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2.
ESC Heart Fail ; 9(3): 1891-1900, 2022 06.
Artigo em Inglês | MEDLINE | ID: mdl-35293145

RESUMO

AIM: Heart failure (HF) outcomes are disproportionately worse in patients discharged to skilled nursing facilities (SNF) as opposed to home. We hypothesized that dementia and delirium were key factors influencing these differences. Our aim was to explore the associations of dementia and delirium with risk of hospital readmission and mortality in HF patients discharged to SNF. METHODS AND RESULTS: The study population included Veterans hospitalized for a primary diagnosis of HF and discharged to SNFs between 2010 and 2015. Pre-existing dementia was identified based on International Classification of Diseases-9 codes. Delirium was determined using the Minimum Data Set 3.0 Confusion Assessment Method algorithm. Proportional hazard regression analyses were used to model outcomes and were adjusted for covariates of interest. Patients (n = 21 655) were older (77.0 ± 10.5 years) and predominantly male (96.9%). Four groups were created according to presence (+) or absence (-) of dementia and delirium. Relative to the dementia-/delirium- group, the dementia-/delirium+ group was associated with increased 30 day mortality [adjusted hazard ratio (HR) = 2.2, 95% confidence interval (CI) = 1.7, 3.0] and 365 day mortality (adjusted HR = 1.5, 95% CI = 1.3, 1.7). Readmission was highest in the dementia-/delirium+ group after 30 days (HR = 1.2, 95% CI = 1.0, 1.5). In the group with dementia (delirium-/dementia+), 30 day mortality (12.8%; HR = 0.7, 95% CI = 0.7, 0.8) and readmissions (5.3%; HR = 1.0, 95% CI = 0.8, 1.1) were not different relative to the reference group. CONCLUSIONS: Delirium, independent of pre-existing dementia, confers increased risk of hospital readmission and mortality in HF patients discharged to SNFs. Managing HF after hospitalization is a complex cognitive task and an increased focus on mental status in the acute care setting prior to discharge is needed to improve HF management and transitional care, mitigate adverse outcomes, and reduce healthcare costs.


Assuntos
Delírio , Demência , Insuficiência Cardíaca , Delírio/epidemiologia , Demência/epidemiologia , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Medicare , Alta do Paciente , Estudos Retrospectivos , Instituições de Cuidados Especializados de Enfermagem , Estados Unidos/epidemiologia
3.
JAMA Netw Open ; 4(3): e2037968, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33724390

RESUMO

Importance: A substantial number of patients discharged to skilled nursing facilities (SNFs) after heart failure (HF) hospitalization experience regression in function or do not improve. Delirium is one of few modifiable risk factors in this patient population. Therefore, understanding the role of delirium in functional recovery may be useful for improving outcomes. Objective: To assess the association of delirium with 30-day functional improvement in patients discharged to SNFs after HF hospitalization. Design, Setting, and Participants: This retrospective cohort study included patients hospitalized for HF in 129 US Department of Veterans Affairs hospitals who were discharged to SNFs from October 1, 2010, to September 30, 2015. Data were analyzed from June 14 to December 18, 2020. Exposures: Delirium, as determined by the Minimum Data Set (MDS) 3.0 Confusion Assessment Method, with dementia as a covariate, determined via International Classification of Diseases, Ninth Revision (ICD-9) coding. Main Outcomes and Measures: The difference between admission and 30-day MDS 3.0 Activities of Daily Living (ADL) scores. Results: A total of 20 495 patients (mean [SD] age, 78 [10.3] years; 78.9% White; and 97% male) were included in the analysis. Of the total sample, 882 patients (4.3%) had delirium on an SNF admission. The mean (SD) baseline ADL score on admission to SNF was significantly worse among patients with delirium than without (18.3 [4.7] vs 16.1 [5.2]; P < .001; d = 0.44.). On the 30-day repeated assessment, mean (SD) function (ADL scores) improved for both patients with delirium (0.6 [2.9]) and without delirium (1.8 [3.6]) (P < .001; d = -0.38). In the multivariate adjusted model, delirium was associated with statistically significant lower ADL improvement (difference in ADL score, -1.07; 95% CI, -1.31 to -0.83; P < .001). Conclusions and Relevance: In this retrospective cohort study, patients with HF discharged to SNFs with delirium were less likely to show improvement in function compared with patients without delirium. Findings suggest a potential need to reexamine how and when health care professionals assess delirium in HF patients throughout their hospitalization and SNF course. Identifying and treating delirium for HF patients earlier in their care trajectory may play an important role in improving care and long-term functional outcomes in this population. Future research is warranted to further investigate the association between delirium and functional recovery for HF and other patient populations.


