Efeitos solo e teto na Avaliação Cognitiva de Montreal em pacientes com doença de Parkinson no Brasil

Koshimoto, Brenda Hanae Bentes; Brandão, Pedro Renato de Paula; Borges, Vanderci; Ferraz, Henrique Ballalai; Schumacher-Schuh, Artur Francisco; Rieder, Carlos Roberto de Mello; Olchik, Maira Rozenfeld; Mata, Ignacio Fernandez; Tumas, Vitor; Santos-Lobato, Bruno Lopes

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Dementia & Neuropsychologia

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Original Article • Dement. neuropsychol. 17 • 2023 • https://doi.org/10.1590/1980-5764-DN-2023-0022 copiar

Efeitos solo e teto na Avaliação Cognitiva de Montreal em pacientes com doença de Parkinson no Brasil

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

A doença de Parkinson (DP) é uma doença neurodegenerativa comum associada ao declínio cognitivo. A Avaliação Cognitiva de Montreal (Montreal Cognitive Assessment — MoCA) tem sido usada como uma escala de cognição global recomendada para pacientes com DP, mas existem algumas preocupações sobre sua aplicação, em parte pelos efeitos solo e teto.

Objetivo:

Explorar os efeitos solo e teto na MoCA em pacientes com DP no Brasil.

Métodos:

Estudo transversal com dados de pacientes com DP oriundos de cinco Clínicas de Distúrbios de Movimento no Brasil, excluindo-se pessoas com possível diagnóstico de demência. Nós analisamos a pontuação total da MoCA, assim como a de seus sete domínios cognitivos. Os efeitos solo e teto foram avaliados para a pontuação total da MoCA e seus domínios. Foram feitas análises multivariadas para a detecção de fatores associados os efeitos solo e teto.

Resultados:

Nós avaliamos dados de 366 pacientes com DP, e aproximadamente 19% das pessoas tinham menos que cinco anos de escolaridade. Para a pontuação total do MoCA, não houve efeito solo ou teto. Houve efeito solo nos domínios abstração e memória de evocação tardia em 20% de nossa amostra. O efeito teto foi demonstrado em todos os domínios (80,8% mais comum em nomeação e 89% orientação), com exceção de memória de evocação tardia. A educação foi o principal fator associado aos efeitos solo e teto, independentemente de região, sexo, idade na avaliação e duração da doença.

Conclusão:

Os efeitos solo e teto estão presentes em domínios específicos da MoCA no Brasil, com forte impacto da educação. Adaptações adicionais à estrutura da MoCA para populações vulneráveis podem reduzir esses efeitos negativos.

Palavras-chave:
Testes de Estado Mental e Demência; Doença de Parkinson; Confiabilidade dos Dados; Brasil

