Gas exchange and exercise capacity affect neurocognitive performance in patients with lung disease

Risk Factors for Postoperative Cognitive Decline After Orthopedic Surgery in Elderly Chinese Patients: A Retrospective Cohort Study

Purpose

We aimed to identify the risk factors for postoperative cognitive decline (POCD) by evaluating the outcomes from preoperative comprehensive geriatric assessment (CGA) and intraoperative anesthetic interventions.

Patients and Methods

Data used in the study were obtained from the Aged Patient Perioperative Longitudinal Evaluation-Multidisciplinary Trial (APPLE-MDT) cohort recruited from the Department of Orthopedics in Xuanwu Hospital, Capital Medical University between March, 2019 and June, 2022. All patients accepted preoperative CGA by the multidisciplinary team using 13 common scales across 15 domains reflecting the multi-organ functions. The variables included demographic data, scales in CGA, comorbidities, laboratory tests and intraoperative anesthetic data. Cognitive function was assessed by Montreal Cognitive Assessment scale within 48 hours after admission and after surgery. Dropping of ≥1 point between the preoperative and postoperative scale was defined as POCD.

Results

We enrolled 119 patients. The median age was 80.00 years [IQR, 77.00, 82.00] and 68 patients (57.1%) were female. Forty-two patients (35.3%) developed POCD. Three cognitive domains including calculation (P = 0.046), recall (P = 0.047) and attention (P = 0.007) were significantly worsened after surgery. Univariate analysis showed that disability of instrumental activity of daily living, incidence rate of postoperative respiratory failure (PRF) ≥4.2%, STOP-Bang scale score, Caprini risk scale score and Sufentanil for maintenance of anesthesia were different between the POCD and non-POCD patients. In the multivariable logistic regression analysis, PRF ≥ 4.2% (odds ratio [OR] = 2.343; 95% confidence interval [CI]: 1.028-5.551; P = 0.046) and Sufentanil for maintenance of anesthesia (OR = 0.260; 95% CI: 0.057-0.859; P = 0.044) was independently associated with POCD as risk and protective factors, respectively.

Conclusion

Our study suggests that POCD is frequent among older patients undergoing elective orthopedic surgery, in which decline of calculation, recall and attention was predominant. Preoperative comprehensive geriatric assessments are important to identify the high-risk individuals of POCD.

Does peak expiratory flow moderate trajectories of cognitive function among individuals with lung diseases? A longitudinal analysis of the National Health and Aging Trends Study

INTRODUCTION

Impaired cognitive function can co-exist in chronic respiratory diseases. However, it is not clear if peak expiratory flow (PEF) impacts changes in cognitive function. Our objective was to explore whether peak expiratory flow moderates trajectories of memory, visuospatial abilities, and executive function in individuals with chronic respiratory diseases.

METHODS

This was an analysis of individuals with lung diseases from the National Health and Aging Trends Study. Multivariable-adjusted generalized linear mixed models were used to estimate trajectories of immediate and delayed recall, and clock drawing over a 10-year follow-up. The interaction between PEF and time were plotted using sex-specific values for peak expiratory flow at 10th, 50th and 90th percentiles.

RESULTS

In females, interactions of time-by-PEF were found for both immediate (n = 489, t = 2.73, p<0.01) and delayed recall (n = 489, t = 3.38, p<0.01). Females in the 10th vs. 90th percentile of PEF declined in immediate recall at 0.14 vs. 0.065 words/year, and 0.17 vs. 0.032 words/year for delayed recall. Among males, recall declined linearly over 10 years (immediate recall: n = 296, t = -3.08, p < 0.01; delayed recall: n = 292, t = -2.46, p = 0.02), with no interaction with PEF. There were no time-by-PEF interactions nor declines over time in clock drawing scores in both sexes (females: n = 484, t = 0.25, p = 0.81; males: n = 291, t = -0.61, p = 0.55).

CONCLUSION

Females with the lowest PEF values experienced the greatest rates of decline in immediate and delayed recall over 10 years of follow-up, whereas males experienced similar declines in memory outcomes across all levels of PEF. Clock drawing scores remained stable over 10 years in both sexes.

Abnormal static and dynamic functional network connectivity in stable chronic obstructive pulmonary disease

Objective

Many studies have explored the neural mechanisms of cognitive impairment in chronic obstructive pulmonary disease (COPD) patients using the functional MRI. However, the dynamic properties of brain functional networks are still unclear. The purpose of this study was to explore the changes in dynamic functional network attributes and their relationship with cognitive impairment in stable COPD patients.

