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BACKGROUND: Alzheimer disease (AD) patients demonstrate various clinical features reminiscent of children (the retrogenesis model). The Binet test is available for assessing mental development and deterioration. However, neuroimaging correlations remain to be clarified. Although AD patients also manifest social judgment disability, there are few cognitive tests, contrary to so many memory tests. Among the database, we noticed that the Binet test includes the subscale of social judgement using illogical sentences and pictures. The aim of this study is to clarify the neuroimaging correlations for the Binet test, especially for the illogical questions. METHODS: Forty participants were selected from the database of the Tajiri Project. The Tanaka-Binet test was used to evaluate the mental age and the basic age. The latter is the age level at which the patient can completely accomplish all questions at the immediately lower age level and is used for calculating the mental age. Using the subtests of illogical sentences/pictures, logical judgment abilities were assessed. Using magnetic resonance imaging, we performed four-grade visual evaluation for cortical atrophy. The cerebral metabolic rate for glucose (CMRglc) was measured using an autoradiographic method of 18 F-fluoreodeoxyglucose - positron emission tomography (FDG-PET). RESULTS: There was a significant Spearman's correlation between the clinical stage and the basic age. Degree of frontal, temporal and hippocampal atrophy were correlated with the basic age. The entire grey matter and frontal and temporal CMRglc were associated with the basic age. The illogical sentences scores were correlated with the bilateral temporal, hippocampal and the left parieto-temporal CMRglc, whereas the illogical picture scores were correlated with the right parieto-temporal CMRglc. CONCLUSIONS: We found that frontal and temporal atrophy as well as hypometabolism were associated with the basic age. Regarding the illogical judgment, the current PET data analysis disclosed that there may be a double dissociation between verbal/non-verbal judgments and the left/right parieto-temporal areas.

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BACKGROUND: Increasing evidence shows that bilingualism or multilingualism may have beneficial effects on preventing dementia. We performed a cross-sectional, community-based study in Taiwan. Some elders (older than 70 years) in Taiwan can speak Japanese because of the formal Japanese education they received before World War II, when Taiwan was under Japanese rule. After the war, Mandarin Chinese was adopted as the official language of Taiwan. We assessed whether constantly using three languages had an effect on dementia prevalence and cognitive function. METHODS: We defined multilingualism as the ability to fluently speak Taiwanese (T), Japanese (J), and Mandarin Chinese (C) in daily life. We evaluated the Mini-Mental State Examination and AD8 questionnaire results of 514 community-dwelling people older than 70 years in Taishan, Taiwan. RESULTS: Seventy-three of the subjects (14.2%) were multilingual (T, J, C) and 441 (85.8%) were bilingual (T, C). No difference was noted in dementia prevalence between multilingual (6.8%) and bilingual (7.4%) populations, but multilinguals were older than bilinguals (mean age: 79.9 vs 77.3 years). Multilinguals had higher Mini-Mental State Examination scores than bilinguals (mean: 24.6 vs. 22.7). However, after the subjects were stratified into low and high education level groups, the Mini-Mental State Examination difference was found to be significant in only the low education level group. CONCLUSIONS: Dementia prevalence did not significantly differ between the multilingual (T, J, C) and bilingual (T, C) groups. However, given that the average age of the multilingual group was approximately 2 years older than that of the bilingual group, there may have been minor effects in the multilingual group.

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BACKGROUND: The Necker cube is usually used for evaluating the visuoconstructional ability of patients with mild cognitive impairment (MCI) and dementia. However, the Necker cube is often considered a drawing with a visual illusionary perspective. The purpose of this study was to investigate whether Necker cube copying could detect participants with MCI due to dementia. METHODS: We retrospectively analyzed the database of the 1998 prevalence study that was part of the Tajiri Project (n = 599). Pencil drawings of the Necker cube on A4-sized white paper by non-demented people (Clinical Dementia Rating (CDR) 0 and 0.5, n = 256) were classified into two patterns: non-three-dimension (3-D) and 3-D. Two neuropsychologists assessed Necker cube copying according to the criteria of the classification. After the classification, the database of the 2003 incidence study was used according to the subjects' conversion to dementia. RESULTS: In the prevalence study, among those who made a non-3-D drawing of the Necker cube, there were significantly fewer people in the CDR 0 group than in the CDR 0.5 and CDR 1+ groups; similarly, there were significantly fewer people in the CDR 0.5 group than in the CDR 1 + group (χ(2) = 32.6, P < 0.001; post-hoc tests using χ(2) tests, CDR 0 > CDR 0.5 > CDR 1+, P < 0.001). In the incidence study, among those who made a non-3-D drawing of the Necker cube, there were significantly fewer people in the non-converter group than in the converter group (χ(2) = 19.9, P < 0.001). However, there was no significant difference between the non-converter group (n = 21) and the converter group (n = 21) when age, sex, educational levels, and Mini-Mental State Examination scores were controlled (χ(2) = 0.0, P = 1.000). CONCLUSIONS: Our results suggested that Necker cube copying may evaluate visual illusion as well as visuoconstructional ability. The Necker cube may not be an appropriate test to detect participants with MCI due to dementia.

