較，多元線性回歸用於分析每一類休閒活動與認知功能的關係，同時控制可能的混雜因素包括年齡，性別，教育程度，職業，婚姻狀況，居住情況，吸煙、酒情況，慢性疾病以及精神狀態。分層回歸用於分析每類休閒活動與認知功能的關係，同時控制其他三類休閒活動以及與認知功能顯著相關的混雜因素。 / 結果: 多元回歸分析表明與家人居住在一起者休閒活動的總類較多 (p=0.01)，休閒活動的時間較長 (p=0.02)。协方差分析檢驗顯示除了每週看電視的時間 （p=0.07），香港長者參與的休閒活動在種類，次數以及每週參與的小時數都明顯多於廣州長者，差異具有顯著性。兩地長者的認知功能測驗的分數未見顯著差異。體育活動（腦-身體鍛煉及有氧鍛煉）的種類與延遲回憶及詞語分類測驗顯著相關。智力活動與所有的認知功能測驗顯著相關。社會活動與語詞回憶和詞語流暢性測驗顯著相關。休閒活動與語詞回憶及連線測驗顯著相關。 / 多元線性回歸分析了休閒活動與認知功能的關係的同時，控制了其他三類休閒活動以及與認知功能顯著相關的協變數。分析結果顯示智力活動的種類與簡易精神狀態量表，語詞回憶，延遲回憶，詞語流暢性測驗以及數位劃消測驗顯著相關 （p<0.001）。體育活動和社會活動與認知功能未見明顯相關。消遣活動的時間與連線測驗顯著相關 （p=0.01）。休閒活動與認知功能的相關性兩地未見明顯顯著差異。 / 結論: 香港的長者參與了較多的休閒活動，但是認知功能測驗的分數與廣州長者卻沒有顯著差別。結果可能與之前的研究結果相矛盾，即參與較多的休閒活動與良好的認知功能相關，這可能與兩地的社會人口學的差異相關。以前的研究證明晚年的婚姻狀態與癡呆或者認知功能的下降相關。未婚或者喪偶的長者罹患癡呆症或者認知功能下降的風險性較高。香港未婚或喪偶長者較廣州多，或許這可以解釋為什麼香港長者參與較多的休閒活動，但是認知功能測驗卻未明顯優於廣州長者。同時也表明，除了休閒活動，社會因素（婚姻及居住狀況）對認知功能也有影響。 / 我們的研究表明參與智力活動尤其是參與各種各樣的智力活動與長者良好的認知功能相關。智力活動與認知功能的相關性在兩地沒有顯著差別，表明智力活動可在不同的社會環境中用於保護長者的認知功能。其他三類的活動與認知功能未發現有顯著相關性，這可能與智力活動的混雜效應有關，也可能與各活動之間其構成成分的重疊有關。儘管這樣，休閒活動對於認知功能的保護作用扔值得進一步研究。 / Background: The two most developed cities in southern China, Hong Kong (HK) and Guangzhou (GZ), are facing rapid population aging. As a result of improvements in medical care, dementia has emerged as a crucial public health problem. With limited treatment options available, early detection and intervention are likely to be the most effective strategies to reduce subsequent impairments and morbidity. Research into the prevention of cognitive decline among older persons is crucial for public health. There is increasing evidence that participation in leisure activities has a favorable effect on cognitive function. Studies have reported that physical exercise, cognitive activity and social engagement are beneficial for cognitive health and may reduce the risk of dementia. However, interpretation of the available evidence is hampered by conceptual discrepancies and methodological variations. As the social context may significantly influence leisure activity participation, it is interesting to explore how social contexts play a role in modulating the effects of leisure activity on cognitive function in older adults. HK and GZ are two major cities in southern China, and they share very similar ethnic, genetic, health and demographic characteristics. However, owing to differences in historical development, the two cities have been run with different social systems over the past few decades. This provided a natural case-control experiment for studying the effect of the social context on cognition. Hence, this study examined the association between leisure activity participation and cognition in the two cities to evaluate the cognitive modulating effects of leisure activities in different social environments. / Objectives of the studies: The main study objectives were to compare the cognitive characteristics and leisure activity participation of the two groups; to examine the association between leisure activity participation and cognitive function and the specific associations in HK and GZ; and to explore the modulating effect of social factors on cognitive function. / Methodology: This was a cross-sectional study. Convenience sampling was used to recruit 557 participants aged 60 years and over without dementia. Of these, 260 were recruited in HK and 297 in GZ. The two groups were recruited with similar demographic characteristics (age, gender and education). Leisure activities were classified as physical, intellectual, social and recreational activities. Leisure activity participation was measured in terms of the total number and total hours of participation per week for each category of activities. A battery of cognitive tests including the Cantonese version of the Mini Mental State Exam (CMMSE), word list learning test, delayed recall test, Category Verbal Fluency Test (CVFT), trail making test, digit cancellation test and Stroop test were used to measure participants’ cognitive function. / Differences in the participants’ demographic characteristics, cognitive performances and leisure activity participation were computed. A multiple linear regression of cognitive performance on leisure activity was performed, while controlling for other categories of activities and potential confounders that were significantly associated with cognitive function. / Results: The multiple linear regression revealed that living arrangement had a significant positive association with the total number of