Adaptación del BRIEF ("Behavior Rating Inventory of Executive Function") a población española y su utilidad para el diagnóstico del trastorno por déficit de atención-hiperactividad subtipos inatento y combinado

La valoración de las funciones ejecutivas tiene una especial dificultad cuando se intenta llevar a cabo mediante un enfoque tradicional de pruebas neuropsicológicas. Este aspecto es especialmente relevante en la evaluación de funciones ejecutivas en población pediátrica, lo que propició el desarrollo de cuestionarios de conducta como el Behavior Rating Inventory of Executive Function (BRIEF), con el fin de convertirse en una medida ecológica de las alteraciones de funciones ejecutivas. Resulta necesario realizar una adaptación completa de una prueba psicométrica para que ésta pueda ser utilizada en una población diferente para la cual fue diseñada. El BRIEF ha sido utilizado para la valoración de las alteraciones ejecutivas en numerosas patologías, pero destacan los estudios realizados en niños con Trastorno por Déficit de Atención - Hiperactividad (TDAH). El TDAH presenta alteraciones neuropsicológicas que implican especialmente a las funciones ejecutivas, lo que justifica el uso de la prueba en esta patología. Incluso, algunas de las teorías más importantes sobre TDAH apuntan a las alteraciones en inhibición como el síntoma nuclear del trastorno. La existencia de dos subtipos principales en el TDAH (subtipo predominantemente inatento y combinado) podría implicar un patrón diferente de alteraciones ejecutiva en cada tipo. OBJETIVOS: Se presentan dos objetivos principales: 1) Adaptación del BRIEF a población española, y 2) Estudio del perfil diferencial del BRIEF entre los subtipos inatento y combinado del TDAH...

Executive function and emotional focus in autobiographical memory specificity in older adults

The current study examined the role of executive function in retrieval of specific autobiographical memories in older adults with regard to control of emotion during retrieval. Older and younger adults retrieved memories of specific events in response to emotionally positive, negative and neutral word cues. Contributions of inhibitory and updating elements of executive function to variance in autobiographical specificity were assessed to determine processes involved in the commonly found age-related reduction in specificity. A negative relationship between age and specificity was only found in retrieval to neutral cues. Alternative explanations of this age preservation of specificity of emotional recall are explored, within the context of control of emotion in the self-memory system and preserved emotional processing and positivity effect in older adults. The pattern of relationships suggests updating, rather than inhibition as the source of age-related reduction in specificity, but that emotional processing (particularly of positively valenced memories) is not influenced by age-related variance in executive control. The tendency of older adults to focus on positive material may thus act as a buffer against detrimental effects of reduced executive function capacity on autobiographical retrieval, representing a possible target for interventions to improve specificity of autobiographical memory retrieval in older adults.

The Effects of the Word of Wisdom Meditation Technique on the Development of Executive Function Skills in Early Childhood Education

This theory-based paper examines the definition of Executive Functioning (EF) skills, their importance in the early childhood classroom and how to aid in their natural development. The Word of Wisdom meditation technique is considered as a viable alternative to increase the natural development of EF skills in early childhood.

A bidirectional relationship between executive function and health behavior : evidence, implications, and future directions

This work was supported by a grant from the UK Economic and Social Research Council (ES/L010437/1).

Attention Deficit Hyperactivity Disorder and Executive Function Impairment: An Overview.

As with any cognitive ability, attention is vulnerable to dysfunction. The most common attentional problem is attention deficit hyperactivity disorder (ADHD). This brief overview will highlight the symptoms and deficits associated with ADHD, its prevalence in today’s society, the association between executive function impairment and ADHD using Barkley’s (1997) work, and the personal and societal effects of the disorder.

Does social–behavioral adjustment mediate the relation between executive function and academic readiness?

Research shows that executive function and social–behavioral adjustment during the preschool years are both associated with the successful acquisition of academic readiness abilities. However, studies bringing these constructs together in one investigation are lacking. This study addresses this gap by testing the extent to which social and behavioral adjustment mediated the association between executive function and academic readiness. Sixty-nine 63–76month old children, enrolled in the last semester of the preschool year, participated in the present study. Tasks were administered to measure executive function and preacademic abilities, and teachers rated preschoolers' social–behavioral adjustment. Hierarchical regression analyses revealed that social–behavioral adaptation was a significant mediator of the effect of executive function on academic readiness, even after controlling for maternal education and child verbal ability. These findings extend prior research and suggest that executive function contributes to early academic achievement by influencing preschoolers' opportunities to be engaged in optimal social learning activities.

Estudio Multimodal de la Funcionalidad Cortical en ratones Transgénicos con Síndrome X Frágil y la modulación del dolor