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BACKGROUND: Dubois et al. proposed the criteria for prodromal Alzheimer's disease (AD) to detect dementia in its very early stage. Because detection requires magnetic resonance imaging and (18) F-fluorodeoxyglucose-positron emission tomography (PET), the prevalence and prognosis have not been fully investigated. METHODS: Our database included 346 healthy participants (Clinical Dementia Rating (CDR) 0), 119 with questionable dementia (CDR 0.5), and 32 dementia participants (CDR 1+) and was applied to investigate the prevalence of prodromal AD. Forty-four CDR 0.5 participants (37%) were randomly selected to undergo (18) F-fluorodeoxyglucose-PET. The same percentage was applied to select 128 CDR 0 and 12 CDR 1 + participants (total: n = 184) to calculate the prevalence. A neuroradiologist classified the PET images in a blinded manner based on the criteria of Silverman et al. Participants were considered to have prodromal AD if they exhibited 'parietal/temporal +/- frontal hypometabolism' (PET) with hippocampal atrophy (magnetic resonance imaging). RESULTS: Eighteen CDR 0.5 participants (40.9%) met the criteria for prodromal AD, which was a prevalence rate of 9.8% among older adults aged ≥ 65 years. Thirteen prodromal AD participants (72%) converted to AD during the 5-year follow-up period. DISCUSSION: The concept and criteria for prodromal AD are useful for predicting which subjects in a community will convert to AD.

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BACKGROUND: We previously demonstrated a positive correlation with nursing home (NH) replacement and donepezil (DNP) administration on lifetime expectancy after the onset of Alzheimer's disease (AD). However, the correlation with quality-adjusted life-year (QALY) remains to be elucidated, along with the additional impact of concomitant cerebrovascular disease (CVD). Based upon our recently reported health state utility values, we retrospectively analyzed the correlation with NH replacement and/or DNP administration on QALY and life expectancy in 'pure' AD (without CVD) and AD with CVD patients. METHODS: All outpatients at the Tajiri Clinic from 1999-2012 with available medical records and death certificates were included. The entry criteria were a dementia diagnosis (DSM-IV) and diagnoses of pure AD or AD with CVD (NINCDS-ADRDA), medical treatment for more than 3 months, and follow up to less than 1 year before death. The main outcomes were lifetime expectancy (months between the onset of dementia and death) and QALY. RESULTS: We identified 390 subjects, of whom 275 had the diagnosis of dementia that met the entry criteria, including 67 pure AD, 33 AD with CVD, and 110 VaD patients. For the AD patients, 52 had taken DNP and 48 had not received the drug due to treatment prior to the introduction of DNP in 1999 in Japan. For the pure AD group, there were positive correlation between NH and DNP and QALY, as well as lifetime expectancy. As for the AD with CVD group, only a correlation between DNP and lifetime expectancy was noted, with no correlation with QALY. CONCLUSIONS: We found positive correlations between DNP administration and NH replacement and lifetime expectancy and QALY after the onset of AD. However, concomitant CVD negated such a positive correlation with QALY. The findings suggest that QALY in AD is affected by CVD; thus, indicating the importance of CVD prevention.

