Supervision Needs Following Veteran and Service Member Moderate to Severe Traumatic Brain Injury: A VA TBI Model Systems Study.

OBJECTIVE: To characterize supervision levels across residential settings at 1 year post-TBI and explore predictors of supervision in a Veteran and Service-member population. SETTING: Five VA Polytrauma Rehabilitation Centers. PARTICIPANTS: A total of 302 individuals enrolled in the VA TBI Model Systems (TBIMS) research program. DESIGN: Prospective, longitudinal, multisite. MAIN MEASURES: Primary residence and supervision levels measured via scores on the Supervision Rating Scale. For predictive modeling, scores were dichotomized into 2 groups: those that were fully independent/living alone or required only some supervision during the day (independent group, n = 195) and those that required overnight supervision, full-time indirect supervision, and full-time direct supervision (dependent group, n = 107). RESULTS: Thirty-five percent were receiving supervision at 1 year post-TBI across residential settings and 28% were living in alternative settings. Multivariate modeling indicated that older age and longer posttraumatic amnesia (PTA) were predictive of having a need for supervision at 1 year postinjury. CONCLUSIONS: Supervision needs are long-term features of moderate and severe TBI. Results of this study lend support to the shift toward conceptualizing TBI as a chronic disease.

Pomegranate Supplementation Protects against Memory Dysfunction after Heart Surgery: A Pilot Study.

Memory dysfunction is a common complaint following heart surgery and may be related to a diffuse ischemic state induced by microemboli dislodged during the procedure. Ischemia can induce damage by a number of mechanisms, including oxidative stress. Because pomegranates contain a variety of polyphenols with antioxidant and other potentially beneficial effects, we tested whether supplementation with a pomegranate extract before and after heart surgery could protect against postoperative cognitive dysfunction. Patients undergoing elective coronary artery bypass graft and/or valve surgery were given either 2 g of pomegranate extract (in 2 POMx pills) or placebo (pills containing no pomegranate ingredients) per day from one week before surgery to 6 weeks after surgery. The patients were also administered a battery of neuropsychological tests to assess memory function at 1 week before surgery (baseline), 2 weeks after surgery, and 6 weeks after surgery. The placebo group had significant deficits in postsurgery memory retention, and the pomegranate treatment not only protected against this effect, but also actually improved memory retention performance for up to 6 weeks after surgery as compared to presurgery baseline performance.

The influence of cognitive reserve on neuropsychological functioning following coronary artery bypass grafting (CABG).

Neuropsychological impairment is common, yet variable, after coronary artery bypass grafting (CABG). Similar variability has been observed in other CNS-related diseases. Empirical findings in Alzheimer's disease and HIV, among other areas, suggest cognitive reserve (CR) may mediate the cognitive impact of these diseases. The present study examined whether CR mediates neuropsychological outcome after CABG. Participants were 42 (N=42) individuals who underwent elective, normothermic CABG. Each was placed in high (n=22) or low (n=20) CR groups based on estimated premorbid intelligence and occupational attainment. All were administered neuropsychological tests preoperatively and at discharge. The total incidence of neuropsychological decline (66.7%) was not significantly different between CR groups. However, on working memory and executive function tests, specifically, the high CR group demonstrated greater post-operative decline compared to the low CR group. These data are considered in the context of a threshold model of CR theory.

The neurobiology of neuropsychiatric syndromes in dementia.

PURPOSE OF REVIEW: Neuropsychiatric disturbances in dementia are prevalent, and research is uncovering their neurobiological correlates. RECENT FINDINGS: Late-onset depression appears to be associated with Alzheimer's disease pathology at autopsy, and lifetime depression episodes may worsen Alzheimer's disease pathology in the hippocampus. Vascular disease and elevated homocysteine increase risk for both late-onset depression and Alzheimer's disease and may partly mediate their relationship. Monoamine changes are robust finding in Alzheimer's disease and may account for many observed depression symptoms. Risk of psychosis of Alzheimer's disease appears to be increased by several genes also implicated in schizophrenia (e.g., catechol-O-methyltransferase, neuregulin-1). Psychosis in dementia with Lewy bodies appears to be related to cholinergic deficits. Alzheimer's disease is associated with changes in the circadian sleep-wake cycles, including decreased night-time melatonin. Sleep apnea may be related to apolipoprotein E genotype and impact cognition in Alzheimer's disease. Rapid eye movement sleep behavior disorder is intricately related to synucleinopathies, such as dementia with Lewy bodies, but synuclein changes may not totally explain this relationship. SUMMARY: Neuropsychiatric disturbances are a core feature of dementia and worsen many clinical outcomes. Among the most validated syndromes are depression, psychosis, and sleep disturbance of Alzheimer's disease. Neuropathology, neuroimaging, and genetic studies increasingly provide insight into the origins of these psychiatric symptoms in dementia.

Neuropsychological and neuroimaging changes in preclinical Alzheimer's disease.

Alzheimer's disease (AD) is a common, devastating form of dementia. With the advent of promising symptomatic treatment, the importance of recognizing AD at its very earliest stages has increased. We review the extant neuropsychological and neuroimaging literature on preclinical AD, focusing on longitudinal studies of initially nondemented individuals and cross-sectional investigations comparing at-risk with normal individuals. We systematically reviewed 91 studies of neuropsychological functioning, structural neuroimaging, or functional neuroimaging in preclinical AD. The neuropsychological studies indicated that preclinical AD might be characterized by subtle deficits in a broad range of neuropsychological domains, particularly in attention, learning and memory, executive functioning, processing speed, and language. Recent findings from neuroimaging research suggest that volume loss and cerebral blood flow or metabolic changes, particularly in the temporal lobe, may be detected before the onset of dementia. There exist several markers of a preclinical period of AD, in which specific cognitive and biochemical changes precede the clinical manifestations. The preclinical indicators of AD reflect early compromise of generalized brain integrity and temporal lobe functioning in particular.

Epidemiology of and risk factors for psychosis of Alzheimer's disease: a review of 55 studies published from 1990 to 2003.

OBJECTIVE: The authors reviewed studies published between 1990 and 2003 that reported the prevalence, incidence, and persistence of, as well as the risk factors associated with, psychosis of Alzheimer's disease. METHOD: PubMed and PsycINFO databases were searched by using the terms "psychosis and Alzheimer disease" and "psychosis and dementia." Empirical investigations presenting quantitative data on the epidemiology of and/or risk factors for psychotic symptoms in Alzheimer's disease were included in the review. A total of 55 studies, including a total of 9,749 subjects, met the inclusion criteria. RESULTS: Psychosis was reported in 41% of patients with Alzheimer's disease, including delusions in 36% and hallucinations in 18%. The incidence of psychosis increased progressively over the first 3 years of observation, after which the incidence seemed to plateau. Psychotic symptoms tended to last for several months but became less prominent after 1 year. African American or black ethnicity and more severe cognitive impairment were associated with a higher rate of psychosis. Psychosis was also associated with more rapid cognitive decline. Some studies found a significant association between psychosis and age, age at onset of Alzheimer's disease, and illness duration. Gender, education, and family history of dementia or psychiatric illness showed weak or inconsistent relationships with psychosis. CONCLUSIONS: Psychotic symptoms are common and persistent in patients with Alzheimer's disease. Improved methods have advanced the understanding of psychosis in Alzheimer's disease, although continued research, particularly longitudinal studies, may unveil biological and clinical associations that will inform treatments for these problematic psychological disturbances.