El dolor es un síntoma frecuente en la práctica médica. En España, un estudio realizado en el año 2000 demostró que cada médico atiende un promedio de 181 pacientes con dolor por mes, la mayoría de ellos con dolor crónico moderado1. Del 7%-8% de la población europea está afectada y hasta el 5% puede ser grave2-3, se estima, que afecta a más de dos millones de españoles4. En la consulta de Atención Primaria, los pacientes con dolor neuropático tienen tasas de depresión mucho mayores 5-6-7. El dolor neuropático8 es el dolor causado por daño o enfermedad que afecta al sistema somato-sensorial, es un problema de salud pública con un alto coste laboral, debido a que existe cierto desconocimiento de sus singularidades, tanto de su diagnóstico como de su tratamiento, que al fallar, el dolor se perpetúa y se hace más rebelde a la hora de tratarlo, en la mayoría de las ocasiones pasa a ser crónico. Los mecanismos fisiopatológicos son evolutivos, se trata de un proceso progresivo e integrado que avanza si no recibe tratamiento, ocasionando graves repercusiones en la calidad de vida de los pacientes afectados9. De acuerdo a Prusiner (premio nobel de medicina 1997), en todas las enfermedades neurodegenerativas hay algún tipo de proceso anormal de la función neuronal. Las enfermedades neurodegenerativas son la consecuencia de anormalidades en el proceso de ciertas proteínas que intervienen en el ciclo celular, por lo tanto da lugar al cúmulo de las mismas en las neuronas o en sus proximidades, disminuyendo o anulando sus funciones, como la enfermedad de Alzheimer y el mismo SXF. La proteína FMRP (Fragile Mental Retardation Protein), esencial para el desarrollo cognitivo normal, ha sido relacionada con la vía piramidal del dolor10-11-12. El Síndrome de X Frágil13-14 (SXF), se debe a la mutación del Gen (FMR-1). Como consecuencia de la mutación, el gen se inactiva y no puede realizar la función de sintetizar la proteína FMRP. Por su incidencia se le considera la primera causa de Deficiencia Mental Hereditaria sólo superada por el Síndrome de Down. La electroencefalografía (EEG) es el registro de la actividad bioeléctrica cerebral que ha traído el desarrollo diario de los estudios clínicos y experimentales para el descubrimiento, diagnóstico y tratamiento de un gran número de anormalidades neurológicas y fisiológicas del cerebro y el resto del sistema nervioso central (SNC) incluyendo el dolor. El objetivo de la presente investigación es por medio de un estudio multimodal, desarrollar nuevas formas de presentación diagnóstica mediante técnicas avanzadas de procesado de señal y de imagen, determinando así los vínculos entre las evaluaciones cognitivas y su correlación anatómica con la modulación al dolor presente en patologías relacionadas con proteína FMRP. Utilizando técnicas biomédicas (funcionalestructural) para su caracterización. Para llevar a cabo esta tarea hemos utilizado el modelo animal de ratón. Nuestros resultados en este estudio multimodal demuestran que hay alteraciones en las vías de dolor en el modelo animal FMR1-KO, en concreto en la modulación encefálica (dolor neuropático), los datos se basan en los resultados del estudio estructural (imagen histología), funcional (EEG) y en pruebas de comportamiento (Laberinto de Barnes). En la Histología se muestra una clara asimetría estructural en el modelo FMR1 KO con respecto al control WT, donde el hemisferio Izquierdo tiene mayor densidad de masa neuronal en KO hembras 56.7%-60.8%, machos 58.3%-61%, en WT hembras 62.7%-62.4%, machos 55%-56.2%, hemisferio derecho-izquierdo respectivamente, esto refleja una correlación entre hemisferios muy baja en los sujetos KO (~50%) con respecto a los control WT (~90%). Se encontró correlación significativa entre las pruebas de memoria a largo plazo con respecto a la asimetría hemisférica (r = -0.48, corregido <0,05). En el estudio de comportamiento también hay diferencias, los sujetos WT tuvieron 22% un de rendimiento en la memoria a largo plazo, mientras que en los machos hay deterioro de memoria de un 28% que se corresponden con la patología en humanos. En los resultados de EEG estudiados en el hemisferio izquierdo, en el área de la corteza insular, encuentran que la latencia de la respuesta al potencial evocado es menor (22vs32 15vs96seg), la intensidad de la señal es mayor para los sujetos experimentales FMR1 KO frente a los sujetos control, esto es muy significativo dados los resultados en la histología (140vs129 145vs142 mv). Este estudio multimodal corrobora que las manifestaciones clínicas del SXF son variables dependientes de la edad y el sexo. Hemos podido corroborar en el modelo animal que en la etapa de adulto, los varones con SXF comienzan a desarrollar problemas en el desempeño de tareas que requieren la puesta en marcha de la función ejecutiva central de la memoria de trabajo (almacenamiento temporal). En el análisis del comportamiento es difícil llegar a una conclusión objetiva, se necesitan más estudios en diferentes etapas de la vida corroborados con resultados histológicos. Los avances logrados en los últimos años en su estudio han sido muy positivos, de tal modo que se están abriendo nuevas vías de investigación en un conjunto de procesos que representan un gran desafío a problemas médicos, asistenciales, sociales y económicos a los que se enfrentan los principales países desarrollados, con un aumento masivo de las expectativas de vida y de calidad. Las herramientas utilizadas en el campo de las neurociencias nos ofrecen grandes posibilidades para el desarrollo de estrategias que permitan ser utilizadas en el área de la educación, investigación y desarrollo. La genética determina la estructura del cerebro y nuestra investigación comprueba que la ausencia de FMRP también podría estar implicada en la modulación del dolor como parte de su expresión patológica siendo el modelo animal un punto importante en la investigación científica fundamental para entender el desarrollo de anormalidades en el cerebro. ABSTRACT Pain is a common symptom in medical practice. In Spain, a study conducted in 2000 each medical professional treats an average of 181 patients with pain per month, most of them with chronic moderate pain. 7% -8% of the European population is affected and up to 5% can be serious, it is estimated to affect more than two million people in Spain. In Primary Care, patients with neuropathic pain have much higher rates of depression. Neuropathic pain is caused by damage or disease affecting the somatosensory system, is a public health problem with high labor costs, there are relatively unfamiliar with the peculiarities in diagnosis and treatment, failing that, the pain is perpetuated and becomes rebellious to treat, in most cases becomes chronic. The pathophysiological mechanisms are evolutionary, its a progressive, if untreated, causing severe impact on the quality of life of affected patients. According to Prusiner (Nobel Prize for Medicine 1997), all neurodegenerative diseases there is some abnormal process of neuronal function. Neurodegenerative diseases are the result of abnormalities in the process of certain proteins involved in the cell cycle, reducing or canceling its features such as Alzheimer's disease and FXS. FMRP (Fragile Mental Retardation Protein), is essential for normal cognitive development, and has been linked to the pyramidal tract pain. Fragile X Syndrome (FXS), is due to mutation of the gene (FMR-1). As a consequence of the mutation, the gene is inactivated and can not perform the function of FMRP synthesize. For its incidence is considered the leading cause of Mental Deficiency Hereditary second only to Down Syndrome. Electroencephalography (EEG) is the recording of bioelectrical brain activity, is a advancement of clinical and experimental studies for the detection, diagnosis and treatment of many neurological and physiological abnormalities of the brain and the central nervous system, including pain. The objective of this research is a multimodal study, is the development of new forms of presentation using advanced diagnostic techniques of signal processing and image, to determine the links between cognitive evaluations and anatomic correlation with pain modulation to this protein FMRP-related pathologies. To accomplish this task have used the mouse model. Our results in this study show alterations in multimodal pain pathways in FMR1-KO in brain modulation (neuropathic pain), the data are based on the results of the structural study (histology image), functional (EEG) testing and behavior (Barnes maze). Histology In structural asymmetry shown in FMR1 KO model versus WT control, the left hemisphere is greater density of neuronal mass (KO females 56.7% -60.8%, 58.3% -61% males, females 62.7% -62.4 WT %, males 55% -56.2%), respectively right-left hemisphere, this reflects a very low correlation between hemispheres in KO (~ 50%) subjects compared to WT (~ 90%) control. Significant correlation was found between tests of long-term memory with respect to hemispheric asymmetry (r = -0.48, corrected <0.05). In the memory test there are differences too, the WT subjects had 22% yield in long-term memory, in males there memory impairment 28% corresponding to the condition in humans. The results of EEG studied in the left hemisphere, in insular cortex area, we found that the latency of the response evoked potential is lower (22vs32 15vs96seg), the signal strength is higher for the experimental subjects versus FMR1 KO control subjects, this is very significant given the results on histology (140vs129 145vs142 mv). This multimodal study confirms that the clinical manifestations of FXS are dependent variables of age and sex. We have been able to corroborate in the animal model in the adult stage, males with FXS begin developing problems in the performance of tasks that require the implementation of the central executive function of working memory (temporary storage). In behavior analysis is difficult to reach an objective conclusion, more studies are needed in different life stages corroborated with histologic findings. Advances in recent years were very positive, being opened new lines of research that represent a great challenge to physicians, health care, social and economic problems facing the major developed countries, with a massive increase in life expectancy and quality. The tools used in the field of neuroscience offer us great opportunities for the development of strategies to be used in the area of education, research and development. Genetics determines the structure of the brain and our research found that the absence of FMRP might also be involved in the modulation of pain as part of their pathological expression being an important animal model in basic scientific research to understand the development of abnormalities in brain.