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BACKGROUND: Cholinesterase inhibitors can delay the progression of Alzheimer's disease (AD). Several clinical trials of the drug in moderate to severe AD have consistently reported clinically positive effects. A combining effect with psychosocial intervention was reported in mild to moderate AD patients. Since a therapeutic approach or rehabilitation combined with cholinesterase inhibitors for severe AD patients remains controversial, we performed a prospective intervention for patients in Long-Term Care Health Facilities (LTCHF). METHODS: Two LTCHFs (N1, N2) were enrolled. N1 is a 126-bed facility that does not treat with donepezil but rather with psychosocial intervention (reality orientation and reminiscence). N2 is a 150-bed facility with a 50-bed special dementia unit, in which the physician can prescribe donepezil. On top of the similar psychosocial intervention, rehabilitation is performed in N2. Thirty-two severe AD patients (MMSE < 6) in N1 and N2 (16 vs. 16) were compared for the effect of donepezil (10 mg/d for 3 months) with or without psychosocial intervention (n = 8 vs. 8 for each facility). The Vitality Index was used to assess daily activities and the introduction of rehabilitation. RESULTS: The response ratio (MMSE 3+) of donepezil was 37.5% in N2. The combination of donepezil with the psychosocial intervention improved the Vitality Index total score, and Communication, Eating, and Rehabilitation subscores (Wilcoxon, p = 0.016, 0.038, 0.023, and 0.011, respectively). Most of them were smoothly introduced to rehabilitation, and the proportion of accidental falls decreased. Psychosocial intervention in N1 without the drug only improved the total score (Wilcoxon, p = 0.046). CONCLUSIONS: A combined therapeutic approach of donepezil and psychosocial intervention can have a positive effect, even for severe patients through the introduction of rehabilitation and decreasing accidental falls. However, these findings require replication in a larger cohort.

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BACKGROUND: Cholinesterase inhibitors (ChEIs) such as donepezil have the effect of delaying progression of Alzheimer's disease (AD), but their effect on life expectancy is unclear. We analyzed the influence of donepezil on life expectancy after onset of AD, together with the effects of antipsychotic drugs and residency in a nursing home. METHODS: All outpatients at the Tajiri Clinic from 1999-2012 with available medical records and death certificates were included in a retrospective analysis. The entry criteria were a dementia diagnosis based on DSM-IV criteria and diagnosis of AD using NINCDS-ADRDA criteria; medical treatment for more than 3 months; and follow up until less than 1 year before death. RESULTS: We identified 390 subjects with medical records and death certificates, of whom 275 had a diagnosis of dementia that met the entry criteria. Of 100 patients diagnosed with AD, 52 had taken donepezil and 48 patients had not received the drug due to treatment prior to the introduction of donepezil in 1999 in Japan. The lifetime expectancies after onset were 7.9 years in the donepezil group and 5.3 years in the non-donepezil group. There was a significant drug effect with a significant covariate effect of nursing home residency. Other covariates did not reach a significant level. CONCLUSIONS: Although this report has the limitation of all retrospective analyses: the lack of randomization, we found a positive effect of donepezil on lifetime expectancy after onset of AD. This may be due to a decreased mortality rate caused by reduction of concomitant diseases such as pneumonia. The similar life expectancies in patients taking donepezil at home and those not taking donepezil in a nursing home indicated a positive health economic effect of the drug.

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Patients with vascular dementia (VaD) are often isolated, withdrawn from society because of negative symptoms and functional disabilities. The aim of this study was to detect factors associated with social withdrawal in patients with VaD. The participants were 36 institutionalized patients with VaD. Social withdrawal was assessed with the social withdrawal of the Multidimensional Observation Scale for Elderly Subjects (MOSES). Possible explanatory variables were the MOSES items depression and self-care, Cognitive Abilities Screening Instrument (CASI), apathy evaluation scale (AES), and Behavioral Pathology in Alzheimer's Disease Frequency-Weighted Severity Scale (BEHAVE-AD-FW). Multiple regression analyses were conducted for two groups: Analysis 1 was performed in all patients (N = 36) and Analysis 2 was performed in the patients with the ability to move by themselves (i.e., independent walking or independent movement with a cane or a wheelchair; n = 28). In Analysis 1, MOSES item social withdrawal was correlated with AES and MOSES item self-care. In Analysis 2, MOSES item social withdrawal was correlated with AES and CASI domain abstraction and judgment. Decreased social activities of VaD were not related to general cognitive function or depression. Disturbed activities of daily living (ADLs) for self-care may involve decreased frontal lobe function, indicating that comprehensive rehabilitation for both ADL and dementia are needed to improve the social activities of patients with VaD.