leisure activities (p=0.01) and total hours of leisure activity participation (p=0.02). Analysis of covariance showed that participants in HK participated in more leisure activities than those in GZ, as measured by the total number of subtypes and hours per week, except total hours of recreational activities per week (p=0.07). No significant differences were found between the cognitive performances of the older persons in the two cities. Pearson’s correlation and x² tests were performed to identify the leisure activities and potential confounders that were significantly correlated with cognitive performance. The total number and total hours of intellectual activity were significantly correlated with CMMSE scores (p<0.001 and p<0.001).The total number of subtypes and total hours per week of intellectual activity (p<0.001 and p<0.001), social activity (p<0.001 and p<0.01) and recreational activity (p<0.001 and p<0.01) were significantly correlated with the word list learning test. The total number of physical activities (p<0.01), total number of intellectual activities (p<0.001) and total hours of intellectual activity (p<0.01) were significantly correlated with the delayed recall test. The total number of physical and intellectual activities (p<0.01 and p<0.001), and total hours of intellectual and social activity (p<0.01 and p<0.001) were correlated with the CVFT. The total number of intellectual activities (p<0.01)and total hours of recreational activity (p<0.01) were significantly correlated with the trail making test (p<0.001). The total number and total hours of intellectual activity were significantly correlated with the digit cancellation test (p<0.001 and p<0.001). The total number and total hours of intellectual activity were significantly correlation with the Stroop test (p<0.01 and p<0.001). / Multiple linear regression using the enter method was conducted to measure the association between leisure activities and cognitive performance. The results showed that the total number of intellectual activities was significantly associated with better performance on cognitive tests, including the CMMSE (p<0.001), word list learning test (p<0.001), delayed recall test (p<0.001), CVFT (p<0.001) and digit cancellation test (p=0.01). Total hours of recreational activity was significantly associated with the trail making test (p=0.01). Multiple linear regression using the enter method also revealed that marital status was significantly associated with the CMMSE (p=0.002), word list learning test (p=0.003), delayed recall test (p=0.002), trail making test (p<0.001) and digit cancellation test (p=0.01). / Conclusions: HK participants participated in more leisure activities than GZ participants. However, HK participants did not show better cognitive performance than GZ participants. This finding appears to be inconsistent with previous studies that found that participation in more leisure activities predicted better cognitive functioning. This inconsistency might be explained by socio-demographic differences between the two cities. Some previous studies have found an association between late-life marital status and the risk of cognitive impairment. Older persons who were unmarried or widowed were at higher risk of dementia or cognitive decline. There were more unmarried or widowed participants among HK participants. The results indicate that in addition to leisure activities, social factors (marital or living status) might also contribute to the preservation of cognitive function among the elderly. / Our results underscore the significance of intellectual activity, especially participation in a variety of intellectual activities, in maintaining better cognitive functioning in older persons. Furthermore, a similar significant association between intellectual activity and cognitive function was found for participants in both HK and GZ, suggesting that the protective effect of intellectual activity could be generalized to different social environments. We failed to find significant associations between physical, social and recreational activities and cognitive function. However, the protective effect of leisure activity participation is recommended for further investigation in future studies. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Su, Xiufang. / Thesis (Ph.D.) Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 88-94). / Abstracts also in Chinese; appendixes in Chinese.

