S-TOFHLA in mild Alzheimer's disease and Mild Cognitive Impairment patients as a measure of functional literacy: Preliminary study

Oliveira, Maira Okada de; Porto, Cláudia Sellitto; Brucki, Sonia Maria Dozzi

doi:10.1590/S1980-57642009DN30400005

Abstract

The greatest difficulty in diagnosing cognitive loss in our population is the diversity of its education which has a broad spectrum ranging from illiteracy, functional illiteracy and different degrees of literacy, even in those with the same level of schooling.

Objectives:

To verify whether there is impairment on the S-TOFHLA among individuals with AD and MCI compared with healthy controls, and to compare performance on the S-TOFHLA performance with neuropsychological tests and the scores achieved on the Raven's Colored Matrices and Vocabulary and Block Design (WAIS-III) as a measure of estimated intellectual level.

Methods:

59 subjects: controls (n=23; age 70.96±8.31y; schooling 10.2±5.87y; 6 men), MCI patients (n=11; age 74.18±8.12y; schooling 7.55±4.32y; 5 men) and AD patients (n=25; age 76.16±4.96y; schooling 7.32±4.78y; 10 men) were submitted to neuropsychological assessment, S-TOFHLA and functional evaluation.

Results:

Differences on BD, Raven and Estimated IQ were found between controls and MCI patients as well as controls and AD patients. On the S-TOFHLA, differences were found between MCI and AD patients, controls and AD patients, but not between control and MCI groups. S-TOFHLA performance correlated strongly with schooling and all neuropsychological tests, except Clock Drawing.

Conclusions:

The S-TOFHLA seems to be a useful measure for determining the level of literacy in MCI patients, but not in AD patients. S-TOFHLA performance was more closely associated with neuropsychological test scores than were years of education and seems to be a good predictor of level of literacy. The Vocabulary subtest proved to be uninfluenced by the disease process in early stages and preserved in both MCI and AD patients, showing that semantic memory and crystallized intelligence are preserved.

Key words:
Mild Cognitive Impairment; Alzheimer's disease; S-TOFHLA; functional literacy.

Resumo

A maior dificuldade no diagnóstico de perda cognitiva na nossa população é sua heterogeneidade educacional, com um espectro que vai do analfabetismo, analfabetismo funcional até os escolarizados com diferentes graus de alfabetização mesmo com o mesmo grau de escolarização.

Objetivos:

Verificar se existe comprometimento no S-TOFHLA em indivíduos com DA Leve e CCL comparados a controle saudáveis, correlacionando o desempenho do S-TOFHLA à avaliação neuropsicológica e aos escores alcançados no teste Matrizes Progressivas Coloridas de Raven e nos subtestes vocabulário e cubos (WAIS-III) como medida de nível intelectual estimado.

Métodos:

59 sujeitos controles (n=23; idade 70.96±8.31 anos; escolaridade 10.2±5.87 anos; 6 homens), pacientes com CCL (n=11; idade 74.18±8.12 anos; escolaridade 7.55±4.32 anos; 5 homens) e pacientes com DA (n=25; idade 76.16±4.96; escolaridade 7.32±4.78;10 homens) foram submetidos a avaliação neuropsicológica, S-TOFHLA e avaliação funcional.

Resultados:

Em Cubos, Raven e QI Estimado foram encontradas diferenças estatísticas entre controle e pacientes com CCL; controles e pacientes com DA, mas não entre os grupos controle e CCL. O S-TOFHLA correlacionou fortemente com escolaridade e todos os testes neuropsicológicos, exceto Desenho do Relógio.

Conclusões:

O S-TOFHLA demonstrou ser uma medida útil em determinar o nível de alfabetismo em paciente com CCL, mas não em pacientes com DA. O S-TOFHLA apresentou maior foi mais relacionado com testes neuropsicológicos do que anos de escolaridade e parece ser um bom preditor do nível de alfabetismo. O subteste Vocabulário demonstrou ser um teste que não sofre com o processo da doença nos estágios iniciais não sofrendo alterações em pacientes com CCL e DA mostrando que memória semântica e inteligência cristalizada são preservadas.

