Refinement of an Emergency Department-Based, Advance Care Planning Intervention for Patients With Cognitive Impairment and Their Caregivers.

BACKGROUND AND OBJECTIVES: Advance care planning (ACP) conversations are important to provide goal-concordant care (i.e., the care that matches the patient's previously stated goals) near end of life. While 31% of older adults presenting to the emergency department (ED) have dementia, only 39% have previously had ACP conversations. We refined and piloted an ED-based, motivational interview designed to stimulate ACP conversations (ED GOAL) for patients living with cognitive impairment and their caregivers. RESEARCH DESIGN AND METHODS: We systematically refined ED GOAL and then conducted an acceptability study in an urban, academic medical center. We prospectively enrolled adults aged 50+ with cognitive impairment and their caregivers. Trained clinicians conducted the intervention. We measured acceptability after the intervention and participants' ACP engagement at baseline and 1-month follow-up. RESULTS: Specific statements to address both the patient and caregiver were added to the ED GOAL script. Of 60 eligible patient/caregiver dyads approached, 26 participated, and 20 (77%) completed follow-up assessments. Patient mean age was 79 years (SD 8.5); 65% were female, 92.3% were White, 96.2% were non-Hispanic, and 69% had moderate dementia. Most patients/caregivers reported feeling completely heard and understood by the study clinician about their future medical care preferences (58%, 15/26). They also reported that the study clinician was very respectful (96%, 25/26) when eliciting those preferences. DISCUSSION AND IMPLICATIONS: Patients living with cognitive impairment and their caregivers found our refined ED GOAL acceptable and respectful. Future studies need to examine the effect of ED GOAL on ACP engagement among these dyads in the ED.

An ultra-sensitive immunoassay detects and quantifies soluble Aß oligomers in human plasma.

INTRODUCTION: Evidence strongly suggests that soluble oligomers of amyloid beta protein (oAß) help initiate the pathogenic cascade of Alzheimer's disease (AD). To date, there have been no validated assays specific for detecting and quantifying oAß in human blood. METHODS: We developed an ultrasensitive oAß immunoassay using a novel capture antibody (71A1) with N-terminal antibody 3D6 for detection that specifically quantifies soluble oAß in the human brain, cerebrospinal fluid (CSF), and plasma. RESULTS: Two new antibodies (71A1; 1G5) are oAß-selective, label Aß plaques in non-fixed AD brain sections, and potently neutralize the synaptotoxicity of AD brain-derived oAß. The 71A1/3D6 assay showed excellent dilution linearity in CSF and plasma without matrix effects, good spike recovery, and specific immunodepletion. DISCUSSION: We have created a sensitive, high throughput, and inexpensive method to quantify synaptotoxic oAß in human plasma for analyzing large cohorts of aged and AD subjects to assess the dynamics of this key pathogenic species and response to therapy.

Improving clinical cognitive testing: report of the AAN Behavioral Neurology Section Workgroup.

OBJECTIVE: To evaluate the evidence basis of single-domain cognitive tests frequently used by behavioral neurologists in an effort to improve the quality of clinical cognitive assessment. METHODS: Behavioral Neurology Section members of the American Academy of Neurology were surveyed about how they conduct clinical cognitive testing, with a particular focus on the Neurobehavioral Status Exam (NBSE). In contrast to general screening cognitive tests, an NBSE consists of tests of individual cognitive domains (e.g., memory or language) that provide a more comprehensive diagnostic assessment. Workgroups for each of 5 cognitive domains (attention, executive function, memory, language, and spatial cognition) conducted evidence-based reviews of frequently used tests. Reviews focused on suitability for office-based clinical practice, including test administration time, accessibility of normative data, disease populations studied, and availability in the public domain. RESULTS: Demographic and clinical practice data were obtained from 200 respondents who reported using a wide range of cognitive tests. Based on survey data and ancillary information, between 5 and 15 tests in each cognitive domain were reviewed. Within each domain, several tests are highlighted as being well-suited for an NBSE. CONCLUSIONS: We identified frequently used single-domain cognitive tests that are suitable for an NBSE to help make informed choices about clinical cognitive assessment. Some frequently used tests have limited normative data or have not been well-studied in common neurologic disorders. Utilizing standardized cognitive tests, particularly those with normative data based on the individual's age and educational level, can enhance the rigor and utility of clinical cognitive assessment.

Subjective cognitive concerns, amyloid-ß, and neurodegeneration in clinically normal elderly.