Modulation of the Endocannabinoids N-Arachidonoylethanolamine (AEA) and 2-Arachidonoylglycerol (2-AG) on Executive Functions in Humans.

Animal studies point to an implication of the endocannabinoid system on executive functions. In humans, several studies have suggested an association between acute or chronic use of exogenous cannabinoids (Δ9-tetrahydrocannabinol) and executive impairments. However, to date, no published reports establish the relationship between endocannabinoids, as biomarkers of the cannabinoid neurotransmission system, and executive functioning in humans. The aim of the present study was to explore the association between circulating levels of plasma endocannabinoids N-arachidonoylethanolamine (AEA) and 2-Arachidonoylglycerol (2-AG) and executive functions (decision making, response inhibition and cognitive flexibility) in healthy subjects. One hundred and fifty seven subjects were included and assessed with the Wisconsin Card Sorting Test; Stroop Color and Word Test; and Iowa Gambling Task. All participants were female, aged between 18 and 60 years and spoke Spanish as their first language. Results showed a negative correlation between 2-AG and cognitive flexibility performance (r = -.37; p<.05). A positive correlation was found between AEA concentrations and both cognitive flexibility (r = .59; p<.05) and decision making performance (r = .23; P<.05). There was no significant correlation between either 2-AG (r = -.17) or AEA (r = -.08) concentrations and inhibition response. These results show, in humans, a relevant modulation of the endocannabinoid system on prefrontal-dependent cognitive functioning. The present study might have significant implications for the underlying executive alterations described in some psychiatric disorders currently associated with endocannabinoids deregulation (namely drug abuse/dependence, depression, obesity and eating disorders). Understanding the neurobiology of their dysexecutive profile might certainly contribute to the development of new treatments and pharmacological approaches.

