Abstracts
Introduction:
The life expectancy of individuals with Chronic Kidney Disease (CKD) on hemodialysis has increased, however, with over years in treatment, there is impairment of cognitive function that affect adherence to therapy and dialysis.
Objective:
To evaluate the cognitive ability of individuals on hemodialysis through the Mini Mental State Examination (MMSE) and the relation to sociodemographic and clinical characteristics of these individuals.
Methods:
We obtained demographic and clinical information of 75 individuals. To assess memory and cognition MMSE was applied, which was analyzed according to the different cutoff points proposed in the literature. After classifying the participants according to proposal of different studies, the causes of CKD and sociodemographic characteristics, individuals were divided into groups with and without cognitive impairment in an attempt to identify differences between them.
Results:
Most participants were men with a mean age of 59.2 years. The mean MMSE score was 24.16 points and there was no difference (p < 0.05) in MMSE results between the different causes of CKD. MMSE scores were correlated (p < 0.05) positively with years of schooling and income and inversely with age. According to the different cutoff points, six to 34 participants showed cognitive impairment and memory, and only three of these were classified with cognitive impairment for all cutoff points evaluated.
Conclusion:
The average MMSE score declined with increasing age and increased with years of schooling and income per capita. No relationships were found to justify the harmful effects of dialysis process on cognition and memory.
cognition; dialysis; kidney failure, chronic; quality of life
Introdução:
O comprometimento da cognição e memória (CM) é comum em indivíduos com Doença Renal Crônica (DRC) em hemodiálise, o que prejudica a aderência ao tratamento.
Objetivo:
Avaliar a capacidade cognitiva de indivíduos renais crônicos em hemodiálise por meio do Miniexame do Estado Mental (MEEM) e a relação com as características sociodemográficas e clínicas desses indivíduos.
Métodos:
Foram obtidas informações clínicas e sociodemográficas de 75 indivíduos. Para avaliação da MC, foi aplicado o MEEM, o qual foi analisado segundo os diversos pontos de corte propostos na literatura. Após classificar os participantes de acordo com as diferentes propostas e pelas causas da DRC, os indivíduos foram alocados em grupos com e sem comprometimento da CM, na tentativa de identificar diferenças entre eles.
Resultados:
A maioria dos participantes eram homens, com idade média de 59,2 anos. O escore médio do MEEM foi 24,16 pontos e não houve diferença (p < 0,05) quanto às diferentes causas da DRC. Os escores do MEEM se correlacionaram (p < 0,05) positivamente com os anos de escolaridade e renda per capita e inversamente com a idade. Segundo os diversos pontos de corte, seis a 34 participantes apresentaram comprometimento da CM e apenas três desses foram classificados com déficit de CM por todas as propostas avaliadas.
Conclusão:
O escore do MEEM reduziu com o aumento da idade e se elevou com os anos de estudo e com a renda per capita. Não foram encontradas relações que justificassem efeitos prejudiciais do processo dialítico sobre a CM.
cognição; diálise; insuficiência renal crônica; qualidade de vida
Introduction
The recent advances in renal replacement therapies have increased the life expectancy
of chronic kidney disease (CKD) patients on hemodialysis.11. Bastos MG, Kirsztajn GM. Doença renal crônica: importância do
diagnóstico precoce, encaminhamento imediato e abordagem interdisciplinar estruturada
para melhora do desfecho em pacientes ainda não submetidos à diálise. 2011;33:93-108.
DOI: http://dx.doi.org/10.1590/S0101-28002011000100013
http://dx.doi.org/10.1590/S0101-28002011...
However, as they accumulate years in treatment, cognitive
function impairment sets in22. Sehgal AR, Grey SF, DeOreo PB, Whitehouse PJ. Prevalence,
recognition, and implications of mental impairment among hemodialysis patients. Am J
Kidney Dis 1997;30:41-9. DOI:
http://dx.doi.org/10.1016/S0272-6386(97)90563-1
http://dx.doi.org/10.1016/S0272-6386(97)...
to considerably
affect quality of life, compliance to therapies and dialysis.33. Kurella M, Chertow GM, Fried LF, Cummings SR, Harris T, Simonsick E,
et al. Chronic kidney disease and cognitive impairment in the elderly: the health,
aging, and body composition study. J Am Soc Nephrol 2005;16:2127-33. DOI:
http://dx.doi.org/10.1681/ASN.2005010005
http://dx.doi.org/10.1681/ASN.2005010005...
Individuals with advanced-stage kidney disease have twice the prevalence of cognitive
impairment and dementia of the general population.22. Sehgal AR, Grey SF, DeOreo PB, Whitehouse PJ. Prevalence,
recognition, and implications of mental impairment among hemodialysis patients. Am J
Kidney Dis 1997;30:41-9. DOI:
http://dx.doi.org/10.1016/S0272-6386(97)90563-1
http://dx.doi.org/10.1016/S0272-6386(97)...
The first meta-analysis to look into this association found that
individuals with CKD are at 65% greater risk of presenting cognitive decline than
healthy subjects.44. Etgen T, Chonchol M, Förstl H, Sander D. Chronic kidney disease and
cognitive impairment: a systematic review and meta-analysis. Am J Nephrol
2012;35:474-82. DOI: http://dx.doi.org/10.1159/000338135
http://dx.doi.org/10.1159/000338135...
Furthermore, cognition
impairment in individuals with renal disease is more pronounced in patients on
chronic hemodialysis (HD).55. Post JB, Jegede AB, Morin K, Spungen AM, Langhoff E, Sano M.
Cognitive profile of chronic kidney disease and hemodialysis patients without
dementia. Nephron Clin Pract 2010;116:c247-55. PMID: 20606486 DOI:
http://dx.doi.org/10.1159/000317206
http://dx.doi.org/10.1159/000317206...
