Association of Renal Clearance with Cerebral White Matter Vascular Disease in Hospitalized Veterans With and Without Delirium.

OBJECTIVES: To assess the relation between renal function and delirium and to assess and compare the relation between cerebral white matter lesion (WML) and renal function as estimated by three formulas for the estimated glomerular filtration rate (eGFR) in older adult hospitalized veterans with and without delirium. METHODS: Commonly used formulas to assess renal function-the four-variable Modification of Diet in Renal Disease (MDRD), the six-variable MDRD, and the Cockcroft-Gault eGFR equations-were used to assess renal function in 100 older adult hospitalized veterans with delirium (delirium group) and 100 hospitalized veterans without delirium (nondelirium group) that were age, sex, and race matched. WML location and volumes were assessed using brain computed tomography imaging for each of the 200 veterans in the study. One radiologist, blinded to the diagnoses of the veterans, examined head computed tomography scans for WML in the cortex, subcortex (frontal, temporal, parietal, occipital lobes), basal ganglia (globus pallidus, caudate, putamen), and internal capsule. WML were graded as not present, <1 cm, 1 to 2 cm, or >2 cm. Exploratory χ2 analyses were used to determine the association between the stage of chronic kidney disease and WML. Simple logistic regression analyses were then used to estimate the strength of association between the stages of kidney disease and WML for particular regions of the brain. RESULTS: The mean age of delirium group and nondelirium group veterans was 66 years. χ2 tests revealed no reliable relation between stages of renal disease and delirium. χ2 exploratory analyses of WML in brain regions by renal disease stages demonstrated significant differences in associations among the MDRD-4, MDRD-6, and Cockcroft-Gault formulas for measuring eGFR. The MDRD-4 formula was least associated with the presence or absence of WML. The Cockcroft-Gault estimation of eGFR was most associated with the presence or absence of WML. Simple logistic regressions showed notable increases in the association between stages of renal failure and WMLs in specific areas of the brain, with the MDRD-4 being the least associative with the fewest specific areas and the Cockcroft-Gault formula being the most associative with the most specific areas. CONCLUSIONS: The association between stages 2 through 5 of chronic kidney disease and WLM support the role of kidney function as a potential risk factor for WML in older adult military veterans. The Cockcroft-Gault formula is an important renal index of suspected WML and renal stages 2 through 5, superior to the MDRD-6 and MDRD-4, respectively, in association with WML in older adult military veterans.

Association of White Matter Lesions, Cerebral Atrophy, Intracranial Extravascular Calcifications, and Ventricular-Communicating Hydrocephalus with Delirium Among Veterans.

OBJECTIVES: The literature regarding the underlying neuropathogenesis of delirium on head computed tomography (CT) is limited. The aim of this research was to investigate, using case-control retrospective chart review, the association of white matter lesions (WML), cerebral atrophy, intracranial extravascular calcifications, and ventricular-communicating hydrocephalus in older adult military veterans with and without delirium hospitalized in a Veterans Affairs Medical Center. METHODS: Head CT scans were examined for WML, atrophy, and intracranial extravascular calcifications globally in the cortex, subcortex (frontal, temporal, parietal, occipital lobes), basal ganglia (globus pallidus, caudate, putamen), and internal capsule, in addition to the presence of ventricular-communicating hydrocephalus. WML were graded as not present, <1 cm, 1 to 2 cm, or >2 cm. Atrophy, cerebral atrophy, intracranial extravascular calcifications, and ventricular-communicating hydrocephalus were graded as present or not present. RESULTS: There was a significant association of WML in the temporal lobe periventricular cortical and subcortical brain and a significant association of atrophy in the parietal lobes and the cerebellum in hospitalized older adult military veterans with delirium compared with hospitalized older adult military veterans without delirium. There were no differences between the delirium and nondelirium groups for intracranial extravascular calcifications and ventricular-communicating hydrocephalus. CONCLUSIONS: The results suggest that atrophy in the parietal lobes and the cerebellum of hospitalized older adult military veterans may be associated with an elevated risk of delirium when compared with age, race, and sex-matched control veterans. Continuing efforts are needed to clarify the role of atrophy during delirium in the veteran and nonveteran older adult population to reduce progressive frailty and decreased quality of life secondary to hospital and posthospital-discharge delirium.

Treatment of Post-Traumatic Stress Disorder Nightmares at a Veterans Affairs Medical Center.