OBJECTIVE: To determine whether neuroimaging biomarkers of amyloid-ß (Aß) and neurodegeneration (ND) are associated with greater self-reported subjective cognitive concerns (SCC) in clinically normal older individuals. METHODS: A total of 257 participants underwent Pittsburgh compound B PET, PET with fluorodeoxyglucose (18)F, and structural MRI, as well as a battery of neuropsychological measures including several questionnaires regarding SCC. Individuals were classified into 4 biomarker groups: biomarker negative (Aß-/ND-), amyloidosis alone (Aß+/ND-), amyloidosis plus ND (Aß+/ND+), and ND alone (Aß-/ND+). RESULTS: Both Aß and ND were independently associated with greater SCC controlling for objective memory performance. By contrast, neither Aß nor ND was associated with objective memory performance controlling for SCC. Further examination revealed greater SCC in individuals with Aß or ND positivity compared to biomarker-negative individuals. In addition, greater SCC predicted Aß positivity when controlling for ND status. CONCLUSIONS: When individuals were grouped by biomarker status, those who were positive on Aß or ND had the highest report of SCC compared to biomarker-negative individuals. Findings were consistent when SCC was used to predict Aß positivity. Taken together, results suggest that both Aß and ND are associated with SCC, independent of objective memory performance. Enrichment of individuals with SCC may increase likelihood of Aß and ND markers in potential participants for secondary prevention trials.

Neuropsychological and psychiatric outcomes in poorly controlled idiopathic generalized epilepsy.

The neuropsychological and psychiatric outcomes of patients with poorly controlled idiopathic generalized epilepsy (IGE) have not been well characterized. The current study aimed to compare these outcomes to a group of patients with medically refractory temporal lobe epilepsy (TLE). A retrospective review of patients admitted to the epilepsy monitoring unit identified 19 patients with IGE and 23 patients with TLE who underwent neuropsychological and psychiatric evaluations. Patients with IGE required a longer time to complete the Trail Making Tests and had lower performance IQ compared to patients with TLE. Despite a higher burden of convulsions, patients with IGE had lower depression scores on the Beck Depression Inventory-II (BDI-II) than patients with TLE. In the group with IGE, the BDI-II scores were inversely correlated with epilepsy duration. These findings indicate that patients with IGE have lower performance IQ, impaired performance on tests of executive functioning, and lower depression scores compared to patients with TLE, implicating different pathophysiological processes.

The role of sleep in forgetting in temporal lobe epilepsy: a pilot study.

The purpose of this study was to examine how sleep impacts memory function in temporal lobe epilepsy (TLE). Patients with TLE (n=7) and control subjects (n=9) underwent training and overnight testing on (1) a motor sequence task known to undergo sleep-dependent enhancement in healthy subjects, and (2) the selective reminding test, a verbal memory task on which patients with TLE have shown impaired performance 24 hours after training. Sleep data were collected by polysomnography. Results indicate that patients with TLE display greater forgetting on the selective reminding test compared with controls over 12 hours of daytime wakefulness, but not over a similar period including a night of sleep. Slow wave sleep is correlated with overnight performance change on the selective reminding test. Patients with TLE show no deficit in sleep-dependent motor sequence task improvement. The findings provide potential insight into the pattern and pathophysiology of forgetting in TLE.

Subjective evaluations of alcohol expectancies and their relevance to drinking game involvement in female college students.

PURPOSE: The purpose of this study was to test whether subjective evaluations of alcohol expectancies mediate the association between perceived drinking expectancies and participation in drinking games (DGs). Participation in DGs facilitates heavy drinking; therefore, we also examined the association between DG participation and alcohol-related problems. METHODS: This cross-sectional study included 187 female athletes from an all-women's college in the Northeastern United States. Respondents completed self-report questionnaires in small groups who reported on their alcohol use, drinking expectancies, and number of DGs played with their teammates during the semester. RESULTS: A mediation effect emerged for subjective evaluation of liquid courage expectancy but not for increased sociability and cognitive/behavioral impairment expectancies. Although perceived expectancies of cognitive/behavioral impairment were associated negatively with DG participation, positive subjective evaluations of this expectancy were related positively with DG participation. Finally, participation in DG was associated positively with alcohol-related problems. CONCLUSIONS: Findings are consistent with notions of social learning and utility theories and sheds light on the link between alcohol expectancies and participation in DGs among female student athletes. Results also highlight the health risks associated with DG involvement. Intervention programs aimed at decreasing the prevalence of DG participation might consider addressing students' perceptions about the desirability of liquid courage expectancies.