,66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8. A study comparing changes in the cognitive
skills of individuals on HD and seniors (aged 65 years and above) revealed greater
decreases in cognition in the group of patients on hemodialysis when compared to
elderly individuals.77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
The causes for such decline are unclear. Compromised protein intake,22. Sehgal AR, Grey SF, DeOreo PB, Whitehouse PJ. Prevalence,
recognition, and implications of mental impairment among hemodialysis patients. Am J
Kidney Dis 1997;30:41-9. DOI:
http://dx.doi.org/10.1016/S0272-6386(97)90563-1
http://dx.doi.org/10.1016/S0272-6386(97)...
lower glomerular filtration rate,33. Kurella M, Chertow GM, Fried LF, Cummings SR, Harris T, Simonsick E,
et al. Chronic kidney disease and cognitive impairment in the elderly: the health,
aging, and body composition study. J Am Soc Nephrol 2005;16:2127-33. DOI:
http://dx.doi.org/10.1681/ASN.2005010005
http://dx.doi.org/10.1681/ASN.2005010005...
,88. Hailpern SM, Melamed ML, Cohen HW, Hostetter TH. Moderate chronic
kidney disease and cognitive function in adults 20 to 59 years of age: Third National
Health and Nutrition Examination Survey (NHANES III). J Am Soc Nephrol
2007;18:2205-13. DOI: http://dx.doi.org/10.1681/ASN.2006101165
http://dx.doi.org/10.1681/ASN.2006101165...
,99. Kurella Tamura M, Muntner P, Wadley V, Cushman M, Zakai NA, Bradbury
BD, et al. Albuminuria, kidney function, and the incidence of cognitive impairment
among adults in the United States. Am J Kidney Dis 2011;58:756-63. DOI:
http://dx.doi.org/10.1053/j.ajkd.2011.05.027
http://dx.doi.org/10.1053/j.ajkd.2011.05...
particularly when
the GFR is under 45 ml/min/1.73 m2,33. Kurella M, Chertow GM, Fried LF, Cummings SR, Harris T, Simonsick E,
et al. Chronic kidney disease and cognitive impairment in the elderly: the health,
aging, and body composition study. J Am Soc Nephrol 2005;16:2127-33. DOI:
http://dx.doi.org/10.1681/ASN.2005010005
http://dx.doi.org/10.1681/ASN.2005010005...
presence of cardiovascular disease,55. Post JB, Jegede AB, Morin K, Spungen AM, Langhoff E, Sano M.
Cognitive profile of chronic kidney disease and hemodialysis patients without
dementia. Nephron Clin Pract 2010;116:c247-55. PMID: 20606486 DOI:
http://dx.doi.org/10.1159/000317206
http://dx.doi.org/10.1159/000317206...
,1010. Weiner DE, Scott TM, Giang LM, Agganis BT, Sorensen EP, Tighiouart
H, et al. Cardiovascular disease and cognitive function in maintenance hemodialysis
patients. Am J Kidney Dis 2011;58:773-81. DOI:
http://dx.doi.org/10.1053/j.ajkd.2011.03.034
http://dx.doi.org/10.1053/j.ajkd.2011.03...
atherosclerotic
complications,1111. Lin CY, Lin LY, Kuo HK, Lin JW. Chronic kidney disease,
atherosclerosis, and cognitive and physical function in the geriatric group of the
National Health and Nutrition Survey 1999-2002. Atherosclerosis 2009;202:312-9. PMID:
18533156 DOI:
http://dx.doi.org/10.1016/j.atherosclerosis.2008.04.020
http://dx.doi.org/10.1016/j.atherosclero...
albuminuria,99. Kurella Tamura M, Muntner P, Wadley V, Cushman M, Zakai NA, Bradbury
BD, et al. Albuminuria, kidney function, and the incidence of cognitive impairment
among adults in the United States. Am J Kidney Dis 2011;58:756-63. DOI:
http://dx.doi.org/10.1053/j.ajkd.2011.05.027
http://dx.doi.org/10.1053/j.ajkd.2011.05...
and anemia44. Etgen T, Chonchol M, Förstl H, Sander D. Chronic kidney disease and
cognitive impairment: a systematic review and meta-analysis. Am J Nephrol
2012;35:474-82. DOI: http://dx.doi.org/10.1159/000338135
http://dx.doi.org/10.1159/000338135...
have been correlated with cognitive impairment in CKD. Additionally,
individuals with CKD usually have multiple comorbidities and are on multiple drugs,
whose side effects and interactions may affect the nervous system.44. Etgen T, Chonchol M, Förstl H, Sander D. Chronic kidney disease and
cognitive impairment: a systematic review and meta-analysis. Am J Nephrol
2012;35:474-82. DOI: http://dx.doi.org/10.1159/000338135
http://dx.doi.org/10.1159/000338135...
The association between CKD and cognitive
impairment has been established, but many are the confounding elements. For example,
cardiovascular risk factors, often present in patients with renal disease, have also
been correlated with cognitive decline,1010. Weiner DE, Scott TM, Giang LM, Agganis BT, Sorensen EP, Tighiouart
H, et al. Cardiovascular disease and cognitive function in maintenance hemodialysis
patients. Am J Kidney Dis 2011;58:773-81. DOI:
http://dx.doi.org/10.1053/j.ajkd.2011.03.034
http://dx.doi.org/10.1053/j.ajkd.2011.03...
thus
making it harder to assess the possible negative effects of CKD on cognitive
function.
The mini-mental state examination (MMSE) developed by Folstein et
al.1212. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A
practical method for grading the cognitive state of patients for the clinician. J
Psychiatr Res 1975;12:189-98. PMID: 1202204 DOI:
http://dx.doi.org/10.1016/0022-3956(75)90026-6
http://dx.doi.org/10.1016/0022-3956(75)9...
and adapted to the Brazilian
population1313. Bertollucci PHF, Brucci SMD, Campacci SR, Juliano Y. O mini-exame do
estado mental em uma população geral: o impacto da escolaridade. Arq Neuropsiquiatr
1994;52:1-7.
14. Almeida OP. Mini-exame do estado mental e o diagnóstico de demência
no Brasil. Arq Neuropsiquiatr 1998;56:605-12.-1515. 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;61:777-81. DOI:
http://dx.doi.org/10.1590/S0004-282X2003000500014
http://dx.doi.org/10.1590/S0004-282X2003...
is a screening tool used to monitor cognitive
status recommended by the Ministry of Health, the Brazilian Academy of Neurology, and
other international organizations. The MMSE has been frequently used in the
evaluation of memory and cognition of CKD patients.22. Sehgal AR, Grey SF, DeOreo PB, Whitehouse PJ. Prevalence,
recognition, and implications of mental impairment among hemodialysis patients. Am J
Kidney Dis 1997;30:41-9. DOI:
http://dx.doi.org/10.1016/S0272-6386(97)90563-1
http://dx.doi.org/10.1016/S0272-6386(97)...