Executive control of working memory in schizophrenia

There is considerable evidence that working memory impairment is a common feature of schizophrenia. The present study assessed working memory and executive function in 54 participants with schizophrenia, and a group of 54 normal controls matched to the patients on age, gender and estimated premorbid IQ, using traditional and newer measures of executive function and two dual tasks-Telephone Search with Counting and the Memory Span and Tracking Task. Results indicated that participants with schizophrenia were significantly impaired on all standardised measures of executive function with the exception of a composite measure of the Trail Making Test. Results for the dual task measures demonstrated that while the participants with schizophrenia were unimpaired on immediate digit span recall over a 2-min period, they recalled fewer digit strings and performed more poorly on a tracking task (box-crossing task) compared with controls. In addition, participants with schizophrenia performed more poorly on the tracking task when they were required to simultaneously recall digits strings than when they performed this task alone. Contrary to expectation, results of the telephone search task under dual conditions were not significantly different between groups. These results may reflect the insufficient complexity of the tone-counting task as an interference task. Overall, the present study showed that participants with schizophrenia appear to have a restricted impairment of their working memory system that is evident in tasks in which the visuospatial sketchpad slave system requires central executive control. (c) 2005 Elsevier Ireland Ltd. All rights reserved.

Rehabilitation of executive dysfunction: A controlled trial of an attention and problem solving treatment group

In this study, the effectiveness of a group-based attention and problem solving (APS) treatment approach to executive impairments in patients with frontal lobe lesions was investigated. Thirty participants with lesions in the frontal lobes, 16 with left frontal (LF) and 14 with right frontal (RF) lesions, were allocated into three groups, each with 10 participants. The APS treatment was initially compared to two other control conditions, an information/education (IE) approach and treatment-as-usual or traditional rehabilitation (TR), with each of the control groups subsequently receiving the APS intervention in a crossover design. This design allowed for an evaluation of the treatment through assessment before and after treatment and on follow up, six months later. There was an improvement on some executive and functional measures after the implementation of the APS programme in the three groups. Size, and to a lesser extent laterality, of lesion affected baseline performance on measures of executive function, but there was no apparent relationship between size, laterality or site of lesion and level of benefit from the treatment intervention. The results were discussed in terms of models of executive functioning and the effectiveness of domain specific interventions in the rehabilitation of executive dysfunction.

Executive dysfunction correlates with impaired functional status in older adults with varying degrees of cognitive impairment

Background: Previous studies have reported an association between executive dysfunction and the ability to perform activities of daily living (ADL)s among older adults. This study aims to examine the association between executive functions and functional status in a cross-section of older adults with varying degrees of cognitive impairment. Methods: 89 individuals (mean age 73.8 years) were recruited at a memory clinic in Sao Paulo, Brazil. Subjects underwent evaluation, and were allocated into three diagnostic groups according to cognitive status: normal controls (NC, n = 32), mild cognitive impairment (MCI, n = 3 1) and mild Alzheimer`s disease (AD, n=26). Executive functions were assessed with the 25-item Executive Interview (EXIT25), and functional status was measured with the Direct Assessment of Functional Status test (DAFS-R). Results: Significantly different total DAFS-R scores were observed across the three diagnostic groups. Patients with AD performed significantly worse in EXIT25 compared with subjects without dementia, and no significant differences were detected between NC and MCI patients. We found a robust negative correlation between the DAFS-R and the EXIT25 scores (r=-0.872, p < 0.001). Linear regression analyses suggested a significant influence of the EXIT-25 and the CAMCOG on the DAFS-R scores. Conclusion: Executive dysfunction and decline in general measures of cognitive functioning are associated with a lower ability to undertake instrumental ADLs. MCI patients showed worse functional status than NC subjects. MCI patients may show subtle changes in functional status that may only be captured by objective measures of ADLs.

Use of the frontal assessment battery in evaluating executive dysfunction in patients with Huntington`s disease

The frontal assessment battery (FAB) is a bedside cognitive scale designed to measure executive functions. Huntington`s disease (HD) is a neurodegenerative disorder characterized by motor, behavioral, and cognitive dysfunction. The aim of this study was to check the validity of the FAB for the evaluation of cognitive impairment in patients with HD. Forty-one patients diagnosed with HD and 53 healthy controls matched by education, sex and age were evaluated with a validated Brazilian version of the UHDRS, the VFT, the SDMT, the SIT, the MMSE, and the FAB. The diagnosis of HD was made by DNA analysis. FAB scores were lower in patients than in the controls (p < 0.001) and had significant correlations with the VFT (r = 0.79; p < 0.05), the SDMT (r = 0.80; p < 0.05), the SIT (r = 0.72; p < 0.05), the MMSE (r = 0.83; p < 0.05), the FCS (r = 0.79; p < 0.05) and the motor section of the UHDRS (r = -0.80; p < 0.05). The FAB differentiated between HD patients in the initial and later stages of the disease. The one-year longitudinal evaluation revealed a global trend toward a worsening in the second score of the FAB. The results demonstrate that the FAB presents good internal consistency and also convergent and discriminative validity; therefore it is a useful scale to assess executive functions and to evaluate cognitive impairment in patients with HD.

