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Prevalence of Age-Associated Memory Impairment and Dementia in a Rural Community

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Prevalence of Age-Associated Memory Impairment and Dementia in a Rural Community J7ournal ofNeurology, Neurosurgery, and Psychiatry 1993;56:973-976 973 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.9.973 on 1 September 1993. Downloaded from Prevalence of age-associated memory impairment and dementia in a rural community F Coria, J A Gomez de Caso, L Minguez, F Rodriguez-Artalejo, L E Claveria Abstract nesses may remain oligosymptomatic for To obtain accurate estimates of the years before dementia develops.2A prevalence of age-associated memory The Segovia Programme on Dementia is a impairment, dementia, and Alzheimer's multidisciplinary project for clinical and mol- disease, a population study was carried ecular research on dementing illnesses. In the out in Turegano, a rural community of initial phase, its main objective was to obtain 1011 inhabitants in the Segovia province accurate information on the prevalence of of Spain. The study was divided into two dementia. For this purpose, we have per- phases: a door to door survey of the formed a door to door survey in Turegano, a entire population aged 40 years and over rural community in the province of Segovia, (503 persons), followed by a clinical Spain. This province has special geographic examination of suspected cases for posi- and demographic characteristics, such as a tive and differential diagnosis of demen- very stable population, an extensive health tia and cognitive impairment. The care network, and a single reference neuro- prevalence of age-associated memory logical clinic, which provides an ideal setting impairment was 3*6% in individuals of 40 for epidemiological studies. years and over and 7l1% in individuals of This is the first door to door survey per- 65 years and over, whereas dementia was formed in a defined community in Spain, found in 2-6% and 5-2%, respectively. using universally accepted standardised crite- The prevalence rates ofboth clinical con- ria for the diagnosis of dementia, thus allow- ditions increased with age. The most ing comparison of prevalence estimates with prevalent clinical category of dementia those from other countries.' In addition, this was dementia of Alzheimer type, which is the first field study which specifically represented 1-8% and 3-8% of these two addresses the prevalence of age-associated age groups. The corresponding figures memory impairment (AAMI),' a clinical syn- for vascular dementia were 0 4% and drome characterised by mild memory distur- 0.90/o and for secondary dementia 044% bances, which in some cases may represent a and 0*5%. Age-associated memory predementing stage of Alzheimer's disease.2A impairment is an age-dependent disor- der with a high prevalence among the elderly; some of these patients may rep- http://jnnp.bmj.com/ resent an early stage of Alzheimer's dis- Methods ease, suggesting that the prevalence of The study was divided into two distinct this disorder may be higher than previ- phases: a field survey, and then a standard- Department of ously estimated. ised clinical interview for positive and differ- Neurology, Segovia General Hospital, ential diagnosis of dementia. Spain ( Neurol Neurosurg Psychiatry 1993;56:973-976) The field study was a door to door survey F Coria of the entire population aged 40 years and J A Gomez de Caso* on September 29, 2021 by guest. Protected copyright. L E Claveria over. Eligible persons were identified and and dementia are localised from the Turegano Health Memory impairment municipal census, updated Center, Segovia, among the most frequent neurological disor- for this study in August 1990. The survey Spain ders of the elderly; Alzheimer's disease instrument was a Spanish version of the L Minguez accounts for most of these cases.' As a conse- Hodkinson's test5; a 10 item cognitive exami- Department of quence of the projected shift in the age distri- nation with 100% sensitivity and 76% speci- Preventive Medicine, 6 Universidad bution of the population in developed ficity for dementia (Rocca et al and our Aut6noma, Madrid, countries, it is expected that the prevalence of unpublished data). This examination was Spain these disorders will increase in the future.' performed by trained university students, and F Rodriguez-Artalejo This has renewed an interest in epidemiologi- took a mean of 5 minutes per person to be Correspondence to: Dr Francisco Coria, Section cal studies to assess their socioeconomic con- completed. The entire available population of Neurology, Hospital sequences, and to identify environmental was surveyed throughout a 4 week period in General de Segovia, 40002 Segovia, Spain. factors of aetiological relevance. August 1990. *Present address: Section of Most previous studies have focused on epi- The second phase was performed by a neu- Epidemiology, Consejeria de demiological aspects of dementia as an inca- rologist (FC) in hospital and included