,33. Kurella M, Chertow GM, Fried LF, Cummings SR, Harris T, Simonsick E,
et al. Chronic kidney disease and cognitive impairment in the elderly: the health,
aging, and body composition study. J Am Soc Nephrol 2005;16:2127-33. DOI:
http://dx.doi.org/10.1681/ASN.2005010005
http://dx.doi.org/10.1681/ASN.2005010005...
,66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8.,99. Kurella Tamura M, Muntner P, Wadley V, Cushman M, Zakai NA, Bradbury
BD, et al. Albuminuria, kidney function, and the incidence of cognitive impairment
among adults in the United States. Am J Kidney Dis 2011;58:756-63. DOI:
http://dx.doi.org/10.1053/j.ajkd.2011.05.027
http://dx.doi.org/10.1053/j.ajkd.2011.05...
,1616. Helmer C, Stengel B, Metzger M, Froissart M, Massy ZA, Tzourio C, et
al. Chronic kidney disease, cognitive decline, and incident dementia: the 3C Study.
Neurology 2011;77:2043-51. PMID: 22116945 DOI:
http://dx.doi.org/10.1212/WNL.0b013e31823b4765
http://dx.doi.org/10.1212/WNL.0b013e3182...
Cognition assessment in individuals with CKD is of the utmost importance. Due to the
complexity of this condition, patients are required to process and understand
significant amounts of information in order to properly comply with the treatment.
Early diagnosis and intervention help contain or mitigate the progress of cognitive
impairment.44. Etgen T, Chonchol M, Förstl H, Sander D. Chronic kidney disease and
cognitive impairment: a systematic review and meta-analysis. Am J Nephrol
2012;35:474-82. DOI: http://dx.doi.org/10.1159/000338135
http://dx.doi.org/10.1159/000338135...
,55. Post JB, Jegede AB, Morin K, Spungen AM, Langhoff E, Sano M.
Cognitive profile of chronic kidney disease and hemodialysis patients without
dementia. Nephron Clin Pract 2010;116:c247-55. PMID: 20606486 DOI:
http://dx.doi.org/10.1159/000317206
http://dx.doi.org/10.1159/000317206...
This study aimed to assess the cognitive skills
of individuals with CKD on chronic hemodialysis through the MMSE and examine the
possible correlations between cognitive status and patient sociodemographic and
clinical characteristics.
Methods
This observational analytical study was carried out in a nephrology service in Viçosa, Minas Gerais, Brazil.
The study enrolled individuals aged 18 or older on hemodialysis for at least three months. Enrolled subjects were required to give informed consent. Individuals diagnosed with hearing loss, visual impairment, or acute kidney injury, with recently implanted catheters, positive for hepatitis B or C viruses, and on glucocorticoids were not included in the study. Eighty-one of the 101 subjects on HD met the enrollment criteria and were invited to join the study, and 75 gave written consent (Figure 1).
The data used in this study were obtained from the patient charts maintained in the nephrology service and from the MMSE. Personal data related to renal disease such as underlying conditions, date of the first HD session, and type of HD access were gathered from patient charts. Laboratory test results and prescriptions were also obtained from patient charts and included number of prescribed medications, Kt/V, serum albumin, pre and post-dialysis urea, creatinine, calcium, phosphorus, and parathyroid hormone (PTH). The calcium-phosphorus product (mg2/dL2) was analyzed for the ratio between both minerals. As set in the recommendations of the Brazilian Clinical Practice Guidelines for Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD),1717. Sociedade Brasileira de Nefrologia. Diretrizes Brasileiras de Prática Clínica para o Distúrbio Mineral e Ósseo na Doença Renal Crônica. 2011;33:S1-S57. albumin-corrected calcium serum levels were used as per the following formula: corrected calcium = total serum calcium + [(4-serum albumin) x 0.8].
The MMSE was used to assess patient memory and cognition. Patients were interviewed
during home visits or during the course of the second HD session of the week
(starting at least 30 minutes after the start of the session and ending no later than
30 minutes before the end of the session) if their arteriovenous fistulas, catheters,
and other conditions allowed them to write and draw. Cognitive function was
categorized based on the the cutoff points indicated by Folstein et
al.1212. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A
practical method for grading the cognitive state of patients for the clinician. J
Psychiatr Res 1975;12:189-98. PMID: 1202204 DOI:
http://dx.doi.org/10.1016/0022-3956(75)90026-6
http://dx.doi.org/10.1016/0022-3956(75)9...
- score of 24 or lower - and
Murden et al.,1818. Murden RA, McRae TD, Kaner S, Bucknam ME. Mini-Mental State exam
scores vary with education in blacks and whites. J Am Geriatr Soc 1991;39:149-55.
PMID: 1991947 Bertolucci
et al.,1313. Bertollucci PHF, Brucci SMD, Campacci SR, Juliano Y. O mini-exame do
estado mental em uma população geral: o impacto da escolaridade. Arq Neuropsiquiatr
1994;52:1-7. Almeida,1414. Almeida OP. Mini-exame do estado mental e o diagnóstico de demência
no Brasil. Arq Neuropsiquiatr 1998;56:605-12. Brucki et al.1515. 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;61:777-81. DOI:
http://dx.doi.org/10.1590/S0004-282X2003000500014
http://dx.doi.org/10.1590/S0004-282X2003...
and Lourenço & Veras1919. Lourenço RA, Veras RP. Mini-exame do estado mental: características
psicométricas em idosos ambulatoriais. Rev Saúde Pública 2006;40:712-9. DOI:
http://dx.doi.org/10.1590/S0034-89102006000500023
http://dx.doi.org/10.1590/S0034-89102006...
for the general population, in which scores are differentiated
based on level of education (Chart 1). The
ratings obtained by the different cutoff points were compared, as were the groups of
individuals with and without involvement based on the approaches proposed by
different authors to analyze possible differences between groups.
Different cutoff points for the categorization of cognitive function using the mini-mental state examination according to level of education
One of the authors treated the data sets. The findings were presented in tables and described in the form of mean values and standard deviations (SD), median values, and minimum and maximum values. The Kolmogorov-Smirnov test was used to test the normality of the distribution, indicating the use of parametric or non-parametric tests for analysis.