Assuntos
Atividades Cotidianas , Delírio , Insuficiência Cardíaca/reabilitação , Hospitalização , Recuperação de Função Fisiológica , Instituições de Cuidados Especializados de Enfermagem , Idoso , Idoso de 80 Anos ou mais , Demência , Feminino , Insuficiência Cardíaca/psicologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Alta do Paciente , Readmissão do Paciente , Estudos Retrospectivos , Estados Unidos
4.
Front Hum Neurosci ; 14: 578216, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33132886

RESUMO

To more efficiently communicate the results of neuropsychological assessment to interdisciplinary teams, the University of Florida Neuropsychology Service developed a Deep Brain Stimulation-Cognitive Rating Scale (DBS-CRS). This tool condensed results of a 3-h exam into a five-point scale ranging from 1 (least) to 5 (most) cognitive concern for DBS surgery. In this study, we evaluated the role of the DBS-CRS in clinical decisions by the interdisciplinary team to proceed to surgery, its relationship to objective neuropsychological scores, and its predictive utility for clinical outcome. We retrospectively examined 189 patients with Parkinson's disease who were evaluated for DBS candidacy (mean age 64.8 [SD 9.2], disease duration 8.9 years [SD 5.0], UPDRS-Part III off medication 38.5 [SD 10.5], Dementia Rating Scale-II 135.4 [SD 6.0]). Approximately 19% of patients did not proceed to surgery, with neuropsychological red flags being the most commonly documented reason (57%). Patients who underwent DBS surgery had significantly better DBS-CRS scores than those who did not (p < 0.001). The two strongest and unique neuropsychological contributors to DBS-CRS ratings were delayed memory and executive function, followed by language and visuoperception, based on hierarchical linear regression that accounted for 77.2% of the variance. In terms of outcome, DBS-CRS scores were associated with higher quality of life, less severe motor symptoms, and better daily functioning 6 months following DBS surgery. Together, these findings support the construct and predictive validity of the DBS-CRS as a concise tool for effectively communicating pre-DBS cognitive concerns to an interdisciplinary team, thereby aiding decision making in potential DBS candidates.

5.
Clin Neuropsychol ; 34(3): 591-610, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-30821610

RESUMO

Background: The Dandy-Walker Malformation (DWM) is a congenital birth malformation that is characterized by a triad of features: cerebellar dysgenesis, cystic dilation of the fourth ventricle, and an enlarged posterior fossa that displaces the dural sinuses and the tentorium. Despite this defining triad, clinical presentation can be highly heterogeneous in part due to severity of structural changes. To date, there been limited consideration of cognitive-behavioral symptoms of DWM in relation to nonmotor functions of the cerebellum, specifically cerebellar cognitive affective syndrome (CCAS).Method: In this case study, we describe the neuropsychological and behavioral profile of a 48-year-old man with DWM who was seen due to concerns, expressed solely by the patient's father, about his son's atypical housing, employment and social skills.Results: Neuropsychological test findings revealed high average intellect on standard intellectual measures (WAIS-IV), with stronger verbal (superior) than perceptual reasoning (average) skills. Across all cognitive domains, performance was generally within expectations, although bilateral fine motor skills were impaired. In contrast, he exhibited weaknesses on nontraditional neuropsychological measures assessing orbitofrontal-limbic circuitry, including reward sensitivity decision making and indices of threat-related emotional physiology.Conclusions: Through the use of traditional and nontraditional neuropsychological measures, subtle cognitive weaknesses in fronto-executive and affective regulation were illuminated and likely explain the patient's functional difficulties. Etiologically, these findings are consistent with the nonmotor functions of the cerebellum as described by CCAS.


Assuntos
Circulação Cerebrovascular/fisiologia , Síndrome de Dandy-Walker/diagnóstico , Testes Neuropsicológicos/normas , Transtornos Psicóticos/complicações , Humanos , Masculino , Pessoa de Meia-Idade
6.
Am J Phys Med Rehabil ; 98(10): 879-887, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31135465

RESUMO

OBJECTIVE: The aim of the study was to examine the role of cognition in device adoption, skill retention, and withdrawal from a study of an advanced upper limb prosthesis (the DEKA Arm). DESIGN: T tests and Wilcoxon rank-sum tests were used to compare test performance among study completers and noncompleters. Multivariable regression analyses were used to predict study withdrawal and DEKA Arm skill retention. RESULTS: Compared with self-withdrawn participants, those who were withdrawn by study staff performed significantly worse on tests indexing processing speed, set-shifting, and memory encoding. The DEKA Arm configuration (transradial, transhumeral, shoulder-based on amputation level) was a stronger predictor of skill retention than neuropsychological test performance. CONCLUSIONS: Frontally-mediated cognitive skills may influence the successful adoption of the DEKA Arm. The DEKA Arm configurations at higher amputation levels (e.g., shoulder) appear to be more strongly associated with prosthetic skill retention than users' cognitive status. This may be due to noncognitive user demands (e.g., device weight) statistically masking the discrete influence of cognitive status on skill retention at higher configuration levels. Neuropsychological assessment warrants consideration as a valuable tool in rehabilitation settings to assist in functional device candidacy evaluations.