Materials and methods

The resting-state functional MRI and cognitive assessments were performed on 19 stable COPD patients and 19 age-, sex-, and education-matched healthy controls (HC). We conducted the independent component analysis (ICA) method on the resting-state fMRI data, and obtained seven resting-state networks (RSNs). After that, the static and dynamic functional network connectivity (sFNC and dFNC) were respectively constructed, and the differences of functional connectivity (FC) were compared between the COPD patients and the HC groups. In addition, the correlation between the dynamic functional network attributes and cognitive assessments was analyzed in COPD patients.

Results

Compared to HC, there were significant differences in sFNC among COPD patients between and within networks. COPD patients showed significantly longer mean dwell time and higher fractional windows in weaker connected State I than that in HC. Besides, in comparison to HC, COPD patients had more extensive abnormal FC in weaker connected State I and State IV, and less abnormal FC in stronger connected State II and State III, which were mainly located in the default mode network, executive control network, and visual network. In addition, the dFNC properties including mean dwell time and fractional windows, were significantly correlated with some essential clinical indicators such as FEV₁, FEV₁/FVC, and c-reactive protein (CRP) in COPD patients.

Conclusion

These findings emphasized the differences in sFNC and dFNC of COPD patients, which provided a new perspective for understanding the cognitive neural mechanisms, and these indexes may serve as neuroimaging biomarkers of cognitive performance in COPD patients.

The Intersection of Aging and Lung Transplantation: its Impact on Transplant Evaluation, Outcomes, and Clinical Care

Purpose

Older adults (age ≥ 65 years) are the fastest growing age group undergoing lung transplantation. Further, international consensus document for the selection of lung transplant candidates no longer suggest a fixed upper age limit. Although carefully selected older adults can derive great benefit, understanding which older adults will do well after transplant with improved survival and health-related qualiy of life is key to informed decision-making. Herein, we review the epidemiology of aging in lung transplantation and its impact on outcomes, highlight selected physiological measures that may be informative when evaluating and managing older lung transplant patients, and identify directions for future research.

Recent Findings

In general, listing and transplanting older, sicker patients has contributed to worse clinical outcomes and greater healthcare use. Emerging evidence suggest that measures of physiological age, such as frailty, body composition, and neurocognitive and psychosocial function, may better identify risk for poor transplant outcomes than chronlogical age.

Summary

The evidence base to inform transplant decision-making and improvements in care for older adults is small but growing. Multipronged efforts at the intersection of aging and lung transplantation are needed to improve the clinical and patient centered outcomes for this large and growing cohort of patients. Future research should focus on identifying novel and ideally modifiable risk factors for poor outcomes specific to older adults, better approaches to measuring physiological aging (e.g., frailty, body composition, neurocognitive and psychosocial function), and the underlying mechanisms of physiological aging. Finally, interventions that can improve clinical and patient centered outcomes for older adults are needed.

Pulmonary Function in Midlife as a Predictor of Later-Life Cognition: The Coronary Artery Risk Development in Adults (CARDIA) Study

BACKGROUND

Studies found associations between pulmonary function (PF) and cognition, but these are limited by mostly cross-sectional design and a single measure of PF (typically forced expiratory volume in 1 second [FEV1]). Our objective was to prospectively analyze the association of repeatedly measured PF with cognition.

METHODS

We studied 3 499 participants in the Coronary Artery Risk Development in Young Adults cohort with cognition measured at year 25 (Y25) and Y30, and PF (FEV1 and forced vital capacity [FVC], reflecting better PF) measured up to 6 times from Y0 to Y20. Cognition was measured via Stroop test, Rey-Auditory Verbal Learning Test [RAVLT], and digit symbol substitution test [DSST], which capture executive function, verbal learning and memory, and attention and psychomotor speed, respectively; lower Stroop, and higher RAVLT and DSST scores indicate better cognition. We modeled linear, cross-sectional associations between cognition and PF at Y30 (mean age 55), and mixed models to examine associations between cognition at Y25-Y30 and longitudinal PF (both annual rate of change, and cumulative PF from Y0 to Y20).

RESULTS

At Y30, FEV1 and FVC were cross-sectionally associated with all 3 measures of cognition (β = 0.08-0.12, p < .01-.02). Annual change from peak FEV1/FVC ratio was associated with Stroop and DSST (β = 18.06, 95% CI = 7.71-28.40; β = 10.30, 95% CI = 0.26-20.34, respectively), but not RAVLT. Cumulative FEV1 and FVC were associated with Stroop and DSST (β = 0.07-0.12, p < .01-.02), but only cumulative FEV1 was associated with RAVLT (β = 0.07, 95% CI = 0.00-0.14).