The difference between continuous variables was assessed using Student's t-test and the Mann-Whitney U test, when appropriate, in addition to ANOVA and Multiple Comparisons. Associations between clinical and demographic variables and MMSE scores were assessed using the Pearson or Spearman correlations, according to the distribution of the variables. A confidence level of 95% was adopted to reject the null hypothesis. All statistical analyses were performed using SPSS for Windows (version 20.0).
The protocol of this study was submitted to and approved by the Internship Committee of the hospital and by the Ethics Committee on Human Research (CEPH) of the Federal University of Viçosa (Nº 002/2012/CEPH).
Results
Seventy-five patients were enrolled in this study. Most were males (60 %, n = 45) and Caucasians (57.4%, n = 41). Patient mean age was 59.2 years (SD = 13.44) and 37 individuals (49.3%) were aged 41-59 years. The main causes of CKD in the studied population were diabetes mellitus (33.3%, n = 25) and hypertension (32%, n = 24). Patients had been on dialysis for three to 220 months and for a mean of 62.88 months (SD = 53.08), and most individuals had been on HD for less than 60 months (57.3%, n = 43). Arteriovenous fistulas (AVF) were the most common type of venous access, and were used by 68 (90.7 %) subjects on hemodialysis. The mean Kt/V was 1.69 (SD = 0.34).
The MMSE yielded a mean score of 24.16 (SD = 4.49) in cognitive function assessment, with scores ranging from seven to thirty. The lowest scores were seen in the domain assessing patient attention and calculation skills, with a score of two out of five points. There was no difference in the MMSE scores between the different causes of CKD (p = 0.140).
The correlations between MMSE scores and sociodemographic, clinical and biochemical variables were tested (Table 1). MMSE scores correlated (p < 0.05) only with demographic data, showing direct associations with years of schooling and per capita income, and an inverse correlation with age. Significant differences in MMSE scores were seen between genders (p = 0.008) and age ranges (p = 0.018); males and individuals aged 60 years and younger had higher scores on the MMSE. No differences were found between genders in terms of schooling (p = 0.144) and per capita income (p = 1.000), and individuals aged 60 and younger did not differ from individuals over 60 years of age in terms of schooling (p = 0.165) or per capita income (p = 0.206), indicating the significance of gender and age on MMSE scores regardless of years of education and per capita income.
Single correlations between mini-mental state examination (MMSE) scores and time on dialysis and sociodemographic and biochemical variables of individuals on hemodialysis - Viçosa, MG - 2013
MMSE scores were analyzed along with level of education based on the cutoff points
proposed by several authors,1212. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A
practical method for grading the cognitive state of patients for the clinician. J
Psychiatr Res 1975;12:189-98. PMID: 1202204 DOI:
http://dx.doi.org/10.1016/0022-3956(75)90026-6
http://dx.doi.org/10.1016/0022-3956(75)9...
13. Bertollucci PHF, Brucci SMD, Campacci SR, Juliano Y. O mini-exame do
estado mental em uma população geral: o impacto da escolaridade. Arq Neuropsiquiatr
1994;52:1-7.
14. Almeida OP. Mini-exame do estado mental e o diagnóstico de demência
no Brasil. Arq Neuropsiquiatr 1998;56:605-12.-1515. 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;61:777-81. DOI:
http://dx.doi.org/10.1590/S0004-282X2003000500014
http://dx.doi.org/10.1590/S0004-282X2003...
,1818. Murden RA, McRae TD, Kaner S, Bucknam ME. Mini-Mental State exam
scores vary with education in blacks and whites. J Am Geriatr Soc 1991;39:149-55.
PMID: 1991947,1919. Lourenço RA, Veras RP. Mini-exame do estado mental: características
psicométricas em idosos ambulatoriais. Rev Saúde Pública 2006;40:712-9. DOI:
http://dx.doi.org/10.1590/S0034-89102006000500023
http://dx.doi.org/10.1590/S0034-89102006...
and six different categorizations of cognitive and memory impairment
were obtained for 34 patients (Table 2). Only
three individuals were categorized as having cognitive and memory impairment for all
proposed cutoff points; these subjects had been to school for zero, two and eleven
years and attained scores of seven, 16, and 23, respectively.
Categorization of individuals on hemodialysis for cognition and memory according to cutoff points proposed by various authors - Viçosa, MG - 2013
MMSE scores were used to divide patients into groups with and without cognitive and
memory impairment. No statistically significant differences (p <
0.05) were found for sociodemographic and biochemical variables based on the
categorization proposed by Murden et al.,1818. Murden RA, McRae TD, Kaner S, Bucknam ME. Mini-Mental State exam
scores vary with education in blacks and whites. J Am Geriatr Soc 1991;39:149-55.
PMID: 1991947 Bertolucci et al.1313. Bertollucci PHF, Brucci SMD, Campacci SR, Juliano Y. O mini-exame do
estado mental em uma população geral: o impacto da escolaridade. Arq Neuropsiquiatr
1994;52:1-7. and Brucki et al.1515. 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;61:777-81. DOI:
http://dx.doi.org/10.1590/S0004-282X2003000500014
http://dx.doi.org/10.1590/S0004-282X2003...
However, according to the classification published by
Almeida,1414. Almeida OP. Mini-exame do estado mental e o diagnóstico de demência
no Brasil. Arq Neuropsiquiatr 1998;56:605-12. patients with higher levels of
education (p = 0.036) and per capita income
(p = 0.016) had no cognitive or memory impairment. According to
Lourenço & Veras,1919. Lourenço RA, Veras RP. Mini-exame do estado mental: características
psicométricas em idosos ambulatoriais. Rev Saúde Pública 2006;40:712-9. DOI:
http://dx.doi.org/10.1590/S0034-89102006000500023
http://dx.doi.org/10.1590/S0034-89102006...
individuals without
cognitive impairment had higher levels of per capita income
(p = 0.027) than their counterparts with cognitive impairment.