Assuntos
Amputação Cirúrgica/psicologia , Amputados/psicologia , Membros Artificiais/psicologia , Participação do Paciente/psicologia , Sujeitos da Pesquisa/psicologia , Adulto , Amputação Cirúrgica/reabilitação , Amputados/reabilitação , Cognição , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Destreza Motora , Testes Neuropsicológicos , Desempenho Psicomotor , Análise de Regressão
7.
Parkinsonism Relat Disord ; 34: 54-58, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27887893

RESUMO

BACKGROUND: Essential tremor is a highly prevalent movement disorder characterized by kinetic tremor and mild cognitive-executive changes. These features are commonly attributed to abnormal cerebellar changes, resulting in disruption of cerebellar-thalamo-cortical networks. Less attention has been paid to alterations in basic emotion processing in essential tremor, despite known cerebellar-limbic interconnectivity. OBJECTIVES: In the current study, we tested the hypothesis that a psychophysiologic index of emotional reactivity, the emotion modulated startle reflex, would be muted in individuals with essential tremor relative to controls. METHODS: Participants included 19 essential tremor patients and 18 controls, who viewed standard sets of unpleasant, pleasant, and neutral pictures for six seconds each. During picture viewing, white noise bursts were binaurally presented to elicit startle eyeblinks measured over the orbicularis oculi. RESULTS: Consistent with past literature, controls' startle eyeblink responses were modulated according to picture valence (unpleasant > neutral > pleasant). In essential tremor participants, startle eyeblinks were not modulated by emotion. This modulation failure was not due to medication effects, nor was it due to abnormal appraisal of emotional picture content. CONCLUSIONS: Neuroanatomically, it remains unclear whether diminished startle modulation in essential tremor is secondary to aberrant cerebellar input to the amygdala, which is involved in priming the startle response in emotional contexts, or due to more direct disruption between the cerebellum and brainstem startle circuitry. If the former is correct, these findings may be the first to reveal dysregulation of emotional networks in essential tremor.


Assuntos
Emoções/fisiologia , Tremor Essencial/fisiopatologia , Tremor Essencial/psicologia , Reflexo de Sobressalto/fisiologia , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Atenção , Piscadela , Eletromiografia , Potencial Evocado Motor/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estimulação Luminosa
8.
J Neuropsychiatry Clin Neurosci ; 28(3): 211-6, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26792098

RESUMO

Studies with healthy elderly adults suggest that apathy, depression, and anxiety are more common among individuals with mild cognitive impairment (MCI). This study examined differences in mood/amotivational symptoms among patients with Parkinson's disease (PD) with and without MCI. Patients with PD (N=214) underwent neurocognitive evaluations including assessment of apathy (Apathy Scale), depression (Beck Depression Inventory-II), and trait anxiety (State-Trait Anxiety Inventory trait scale). Trait anxiety and depression were more severe in patients with PD with MCI. Delineation of MCI into amnestic and nonamnestic subtypes revealed greater depression, apathy, and anxiety among patients with PD with amnestic MCI relative to cognitively intact patients with PD. Patients with PD and MCI report greater mood symptoms compared to patients with PD who are cognitively intact.


Assuntos
Disfunção Cognitiva/complicações , Disfunção Cognitiva/psicologia , Transtornos do Humor/etiologia , Doença de Parkinson/complicações , Doença de Parkinson/psicologia , Idoso , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos do Humor/diagnóstico , Testes Neuropsicológicos , Escalas de Graduação Psiquiátrica , Análise de Regressão , Inquéritos e Questionários
9.
Clin Neuropsychol ; 29(7): 985-1001, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26689342