The effectiveness of medications for PTSD in general has been well studied, but the effectiveness of medicatio.ns prescribed specifically for post-traumatic stress disorder (PTSD) nightmares is less well known. This retrospective chart review examined the efficacy of various medications used in actual treatment of PTSD nightmares at one Veteran Affairs Hospital. Records at the Salem, VA Veterans Affairs Medical Center (VAMC) were examined from 2009 to 2013 to check for the efficacy of actual treatments used in comparis.on with treatments suggested in three main review articles. The final sample consisted of 327 patients and 478 separate medication trials involving 21 individual medications plus 13 different medication combinations. The three most frequently utilized medications were prazosin (107 trials), risperidone (81 trials), and quetiapine (72 trials). Five medications had 20 or more trials with successful results (partial to full nightmare cessation) in >50% of trials: risperidone (77%, 1.0-6.0 mg), clonidine (63%, 0.1-2.0 mg), quetiapine (50%, 12.5-800.0 mg), mirtazapine (50%; 7.5-30.0 mg), and terazosin (64%, 50.0-300.0 mg). Notably, olanzapine (2.5-10.0) was successful (full remission) in all five prescription trials in five separate patients. Based on the clinical results, the use of risperidone, clonidine, terazosin, and olanzapine warrants additional investigation in clinically controlled trials as medications prescribed specifically for PTSD nightmares.

Horticultural therapy: a pilot study on modulating cortisol levels and indices of substance craving, posttraumatic stress disorder, depression, and quality of life in veterans.

CONTEXT: Horticultural therapy (HT) is a subgroup of occupational therapy (OT). Both HT and OT have been successful as adjunctive treatment modalities in substance abuse treatment. Studies have indicated that gardening promotes neuroendocrine and affective restoration from stress. OBJECTIVES: The study intended to assess the effect of HT versus nonhorticultural OT on cortisol levels, depression, symptoms of posttraumatic stress disorder (PTSD), alcohol cravings, and quality of life. METHODS: The research team designed a randomized pilot study. SETTING: The study was open for participation from July 2012-October 2012. It took place during multiple occurrences of a 28-d treatment programs for substance use disorder at a Veterans Affairs medical center. Participants • Participants were 49 veterans, averaging 46.4 y old (SD = 11.9); the dropout rate was 37%. INTERVENTION: Participants were randomly assigned to the HT or the OT group. They attended supervised HT and OT groups 5 h/d for 3 wk. Outcome Measures • Pre- and posttreatment, participants completed the Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form (Q-LES-Q-SF), the Alcohol Craving Questionnaire (ACQ-NOW), the Posttraumatic Stress Disorder Checklist Civilian Version (PCLC), and the Center for Epidemiologic Studies Depression Scale (CES-D). Salivary cortisol samples were taken at wk 1, 2, and 3. RESULTS: A repeated measures analysis of variance (ANOVA) (F2,20 = 0.878) revealed that the HT performed was associated with a 12% reduction in salivary cortisol levels from wk 1 to wk 3, but the difference was not statistically significant (P = .43). Separate 1-way analyses of covariance (ANCOVAs) revealed no statistically significant differences in the self-administered tests, although both the Q-LES-Q-SF and CES-D showed a trend toward improving quality of life and depressive symptoms in the HT group compared with the OT group. Additional analysis of the nonbiologic tests suggests that most participants in the HT and OT had some benefit from the programmed activities. CONCLUSIONS: The trends suggest that HT may modulate stress in veterans, as evidenced by decreased cortisol levels and depressive symptoms, and may improve quality of life more than the programs in which the OT group participated. Further investigation with larger samples, including a nontreatment control group, is needed to determine whether the observed trends are treatment effects or due to abstinence.

Comparison of advance medical directive inquiry and documentation for hospital inpatients in three medical services: implications for policy changes.

Following the introduction of the Patient Self-Determination Act of 1990, the Veterans Health Administration developed its own advance medical directive (AMD) policy, which most recently states that documentation is mandatory for all hospital patients in all settings. The object of this study was to assess the effectiveness of AMD documentation at a local Veterans Affairs Medical Center. AMD documentation was compared among three inpatient services: surgery, medicine, and psychiatry. Retrospective in nature, 594 inpatient cases were compared. Results revealed that, overall, the rate of AMD documentation was 37.7%. AMD documentation on surgery was statistically more frequent (45.6%) than for either medicine (33.2%) or psychiatry (34.5%). The difference between the numbers of days to AMD documentation for all three services was not statistically significant. While there was no statistically significant difference across gender, Caucasians had AMDs documented more frequently than African Americans (p < .001). Logistic regression reveals that social worker and physician intervention, not patient-specific variables, are the primary predictors of AMD incidence. Policy makers may need to consider the realities of hospital care, especially in emergency settings, and be more specific in the steps of implementation of the policy in the evenings, weekends, and holidays. True adherence to policy implementation may require hospital administrators to increase staff and educational efforts so that the concept of AMD communication and documentation is completely explained to all staff and patients. Policy should include an electronic record reminder that is renewed every 3 years and provisions for accommodating patients who arrive on weekends and holidays, with special awareness of the particular communication needs of minority groups. The study conclusions are that further inquiry is needed to understand these policy nuances to enable the Veterans Affairs Administration to improve its policies and performance in this important aspect of healthcare.