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Vascular dementia (VaD) is a condition whereby decreased cerebral perfusion causes cognitive deterioration. We hypothesized that lesions of the anterior nucleus (AN) including the mammillo-thalamic tract cause a decline in the recollection of past episodes/events, and that the left thalamic infarction can cause frontal dysfunction through the "diaschisis." We investigated 18 VaD cases with only left thalamic infarction. (99m)Tc-ECD single photon emission computed tomography (SPECT) was used to assess regional cerebral blood flow (CBF). To test the first hypothesis, the scores on the Cognitive Abilities Screening Instrument (CASI) domain Recent memory or the rating on the Clinical Dementia Rating (CDR) domain Memory were analyzed. To test the second hypothesis, we selected the six regions of interest that correlated with the two measures, i.e., word fluency and/or depressive state, as assessed with the Geriatric Depression Scale (GDS). We found that all patients had amnesia, especially in the AN group, six of the eight patients had scores of 1+ on the CDR Memory scale, and all but one disclosed the CASI domain Recent memory impairment. There were significant correlations between the left anterior cingulate CBF and word fluency scores, and between the right rectal gyrus CBF and GDS scores. We suggest that these observations are due to a remote effect of the thalamic lesion.

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AIM: The Clinical Dementia Rating (CDR) is an assessment of dementia severity based on observations of activities of daily living, and a CDR of 0.5 (CDR 0.5) represents questionable dementia. A combination of the Cognitive Abilities Screening Instrument (CASI) and the Trail Making Test (TMT) scores discriminated CDR 0.5 subjects from healthy participants with a high degree of accuracy. We investigated the neurological background of CDR 0.5 subjects by correlating CASI and TMT scores with regional cerebral blood flow (rCBF) as measured by single photon emission computed tomography (SPECT). METHODS: From a community-based cohort, 22 CDR 0.5 participants were recruited. CASI and TMT scores, rCBF measure using [(123) I]-N-isopropyl-p-iodoamphetamine and SPECT were obtained. We evaluated the relationships between the CASI domain scores, between TMT scores and rCBF in a regions-of-interest-based analysis, and voxel-based analysis using Statistical Parametric Mapping 5 software. RESULTS: We found that lower rCBF in the left medial temporal cortex correlated with a decreased CASI domain recent memory score both in the regions-of-interest and statistical parametric mapping analysis. In both the regions-of-interest and statistical parametric mapping analysis, the rCBF in the left prefrontal cortex correlated with CASI domain remote memory and mental manipulation and concentration. CONCLUSIONS: Our results indicate that some CDR 0.5 subjects have functional impairments in the medial temporal lobe as well as in the prefrontal cortex, as reflected in the cognitive decline measured by CASI and TMT.

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AIM: To determine whether impaired instrumental activities of daily living affect conversion from mild cognitive impairment to dementia for subjects in a community. METHODS: This is a 7-year retrospective study that followed 226 randomly selected participants from the Prevalence Study 1998 in Tajiri in northern Japan who had Clinical Dementia Rating 0.5. Instrumental activities of daily living levels were assessed with a 21-item questionnaire. We analyzed the scores at baseline between the converters to dementia and non-converters. RESULTS: The converters had lower baseline scores on the 'bed making' and 'mode of transportation' items compared with the non-converters; the former item was significant after a stepwise logistic regression analysis that excluded age and Mini-Mental State Examination effects. In gender analysis, female converters had lower baseline scores on the 'bed making' and 'cleaning' items. For male participants, no items were found to have such an effect. CONCLUSIONS: We suggest that when individuals with mild cognitive impairment are limited in their performance of instrumental activities of daily living, this is predictive of dementia onset.

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Herein we report the case of a 77-year-old, right-handed man, without dementia, who had a cerebral infarction in the left caudate head that manifested recurrent delusional ideas. He experienced three episodes of delusional ideas; the first two occurred after loss of consciousness and the third after delirium at night. MRI findings of left caudate head infarction were the same for all three episodes. An unstable cerebral perfusion may have caused problems in the cerebral network between the caudate head and cerebral cortex. Decreased cerebral blood flow in the frontal lobe was noted particularly in the second and third episodes, supporting the neurological background of disinhibition of emotional behaviour. Antipsychotic drugs and a small dose of risperidone were effective in controlling the patient's delusional ideas.