RESUMO

OBJECTIVE: A growing body of literature supports the view that essential tremor (ET) involves alteration of cerebellar-thalamo-cortical networks which can result in working memory and executive deficits. In this study, we tested the hypothesis that individuals with ET would exhibit worse performance on memory tasks requiring more intrinsic organization and structuring (i.e., word lists) relative to those with fewer 'executive' demands (i.e., stories), similar to that previously observed in individuals with Parkinson's disease (PD). METHOD: Participants included a convenience sample of 68 ET patients and 68 idiopathic PD patients, retrospectively matched based on age, education, and sex. All patients underwent routine neuropsychological evaluation assessing recent memory, auditory attention/working memory, language, and executive function. Memory measures included the Hopkins Verbal Learning Test-R and WMS-III Logical Memory. RESULTS: Both ET and PD patients performed significantly worse on word list than story memory recall tasks. The magnitude of the difference between these two memory tasks was similar for ET and PD patients. In both patient groups, performance on measures of executive function and auditory attention/working memory was not distinctly correlated with word list vs. story recall. CONCLUSIONS: These findings suggest that frontal-executive dysfunction in both ET and PD may negatively influence performance on memory tests that are not inherently organized. Although the pathophysiology of these two 'movement disorders' are quite distinct, both have downstream effects on thalamo-frontal circuitry which may provide a common pathway for a similar memory phenotype. Findings are discussed in terms of neuroimaging evidence, conceptual models, and best practice.


Assuntos
Atenção , Tremor Essencial/psicologia , Função Executiva , Idioma , Memória de Curto Prazo , Doença de Parkinson/psicologia , Aprendizagem Verbal , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Testes Neuropsicológicos , Estudos Retrospectivos
10.
J Neuropsychiatry Clin Neurosci ; 27(3): 213-8, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25162776

RESUMO

Due to controversy regarding the influence of apathy on quality of life (QoL), the authors examined the independent influence of apathy, depression, and trait anxiety in a nondemented sample of patients with Parkinson disease (PD). Participants (N=107) completed standard self-report measures of QoL and mood/motivation. Analyses investigated the contribution of these measures and empirically derived factor scores on QoL. QoL was predicted by trait anxiety, dysphoria, and decreased interest, with no independent contribution of apathy. Different patterns emerged with respect to domain-specific QoL, with trait anxiety being the strongest predictor across most domains. Anxiety was most widely related to QoL in PD, with minimal contribution of apathy. Future studies should examine different roles of PD mood/motivation symptoms on caregiver QoL.


Assuntos
Ansiedade/etiologia , Apatia , Depressão/etiologia , Doença de Parkinson/complicações , Doença de Parkinson/psicologia , Qualidade de Vida/psicologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Escalas de Graduação Psiquiátrica , Autorrelato , Estatística como Assunto , Inquéritos e Questionários
11.
Parkinsonism Relat Disord ; 20(11): 1236-41, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-25260967

RESUMO

INTRODUCTION: The Parkinson's disease questionnaire-39 (PDQ-39) is a common measure of health related quality of life (HRQoL) that is widely used with Parkinson disease (PD) patients. Previous evidence suggests that the PDQ-39 reflects at least 8 dimensions (i.e., Emotion, Cognitions, Mobility, etc). To date, little research has examined the external/convergent validity of the Cognitions and Emotional Well-being domains of the PDQ-39. METHODS: A convenience sample of 303 PD patients underwent a comprehensive multi-domain neuropsychological evaluation, including tests of execution function, episodic verbal memory, processing speed, language and working memory, as well as completing measures of depression, apathy, state and trait anxiety and HRQoL (PDQ-39). Hierarchical regressions were conducted in order to examine the relationship between scores on neuropsychological tests and the Cognitions index, as well as mood measures and the Emotional Well-being index of the PDQ-39. RESULTS: Neuropsychological test performance did not account for a significant amount of variance in the PDQ-39 Cognitions index scores. Instead, it was depression that significantly contributed to the Cognitions index, above and beyond neuropsychological performance. The PDQ-39 Emotional Well-being index was also related to mood measures, primarily depression and trait anxiety. CONCLUSIONS: The PDQ-39 Cognition index may be more related to mood functioning, as opposed to cognitive functioning, and should not be considered a "proxy" for cognitive functioning. Future studies are needed to better explain the construct of this index.