According to Folstein et al.,1212. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A
practical method for grading the cognitive state of patients for the clinician. J
Psychiatr Res 1975;12:189-98. PMID: 1202204 DOI:
http://dx.doi.org/10.1016/0022-3956(75)90026-6
http://dx.doi.org/10.1016/0022-3956(75)9...
better educated individuals (p = 0.000), subjects with
higher levels of per capita income (p = 0.007), and
patients with higher levels of serum calcium, both corrected (p =
0.046) and uncorrected (p = 0.039) for albumin, had no cognitive or
memory impairment.
Discussion
The cognitive skills of 75 individuals on chronic HD were assessed to elicit possible
correlations between cognition and clinical and sociodemographic variables. The
studied population presented characteristics commonly seen in local and international
studies comprising individuals on HD: most were males33. Kurella M, Chertow GM, Fried LF, Cummings SR, Harris T, Simonsick E,
et al. Chronic kidney disease and cognitive impairment in the elderly: the health,
aging, and body composition study. J Am Soc Nephrol 2005;16:2127-33. DOI:
http://dx.doi.org/10.1681/ASN.2005010005
http://dx.doi.org/10.1681/ASN.2005010005...
,66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8.,2020. Frankenfield DL, McClellan WM, Helgerson SD, Lowrie EG, Rocco MV,
Owen WF Jr. Relationship between urea reduction ratio, demographic characteristics,
and body weight for patients in the 1996 National ESRD Core Indicators Project. Am J
Kidney Dis 1999;33:584-91. PMID: 10070924 DOI:
http://dx.doi.org/10.1016/S0272-6386(99)70197-6
http://dx.doi.org/10.1016/S0272-6386(99)...
21. Chiu YW, Teitelbaum I, Misra M, de Leon EM, Adzize T, Mehrotra R.
Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance
dialysis patients. Clin J Am Soc Nephrol 2009;4:1089-96. DOI:
http://dx.doi.org/10.2215/CJN.00290109
http://dx.doi.org/10.2215/CJN.00290109...
22. Cherchiglia MI, Gomes IC, Alvares J, Guerra Jr A, Acúrcio FA,
Andrade EIG, et al. Determinantes dos gastos com diálises no sistema único de saúde,
Brasil, 2000 a 2004. Cad Saúde Pública 2010;26:1627-41. DOI:
http://dx.doi.org/10.1590/S0102-311X2010000800016
http://dx.doi.org/10.1590/S0102-311X2010...
23. Nerbass FB, Morais JG, Santos RG, Krüger TS, Koene TT, Filho HAL.
Adesão e conhecimento sobre o tratamento da hiperfosfatemia de pacientes
hiperfosfatêmicos em hemodiálise. J Bras Nefrol 2010;32:149-55. DOI:
http://dx.doi.org/10.1590/S0101-28002010000200003
http://dx.doi.org/10.1590/S0101-28002010...
-2424. Noori N, Kalantar-Zadeh K, Kovesdy CP, Bross R, Benner D, Kopple JD.
Association of dietary phosphorus intake and phosphorus to protein ratio with
mortality in hemodialysis patients. Clin J Am Soc Nephrol 2010;5:683-92. DOI:
http://dx.doi.org/10.2215/CJN.08601209
http://dx.doi.org/10.2215/CJN.08601209...
and Caucasians.2424. Noori N, Kalantar-Zadeh K, Kovesdy CP, Bross R, Benner D, Kopple JD.
Association of dietary phosphorus intake and phosphorus to protein ratio with
mortality in hemodialysis patients. Clin J Am Soc Nephrol 2010;5:683-92. DOI:
http://dx.doi.org/10.2215/CJN.08601209
http://dx.doi.org/10.2215/CJN.08601209...
,2525. Evans PD, Taal MW. Epidemiology and causes of chronic kidney
disease. Medicine 2011;39(7):402-6. DOI:
http://dx.doi.org/10.1016/j.mpmed.2011.04.007
http://dx.doi.org/10.1016/j.mpmed.2011.0...
As in the present
study, Sehgal et al.22. Sehgal AR, Grey SF, DeOreo PB, Whitehouse PJ. Prevalence,
recognition, and implications of mental impairment among hemodialysis patients. Am J
Kidney Dis 1997;30:41-9. DOI:
http://dx.doi.org/10.1016/S0272-6386(97)90563-1
http://dx.doi.org/10.1016/S0272-6386(97)...
and
Frankenfield et al.2020. Frankenfield DL, McClellan WM, Helgerson SD, Lowrie EG, Rocco MV,
Owen WF Jr. Relationship between urea reduction ratio, demographic characteristics,
and body weight for patients in the 1996 National ESRD Core Indicators Project. Am J
Kidney Dis 1999;33:584-91. PMID: 10070924 DOI:
http://dx.doi.org/10.1016/S0272-6386(99)70197-6
http://dx.doi.org/10.1016/S0272-6386(99)...
reported diabetes, followed by hypertension, accounted for most cases of CKD,
indicating that diabetes may be the main cause of kidney failure not only in
developed nations,2525. Evans PD, Taal MW. Epidemiology and causes of chronic kidney
disease. Medicine 2011;39(7):402-6. DOI:
http://dx.doi.org/10.1016/j.mpmed.2011.04.007
http://dx.doi.org/10.1016/j.mpmed.2011.0...
but also in developing
countries, as indicated by this study. The projected increase in the prevalence of
hypertension, diabetes, and obesity,2626. World Health Organization. Mental Health Atlas 2011. WHO: Geneva;
2012. the
latter a risk factor for the first two, suggests a rise in the number of cases of
CKD.
The mean time of 62.88 months on dialysis seen in the studied population was similar
to the mean time found in other Brazilian studies with hemodialysis patients.66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8.,2323. Nerbass FB, Morais JG, Santos RG, Krüger TS, Koene TT, Filho HAL.
Adesão e conhecimento sobre o tratamento da hiperfosfatemia de pacientes
hiperfosfatêmicos em hemodiálise. J Bras Nefrol 2010;32:149-55. DOI:
http://dx.doi.org/10.1590/S0101-28002010000200003
http://dx.doi.org/10.1590/S0101-28002010...
Many of the individuals were adults with a mean age was close to that
reported by Condé et al.66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8. for
dialysis patients seen in Juiz de Fora, MG, Brazil, and higher than the mean age
reported in studies carried out in the United States.2121. Chiu YW, Teitelbaum I, Misra M, de Leon EM, Adzize T, Mehrotra R.