Alterações da substância branca cerebral relacionadas com o envelhecimento

INTRODUÇÃO: Estudos prévios, com técnicas de imagem, documentam de forma consistente a existência de alterações da substância branca cerebral relacionadas com o envelhecimento (ASBRE). Tais alterações poderão ter um papel importante no declínio funcional do idoso, reflectindo‐se sobretudo no desempenho motor e cognitivo, com repercussão evidente na prática clínica. Apesar disso, a caracterização em definitivo dos fenótipos clínicos e da evolução das ASBRE continua por esclarecer, possivelmente pelas dificuldades metodológicas de que se reveste o seu estudo, incluindo: a adequação das baterias neuropsicológicas, a utilização de amostras de doentes com diferentes graus de severidade e de envolvimento regional, as limitações das diferentes escalas e a sensibilidade dos diferentes métodos de imagem. A Ressonância Magnética (RM) de difusão tem revelado grande sensibilidade para as alterações isquémicas, admitindo‐se que poderá permitir uma melhor caracterização das ASBRE e deste modo possibilitar uma correlação mais precisa com as variáveis cognitivas e motoras, permitindo avaliar ainda a substância branca aparentemente normal (SBAN). OBJECTIVOS: Descrever a evolução imagiológica das ASBRE no intervalo de um ano e analisar a sua expressão clínica e impacto funcional; identificar factores preditivos de progressão das ASBRE e de declínio funcional associado. Descrever a expressão clínica e perfil evolutivo dos doentes com ASBRE com envolvimento preferencial da região parieto‐occipital; comparar este grupo de doentes com os doentes com ASBRE, sem envolvimento preferencial desta região. Medir os coeficientes de difusão aparente (CDA), utilizando regiões de interesse (RDI), em diferentes localizações da substância branca, incluindo substância branca lesada e SBAN, descrever sua evolução temporal no intervalo de um ano e determinar suas correlações clínicas e imagiológicas. MÉTODOS: Utilizando uma amostra de conveniência, foram estudados 30 doentes, com mais de 65 anos, sem incapacidade funcional ou com incapacidade mínima, avaliada pela escala de actividades instrumentais da vida diária (IADL), apresentando ASBRE em TC. Foi utilizado um protocolo exaustivo de avaliação clínica (com particular destaque para as funções motoras e cognitivas) e imagiológica, em dois momentos de avaliação separados por um ano de intervalo (t0 e t1). As ASBRE foram avaliadas com escalas visuais, escala ARWMC e escala de Fazekas, e os doentes foram estudados em função do grau de severidade (ligeiro versus moderado a grave na escala de Fazekas) e de um envolvimento preferencial posterior (definido como 2 ou mais pontos na escala ARWMC na região parieto‐occipital por comparação com a região frontal). Os CDA foram avaliados mediante estudo de RDI, na substância branca frontal lesada (SBFL) e SBAN frontal, parieto‐occipital e dos pedúnculos cerebelosos. Para verificar diferenças na ordem de distribuição das variáveis foi usado o teste de Mann‐Whitney e para comparação de proporções, o teste exacto de Fisher. Na comparação entre a avaliação em t0 e t1 foi usado o teste Wilcoxon Signed Ranks na comparação da distribuição da ordem das variáveis e o teste McNemar na análise de frequências. Na análise correlacional foram utilizados os testes de T para variáveis emparelhadas e as correlações entre estas foram efectuadas com o coeficiente de correlação de Spearman ou de Pearson. O trabalho foi aprovado pela Comissão de Ética do hospital onde foi realizado e todos os doentes incluídos assinaram um consentimento informado. RESULTADOS: A idade média da população estudada foi 72,5 anos (17 doentes eram do sexo masculino). No final de um ano, 1 doente tinha falecido e 3 doentes não completaram a avaliação imagiológica. Registou‐se uma progressão significativa das ASBRE segundo a escala ARWMC (t0: 8,37 / t1: 9,65 ; p<0,001). Na análise funcional, motora e cognitiva, não houve um agravamento significativo. Avaliando os doentes em t0 e t1 segundo o grau de severidade das ASBRE, o grupo com atingimento moderado a grave (ASBRE2) comparado com o grupo com atingimento ligeiro (ASBRE1) apresentava: maior extensão de lesão da substância branca (ARWMC t0: 11,9 / 4,8 ; p<0.001 ; t1: 14,0 / 5,9 ; p<0,001); tendência a pior desempenho funcional (IADL t0: 90,7 / 99,2 ; p=0,023; t1: 86,4 / 96,7 ; p=n.s.) e motor (SPPB t0: 9,8 / 10,3 ; p=n.s. ; t1: 9,5 / 10,5 ; p=0,058); tendência a maior compromisso do humor (Escala Cornell t0: 6,7 / 3,5 ; p=0,037; t1: 6,2 / 4,5 ; p=n.s.). Analisando a evolução, de t0 para t1, de cada um dos grupos (ASBRE2 e ASBRE1) registou‐se: aumento da extensão da lesão da substância branca em ambos (ASBRE2: 12,0 / 14,0;z=‐2,687 ; p=0,007; ASBR1: 4,8 / 5,9 ; z=‐2,724 ; p=0,006); variação não significativa funcional e motora; tendência ao agravamento em ambos na prova de Cancelamento de dígitos (ASBRE2: 17,5 / 17,4 ; p=n.s. ; ASBRE1: 19,9 / 16,9 ; z=‐2,096 ; p=0,036);tendência à melhoria em ambos no MMS (ASBRE2: 25,7 / 27,5 ; z=‐2,155 ; p=0,031; ASBRE1: 