Palavras-chave:
Comprometimento Cognitivo Leve; doença de Alzheimer; S-TOFHLA; alfabetismo funcional.

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Full text available only in PDF format.

References

¹
Nitrini R, Caramelli P. Demências. In:Nitrini R, Bacheschi LA. A Neurologia que Todo Médico Deve Saber. 2ª edição. São Paulo: Editora Atheneu, 2008;323-334.
²
Herrera Jr. E, Caramelli P, Silveira ASB, Nitrini R. Epidemiologic survey of dementia in a community-dwelling Brazilian population. Alz Dis Associated Disorder 2002;16:103-108.
³
Hototian SR, Lopes MA, Azevedo D, et al. Prevalence of Cognitive and Functional Impairment in a Community Sample From São Paulo, Brazil. Dement Geriatr Cogn Disord 2008; 25:135-143.
⁴
Petersen RC, Doody R, Kurz A, et al. Current concepts in Mild Cognitive Impairment. Arch Neurol 2001;58:1985-1992.
⁵
Boyle PA, Wilson RS, Aggarwal NT, Tang Y, Bennett DA. Mild cognitive impairment: Risk of Alzheimer disease and rate of cognitive decline. Neurology 2006;67:441-445.
⁶
Petersen RC, Smith GE, Waring SC, et al. Mild Cognitive Impairment: clinical characterization and outcome. Arch Neurol 1999;56:303-308.
⁷
Daly E, Zaitchik D, Copeland M, Schmahmann J, Gunther J, Albert M. Predicting conversion to Alzheimer Disease using standardized clinical information. Arch Neurol 2000;57: 675-680.
⁸
Busse A, Hensel A, Gühne U, Angermeyer MC, Riedel-Heller SG. Mild cognitive impairment:long-term course of four clinical subtypes. Neurology 2006;67:2176-2185.
⁹
Grober E, Charles BH, Lipton RB, Zonderman AB, Resnick SM, Kawas C. Memory impairment, executive dysfunction, and intellectual decline in preclinical Alzheimer's disease. J Int Neuropsychol Soc 2008;14:266-278.
¹⁰
Charchat-Fichman H, Caramelli P, Sameshima K, Nitrini R. Declínio da capacidade cognitiva durante o envelhecimento. Rev Bras Psiquiatr 2005;27(12):79-82.
¹¹
Instituto Brasileiro de Geografia e Estatística, 2008. Disponível em http://www.ibge.gov.br/home/
» http://www.ibge.gov.br/home/
¹²
Baker DW. The Meaning and the Measure of Health Literacy. J Gen Intern Med 2006;21:878-883.
¹³
Baker DW, Gazmararian JA, Sudano J, et al. The association between age and health literacy among elderly persons. J Gerontol B Psychol Sci Soc Sci 2000;55:S368-S374.
¹⁴
Baker DW, Williams MV, Parker RM, et al. Development of a brief test to measure functional health literacy. Patient Educ Couns 1999;38:33-42.
¹⁵
Jastak S, Wilkinson GS. WRAT-R:Wide range achievement test administration manual. Los Angeles: Western Psychological Services; 1984.
¹⁶
Parker RM, Baker DW, Williams MV, et al. the test of functional health literacy in adults: a new instrument for measuring patients' literacy skills. J Gen Intern Med 1995;10:537-541.
¹⁷
Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine:a shortened screening instrument. Fam Med 1993;25:391-395.
¹⁸
Brucki SM.D. Functional Healthy literacy in adults-short version (S-TOFHLA), schooling, and Mini-Mental State Examination. In: VI Reunião de pesquisadores em Doença de Alzheimer e desordens relacionadas, 2007, Ouro Preto. Dement Neuropsychol 2007;1:48-49.
¹⁹
Manly JJ, Schupf N, Tang M, Stern Y. Cognitive Decline and literacy among ethnically diverse elders. J Geriatr Psychiatry Neurol 2005;18:213-217.
²⁰
Gazmararian, JA, Baker DW, Williams MV, et al. Health literacy among medicare enrollees in a managed care organization. JAMA 1999;281:545-551.
²¹
Ardila A, Rosselli M, Rosas P. Neuropsychological assessment of illiterates: Visuospatial and memory abilities. Brain Cogn 1989;11:147-166.
²²
Bertolucci PHF, Brucki SMD, Campacci R, Juliano Y. O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr 1994;52:1-7.
²³
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do Mini-Exame do Estado Mental no Brasil. Arq Neuropsiquiatr 2003;61:777-781.
²⁴
Laks J, Baptista EMR, Contino ALB, Paula EO, Engelhardt E. Mini-Mental State Examination norms in community-dwelling sample of elderly with low schooling in Brazil. Cad Saúde Pública 2007;23:315-319.
²⁵
Mattis S. Dementia Rating Scale. Professional Manual. Florida: Psychological Assessment Resource, Inc; 1988.
²⁶