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The relationship of predementia stage with cerebrovascular disease (CVD) has not been fully clarified. Following our Prevalence Study 1998 in Tajiri, Japan, Incidence Study 2003 disclosed that 17.9% of subjects developed vascular dementia (VaD). Some cases developed after stroke (type I), whereas others already met the criteria for subcortical VaD (SVD) despite very mild stage (Clinical Dementia Rating [CDR] 0.5) and progressed to mild stage (CDR 1) (type II). We hypothesized that prognosis of vascular mild cognitive impairment (MCI) included type II VaD or death due to causes associated with vascular risk factors. Prevalence Study 1998 included 497 randomly selected participants, including 346 with a CDR of 0, 119 with a CDR of 0.5, and 32 with a CDR of 1+. The first 2 groups were targeted for Incidence Study 2003. Based on the database, we reanalyzed the ratio of SVD in the subjects with CDR 0.5 and VaD, prognosis with or without CVD, and 2 types of VaD onset. The criteria for SVD were achieved by 67% of those with VaD and by 7% of those with vascular MCI (ie, CDR 0.5). In the CDR 0 group, CVD had no affect on prognosis; however, in the CDR 0.5 group, CVD had an affect on death by cardiovascular disease. The majority of subjects in the CDR 0 and CDR 0.5-CVD (-) groups were classified as type I, whereas all subjects in the CDR 0.5-CVD (+) group were type II. Although vascular MCI is treatable, it may progress to death as well as apparent dementia. Individuals with this "buried under the community" phenomenon of SVD should be targeted for secondary prevention interventions.

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A group reminiscence approach (GRA) with reality orientation (RO) is widely used as a psychosocial intervention for dementia. Since clinical effectiveness was reported for the intervention, interest has been directed toward areas of the neuronal network that might be being stimulated. We hypothesized that the frontal lobe associated with social interaction was being stimulated. To test this hypothesis, we studied 24 patients with vascular dementia. In addition to conventional care, a 1-h session of GRA with RO was provided once a week for 3 months in the GRA-RO arm (n=12). Only supportive care was provided in the control arm (n=12). Before and after the interventions, cognitive function, depressive state, and social activities were assessed. Since glucose metabolism is associated with brain function, cerebral glucose metabolism was measured by positron emission tomography (PET). Regarding behavioral improvement, 10 patients in the GRA-RO arm showed improvement compared with only two patients in the control arm, a significant difference. PET demonstrated that metabolism in the anterior cingulate was increased in the GRA-RO arm, whereas no significant changes were observed in the control arm. These results suggest that GRA-RO stimulates the anterior cingulate and has a positive effect on social interaction.

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Our aim was to investigate the relationships between sleep disturbance and activities of daily living (ADL) and 24-h blood pressure patterns in institutionalized dementia patients. Using 107 institutionalized dementia patients (32 males and 75 females, mean age 76.3 years), patients with a mini mental state examination (MMSE) score<24 were classified into four groups based on ADL (normal or declined) and nocturnal reduction in blood pressure (dipper or non-dipper). The sleep/wake state was visually monitored hourly for 14 consecutive days, and daytime and nighttime sleep ratios were determined. MMSE scores were significantly lower in the declined ADL group than in the normal ADL group. The nighttime sleep ratio of the non-dipper/declined ADL group was significantly lower than in the other groups. Sleep disturbance was associated with the deterioration of MMSE scores, low ADL, and impaired nocturnal reduction in blood pressure in dementia patients.

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In 1997 we examined the prevalence of dementia among the Japanese elderly immigrants living in the São Paulo metropolitan area (n=166). Herein, we followed up on these subjects for causes of death and dementia incidence. We were able to contact 108 subjects: 54 were already dead. The most common cause of death was cardiac disease. For dementia, 31.6% of the dead subjects were found to have developed dementia before they died, and 20.8 % of the living subjects were demented. As for the baseline the clinical dementia rating (CDR), 20.8 % of CDR 0 and 50.0 % of CDR 0.5 subjects developed dementia in the dead group; whereas in the living group, 23.9 % of CDR 0 and 52.6 % of CDR 0.5 developed dementia. As a whole, the incidence was 34.2 ‰ per 1000 person-years. Cardiac disease as the most common cause of death was probably due to the higher prevalence of diabetes mellitus. Compared with the previous study, the lower incidence of dementia from the CDR 0.5 group may have been due to a higher mortality rate. This is the first study on the incidence of dementia in elderly Japanese immigrants in Brazil.