27,5 / 28,2 ; p=n.s). Avaliando os doentes em t0 e t1 em função do padrão de distribuição das ASBRE, os doentes com um envolvimento preferencial posterior (ASBREP) comparados com os restantes (ASBREnP), apresentavam: maior extensão da lesão (ARWMC t0: 10,8 / 6,9 ; p=0,025; t1: 12,9 / 7,6 ; p=0,011); diferenças não significativas no desempenho motor; tendência a melhor desempenho na prova dos Labirintos (t0: 8,1 / 11,8 ; p=0,06; t1: 8,7 / 9,5 ; p=n.s.) e Cancelamento de dígitos (t0: 20,9 / 17,4 ; p=0,045; t1: 18,5 / 16,3 ; p=n.s.); tendência a maior compromisso depressivo na GDS (t0: 5,0 / 3,68 ; p=n.s. ; t1: 5,7 / 3,3 p=0,033). Analisando o perfil evolutivo de t0 para t1, registou‐se: aumento da extensão da lesão nos dois grupos (ASBREP: 10,8 / 12,9 ; z=‐2,555 ; P=0,011; ASBREnP: 6,4 / 7,6 ; z=‐2,877 ; p=0,04); variação em sentidos diferentes com melhoria funcional no grupo ASBREP (91,0 / 95,5 ; z=‐0,926 ; p=0,036) e agravamento no grupo ASBREnP (96,7 / 89,8 ; z=‐2,032 ; p=0,042); variação sem sentidos diferentes, com agravamento significativo no grupo ASBREnP no item estação de pé do SPPB (ASBREP 3,8/3,9 p=n.s.; ASBREnP 3,9/3,6; z=‐2,236 ; p=0,025); tendência à melhoria nos dois grupos no MMS (ASBREP: 27,2 / 28,2 ; p=n.s.; ASBREnP: 26,3 / 27,7 ; z=‐2,413 ; p=0,016) e tendência em sentidos diferentes no Trail Making, com eventual melhoria no grupo ASBREP (113,9 / 91,6 ; p=n.s.) e agravamento no grupo ASBREnP (113,7 / 152,0 ; z=‐2,155 ; p=0,031). Na análise da imagem, utilizando a escala ARWMC e o estudo dos CDA, na avaliação transversal na inclusão, a comparação entre as pontuações médias da escala ARWML nas diferentes regiões mostrava diferenças significativas (F=39,54 , p<0,0001). A análise comparativa post‐hoc de Bonferroni mostrou valores significativamente mais altos para as regiões frontais e parieto‐occipitais (p<0,0001). Os valores médios dos CDA eram significativamente diferentes entre regiões (F=44,56; p<0,0001), sendo mais altos na SBFL (p<0,0001). Não existia diferença significativa entre os valores registados na SBAN nas regiões frontais e parieto‐occipitais. As pontuações regionais da escala ARWMC e os valores médios dos CDA correlacionavam‐se todos de forma positiva. A pontuação da escala ARWMC na região frontal correlacionava‐se significativamente com os valores do CDA da SBFL (r=0,467 ; p=0,012). Existia tendência para uma correlação positiva entre as pontuações da escala ARWMC na região frontal e os valores médios dos CDA na SBAN frontal (r=0,276 ; p=0,155). As pontuações da escala ARWMC e os CDA correlacionavam‐se de forma positiva com a idade e com a tensão arterial (TA). Foram encontradas correlações significativas entre: idade e SBAN frontal (r=0,440 ; p=0,019); TA diastólica e SBFL (r=0,386 ; p=0,034); TA sistólica e SBAN Parieto‐occipital (r=0,407 ; P=0,032). Na avaliação motora e cognitiva, dado elevado número de variáveis, foi efectuada uma análise de factor principal. Registou‐se uma tendência global negativa na correlação entre as pontuações da escala visual na região frontal, os valores dos CDA, e o desempenho motor e cognitivo. Na análise evolutiva, (n=19), registou‐se variação significativa dos CDA, com aumento na SBFL (Direita: z=‐2,875 ; p=0,004 ; Esquerda: z=‐2,113 ; p=0,035) e diminuição na SBAN dos pedúnculos cerebelosos (Direita: z=‐2,094 ; p=0,036 ; Esquerda: z=‐1,989 ; p=0,047). Foi observada uma correlação negativa entre a variação do CDA na SBAN dos pedúnculos cerebelosos e na SBFL contralateral (SBAN pedúnculo cerebeloso Esquerdo / SBFL Direita: r=‐0,133 ; p=n.s.; SBAN pedúnculo cerebeloso Direito / SBFL Esquerda: r=‐0,561 ; p=0,012). Os valores dos CDA à direita correlacionavam‐se de forma positiva com a velocidade da marcha (r=0,562 ; p=0,012). CONCLUSÕES: A progressão das ASBRE pode ser observada com uma escala visual detalhada no intervalo de um ano. Contudo, o eventual agravamento da incapacidade funcional, motora e cognitiva, não parece ser apreciável em igual intervalo de tempo. A maior severidade das ASBRE associa‐se a uma tendência para um maior compromisso funcional, motor e possivelmente do humor. A questão da progressão em escalas simplificadas, de um estádio ligeiro para um estádio moderado a grave, não é elucidada pelos resultados do presente trabalho. Os doentes com um envolvimento preferencial da região parieto‐occipital poderão constituir um subgrupo distinto que, apesar de ter maior extensão de lesão, parece ter um melhor desempenho motor e cognitivo. O perfil evolutivo destes doentes parece igualmente ser distinto, não se observando a tendência ao agravamento funcional, motor e cognitivo (sobretudo em provas de função executiva) que se encontra nos restantes doentes. A análise transversal na inclusão, utilizando uma escala visual e o estudo dos CDA, sugere que a severidade das ASBRE se correlaciona com o compromisso motor e cognitivo, bem como com a idade e com a TA. Uma maior vulnerabilidade da substância branca frontal à lesão vascular parece ter um papel importante no compromisso motor e na disfunção