Pill burden, adherence, hyperphosphatemia, and quality of life in maintenance
dialysis patients. Clin J Am Soc Nephrol 2009;4:1089-96. DOI:
http://dx.doi.org/10.2215/CJN.00290109
http://dx.doi.org/10.2215/CJN.00290109...
,2424. Noori N, Kalantar-Zadeh K, Kovesdy CP, Bross R, Benner D, Kopple JD.
Association of dietary phosphorus intake and phosphorus to protein ratio with
mortality in hemodialysis patients. Clin J Am Soc Nephrol 2010;5:683-92. DOI:
http://dx.doi.org/10.2215/CJN.08601209
http://dx.doi.org/10.2215/CJN.08601209...
The high
prevalence of AVF in hemodialysis patients may represent savings to the health care
system as fistulas can be left in place for a long time, in addition to benefitting
individuals with CKD, as AVFs have been correlated with lower incidence of
complications and infection.2727. Marcus RJ, Marcus DA, Sureshkumar KK, Hussain SM, McGill RL. Gender
differences in vascular access in hemodialysis patients in the United States:
developing strategies for improving access outcome. Gend Med 2007;4:193-204. DOI:
http://dx.doi.org/10.1016/S1550-8579(07)80040-4
http://dx.doi.org/10.1016/S1550-8579(07)...
Studies have shown that individuals on hemodialysis had lower cognition and memory
scores than the general population.33. Kurella M, Chertow GM, Fried LF, Cummings SR, Harris T, Simonsick E,
et al. Chronic kidney disease and cognitive impairment in the elderly: the health,
aging, and body composition study. J Am Soc Nephrol 2005;16:2127-33. DOI:
http://dx.doi.org/10.1681/ASN.2005010005
http://dx.doi.org/10.1681/ASN.2005010005...
,66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8.,77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
According to Murray et
al.,2828. Murray AM, Tupper DE, Knopman DS, Gilbertson DT, Pederson SL, Li S,
et al. Cognitive impairment in hemodialysis patients is common. Neurology
2006;67:216-23. DOI:
http://dx.doi.org/10.1212/01.wnl.0000225182.15532.40
http://dx.doi.org/10.1212/01.wnl.0000225...
patients on hemodialysis
are 3.54 times more likely to have cognitive impairment than healthy individuals of
the same age. The mean score of the studied population was similar to the median
score of healthy individuals with lower levels of education,1313. Bertollucci PHF, Brucci SMD, Campacci SR, Juliano Y. O mini-exame do
estado mental em uma população geral: o impacto da escolaridade. Arq Neuropsiquiatr
1994;52:1-7.,1515. 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;61:777-81. DOI:
http://dx.doi.org/10.1590/S0004-282X2003000500014
http://dx.doi.org/10.1590/S0004-282X2003...
higher
than the scores observed in a group of seniors on HD77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
and elderly subjects without CKD with at least one year of
schooling,2929. Machado JC, Ribeiro RCL, Cotta RMM, Leal PFG. Declínio cognitivo de
idosos e sua associação com fatores epidemiológicos em Viçosa, Minas Gerais. Rev Bras
Geriatr Gerontol 2011;14:109-21. DOI:
http://dx.doi.org/10.1590/S1809-98232011000100012
http://dx.doi.org/10.1590/S1809-98232011...
but lower than the mean score
obtained for a sample of healthy Brazilian individuals,3030. Kochhann R, Cerveira MO, Godinho C, Camozzato A, Chaves MLF.
Evaluation of Mini-Mental State Examination scores according to different age and
education strata, and sex, in a large Brazilian healthy sample. Dement Neuropsychol
2009;3:88-93. pointing to disagreements on the negative effects of
hemodialysis on cognition and memory.
The impact of level of education and age seen in this study, previously established
for healthy populations,1313. Bertollucci PHF, Brucci SMD, Campacci SR, Juliano Y. O mini-exame do
estado mental em uma população geral: o impacto da escolaridade. Arq Neuropsiquiatr
1994;52:1-7.,1515. 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;61:777-81. DOI:
http://dx.doi.org/10.1590/S0004-282X2003000500014
http://dx.doi.org/10.1590/S0004-282X2003...
,3030. Kochhann R, Cerveira MO, Godinho C, Camozzato A, Chaves MLF.
Evaluation of Mini-Mental State Examination scores according to different age and
education strata, and sex, in a large Brazilian healthy sample. Dement Neuropsychol
2009;3:88-93. has also been confirmed for subjects on HD.22. Sehgal AR, Grey SF, DeOreo PB, Whitehouse PJ. Prevalence,
recognition, and implications of mental impairment among hemodialysis patients. Am J
Kidney Dis 1997;30:41-9. DOI:
http://dx.doi.org/10.1016/S0272-6386(97)90563-1
http://dx.doi.org/10.1016/S0272-6386(97)...
,77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
However,
when patients were divided into groups of individuals with and without cognitive
impairment according to the many cutoff points published in the literature, only
level of education and household income were verified to have been higher among
individuals without cognitive impairment. Even the categorization proposed by
Folstein et al.,1212. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A
practical method for grading the cognitive state of patients for the clinician. J
Psychiatr Res 1975;12:189-98. PMID: 1202204 DOI:
http://dx.doi.org/10.1016/0022-3956(75)90026-6
http://dx.doi.org/10.1016/0022-3956(75)9...
in which
cutoff points are not stratified by level of education, individuals categorized as
cognitively impaired had fewer years of formal education.
There is no consensus in the literature over the protective effect of higher levels
of education against lower scores in cognitive skill tests.66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8. Literacy may be a more decisive factor than the level of
education not only within the realm of cognitive function, as it also impacts one's
ability to understand commands and take appropriate action to comply with the
proposed course of therapy.3131. Passamai MPB, Sampaio HAC, Dias AMI, Cabral LA. Functional health
literacy: reflections and concepts on its impact on the interaction among users,
professionals and the health system. Interface 2012;16:301-14. DOI:
http://dx.doi.org/10.1590/S1414-32832012005000027
http://dx.doi.org/10.1590/S1414-32832012...
However, there
currently are no instruments capable of measuring literacy, particularly in health
care.