Variable		Total (n=366)	Belém (n=90)	Ribeirão Preto (n=58)	São Paulo (n=74)	Porto Alegre (n=83)	Brasília (n=61)	p-value
Male sex, % (n)		59.3 (217)	62.2 (56)	58.6 (34)	67.6 (50)	36.1 (30)	77.0 (47)	<0.001 ^* * Pearson’s chi-square test comparing frequencies between patients from Brazilian centers
Age at evaluation^† † Values in median (interquartile range)		59 (52–67)	57 (50–71)	60 (50–71)	58 (52–66)	60 (52–67)	64 (52–71)	0.12^‡ ‡ Kruskal-Wallis test comparing medians between patients from Brazilian centers. Bold numbers indicate p<0.05.
PD duration^† † Values in median (interquartile range)		7 (4–11)	5 (3–10)	7 (3–13)	7 (5–11)	11 (6–14)	3 (2–6)	<0.001 ^‡ ‡ Kruskal-Wallis test comparing medians between patients from Brazilian centers. Bold numbers indicate p<0.05.
Hoehn & Yahr stage. % (n)	1	12 (44)	5.1 (5)	8.3 (5)	2.5 (2)	3.44 (3)	47.8 (29)	<0.001 ^* * Pearson’s chi-square test comparing frequencies between patients from Brazilian centers
	2	67.4 (247)	78.2 (70)	77.8 (45)	71.6 (53)	56 (47)	52.1 (32)
	3	13.6 (50)	9 (8)	8.3 (5)	23.5 (17)	24.5 (20)	0 (0)
	4	5.73 (21)	7.1 (6)	5.6 (3)	1.2 (1)	12.9 (11)	0 (0)
	5	1 (4)	0.6 (1)	0 (0)	1.2 (1)	3.01 (2)	0 (0)
Years of education^† † Values in median (interquartile range)		11 (6–13)	11 (8–11)	8 (4–13)	8 (4–11)	8 (5–12)	16 (11–18)	<0.001 ^‡ ‡ Kruskal-Wallis test comparing medians between patients from Brazilian centers. Bold numbers indicate p<0.05.
Education level, % (n)	No formal education	3 (11)	2.2 (2)	0 (0)	5.4 (4)	6 (5)	0 (0)	<0.001 ^* * Pearson’s chi-square test comparing frequencies between patients from Brazilian centers
	1–4 years	16.7 (61)	7.8 (7)	32.8 (19)	31.1 (23)	12 (10)	3.3 (2)
	5–8 years	22.4 (82)	20 (18)	22.4 (13)	23 (17)	37.3 (31)	4.9 (3)
	9–11 years	27.3 (100)	54.4 (49)	17.2 (10)	20.3 (15)	19.3 (16)	16.4 (10)
	≥12 years	30.6 (112)	15.6 (14)	27.6 (16)	20.3 (15)	25.3 (21)	75.4 (46)
MoCA total score^b	Median (IQR)	24 (21–26)	23 (21–26)	23 (21–26)	23 (20–26)	24 (21–26)	26 (24–27)	<0.001 ^‡ ‡ Kruskal-Wallis test comparing medians between patients from Brazilian centers. Bold numbers indicate p<0.05.
MoCA total score^b	Minimum-Maximum	11–30	13–30	18–30	13–30	11–30	20–30