executiva, (essencialmente à custa do compromisso da atenção), possivelmente associada à desconexão dos circuitos fronto‐subcorticais. A análise dos CDA sugere que isso é válido igualmente para a SBAN e sublinha que, as imagens de RM convencional poderão não traduzir a verdadeira extensão da lesão e consequentemente do compromisso motor e cognitivo. A relação entre a progressão da doença vascular em lesões frontais constituídas e a redução do CDA no pedúnculo cerebeloso contralateral poderá estar associada a um pior desempenho motor. A disrupção dos circuitos fronto‐cerebelosos, determinando hipometabolismo e diminuição da perfusão no cerebelo, poderá ser responsável pela diminuição do CDA no cerebelo. ABSTRACT INTRODUCTION: Previous studies, with new imaging techniques, have consistently documented the presence of age‐related white matter lesions (ARWML), emphasizing their role in agerelated functional decline, mainly related to motor and cognitive impairment, and inherent consequences in clinical practice. However clinical significance of ARWML remains to be elucidated, probably on account of methodological difficulties such as: specific neuropsychological batteries, utilization of samples with different degrees of severity and regional involvement, utilization of different imaging scales and different sensitivity of imaging techniques. Recently, Diffusion Weighted Magnetic Ressonance imaging (DWI) has shown a higher sensitivity to ischemic lesions, suggesting it might be superior for characterization of ARWML, allowing more precise correlation with motor and cognitive variables, and evaluating also normal appearing white matter (NAWM). OBJECTIVES: To describe imagiologic evolution of ARWML within one year interval and to analyse its clinical and functional significance. To identify predictors of ARWML progression and associated functional impairment. To describe clinical characteristics and evolution profile of patients with predominantly posterior lesions; to compare this group of patients with patients without predominantly posterior lesions. To study average Apparent Diffusion Coeficcients (ADC) in different white matter regions using regions of interest (ROI); to analyse their evolution profile and to determine their clinical and imagiologic correlations. METHODS: A sample of 30 patients older than 65 years, without functional impairment or with minimal impairment, according to the Instrumental Activities of Daily Lliving scale, with ARWML on CT scan, were studied in a cross‐sectional design. An extensive clinical(with detailed motor and cognitive evaluation) and imagiologic protocol was applied in two one‐year interval separate moments (t0 and t1). ARWML were studied using visual scales, ARWMC and Fazekas’s scale, and patients were studied according to degree of severity (Fazekas scale mild versus moderate / severe) and preferential involvement of the posterior region (defined as 2 or more points in the ARWMC scale in the parietooccipital region compared with frontal region). Evaluation of ADC was performed using ROI in frontal lesioned white matter (FLWM) and NAWM (frontal, parieto‐occipital and cerebellar regions). To study differences in the distribution of variables the Mann‐Whitney test was used and to compare proportions the exact Fisher Test was used. To compare temporal evolution profile between t0 and t1, the Wilcoxon Signed ranks Test was used to analyse the distribution of variables and the Mc Nemar Test to analyse frequencies. Correlation analysis was performed using Spearman or Pearson tests. The study was approved by the local Ethics Committee and all patients signed an informed consent. RESULTS: Mean age was 72.5 years (17 patients were male). By the end of the study, one patient was dead and 3 patients did not undergo brain imaging. There was a higher extent of ARWML evaluated with the ARWMC scale (t0: 8.37 / t1: 9.65 ; p<0.001). Functional, motor and cognitive performance did not progress significantly. Evaluating patients in t0 and t1 according to the degree of severity (Fazekas scale), the moderate / severe group of patients (WML2), compared with the mild group (WML1), showed: higher extent of lesion (ARWMC scale t0: 11.9 / 4.8 ; p<0.001 ; t1: 14.0 / 5.9 ; p<0.001); tendency to worse functional (IADL t0: 90.7 / 99.2 ; p=0.023; t1: 86.4 / 96.7 ; p=n.s.) and motor (SPPB t0: 9.8 / 10.3 ; p=n.s. ; t1: 9.5 / 10.5 ; p=0.058) performance; tendency to higher depressive scores (Cornell Scale t0: 6.7 / 3.5 ; p=0.037; t1: 6.2 / 4.5; p=n.s.). Analysing the evolution profile from t0 to t1 of each group (WML2 and WML1), there was a higher extent of lesion (ARWMC scale) in both (WML2: 12.0 / 14.0; z=‐2.687 ; p=0.007; WML1: 4.8 / 5.9 ; z=‐2.724 ; p=0.006); non‐significant variation in functional and motor performances; tendency to worse performance on the Digit Cancelling (WML2: 17.5 / 17.4 ; p=n.s. ; WML1: 19.9 / 16.9 ; z=‐2.096 ; p=0,036) and to better performance on the MMS (WML2: 25.7 / 27.5 ; z=‐2.155 ; p=0.031; WML1: 27.5/ 28.2 ; p=n.s). Evaluating patients in t0 and t1 