Introdução: O AVC (acidente vascular cerebral) é uma das mais importantes causas de alterações neuropsicológicas. Uma avaliação cognitiva inicial realizada por telefone implicaria em um diagnóstico mais precoce de prejuízo cognitivo e demência, reduzindo custos e tempo. Objetivo: Examinar as propriedades psicométricas da versão brasileira da Entrevista Telefônica para Avaliação do Estado Cognitivo - Modificada (TICS-M) em pacientes pós-AVC. Métodos: Previamente à validação da TICS-M em indivíduos acometidos por AVC, foi realizada tradução para o Português do Brasil e adaptação transcultural da versão original da TICS-M em uma amostra de 30 sujeitos não clínicos. Após esta fase, um subgrupo de 61 pacientes com AVC, participantes do Estudo da Mortalidade e Morbidade do AVC (EMMA) que ocorre no Hospital Universitário da Universidade de São Paulo, foram convidados a participar da validação da TICS-M, seis meses após o evento agudo. A TICS-M foi aplicada em três momentos: avaliação inicial (entrevista presencial), uma e duas semanas após a primeira avaliação. Na avaliação inicial, além da TICS-M, questionários adicionais foram aplicados para avaliar a cognição: MoCA (Montreal Cognitive Assessment), MEEM (Mini Exame do Estado Mental); e para a depressão, HDRS (Hamilton Depression Rating Scale). Todos os questionários foram aplicados por duas entrevistadoras treinadas para o estudo. A confiabilidade intra-observador da TICS-M foi testada através dos coeficientes de Pearson, Intraclasse e alfa de Cronbach. As características internas do TICS-M também foram avaliadas através de uma análise exploratória utilizando o método Análise de Componentes Principais. A validade discriminatória do instrumento para rastreamento de demência pós-AVC foi avaliada em comparação a MEEM pela análise da área sob a curva (AUC) determinada pela curva ROC. Foram calculadas sensibilidade e especificidade para o ponto de corte ideal para rastrear demência. Resultados: De maneira geral, a TICS-M traduzida para o português apresentou um bom entendimento dos itens na mostra de indivíduos não clínicos. Foi observada uma frequência de 23% sugestiva de demência pós-AVC. O nível de escolaridade esteve positivamente associado ao estado demencial rastreado pelo MEEM. O estado depressivo assim como outras características de base não se associou à demência sugerida pelo MEEM. A confiabilidade teste-reteste intra-observador revelou taxas quase totais nos três momentos avaliados (Pearson Coeficiente > 0,85, Coeficientes de Correlação Intraclasse > 0,85 e Coeficiente alfa de Cronbach: 0,96). A análise fatorial determinou três domínios: memória de trabalho e atenção; memória recente e de evocação e orientação. A área sob a curva (AUC) determinada para a TICS-M em comparação com MEEM foi de 0,89 (intervalo de confiança 95%: 0,80-0,98). O ponto de corte sugerido para TICS-M foi de 14 pontos (escala de 0-39 pontos) para rastrear demência com sensibilidade de 91,5% e especificidade de 71,4%. Resultados semelhantes foram observadas com o MoCA. Conclusão: A versão brasileira da TICS-M sugere ser um instrumento de pesquisa útil e confiável para rastrear demência em pacientes pós-AVC / Introduction: Stroke is one most important cause of neuropsychological disorders. An initial cognitive assessment performed by telephone resulting in an early diagnosis of cognitive impairment and dementia, reducing costs and time. Objective: To examine the psychometric properties of the Brazilian version of the Modified Telephone Interview for Cognitive Status Assessment (TICS-M) for assessment of dementia in post-stroke patients. Methods: Prior to validation of TICS-M in post-stroke patients, translation was performed for the Brazilian-Portuguese and cross-cultural adaptation of the original version of TICS-M in a non-clinical sample of 30 subjects. After this phase, 61 stroke patients enrolled in the Stroke Mortality and Morbidity Study (The EMMA study) that occurs at the University Hospital of the University of São Paulo, were invited to participate in this sub-study to validate the TICS-M six months after the acute event. The TICS-M was applied in three moments: first evaluation (personal interview), one