per- Bienestar Social, Junta de Castilla-Le6n, Segovia, pacitating chronic condition.' While they may sons judged to be cognitively impaired on the Spain. provide data to assess health care needs, they basis of their performance on Hodkinson's Received 13 January 1992 are unlikely to provide clues to environmental test. We defined a score of 7 or less as indica- and in final revised form 28 September 1992. causal factors, since dementia is a pluriaetio- tive of cognitive impairment in our commu- Accepted 19 November 1992 logical syndrome, and most dementing ill- nity. The clinical examination was performed 974 Cona, Gomez de Caso, Mtnguez, Rodnguez-Artalejo, Clavena J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.9.973 on 1 September 1993. Downloaded from with the aid of a standardised instrument according to Fleiss.14 Confidence intervals (CEMEDO'), which is divided into three were calculated assuming a Poisson distribu- parts. The first assesses subjective complaints tion. obtained from the patient and a close relative, and includes a semistructured general and neurological medical history, which contains Results in full the Hachinski's scale for vascular On prevalence day (1 August 1990), dementia,7 the Hamilton's scale for depres- Turegano had a total population of 1011 sion, 8 a modified structured Spanish version inhabitants, 503 were 40 years and over. The of the informant-based dementia scale of distribution of this group by age is shown in Blessed et al,9 and the global deterioration table 1. Only five people (1%) were living in a scale of Reisberg et al.10 The second part nursing home in or outside the province. assesses the mental status with a set of cogni- In the field survey 476 of 503 (94 6%) tive performance tests, which includes a were interviewed; 52 of these scored 7 or less Spanish modified version of the mini mental on the Hodkinson's test and therefore entered state examination,1' complemented with non- the second phase. Of the target population equivalent items from the information mem- 27 (5 4%) were not available for interview, ory concentration test.9 The third part because of refusal to participate, immigration includes a set of algorithms for positive and to other areas, or institutionalisation. To differential diagnosis of dementia using stan- complete the survey, we contacted close rela- dardised criteria. tives or medical institutions in and outside Positive diagnosis relied on the following Segovia. The informants were requested by definitions and criteria. Cognitive impairment telephone to complete the dementia scale of is an objective deficiency of higher mental Blessed et al. Information obtained in this functions. Based on previous longitudinal way was sufficient to decide upon the mental studies,4 a person is considered cognitively status in 24 cases. Five of them were consid- impaired when he or she scores 4 or more on ered to be cognitively impaired and accepted the dementia scale of Blessed et al and/or 26 for clinical examination. Thus information or less on the Mini-Mental State Exam- was lacking from only three (0-6%) people. ination. Cognitive impairnent may be conna- A total of 57 persons (1 1-3% of the target tal or acquired. In the latter case, it may also population) entered the second phase. True result from an organic brain disease or a psy-. cognitive impainnent was found in all except chiatric illness. AAMI is a clinical condition five cases (10-3% of the target population). particularly frequent in the elderly which is Apart from affective disorders, severe sensory characterised by complaints of forgetfulness deficiencies, and mental retardation, 38 and objective evidence of memory loss in (66 6%) persons were found to have an neuropsychological tests, and has no identifi- acquired organic cognitive impairment. Of able cause with the presently available diag- these, 25 were not demented (43 9%) and 13 nostic methods.3 Dementia is a pluraetiologic were demented (22.8%). In the non-dement- neurological syndrome which fulfils the ed group, there were patients with recognis- DSM-IIIR clinical criteria. Alzheimer's dis- able medical causes of brain dysfunction, but ease is a specific dementing illness, indepen- the great majority of them (18 of 25) had an dent of the age at onset and the stage it has amnestic syndrome of unclear aetiology, http://jnnp.bmj.com/ reached, whereas dementia of Alzheimer type which is best ca.tegorised as AAMI. By the (DAT) is an advanced stage in the course of global deterioration scale,'0 dementia was Alzheimer's disease when the degree of cogni- graded as severe (stages 6 and 7) in six cases tive impairment fulfils DSM-IIIR criteria for and mild to moderate (stages 4 and 5) in the dementia. other seven cases. Differential diagnosis between dementia A diagnosis could be established with con- and primary depression was made by infer- fidence in all demented cases. The most fre- ence from the data obtained by the CEMED, quent diagnostic category was DAT (nine on September 29, 2021 by guest.
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