Porto CS, Fichman HC, Caramelli P, Bahia VS, Nitrini R. Brazilian version of the Mattis Dementia Rating Scale: Diagnosis of mild dementia in Alzheimer's Disease. Arq Neuropsiquiatr 2003;61:339-345.
²⁷
Flaks MK, Yassuda MS, Regina ACB, et al. The Short Cognitive Performance Test (SKT):a preliminary study of its psychometric properties in Brazil. Int Psychogeriatr 2006;18:121-133.
²⁸
Schultz RR, Silviero MO, Bertolucci PHF. The cognitive subscale of the "Alzheimer's Disease Assessment Scale" in a Brazilian sample. Braz J Med Biol Res 2001;34:1295-1302.
²⁹
Carthery-Goulart MT, Anghinah R, Areza-Fegyveres R, et al. Performance of a Brazilian population on the test of functional health literacy in adults. Rev Saude Publica 2008.
³⁰
Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression scale:a preliminary report. J Psychiat Res 1983;17:37-49.
³¹
Almeida OP, Almeida SA. Confiabilidade da versão brasileira da Escala de Depressão em Geriatria (GDS) versão reduzida. Arq Neuropsiquiatr 1999;57:421-426.
³²
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in dementia. Biol Psychiatry 1988;23: 271-284.
³³
Carthery-Goulart MT, Areza-Fegyveres R, Schultz RR, et al. Versão brasileira da escala Cornell de Depressão em Demência (Cornell Depression Scale in Dementia). Arq Neuropsiquiatr 2007;65:912-915.
³⁴
McKhann G, Drachman D, Folstein M, et al. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA work group under the auspice of the Department of Health And Human Services Task Force on Alzheimer's disease. Neurology 1984;34:939-944.
³⁵
Pfeffer RI Pfeffer RI, Kurosaki TT, Harrah CH, Chance JM, Filos S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323-329.
³⁶
Nitrini R , Caramelli P , Herrera H, et al. Performance of illiterate and literate nondemented elderly subjects in two tests of long-term memory. J Int Neuropsychol Soc 2004;10: 634-638.
³⁷
Nitrini R, Caramelli P, Porto CS, et al. Brief cognitive battery in the diagnosis of mild Alzheimer's disease in subjects with medium and high levels of education. Dement Neuropsychol 2007;1:32-36.
³⁸
Spreen O, Strauss E, Sherman EMS. A compendium of neuropsychological tests:administration, norms, and commentary. 3 Ed. New York: Oxford UnivPress; 2006.
³⁹
Malloy-Diniz LF, Lasmar VAP, Gazinelli LSR, Fuentes D, Salgado JV. The Rey Auditory-Verbal Learning Test:applicability for the Brazilian elderly population. Rev Bras Psiquiatr 2007;29: 324-329.
⁴⁰
Angelini AL, Alves ICB, Custódio EM, et al. Manual Matrizes Progressivas Coloridas de Raven: escala especial. São Paulo: Centro Editor de Testes e Pesquisas em Psicologia, 1999.
⁴¹
Sunderland T, Hill JL, Melow AM, et al. Clock drawing in Alzheimer's disease: a novel measure of dementia severity. JAGS 1989;37:725-729.
⁴²
Jorm AF, Jacomb PA. The informant questionnaire on cognitive decline in the elderly (IQCODE): Socio-demographic correlates, reliability, validity and some norms. Psychol Med 1989;19:1015:1022.
⁴³
Bustamante SEZ, Bottino, CMC, Lopes, MA, et al. Instrumentos combinados na avaliação de demência em idosos: Resultados preliminares. Arq Neuropsiquiatr 2003;61:601-606.
⁴⁴
Perroco TR, Damin AE, Frota NA. Short IQCODE as a screening tool for MCI and dementia. Dement Neuropsychol 2008; 2:300-304.
⁴⁵
Stein LM. Teste de Desempenho Escolar: Manual para Aplicação e Interpretação. São Paulo: Casa do Psicólogo; 1994.
⁴⁶
Manly JJ, Jacobs DM, Sano M, et al. Effect of literacy on neuropsychological test performance in nondemented, education-matches elders. J Int Neuropsychol Soc 1999;5: 191-202.
⁴⁷
Yassuda MS, Diniz BSO, Flaks MK, et al. Neuropsychological profile of Brazilian older with heterogeneous educational backgrounds. Arch Clin Neuropsychol 2009;24:71-79.
⁴⁸
Bennett A, Nadler J, Spigler M, Rafalson L, Abrahan S, Relkin N. The Mattis Dementia Rating Scale in nursing home octagenarians and nonagenarians: effects of age and education. J Geriatr Psychiatry Neurol 1997;10:114-118.
⁴⁹
Anstey KJ, Giles MAL, Andrews GR. Demographic, health, cognitive, and sensory variables as predictors of mortality in very old adults. Psychol Aging 2001;16:3-11.
⁵⁰
Lourenço RA, Ribeiro-Filho ST, Moreira IFH, Paradela EMP, Miranda AS. The Clock Drawing Test: performance among elderly with low education level. Rev Bras Psiquiatr. 2008; 30:309-315.