Considering gender differences, other authors have also reported higher scores among
male subjects.77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
,1515. 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;61:777-81. DOI:
http://dx.doi.org/10.1590/S0004-282X2003000500014
http://dx.doi.org/10.1590/S0004-282X2003...
A study with healthy individuals revealed that
women with fewer years of education had lower MMSE scores than men with low and high
levels of education.3030. Kochhann R, Cerveira MO, Godinho C, Camozzato A, Chaves MLF.
Evaluation of Mini-Mental State Examination scores according to different age and
education strata, and sex, in a large Brazilian healthy sample. Dement Neuropsychol
2009;3:88-93. No differences between
genders were found in this study when levels of income and education were considered,
suggesting that the diversity in results may be due to more specific distinctions
between genders, or social (more stimuli) and biological factors.
In this study, elderly patients had lower MMSE scores, although without differences
in terms of levels of income and education. Decline in physical and cognitive skills,
with diminished information processing rates, are natural consequences of aging.66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8. Hemodialysis and the intense catabolism
characteristically seen in CKD may contribute to and maximize the aging of the brain.
When compared to other individuals, patients on HD with lower66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8. or equal77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
,88. Hailpern SM, Melamed ML, Cohen HW, Hostetter TH. Moderate chronic
kidney disease and cognitive function in adults 20 to 59 years of age: Third National
Health and Nutrition Examination Survey (NHANES III). J Am Soc Nephrol
2007;18:2205-13. DOI: http://dx.doi.org/10.1681/ASN.2006101165
http://dx.doi.org/10.1681/ASN.2006101165...
mean ages in
relation to their counterparts had lower scores on cognitive skill tests. Bossola
et al.3232. Bossola M, Ciciarelli C, Di Stasio E, Panocchia N, Conte GL, Rosa F,
et al. Relationship between appetite and symptoms of depression and anxiety in
patients on chronic hemodialysis. J Ren Nutr 2012;22:27-33. DOI:
http://dx.doi.org/10.1053/j.jrn.2011.02.005
http://dx.doi.org/10.1053/j.jrn.2011.02....
reported older
individuals on HD had lower scores in the MMSE and correlated this finding with the
greater number of comorbidities and symptoms of depression they presented. The
correlation between symptoms of depression and lower cognitive test scores has been
described.77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
Interestingly, depression and
dementia or cognitive impairment are commonly observed in patients with CKD and may
be correlated to each other, although further clarification is still needed. Birmelé
et al.3333. Birmelé B, Le Gall A, Sautenet B, Aguerre C, Camus V. Clinical,
sociodemographic, and psychological correlates of health-related quality of life in
chronic hemodialysis patients. Psychosomatics 2012;53:30-7. DOI:
http://dx.doi.org/10.1016/j.psym.2011.07.002
http://dx.doi.org/10.1016/j.psym.2011.07...
studied a
population of 300 individuals on HD and correlated greater numbers of signs of
depression and comorbidities with lower mental test scores. In this population, the
authors found 10.3% of individuals had dementia. Feroze et al.3434. Feroze U, Martin D, Kalantar-Zadeh K, Kim JC, Reina-Patton A, Kopple
JD. Anxiety and depression in maintenance dialysis patients: preliminary data of a
cross-sectional study and brief literature review J Ren Nutr
2012;22:207-10. assessed 170 individuals on dialysis and
reported 36% of them had some degree of depression, and 21% had moderate to severe
depression.
Our study failed to establish correlations between MMSE scores and biochemical
variables albumin - as similarly reported by Hailpern et al.,88. Hailpern SM, Melamed ML, Cohen HW, Hostetter TH. Moderate chronic
kidney disease and cognitive function in adults 20 to 59 years of age: Third National
Health and Nutrition Examination Survey (NHANES III). J Am Soc Nephrol
2007;18:2205-13. DOI: http://dx.doi.org/10.1681/ASN.2006101165
http://dx.doi.org/10.1681/ASN.2006101165...
creatinine - as described by Hailpern
et al.,88. Hailpern SM, Melamed ML, Cohen HW, Hostetter TH. Moderate chronic
kidney disease and cognitive function in adults 20 to 59 years of age: Third National
Health and Nutrition Examination Survey (NHANES III). J Am Soc Nephrol
2007;18:2205-13. DOI: http://dx.doi.org/10.1681/ASN.2006101165
http://dx.doi.org/10.1681/ASN.2006101165...
Condé et
al.66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8. and Bossola et
al.,77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
urea - as reported by Condé
et al.66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8. and Bossola
et al.,77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
calcium and
phosphorus - in agreement with Condé et al.,66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8. and PTH - as also observed by Bossola et
al.77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
No correlations were found in
this study between MMSE scores, number of comorbidities, and time on HD, as also
reported by Sehgal et al.,22. Sehgal AR, Grey SF, DeOreo PB, Whitehouse PJ. Prevalence,
recognition, and implications of mental impairment among hemodialysis patients. Am J
Kidney Dis 1997;30:41-9. DOI:
http://dx.doi.org/10.1016/S0272-6386(97)90563-1
http://dx.doi.org/10.1016/S0272-6386(97)...
Griva et al.3535. Griva K, Stygall J, Hankins M, Davenport A, Harrison M, Newman SP.
Cognitive impairment and 7-year mortality in dialysis patients. Am J Kidney Dis
2010;56:693-703. DOI: http://dx.doi.org/10.1053/j.ajkd.2010.07.003
http://dx.doi.org/10.1053/j.ajkd.2010.07...
and Bossola
et al.77. Bossola M, Antocicco M, Di Stasio E, Ciciarelli C, Luciani G, Tazza
L, et al. Mini Mental State Examination over time in chronic hemodialysis patients. J
Psychosom Res 2011;71:50-4. PMID: 21665013 DOI:
http://dx.doi.org/10.1016/j.jpsychores.2011.01.001
http://dx.doi.org/10.1016/j.jpsychores.2...