and two weeks after of the first evaluation. At the first evaluation, beyond the TICS-M, additional questionnaires were applied to assess cognition: MoCA (Montreal Cognitive Assessment), MMSE (Mini-Mental Status Examination), and for depression, HDRS (Hamilton Depression Rating Scale). All questionnaires were administered by two trained interviewers for the study. Reliability of the TICS-M was tested by intra-observer rates using Pearson, Intraclass and Cronbach´s alpha coefficients. The internal characteristics of TICS-M were also evaluated by an exploratory analysis using Principal Component Analysis. The discrimination validity of the instrument to assess dementia was evaluated by comparison to the MMSE analysis of the area under the curve (AUC) determined by the ROC curve. Sensitivity and specificity for the ideal cutoff to assess dementia were calculated. Results: In general, the TICS-M translated into Portuguese version showed a good understanding of the items in non-clinical individuals. A frequency of 23% suggestive of post-stroke dementia was observed. The level of education was positively associated with dementia status assessed by MMSE. The depressive status, as well as, other baseline characteristics was not associated with dementia suggested by MMSE. Test-retest reliability intra-observer revealed almost total rates in the three evaluation moments (Pearson coefficient > 0.85, Intraclass Correlation Coefficient > 0.85 and Cronbach\'s alpha coefficient: 0.96). The factorial analysis determined three domains: working memory and attention, recent and recall memory and orientation. The area under the curve (AUC) determined by TICS-M compared to MMSE was 0.89 (95% confidence interval: 0.80-0.98). The cutoff suggested for TICS-M was equal or greater than 14 points (range 0-39 points) to assess dementia (91.5% sensitivity, 71.4 % specificity). Similar results were observed with the MoCA. Conclusion: The Brazilian version of TICSM suggests being a useful and reliable research instrument to evaluate dementia in poststroke patients in epidemiological studies

Introdução: O AVC (acidente vascular cerebral) é uma das mais importantes causas de alterações neuropsicológicas. Uma avaliação cognitiva inicial realizada por telefone implicaria em um diagnóstico mais precoce de prejuízo cognitivo e demência, reduzindo custos e tempo. Objetivo: Examinar as propriedades psicométricas da versão brasileira da Entrevista Telefônica para Avaliação do Estado Cognitivo - Modificada (TICS-M) em pacientes pós-AVC. Métodos: Previamente à validação da TICS-M em indivíduos acometidos por AVC, foi realizada tradução para o Português do Brasil e adaptação transcultural da versão original da TICS-M em uma amostra de 30 sujeitos não clínicos. Após esta fase, um subgrupo de 61 pacientes com AVC, participantes do Estudo da Mortalidade e Morbidade do AVC (EMMA) que ocorre no Hospital Universitário da Universidade de São Paulo, foram convidados a participar da validação da TICS-M, seis meses após o evento agudo. A TICS-M foi aplicada em três momentos: avaliação inicial (entrevista presencial), uma e duas semanas após a primeira avaliação. Na avaliação inicial, além da TICS-M, questionários adicionais foram aplicados para avaliar a cognição: MoCA (Montreal Cognitive Assessment), MEEM (Mini Exame do Estado Mental); e para a depressão, HDRS (Hamilton Depression Rating Scale). Todos os questionários foram aplicados por duas entrevistadoras treinadas para o estudo. A confiabilidade intra-observador da TICS-M foi testada através dos coeficientes de Pearson, Intraclasse e alfa de Cronbach. As características internas do TICS-M também foram avaliadas através de uma análise exploratória utilizando o método Análise de Componentes Principais. A validade discriminatória do instrumento para rastreamento de demência pós-AVC foi avaliada em comparação a MEEM pela análise da área sob a curva (AUC) determinada pela curva ROC. Foram calculadas sensibilidade e especificidade para o ponto de corte ideal para rastrear demência. Resultados: De maneira geral, a TICS-M traduzida para o português apresentou um bom entendimento dos itens na mostra de indivíduos não clínicos. Foi