Publication Dates

Publication in this collection
Oct-Dec 2009

History

Received
30 Oct 2009
Accepted
05 Nov 2009

This is an open-access article distributed under the terms of the Creative Commons Attribution License

[1] ¹
Nitrini R, Caramelli P. Demências. In:Nitrini R, Bacheschi LA. A Neurologia que Todo Médico Deve Saber. 2ª edição. São Paulo: Editora Atheneu, 2008;323-334.

[2] ²
Herrera Jr. E, Caramelli P, Silveira ASB, Nitrini R. Epidemiologic survey of dementia in a community-dwelling Brazilian population. Alz Dis Associated Disorder 2002;16:103-108.

[3] ³
Hototian SR, Lopes MA, Azevedo D, et al. Prevalence of Cognitive and Functional Impairment in a Community Sample From São Paulo, Brazil. Dement Geriatr Cogn Disord 2008; 25:135-143.

[4] ⁴
Petersen RC, Doody R, Kurz A, et al. Current concepts in Mild Cognitive Impairment. Arch Neurol 2001;58:1985-1992.

[5] ⁵
Boyle PA, Wilson RS, Aggarwal NT, Tang Y, Bennett DA. Mild cognitive impairment: Risk of Alzheimer disease and rate of cognitive decline. Neurology 2006;67:441-445.

[6] ⁶
Petersen RC, Smith GE, Waring SC, et al. Mild Cognitive Impairment: clinical characterization and outcome. Arch Neurol 1999;56:303-308.

[7] ⁷
Daly E, Zaitchik D, Copeland M, Schmahmann J, Gunther J, Albert M. Predicting conversion to Alzheimer Disease using standardized clinical information. Arch Neurol 2000;57: 675-680.

[8] ⁸
Busse A, Hensel A, Gühne U, Angermeyer MC, Riedel-Heller SG. Mild cognitive impairment:long-term course of four clinical subtypes. Neurology 2006;67:2176-2185.

[9] ⁹
Grober E, Charles BH, Lipton RB, Zonderman AB, Resnick SM, Kawas C. Memory impairment, executive dysfunction, and intellectual decline in preclinical Alzheimer's disease. J Int Neuropsychol Soc 2008;14:266-278.

[10] ¹⁰
Charchat-Fichman H, Caramelli P, Sameshima K, Nitrini R. Declínio da capacidade cognitiva durante o envelhecimento. Rev Bras Psiquiatr 2005;27(12):79-82.