according to the regional distribution of ARWML, patients with predominantly posterior lesions (WMLP) compared with the rest of the group (WMLnP), showed: higher extent of lesion (ARWMC scale t0: 10.8 / 6.9 ; p=0.025; t1:12.9 / 7.6 ; p=0.011); non significant differences on motor evaluation; tendency to a better performance on Maze (t0: 8.1 / 11.8 ; p=0.06; t1: 8.7 / 9.5 ; p=n.s.) and Digit cancelling (t0: 20.9 / 17.4 ; p=0.045; t1: 18.5 / 16.3 ; p=n.s.) tests;tendency to higher scores on GDS (t0: 5.0 / 3.68 ; p=n.s. ; t1: 5.7 / 3.3 p=0.033). Analysing the evolution profile from t0 to t1 of each group (WMLP and WMLnP), there was: higher extent of lesion (ARWMC scale) in both groups (WMLP: 10.8 / 12.9 ;z=‐2,555 ; P=0,011; WMLnP: 6.4 / 7.6 ; z=‐2.877; p=0.04); variation in different directions with better functional performance in the group WMLP (91.0 / 95.5 ;z=‐0.926 ; p=0.036) and worse in WMLnP (96.7 / 89.8 ; z=‐2.032 ; p=0.042); variation in different directions with worse motor performance in one SPPB item (total stands) in the group WMLnP (WMLP 3.8/3.9 p=n.s.; ASBREnP 3.9/3.6; z=‐2.236 ; p=0.025);tendency to improvement in both groups in MMS (WMLP: 27.2 / 28.2 ; p=n.s.; WMLnP:26.3 / 27.7 ; z=‐2.413 ; p=0.016); tendency to a variation in different directions in the Trail Making Test, with possible improvement in the group WMLP (113.9 / 91.6 ;p=n.s.) and worsening in the group WMLnP (113.7 / 152.0 ; z=‐2.155 ; p=0.031). Imaging analysis in the inclusion, using the ARWMC scale and ADC evaluation, showed significant differences in different regions (F=39.54, p<0.0001). Comparative post‐hoc Bonferroni analysis showed significantly higher scores in the frontal and parieto‐occipital regions (p<0.0001. ADC values were significantly different between regions (F=44.56; p<0.0001), being higher in FLWM (p<0‐0001). There was no significant difference between ADC in NAWM in frontal and parieto‐occipital regions. ARWMC scores and ADC values correlated positively. Significant correlations were found between frontal ARWMC score and FLWM ADC values (r=0.467 ; p=0.012). ARWMC scores and ADC values correlated positively with age and blood pressure. Significant correlations were: age and frontal NAWM (r=0.440 ; p=0.019); Diastolic blood pressure and FLWM (r=0.386 ; p=0.034); sistolic blood pressure and parietooccipital NAWM (r=0.407 ; P=0.032). Due to the higher number of motor and cognitive variables a preliminary study was done, using principal component analysis. A global tendency to a negative correlation was found between ARWMC scores, ADC values and motor and cognitive performances. Evolutive analysis of ADC (n=19), showed a significant variation, with higher values in t1 in FLWM (Right: z=‐2.875 ; p=0.004 ; Left: z=‐2.113 ; p=0.035) and lower values in t1 in cerebellar NAWM (Right: z=‐2.094 ; p=0.036 ; Left: z=‐1.989 ; p=0.047). A negative correlation was found between ADC variation in cerebellar NAWM and contralateral FLWM (Left cerebellar NAWM / Right FLWM: r=‐0.133 ; p=n.s.; Right cerebellar NAWM/ Left FLWM: r=‐0.561 ; p=0.012). ADC values on the right correlated positively with walking speed (r=0,562 ; p=0,012). CONCLUSIONS: Progression of ARWML can be documented with a detailed visual scale in a one year interval. However, functional, motor and cognitive impairment, do not seem to progress significantly within the same period. A higher severity of ARWML is associated with a tendency to a worse functional and motor performance (and possibly to higher scores in depression scales). The issue of progression in a simplified visual scale from a mild to a moderate / severe degree of ARWML is not further elucidated. Patients with predominantly posterior lesions may be a subset of ARWML patients, with a different profile, that despite higher extent of lesion, seem to fair better than the rest of the group, namely with better performance on motor and cognitive tests. Evolution profile of this subset of patients also seems to be different, without a clearcut tendency to worsening functional, motor and cognitive (particularly for executive function tests) performance that is observed in the rest of the group. Imaging analysis, with a visual scale and ADC evaluation, suggests that severity of ARWML correlates negatively with cognitive and motor performance and positively with age and blood pressure. A higher vulnerability of frontal white matter to vascular disease seems to play an important role in motor and cognitive dysfunction, mainly determined by impairment of attention skills associated with frontal‐subcortical disconnection. DWI results, suggest that this may also be true for NAWM, underlining that conventional MR images may not represent the true extent of cognitive decline. The relation between vascular disease progression inside frontal lesions and ADC reduction in contralateral cerebellar peduncles, may be associated with a worse motor performance. Disruption of fronto‐cerebellar cicuits, with associated regional hypometabolism, may be responsible for the reduction of cerebellar ADC.