Variable		Mean	SD	Mean	SD	Mean	SD	Mean	SD	Mean	SD	p-value^* * Analysis of variance comparing domain scores between education levels: 0y, 1–4y, 5–8y, 9–11y, and 12+y indicate the education level in years. Bold numbers indicate p<0.05.
Belém (n=90)		0y (n=2)		1–4y (n=7)		5–8y (n=18)		9–11y (n=49)		12+y (n=14)
	Visual-spatial/executive functions	1.00	1.41	2.28	1.38	2.83	1.46	3.67	1.32	4.07	0.82	0.001
	Naming	1.33	1.15	2.28	0.75	2.44	0.70	2.77	0.42	2.85	0.53	0.012
	Attention	1.50	0.70	4.42	1.39	3.88	1.13	4.87	1.18	5.21	0.57	<0.001
	Language	0.00	0.00	1.71	0.75	1.44	0.98	2.12	0.90	2.14	0.94	0.003
	Abstraction	0.00	0.00	1.00	0.81	0.83	0.78	1.22	0.77	1.71	0.46	0.003
	Delayed recall	2.00	0.00	0.57	1.51	1.22	1.11	1.91	1.65	3.14	1.74	0.003
	Orientation	5.00	1.41	5.71	0.48	5.77	0.42	5.91	0.27	5.92	0.26	0.007
	MoCA Total Score	13.50	0.70	19.85	3.28	20.33	2.78	24.40	3.07	25.92	2.49	<0.001
Ribeirão Preto (n=58)		0y (n=0)		1–4y (n=19)		5–8y (n=13)		9–11y (n=10)		12+y (n=16)
	Visual-spatial/executive functions	NA	NA	2.84	1.46	2.69	1.37	3.20	1.03	4.12	1.02	0.012
	Naming	NA	NA	2.89	0.31	2.46	0.66	2.90	0.31	2.87	0.34	0.023
	Attention	NA	NA	4.31	1.52	4.76	1.09	4.80	0.91	5.37	0.80	0.080
	Language	NA	NA	1.68	0.82	1.69	0.94	1.70	1.15	2.37	0.61	0.070
	Abstraction	NA	NA	0.84	0.76	0.76	0.92	1.20	0.91	1.75	0.44	0.002
	Delayed recall	NA	NA	2.42	1.38	2.15	1.51	2.90	1.19	3.12	1.36	0.230
	Orientation	NA	NA	5.84	0.50	5.92	0.27	5.46	1.24	5.95	0.21	0.440
	MoCA Total Score	NA	NA	21.84	3.18	21.46	3.35	23.70	2.49	25.68	2.21	<0.001
São Paulo (n=74)		0y (n=4)		1–4y (n=23)		5–8y (n=17)		9–11y (n=15)		12+y (n=15)
	Visual-spatial/executive functions	1.25	0.95	2.08	1.47	2.94	1.19	3.93	1.16	4.26	1.22	<0.001
	Naming	2.75	0.50	2.82	0.38	2.82	0.39	2.86	0.35	3.00	0.00	0.520
	Attention	2.75	1.50	3.95	1.49	4.88	0.85	5.40	0.63	5.53	0.83	<0.001
	Language	0.75	0.50	1.82	0.75	2.17	1.07	1.93	1.03	2.40	0.94	0.014
	Abstraction	0.50	1.00	0.65	0.64	1.17	0.88	1.80	0.41	1.73	0.70	<0.001
	Delayed recall	0.00	0.00	1.82	1.61	2.11	1.57	1.93	1.65	3.06	1.33	0.005
	Orientation	4.75	2.50	5.82	0.38	5.88	0.33	5.86	0.51	6.00	0.00	0.017
	MoCA Total Score	13.75	0.95	20.00	2.74	23.00	2.78	24.73	3.03	26.13	2.64	<0.001
Porto Alegre (n=83)		0y (n=5)		1–4y (n=10)		5–8y (n=31)		9–11y (n=16)		12+y (n=21)
	Visual-spatial/executive functions	1.80	2.04	1.70	1.88	2.61	1.66	3.12	1.58	3.76	1.22	0.007
	Naming	2.60	0.64	2.80	0.42	2.70	0.58	2.83	0.46	2.90	0.30	0.160
	Attention	2.80	1.50	3.80	1.22	4.67	1.01	4.87	1.25	4.61	1.24	0.006
	Language	1.40	0.54	1.80	0.42	2.09	0.65	2.31	0.70	2.33	0.73	0.023
	Abstraction	0.20	0.44	1.00	0.47	1.22	0.71	1.68	0.47	1.47	0.67	<0.001
	Delayed recall	0.60	0.54	2.10	1.85	1.61	1.58	2.68	1.16	3.14	1.52	<0.001
	Orientation	5.00	1.41	5.80	0.42	5.83	0.45	5.87	0.51	5.90	0.30	0.010
	MoCA Total Score	16.00	6.08	20.90	2.46	22.70	3.44	25.50	3.07	25.66	3.05	<0.001
Brasília (n=61)		0y (n = 0)		1–4y (n = 2)		5–8y (n = 3)		9–11y (n = 10)		12+y (n = 16)
	Visual-spatial/executive functions	NA	NA	4.00	1.41	3.66	2.30	3.20	1.39	4.36	0.99	0.037
	Naming	NA	NA	2.00	0.00	2.66	0.57	2.60	0.51	2.93	0.24	<0.001
	Attention	NA	NA	5.00	0.00	4.33	0.98	5.10	0.87	5.32	0.94	0.330
	Language	NA	NA	2.50	0.70	2.00	1.00	1.70	0.94	2.19	0.80	0.340
	Abstraction	NA	NA	1.50	0.70	1.33	0.57	1.40	0.69	1.78	0.51	0.140
	Delayed recall	NA	NA	1.50	2.12	3.00	1.73	2.70	1.94	3.30	1.22	0.230
	Orientation	NA	NA	5.50	0.70	6.00	0.00	5.90	0.31	5.95	0.20	0.070
	MoCA Total Score	NA	NA	25.00	4.24	24.00	4.00	23.60	2.91	26.10	2.14	0.008