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This study verifies the environmental effects on agraphia in mild cognitive impairment and dementia. We compared elderly Japanese subjects living in Japan and Brazil. Methods: We retrospectively analyzed the database of the Prevalence Study 1998 in Tajiri (n=497, Miyagi, Japan) and the Prevalence Study 1997 of elderly Japanese immigrants living in Brazil (n=166, migrated from Japan and living in the São Paulo Metropolitan Area). In three Clinical Dementia Rating (CDR) groups, i.e., CDR 0 (healthy), CDR 0.5 (questionable dementia), and CDR 1+ (dementia) , the Mini-Mental State Examination (MMSE) item of spontaneous writing and the Cognitive Abilities Screening Instrument (CASI) domain of dictation were analyzed with regard to the number of Kanji and Kana characters. Formal errors in characters and pragmatic errors were also analyzed. Results: The immigrants in Brazil wrote similar numbers of Kanji or Kana characters compared to the residents of Japan. In spontaneous writing, the formal Kanji errors were greater in the CDR 1+ group of immigrants. In writing from dictation, all the immigrant CDR groups made more formal errors in Kana than the Japan residents. No significant differences in pragmatic errors were detected between the two groups. Conclusions: Subjects living in Japan use Kanji frequently, and thus the form of written characters was simplified, which might be assessed as mild formal errors. In immigrants, the deterioration in Kanji and Kana writing was partly due to decreased daily usage of the characters. Lower levels of education of immigrants might also be related to the number of Kanji errors.

Este estudo verifica os efeitos do meio ambiente sobre a agrafia em comprometimento cognitivo leve e demência. Nós comparamos indivíduos idosos vivendo no Japão e Brasil. Métodos: Nós, retrospectivamente, analisamos a base de dados do Estudo de Prevalência 1998 em Tajiri (n=497, Miyagi, Japão) e do Estudo de Prevalência 1997 de imigrantes idosos japoneses vivendo no Brasil (n=166, imigrados do Japão e residindo na área metropolitana da cidade de São Paulo). Em três grupos de CDR (Clinical Dementia Rating), isto é, CDR 0 (saudáveis), CDR 0.5 (demência questionável) e CDR1+ (demência), o item de escrita espontânea do Mini-Exame do Estado Mental (MEEM) e o domínio de ditado do Cognitive Abilities Screening Instrument (CASI) foram analisados em relação ao número de caracteres em Kanji e Kana. Erros formais nos caracteres e erros pragmáticos foram também analisados. Resultados: Os imigrantes no Brasil escreveram número similar de caracteres de Kanji e Kana comparados aos residentes no Japão. Na escrita espontânea, os erros formais de Kanji foram maiores no grupo de CDR1+ em imigrantes. Na escrita sob ditado, todos os grupos de CDR de imigrantes fizeram mais erros formais em Kana do que os residentes no Japão. Nenhuma diferença foi encontrada em erros pragmáticos entre os grupos. Conclusões: Sujeitos vivendo no Japão usam Kanji freqüentemente, e então, a forma de caracteres escritos foi simplificada, o que pode ser avaliado como discretos erros formais. Em imigrantes, a deterioração na escrita em Kanji e Kana foi parcialmente devida ao uso diário restrito dos caracteres. Baixos níveis educacionais dos imigrantes podem estar relacionados ao número de erros em Kanji.