Assuntos
Ansiedade/fisiopatologia , Cognição/fisiologia , Depressão/fisiopatologia , Emoções/fisiologia , Doença de Parkinson/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/diagnóstico , Doença de Parkinson/psicologia , Qualidade de Vida/psicologia , Inquéritos e Questionários
12.
Neurology ; 81(18): 1604-10, 2013 Oct 29.
Artigo em Inglês | MEDLINE | ID: mdl-24089386

RESUMO

OBJECTIVE: To develop a cutaneous biomarker for Parkinson disease (PD). METHODS: Twenty patients with PD and 14 age- and sex-matched control subjects underwent examinations, autonomic testing, and skin biopsies at the distal leg, distal thigh, and proximal thigh. α-Synuclein deposition and the density of intraepidermal, sudomotor, and pilomotor nerve fibers were measured. α-Synuclein deposition was normalized to nerve fiber density (the α-synuclein ratio). Results were compared with examination scores and autonomic function testing. RESULTS: Patients with PD had a distal sensory and autonomic neuropathy characterized by loss of intraepidermal and pilomotor fibers (p < 0.05 vs controls, all sites) and morphologic changes to sudomotor nerve fibers. Patients with PD had greater α-synuclein deposition and higher α-synuclein ratios compared with controls within pilomotor nerves and sudomotor nerves (p < 0.01, all sites) but not sensory nerves. Higher α-synuclein ratios correlated with Hoehn and Yahr scores (r = 0.58-0.71, p < 0.01), with sympathetic adrenergic function (r = -0.40 to -0.66, p < 0.01), and with parasympathetic function (r = -0.66 to -0.77, p > 0.01). CONCLUSIONS: We conclude that α-synuclein deposition is increased in cutaneous sympathetic adrenergic and sympathetic cholinergic fibers but not sensory fibers of patients with PD. Higher α-synuclein deposition is associated with greater autonomic dysfunction and more advanced PD. These data suggest that measures of α-synuclein deposition in cutaneous autonomic nerves may be a useful biomarker in patients with PD.


Assuntos
Vias Autônomas/fisiopatologia , Doenças do Sistema Nervoso/etiologia , Doença de Parkinson , Pele/patologia , alfa-Sinucleína/metabolismo , Idoso , Estudos de Casos e Controles , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Fibras Nervosas/patologia , Exame Neurológico , Doença de Parkinson/complicações , Doença de Parkinson/metabolismo , Doença de Parkinson/patologia , Postura/fisiologia , Respiração , Pele/inervação , Estatística como Assunto
13.
Arch Neurol ; 69(11): 1488-92, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-22868966

RESUMO

BACKGROUND: Cutaneous autonomic function can be quantified by the assessment of sudomotor and vasomotor responses. Although piloerector muscles are innervated by the sympathetic nervous system, there are at present no methods to quantify pilomotor function. OBJECTIVE: To quantify piloerection using phenylephrine hydrochloride in humans. DESIGN: Pilot study. SETTING: Hospital-based study. PARTICIPANTS: Twenty-two healthy volunteers (18 males,4 females) aged 24 to 48 years participated in 6 studies. INTERVENTIONS: Piloerection was stimulated by iontophoresis of 1% phenylephrine. Silicone impressions of piloerection were quantified by number and area. The direct and indirect responses to phenylephrine iontophoresis were compared on both forearms after pre treatment to topical and subcutaneous lidocaine and iontophoresis of normal saline. RESULTS: Iontophoresis of phenylephrine induced piloerection in both the direct and axon reflex­mediated regions, with similar responses in both arms. Topical lidocaine blocked axon reflex­mediated piloerection post-iontophoresis (mean [SD], 66.6 [19.2] for control impressions vs 7.2 [4.3] for lidocaine impressions;P.001). Subcutaneous lidocaine completely blocked piloerection.The area of axon reflex­mediated piloerection was also attenuated in the lidocaine-treated region postiontophoresis (mean [SD], 46.2 [16.1]cm2 vs 7.2 [3.9]cm2; P.001). Piloerection was delayed in the axon reflex region compared with the direct region. Normal saline did not cause piloerection. CONCLUSIONS: Phenylephrine provoked piloerection directly and indirectly through an axon reflex­mediated response that is attenuated by lidocaine. Piloerection is not stimulated by iontophoresis of normal saline alone.The quantitative pilomotor axon reflex test (QPART) may complement other measures of cutaneous autonomic nerve fiber function.


Assuntos
Axônios/fisiologia , Piloereção/fisiologia , Reflexo/fisiologia , Fenômenos Fisiológicos da Pele , Adulto , Anestésicos Locais/farmacologia , Axônios/efeitos dos fármacos , Estimulação Elétrica , Feminino , Humanos , Iontoforese , Lidocaína/farmacologia , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/efeitos dos fármacos , Músculo Esquelético/inervação , Nitroprussiato/farmacologia , Fenilefrina/farmacologia , Piloereção/efeitos dos fármacos , Projetos Piloto , Tempo de Reação/efeitos dos fármacos , Reflexo/efeitos dos fármacos , Silicones , Fenômenos Fisiológicos da Pele/efeitos dos fármacos , Vasoconstritores/farmacologia , Vasodilatadores/farmacologia , Adulto Jovem
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