observada uma frequência de 23% sugestiva de demência pós-AVC. O nível de escolaridade esteve positivamente associado ao estado demencial rastreado pelo MEEM. O estado depressivo assim como outras características de base não se associou à demência sugerida pelo MEEM. A confiabilidade teste-reteste intra-observador revelou taxas quase totais nos três momentos avaliados (Pearson Coeficiente > 0,85, Coeficientes de Correlação Intraclasse > 0,85 e Coeficiente alfa de Cronbach: 0,96). A análise fatorial determinou três domínios: memória de trabalho e atenção; memória recente e de evocação e orientação. A área sob a curva (AUC) determinada para a TICS-M em comparação com MEEM foi de 0,89 (intervalo de confiança 95%: 0,80-0,98). O ponto de corte sugerido para TICS-M foi de 14 pontos (escala de 0-39 pontos) para rastrear demência com sensibilidade de 91,5% e especificidade de 71,4%. Resultados semelhantes foram observadas com o MoCA. Conclusão: A versão brasileira da TICS-M sugere ser um instrumento de pesquisa útil e confiável para rastrear demência em pacientes pós-AVC / Introduction: Stroke is one most important cause of neuropsychological disorders. An initial cognitive assessment performed by telephone resulting in an early diagnosis of cognitive impairment and dementia, reducing costs and time. Objective: To examine the psychometric properties of the Brazilian version of the Modified Telephone Interview for Cognitive Status Assessment (TICS-M) for assessment of dementia in post-stroke patients. Methods: Prior to validation of TICS-M in post-stroke patients, translation was performed for the Brazilian-Portuguese and cross-cultural adaptation of the original version of TICS-M in a non-clinical sample of 30 subjects. After this phase, 61 stroke patients enrolled in the Stroke Mortality and Morbidity Study (The EMMA study) that occurs at the University Hospital of the University of São Paulo, were invited to participate in this sub-study to validate the TICS-M six months after the acute event. The TICS-M was applied in three moments: first evaluation (personal interview), one and two weeks after of the first evaluation. At the first evaluation, beyond the TICS-M, additional questionnaires were applied to assess cognition: MoCA (Montreal Cognitive Assessment), MMSE (Mini-Mental Status Examination), and for depression, HDRS (Hamilton Depression Rating Scale). All questionnaires were administered by two trained interviewers for the study. Reliability of the TICS-M was tested by intra-observer rates using Pearson, Intraclass and Cronbach´s alpha coefficients. The internal characteristics of TICS-M were also evaluated by an exploratory analysis using Principal Component Analysis. The discrimination validity of the instrument to assess dementia was evaluated by comparison to the MMSE analysis of the area under the curve (AUC) determined by the ROC curve. Sensitivity and specificity for the ideal cutoff to assess dementia were calculated. Results: In general, the TICS-M translated into Portuguese version showed a good understanding of the items in non-clinical individuals. A frequency of 23% suggestive of post-stroke dementia was observed. The level of education was positively associated with dementia status assessed by MMSE. The depressive status, as well as, other baseline characteristics was not associated with dementia suggested by MMSE. Test-retest reliability intra-observer revealed almost total rates in the three evaluation moments (Pearson coefficient > 0.85, Intraclass Correlation Coefficient > 0.85 and Cronbach\'s alpha coefficient: 0.96). The factorial analysis determined three domains: working memory and attention, recent and recall memory and orientation. The area under the curve (AUC) determined by TICS-M compared to MMSE was 0.89 (95% confidence interval: 0.80-0.98). The cutoff suggested for TICS-M was equal or greater than 14 points (range 0-39 points) to assess dementia (91.5% sensitivity, 71.4 % specificity). Similar results were observed with the MoCA. Conclusion: The Brazilian version of TICSM suggests being a useful and reliable research instrument to evaluate dementia in poststroke patients in epidemiological studies