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This study verifies the environmental effects on agraphia in mild cognitive impairment and dementia. We compared elderly Japanese subjects living in Japan and Brazil. METHODS: We retrospectively analyzed the database of the Prevalence Study 1998 in Tajiri (n=497, Miyagi, Japan) and the Prevalence Study 1997 of elderly Japanese immigrants living in Brazil (n=166, migrated from Japan and living in the São Paulo Metropolitan Area). In three Clinical Dementia Rating (CDR) groups, i.e., CDR 0 (healthy), CDR 0.5 (questionable dementia), and CDR 1+ (dementia) , the Mini-Mental State Examination (MMSE) item of spontaneous writing and the Cognitive Abilities Screening Instrument (CASI) domain of dictation were analyzed with regard to the number of Kanji and Kana characters. Formal errors in characters and pragmatic errors were also analyzed. RESULTS: The immigrants in Brazil wrote similar numbers of Kanji or Kana characters compared to the residents of Japan. In spontaneous writing, the formal Kanji errors were greater in the CDR 1+ group of immigrants. In writing from dictation, all the immigrant CDR groups made more formal errors in Kana than the Japan residents. No significant differences in pragmatic errors were detected between the two groups. CONCLUSIONS: Subjects living in Japan use Kanji frequently, and thus the form of written characters was simplified, which might be assessed as mild formal errors. In immigrants, the deterioration in Kanji and Kana writing was partly due to decreased daily usage of the characters. Lower levels of education of immigrants might also be related to the number of Kanji errors.

Este estudo verifica os efeitos do meio ambiente sobre a agrafia em comprometimento cognitivo leve e demência. Nós comparamos indivíduos idosos vivendo no Japão e Brasil. MÉTODOS: Nós, retrospectivamente, analisamos a base de dados do Estudo de Prevalência 1998 em Tajiri (n=497, Miyagi, Japão) e do Estudo de Prevalência 1997 de imigrantes idosos japoneses vivendo no Brasil (n=166, imigrados do Japão e residindo na área metropolitana da cidade de São Paulo). Em três grupos de CDR (Clinical Dementia Rating), isto é, CDR 0 (saudáveis), CDR 0.5 (demência questionável) e CDR1+ (demência), o item de escrita espontânea do Mini-Exame do Estado Mental (MEEM) e o domínio de ditado do Cognitive Abilities Screening Instrument (CASI) foram analisados em relação ao número de caracteres em Kanji e Kana. Erros formais nos caracteres e erros pragmáticos foram também analisados. RESULTADOS: Os imigrantes no Brasil escreveram número similar de caracteres de Kanji e Kana comparados aos residentes no Japão. Na escrita espontânea, os erros formais de Kanji foram maiores no grupo de CDR1+ em imigrantes. Na escrita sob ditado, todos os grupos de CDR de imigrantes fizeram mais erros formais em Kana do que os residentes no Japão. Nenhuma diferença foi encontrada em erros pragmáticos entre os grupos. CONCLUSÕES: Sujeitos vivendo no Japão usam Kanji freqüentemente, e então, a forma de caracteres escritos foi simplificada, o que pode ser avaliado como discretos erros formais. Em imigrantes, a deterioração na escrita em Kanji e Kana foi parcialmente devida ao uso diário restrito dos caracteres. Baixos níveis educacionais dos imigrantes podem estar relacionados ao número de erros em Kanji.

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Abstract: Although the collage art technique has been introduced as a psychotherapeutic method, it has not been fully applied in dementia. Objectives: To analyze characteristics of the collage articles produced by patients with Alzheimer's disease (AD). Methods: Twenty AD patients were asked to select and place several clippings as they wished. The MMSE was used for cognitive assessments. Results: Simplification and poor organization in their articles were found. The themes of one patient were found to change according to behavior. We discussed the images of the articles, especially spiritual images in the early stage and family images in the later stage. Conclusions: We concluded that the collage technique could provide new perspectives for dementia patients by exploring messages from their inner world.

Resumo: Embora a técnica de colagem tenha sido introduzida como um método psicoterapêutico, ela não foi totalmente aplicada em demência. Objetivos: Analisar as características de trabalhos de colagens feitos por pacientes com doença de Alzheimer (DA). Métodos: A 20 pacientes foi solicitado que selecionassem e colocassem peças que apreciassem. O MEEM foi utilizado para avaliação cognitiva. Resultados: Simplificação e organização pobres foram encontradas. Nós demonstramos um paciente cujos temas foram mudando em relação ao comportamento. Nós discutimos as imagens dos artigos, especialmente imagens espirituais no estágio precoce e imagens familiares no estágio tardio. Conclusões: Nós consideramos que a técnica de colagem poderia dar novas perspectivas na demência, explorando a mensagem do mundo interior.

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