[11] ¹¹
Instituto Brasileiro de Geografia e Estatística, 2008. Disponível em http://www.ibge.gov.br/home/
» http://www.ibge.gov.br/home/

[12] ¹²
Baker DW. The Meaning and the Measure of Health Literacy. J Gen Intern Med 2006;21:878-883.

[13] ¹³
Baker DW, Gazmararian JA, Sudano J, et al. The association between age and health literacy among elderly persons. J Gerontol B Psychol Sci Soc Sci 2000;55:S368-S374.

[14] ¹⁴
Baker DW, Williams MV, Parker RM, et al. Development of a brief test to measure functional health literacy. Patient Educ Couns 1999;38:33-42.

[15] ¹⁵
Jastak S, Wilkinson GS. WRAT-R:Wide range achievement test administration manual. Los Angeles: Western Psychological Services; 1984.

[16] ¹⁶
Parker RM, Baker DW, Williams MV, et al. the test of functional health literacy in adults: a new instrument for measuring patients' literacy skills. J Gen Intern Med 1995;10:537-541.

[17] ¹⁷
Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine:a shortened screening instrument. Fam Med 1993;25:391-395.

[18] ¹⁸
Brucki SM.D. Functional Healthy literacy in adults-short version (S-TOFHLA), schooling, and Mini-Mental State Examination. In: VI Reunião de pesquisadores em Doença de Alzheimer e desordens relacionadas, 2007, Ouro Preto. Dement Neuropsychol 2007;1:48-49.

[19] ¹⁹
Manly JJ, Schupf N, Tang M, Stern Y. Cognitive Decline and literacy among ethnically diverse elders. J Geriatr Psychiatry Neurol 2005;18:213-217.

[20] ²⁰
Gazmararian, JA, Baker DW, Williams MV, et al. Health literacy among medicare enrollees in a managed care organization. JAMA 1999;281:545-551.

[21] ²¹
Ardila A, Rosselli M, Rosas P. Neuropsychological assessment of illiterates: Visuospatial and memory abilities. Brain Cogn 1989;11:147-166.

[22] ²²
Bertolucci PHF, Brucki SMD, Campacci R, Juliano Y. O Mini-Exame do Estado Mental em uma população geral: impacto da escolaridade. Arq Neuropsiquiatr 1994;52:1-7.

[23] ²³
Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões para o uso do Mini-Exame do Estado Mental no Brasil. Arq Neuropsiquiatr 2003;61:777-781.

[24] ²⁴
Laks J, Baptista EMR, Contino ALB, Paula EO, Engelhardt E. Mini-Mental State Examination norms in community-dwelling sample of elderly with low schooling in Brazil. Cad Saúde Pública 2007;23:315-319.

[25] ²⁵
Mattis S. Dementia Rating Scale. Professional Manual. Florida: Psychological Assessment Resource, Inc; 1988.

[26] ²⁶
Porto CS, Fichman HC, Caramelli P, Bahia VS, Nitrini R. Brazilian version of the Mattis Dementia Rating Scale: Diagnosis of mild dementia in Alzheimer's Disease. Arq Neuropsiquiatr 2003;61:339-345.

[27] ²⁷
Flaks MK, Yassuda MS, Regina ACB, et al. The Short Cognitive Performance Test (SKT):a preliminary study of its psychometric properties in Brazil. Int Psychogeriatr 2006;18:121-133.

[28] ²⁸
Schultz RR, Silviero MO, Bertolucci PHF. The cognitive subscale of the "Alzheimer's Disease Assessment Scale" in a Brazilian sample. Braz J Med Biol Res 2001;34:1295-1302.

[29] ²⁹
Carthery-Goulart MT, Anghinah R, Areza-Fegyveres R, et al. Performance of a Brazilian population on the test of functional health literacy in adults. Rev Saude Publica 2008.

[30] ³⁰
Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression scale:a preliminary report. J Psychiat Res 1983;17:37-49.

[31] ³¹
Almeida OP, Almeida SA. Confiabilidade da versão brasileira da Escala de Depressão em Geriatria (GDS) versão reduzida. Arq Neuropsiquiatr 1999;57:421-426.

