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Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Study design and conceptualization: Nilsson, Nyberg, Adolfsson, Bergdahl, Bergdahl. Statistical analyses: Hansson, S€ orman. Interpretation of results and reviewing the manuscript: all authors. Drafting and revising manuscript: Hansson, S€ orman. All authors approved the final manuscript. Sponsor’s Role: None.

REFERENCES 1. Habib R, Nyberg L, Nilsson L-G. Cognitive and non-cognitive factors contributing to the longitudinal identification of successful older adults in the Betula study. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn 2007;14:257–273. 2. Weijenberg RAF, Scherder EJA, Lobbezoo F. Mastication for the mind: The relationship between mastication and cognition in ageing and dementia. Neurosci Biobehav Rev 2011;35:483–497. 3. Paganini-Hill A, White SC, Atchison KA. Dentition, dental health habits, and dementia: The Leisure World Cohort Study. J Am Geriatr Soc 2012;60:1556–1563. 4. Nilsson L-G, B€ ackman L, Erngrund K et al. The Betula prospective cohort study: Memory, health, and aging. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn 1997;4:1–32. 5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. Text Revision. Washington, DC: American Psychiatric Press, 2000. 6. Eriksson-S€ orman D, Sundstr€ om A, R€ onnlund M et al. Leisure activity in old age and risk of dementia: A 15-year prospective study. J Gerontol B Psychol Sci Soc Sci 2013 Jun 13. doi:10.1093/geronb/gbt056 7. Nilsson L-G, Adolfsson R, B€ackman L et al. The influence of APOE status on episodic and semantic memory: Data from a population-based study. Neuropsychology 2006;20:645–657. 8. Corder EH, Saunders AM, Risch NJ et al. Protective effect of apolipoprotein E type 2 allele for late onset Alzheimer disease. Nat Genet 1994;7:180–184. 9. Farrer LA, Cupples LA, Haines JL et al. Effects of age, sex, and ethnicity on the association between apolipoprotein E genotype and Alzheimer disease: A meta-analysis. JAMA 1997;278:1349–1356. 10. Bergdahl M, Habib R, Bergdahl J et al. Natural teeth and cognitive function in humans. Scand J Psychol 2007;48:557–565.

ASSOCIATION BETWEEN PLASMA TESTOSTERONE LEVEL AND BONE MINERAL DENSITY IN HEALTHY ELDERLY MEN To the Editor: Osteoporosis affects mainly women, and the disease and its consequences are often underestimated

LETTERS TO THE EDITOR

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in men.1,2 Male osteoporosis occurs later than in women, and with the population aging, it is becoming a relevant public health problem.3,4 Total and free testosterone have been positively related to male bone mineral density (BMD).3,5 It is suggested that bone mass loss and thus higher fracture risk follow the reduction of plasma testosterone in elderly men.5,6 More recently, plasma estrogen levels have also been found to be an important contributor to the maintenance of bone quality in elderly men2,7 even though, in men, estrogen can be obtained by testosterone aromatization.3,5 The objective of the current study was to assess BMD in healthy asymptomatic elderly men with good socioeconomic status living in a healthy environment and correlate it to plasma total testosterone.

METHODOLOGY This study was conducted in a specialized elderly private clinic after approval by the ethics committee of the University of Ribeir~ ao Preto, School of Medicine, S~ ao Paulo, Brazil (Process 052/2013). All subjects were informed of the purpose of the study and gave informed consent to take part in the investigation. Of 52 men aged 60 and older contacted, 16 agreed to participate, with one dropping out during the study, leaving 15 remaining volunteers. None had debilitating chronic diseases or comorbidities.8 All underwent BMD and plasma testosterone measurement. Bone densitometry was used to determine BMD (QDR 4500W, Hologic, Bedford, MA). Anteroposterior lumbar spine BMD was measured and mean BMD was computed from the first through fourth lumbar vertebrae. Proximal femur examination involved measurement at the femoral neck, great trochanter, and Wards triangle. As the International Society for Clinical Densitometry recommends, t-score was used for BMD assessment.6 Each volunteer provided a blood sample at the laboratory. Testosterone was determined using chemoluminescence (Immulite 2000, Siemens, S~ ao Paulo, Brazil). Samples were collected into tubes with separating gel buffer (S-Monovette, Sarsted AG & Co., N€ umbrecht, Germany). The samples were centrifuged for 10 minutes at 3,000 revolutions per minute 30 minutes after collection to permit complete clot formation.

Figure 1. Correlation between testosterone and proximal femur t-score (correlation coefficient (r) = between testosterone and spinal lumbar t-score (r = 0.638, P = .01).

0.554, P = .03) and

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LETTERS TO THE EDITOR

RESULTS Mean age was 68  4. Mean total testosterone was 411  192 ng/dL; mean t-score was 0.4  1.4 for the lumbar spine and 0.8  0.9 for the proximal femur. The results showed a negative correlation between BMD and testosterone levels for the proximal femur and lumbar spine (Figure 1).