Domains/Clinical variables		Floor effect				Ceiling effect
Domains/Clinical variables		B	aOR	95%CI	p-value	B	aOR	95%CI	p-value
Visual-spatial/executive functions	Female sex	0.223	1.25	0.47–3.29	0.65	0.149	1.16	0.62–2.14	0.63
	Age at evaluation	-0.006	0.99	0.94–1.04	0.82	-0.007	0.99	0.96–1.02	0.63
	Disease duration	0.05	1.05	0.97–1.14	0.16	-0.009	0.99	0.93–1.05	0.75
	Years of education	-0.222	0.80	0.70–0.91	0.001	0.190	1.20	1.12–1.29	<0.0001
Naming	Female sex	37.8	0.00	0.00–0.00	0.99	-0.266	0.76	0.41–1.42	0.39
	Age at evaluation	-0.954	0.38	0.00–0.00	0.98	-0.007	0.99	0.96–1.02	0.65
	Disease duration	-12.54	0.00	0.00–0.00	0.97	-0.036	0.96	0.91–1.01	0.20
	Years of education	-6.249	0.00	0.00–0.00	0.97	0.147	1.15	1.07–1.25	<0.0001
Attention	Female sex	33.823	0.00	0.00–0.00	0.84	-0.031	0.97	0.56–1.65	0.91
	Age at evaluation	-0.331	0.71	0.31–1.66	0.43	-0.001	0.99	0.97–1.02	0.96
	Disease duration	0.766	2.15	0.81–5.69	0.12	0.005	1.00	0.95–1.05	0.83
	Years of education	-1.933	0.14	0.01–2.60	0.19	0.126	1.13	1.07–1.20	<0.0001
Language	Female sex	0.059	1.06	0.37–2.99	0.91	-0.053	0.94	0.55–1.61	0.84
	Age at evaluation	-0.021	0.97	0.93–1.02	0.38	-0.017	0.98	0.95–1.00	0.17
	Disease duration	-0.003	0.99	0.91–1.09	0.95	-0.018	0.98	0.93–1.03	0.48
	Years of education	-0.151	0.86	0.75–0.97	0.022	0.108	1.11	1.05–1.17	<0.0001
Abstraction	Female sex	-0.862	0.42	0.21–0.81	0.01	0.355	1.42	0.82–2.45	0.20
	Age at evaluation	0.022	1.02	0.99–1.05	0.15	-0.013	0.98	0.96–1.01	0.31
	Disease duration	0.036	1.03	0.98–1.09	0.19	-0.023	0.97	0.92–1.02	0.38
	Years of education	-0.25	0.77	0.71–0.84	<0.0001	0.241	1.27	1.18–1.36	<0.0001
Delayed memory recall	Female sex	-0.342	0.71	0.38–1.31	0.27	0.187	1.20	0.52–2.78	0.72
	Age at evaluation	-0.008	0.99	0.96–1.02	0.61	0.007	1.00	0.96–1.04	0.66
	Disease duration	0.019	1.01	0.96–1.07	0.50	-0.007	0.99	0.91–1.07	0.87
	Years of education	-0.198	0.82	0.75–0.88	<0.0001	0.111	1.11	1.02–1.21	0.008
Orientation	Female sex	-0.342	0.71	0.38–1.31	0.27	-0.814	0.44	0.20–0.95	0.03
	Age at evaluation	-0.008	0.99	0.96–1.02	0.61	-0.017	0.98	0.94–1.02	0.37
	Disease duration	0.019	1.01	0.96–1.07	0.50	-0.048	0.95	0.89–1.01	0.15
	Years of education	-0.198	0.82	0.75–0.88	<0.0001	0.132	1.14	1.04–1.25	0.005

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[1] Correspondence: Bruno Lopes Santos-Lobato; Email: bruls4@ufpa.br.