However, other
authors have described correlations between cognitive involvement and poor protein
nutritional status,22. Sehgal AR, Grey SF, DeOreo PB, Whitehouse PJ. Prevalence,
recognition, and implications of mental impairment among hemodialysis patients. Am J
Kidney Dis 1997;30:41-9. DOI:
http://dx.doi.org/10.1016/S0272-6386(97)90563-1
http://dx.doi.org/10.1016/S0272-6386(97)...
higher creatinine
levels,33. Kurella M, Chertow GM, Fried LF, Cummings SR, Harris T, Simonsick E,
et al. Chronic kidney disease and cognitive impairment in the elderly: the health,
aging, and body composition study. J Am Soc Nephrol 2005;16:2127-33. DOI:
http://dx.doi.org/10.1681/ASN.2005010005
http://dx.doi.org/10.1681/ASN.2005010005...
lower levels of serum
hemoglobin66. Condé SAL, Fernandes N, Santos FR, Chouab A, Mota MMEP, Bastos MG.
Declínio cognitivo, depressão e qualidade de vida em pacientes de diferentes estágios
da doença renal crônica. J Bras Nefrol 2010;32:242-8. and albumin.3535. Griva K, Stygall J, Hankins M, Davenport A, Harrison M, Newman SP.
Cognitive impairment and 7-year mortality in dialysis patients. Am J Kidney Dis
2010;56:693-703. DOI: http://dx.doi.org/10.1053/j.ajkd.2010.07.003
http://dx.doi.org/10.1053/j.ajkd.2010.07...
Improvements in the effectiveness of dialysis11. Bastos MG, Kirsztajn GM. Doença renal crônica: importância do
diagnóstico precoce, encaminhamento imediato e abordagem interdisciplinar estruturada
para melhora do desfecho em pacientes ainda não submetidos à diálise. 2011;33:93-108.
DOI: http://dx.doi.org/10.1590/S0101-28002011000100013
http://dx.doi.org/10.1590/S0101-28002011...
may have reduced the potential impact of HD on patient cognitive function. Kurella
Tamura et al.3636. Kurella Tamura M, Unruh ML, Nissenson AR, Larive B, Eggers PW,
Gassman J, et al.; Frequent Hemodialysis Network (FHN) Trial Group. Effect of more
frequent hemodialysis on cognitive function in the frequent hemodialysis network
trials. Am J Kidney Dis 2013;61:228-37. DOI:
http://dx.doi.org/10.1053/j.ajkd.2012.09.009
http://dx.doi.org/10.1053/j.ajkd.2012.09...
looked into
the impact of hemodialysis upon the cognitive function of chronic renal patients and
found no differences between individuals enrolled in programs with three or six HD
sessions per week, suggesting residual syndrome is not the cause of the cognitive
impairment seen in patients on HD. The biochemical parameters analyzed in the studied
population were not much above or below desired levels (data not shown), suggesting
patients complied with the proposed therapy and effectively managed CKD and the
existing comorbidities, thus mitigating possible impacts on test results.
In the categorization proposed by Folstein et al.,1212. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A
practical method for grading the cognitive state of patients for the clinician. J
Psychiatr Res 1975;12:189-98. PMID: 1202204 DOI:
http://dx.doi.org/10.1016/0022-3956(75)90026-6
http://dx.doi.org/10.1016/0022-3956(75)9...
individuals without cognitive and memory
impairment had unexpectedly higher serum calcium levels, albumin-corrected or not.
The association between high levels of serum phosphorus and calcium may produce
extraosseous calcification and increase the patient's risk for cardiovascular
events.3737. Hruska KA, Mathew S, Lund R, Qiu P, Pratt R. Hyperphosphatemia of
chronic kidney disease. Kidney Int 2008;74:148-57. PMID: 18449174 DOI:
http://dx.doi.org/10.1038/ki.2008.130
http://dx.doi.org/10.1038/ki.2008.130...
Cardiovascular diseases rank atop
the causes of cognitive impairment in the general population.3838. World Health Organization. World Health Statistics - A snapshop of
global health. WHO: Geneva; 2012. The high levels of calcium found in cognitively impaired
individuals with or without CKD may be correlated with blood vessel calcifications,
reduced cerebral blood flow and impaired neuronal synapses.33. Kurella M, Chertow GM, Fried LF, Cummings SR, Harris T, Simonsick E,
et al. Chronic kidney disease and cognitive impairment in the elderly: the health,
aging, and body composition study. J Am Soc Nephrol 2005;16:2127-33. DOI:
http://dx.doi.org/10.1681/ASN.2005010005
http://dx.doi.org/10.1681/ASN.2005010005...
Beck et al.3939. Beck DA, Gray L, Lyles KW. Dementia associated with
hyperphosphatemic tumoral calcinosis. Clin Neurol Neurosurg 1998;100:121-5. PMID:
9746300 DOI: http://dx.doi.org/10.1016/S0303-8467(98)00010-9
http://dx.doi.org/10.1016/S0303-8467(98)...
analyzed two cases of hyperphosphatemic tumoral calcinosis with
dementia and suggested a correlation between cognitive impairment and abnormal
deposition of calcium and phosphorus in the arteries.
In this study, serum calcium values corrected and uncorrected for albumin ranged from 7.44 to 11.4 mg/dL and 7.2 to 10.8 mg/dL, respectively, showing the higher values found in the studied individuals do not refer to hypercalcemia, but to levels within the desired range between 9 and 11 mg/dL,1717. Sociedade Brasileira de Nefrologia. Diretrizes Brasileiras de Prática Clínica para o Distúrbio Mineral e Ósseo na Doença Renal Crônica. 2011;33:S1-S57. known to be favorable to mental health when compared to hypocalcemia.
Conclusions
Mean MMSE scores decreased with increases in patient age and were higher among patients with higher levels of education and income. Six of 34 patients had cognitive and memory impairment in all different scales used in the assessment. However, no correlations were found to explain the harmful effects of hemodialysis on cognition and memory.
Nonetheless, the importance of assessing cognitive and memory skills of individuals with chronic kidney disease cannot be denied, given the complex nature of this condition and the need for patients to understand medical recommendations in order to appropriately comply with the prescribed treatment. As a tool to assess cognition and memory, the MMSE can be easily used for patient screening purposes and monitoring of individuals in all stages of CKD.
However, more studies with representative populations of CKD patients at different stages of the disease are needed to define suitable cutoff points that take the characteristics of these individuals into account.
-
CAPES
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Publication Dates
-
Publication in this collection
Apr-Jun 2014
History
-
Received
02 May 2013 -
Accepted
10 Sept 2013