DISCUSSION The results showed an inverse correlation between plasma testosterone and BMD in healthy elderly men. It is only recently, with the aging of the population, that male osteoporosis has become a problem. It is still poorly understood but is probably multifactorial.2 Testosterone deficit may be one of the indicators of male osteoporosis,3 although it is certainly not the only cause.4 The current study supports the notion that, in older men, higher plasma testosterone may not be sufficient to guarantee adequate bone mass and a lower level does not always indicate osteopenia or osteoporosis. Thus, even when healthy, active, and of good socioeconomic level, elderly men should undergo bone health evaluation. Nelson Iucif, Jr, MD, PhD Faculty of Medicine, University of Ribeir~ ao Preto, Ribeir~ ao Preto, S~ ao Paulo, Brazil Discipline of Medical Nutrition, Department of Internal Medicine, Faculty of Medicine of Ribeir~ ao Preto, University of S~ao Paulo, Ribeir~ ao Preto, S~ ao Paulo, Brazil Julio S. Marchini, MD, PhD Discipline of Medical Nutrition, Department of Internal Medicine, Faculty of Medicine of Ribeir~ ao Preto, University of S~ao Paulo, Ribeir~ ao Preto, S~ ao Paulo, Brazil Maria do Carmo Sitta, MD, PhD Discipline of Geriatrics, Department of Internal Medicine, University of S~ ao Paulo, S~ ao Paulo, Brazil Selma F. C. Cunha, MD, PhD Discipline of Medical Nutrition, Department of Internal Medicine, Faculty of Medicine of Ribeir~ ao Preto, University of S~ao Paulo, Ribeir~ ao Preto, S~ ao Paulo, Brazil Reinaldo B. Bestetti, MD, PhD Faculty of Medicine, University of Ribeir~ ao Preto, Ribeir~ ao Preto, S~ ao Paulo, Brazil Vivian M. M. Suen, MD, PhD Discipline of Medical Nutrition, Department of Internal Medicine, Faculty of Medicine of Ribeir~ ao Preto, University of S~ao Paulo, Ribeir~ ao Preto, S~ ao Paulo, Brazil

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.

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Author Contributions: Iucif, Marchini: study concept and design, acquisition of subjects and data, analysis and interpretation of data, preparation of manuscript. Sitta, Freire: study concept and design, analysis and interpretation of data. Bestetti, Suen: interpretation of data. Sponsor’s Role: None.

REFERENCES 1. Eastell R. Osteoporosis. Medicine 2009;37:475–480. 2. Gielen E, Vanderschueren D, Callewaert F et al. Osteoporosis in men. Best Pract Res Clin Endocrinol Metab 2011;25:321–335. 3. Ebeling PR. Clinical practice. Osteoporosis in men. N Engl J Med 2008;358:1474–1482. 4. Gates BJ, Das S. Management of osteoporosis in elderly men. Maturitas 2011;69:113–119. 5. Mosekilde L, Vestergaard P, Rejnmark L. The pathogenesis, treatment and prevention of osteoporosis in men. Drugs 2013;73:15–29. 6. Daniell HW. Osteoporosis after orchiectomy for prostate cancer. J Urol 1997;157:439–444. 7. Surampudi PN, Wang C, Swerdloff R. Hypogonadism in the aging male diagnosis, potential benefits, and risks of testosterone replacement therapy. Int J Endocrinol 2012;2012:625434. 8. Iucif N Jr, Rocha JS. Study of inequalities in hospital mortality using the Charlson comorbidity index. Rev Saude Publica 2004;38:780–786.

SINGING CAN ENHANCE EPISODIC MEMORY FUNCTIONING IN ELDERLY PEOPLE WITH ALZHEIMER’S DISEASE To the Editor: Alzheimer’s disease (AD), the most common form of dementia, is characterized by a general, progressive decline in cognitive function. Individuals with AD have impaired episodic memory, which appears in the form of difficulty learning new information and remembering recent events. Previous research has shown that music has a memory-enhancing effect for associated information in implicit memory functioning1 and explicit memory performance2 in cognitively healthy individuals and those with neurological conditions. To the knowledge of the authors of the current letter, no study has examined the memory-enhancing effects of singing for associated information in explicit memory functioning in elderly people with AD. The current study aimed to determine whether singing can enhance episodic memory functioning (learning of new information) in elderly adults with AD. It was hypothesized that recall performance would be better for the singing condition than the speaking condition.

METHODS Twenty-one individuals with a clinical diagnosis of moderate to severe AD from two elderly homes in France were recruited for this study (Mini-Mental State Examination (MMSE) score 15.6  4.2). Individuals with frontotemporal dementia, Lewy body dementia, intellectual impairment, uncorrected hearing problems, and amusia were excluded. All subjects were administered two word-list memory tests under two encoding conditions: speaking and singing. To measure recall performance, memory tests based on the

Association between plasma testosterone level and bone mineral density in healthy elderly men.

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