[32] ³²
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in dementia. Biol Psychiatry 1988;23: 271-284.

[33] ³³
Carthery-Goulart MT, Areza-Fegyveres R, Schultz RR, et al. Versão brasileira da escala Cornell de Depressão em Demência (Cornell Depression Scale in Dementia). Arq Neuropsiquiatr 2007;65:912-915.

[34] ³⁴
McKhann G, Drachman D, Folstein M, et al. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA work group under the auspice of the Department of Health And Human Services Task Force on Alzheimer's disease. Neurology 1984;34:939-944.

[35] ³⁵
Pfeffer RI Pfeffer RI, Kurosaki TT, Harrah CH, Chance JM, Filos S. Measurement of functional activities in older adults in the community. J Gerontol 1982;37:323-329.

[36] ³⁶
Nitrini R , Caramelli P , Herrera H, et al. Performance of illiterate and literate nondemented elderly subjects in two tests of long-term memory. J Int Neuropsychol Soc 2004;10: 634-638.

[37] ³⁷
Nitrini R, Caramelli P, Porto CS, et al. Brief cognitive battery in the diagnosis of mild Alzheimer's disease in subjects with medium and high levels of education. Dement Neuropsychol 2007;1:32-36.

[38] ³⁸
Spreen O, Strauss E, Sherman EMS. A compendium of neuropsychological tests:administration, norms, and commentary. 3 Ed. New York: Oxford UnivPress; 2006.

[39] ³⁹
Malloy-Diniz LF, Lasmar VAP, Gazinelli LSR, Fuentes D, Salgado JV. The Rey Auditory-Verbal Learning Test:applicability for the Brazilian elderly population. Rev Bras Psiquiatr 2007;29: 324-329.

[40] ⁴⁰
Angelini AL, Alves ICB, Custódio EM, et al. Manual Matrizes Progressivas Coloridas de Raven: escala especial. São Paulo: Centro Editor de Testes e Pesquisas em Psicologia, 1999.

[41] ⁴¹
Sunderland T, Hill JL, Melow AM, et al. Clock drawing in Alzheimer's disease: a novel measure of dementia severity. JAGS 1989;37:725-729.

[42] ⁴²
Jorm AF, Jacomb PA. The informant questionnaire on cognitive decline in the elderly (IQCODE): Socio-demographic correlates, reliability, validity and some norms. Psychol Med 1989;19:1015:1022.

[43] ⁴³
Bustamante SEZ, Bottino, CMC, Lopes, MA, et al. Instrumentos combinados na avaliação de demência em idosos: Resultados preliminares. Arq Neuropsiquiatr 2003;61:601-606.

[44] ⁴⁴
Perroco TR, Damin AE, Frota NA. Short IQCODE as a screening tool for MCI and dementia. Dement Neuropsychol 2008; 2:300-304.

[45] ⁴⁵
Stein LM. Teste de Desempenho Escolar: Manual para Aplicação e Interpretação. São Paulo: Casa do Psicólogo; 1994.

[46] ⁴⁶
Manly JJ, Jacobs DM, Sano M, et al. Effect of literacy on neuropsychological test performance in nondemented, education-matches elders. J Int Neuropsychol Soc 1999;5: 191-202.

[47] ⁴⁷
Yassuda MS, Diniz BSO, Flaks MK, et al. Neuropsychological profile of Brazilian older with heterogeneous educational backgrounds. Arch Clin Neuropsychol 2009;24:71-79.

[48] ⁴⁸
Bennett A, Nadler J, Spigler M, Rafalson L, Abrahan S, Relkin N. The Mattis Dementia Rating Scale in nursing home octagenarians and nonagenarians: effects of age and education. J Geriatr Psychiatry Neurol 1997;10:114-118.

[49] ⁴⁹
Anstey KJ, Giles MAL, Andrews GR. Demographic, health, cognitive, and sensory variables as predictors of mortality in very old adults. Psychol Aging 2001;16:3-11.

[50] ⁵⁰
Lourenço RA, Ribeiro-Filho ST, Moreira IFH, Paradela EMP, Miranda AS. The Clock Drawing Test: performance among elderly with low education level. Rev Bras Psiquiatr. 2008; 30:309-315.

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