CONCLUSIONS

We identified prospective associations between measures of PF and cognition even at middle ages, adding evidence of a prospective association between reduced PF and cognitive decline.

Consensus document for the selection of lung transplant candidates: An update from the International Society for Heart and Lung Transplantation

Tens of thousands of patients with advanced lung diseases may be eligible to be considered as potential candidates for lung transplant around the world each year. The timing of referral, evaluation, determination of candidacy, and listing of candidates continues to pose challenges and even ethical dilemmas. To address these challenges, the International Society for Heart and Lung Transplantation appointed an international group of members to review the literature, to consider recent advances in the management of advanced lung diseases, and to update prior consensus documents on the selection of lung transplant candidates. The purpose of this updated consensus document is to assist providers throughout the world who are caring for patients with pulmonary disease to identify potential candidates for lung transplant, to optimize the timing of the referral of these patients to lung transplant centers, and to provide transplant centers with a framework for evaluating and selecting candidates. In addition to addressing general considerations and providing disease specific recommendations for referral and listing, this updated consensus document includes an ethical framework, a recognition of the variability in acceptance of risk between transplant centers, and establishes a system to account for how a combination of risk factors may be taken into consideration in candidate selection for lung transplantation.

Asthma and Chronic Obstructive Pulmonary Disease as a Comorbidity and Association with the Choice of Antidementia Medication Among Persons with Alzheimer's Disease

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) are common comorbidities in persons with Alzheimer's disease (AD). However, pharmacotherapy of these diseases may have opposite mechanisms of action; anticholinergics in asthma/COPD and acetylcholinesterase inhibitors (AChEI) in AD.

OBJECTIVE

To investigate whether existing asthma/COPD affects the choice of AD medication, and the survival of the patients with AD.

METHODS

In this retrospective cohort study, data from the MEDALZ-study, which includes all community-dwelling persons with AD during 2005-2011 in Finland (n = 70718) was utilized. Persons with asthma/COPD (N = 7211) were defined as having a special reimbursement for asthma/COPD, or long-term use (≥250 days) of inhaled anticholinergics, inhaled corticosteroids, or leukotriene antagonists during the year before AD diagnosis. We compared persons with and without asthma/COPD regarding the choice of the initial antidementia medication (AChEI versus memantine) with logistic regression and mortality with Cox regression model during the follow-up (up to end of 2015).

RESULTS

Memantine was favored over AChEIs as first-line treatment to AD in persons with asthma/COPD compared to those without asthma/COPD (odds ratio 1.23, 95% confidence interval (CI) 1.15-1.31). Memantine was also more commonly used among those who used multiple asthma/COPD medications (7.9% of memantine initiators used ≥3 asthma/COPD medications compared with 5.5% of those who initiated with AChEI). Mortality was higher in persons with asthma/COPD compared to those without asthma/COPD (adjusted hazard ratio 1.10, 95% CI 1.07-1.13).

CONCLUSION

More frequent use of memantine instead of AChEI may result from an attempt to prevent possible worsening of asthma/COPD by AChEIs. Vulnerable persons with both AD and asthma/COPD need individually assessed pharmacotherapy for their medical conditions.

Cognitive Function After Lung Transplantation

Cognitive functioning after transplantation, which could influence medication compliance and independence, has not been well studied. This study investigated cognitive impairment after lung transplantation. Patients undergoing bilateral transplant between March 2013 and October 2015 underwent comprehensive neuropsychological assessment at 60.1 ± 44.1 months post-transplantation: verbal memory (Auditory-Verbal Learning Test, digit span forward), visual memory (Corsi Block-Tapping Test forward, Benton Visual Retention Test), concentration/speed of processing/attention (D2 Test of Attention, Trail Making Test (TMT) A, Grooved Pegboard), and executive functioning (TMT B, Stroop Color-Word Test, semantic and phonematic verbal fluency, digit span backward, Corsi Block-Tapping Test backward). Mean scores were compared with a normative dataset using a one-sample t-test. A cognitive domain was judged impaired if the score on two or more domain-specific tests was greater than one standard deviation below the normative dataset age range mean. Of 124 lung transplant recipients (51% male, 54.3 ± 9.0 years), 70% showed cognitive impairment in one or more domains. Executive function was most often impaired (78% of recipients not within the age range) followed by verbal memory impairment (72% not within the age range). Cognitive function reductions were largely independent of age, gender, education, immunosuppressive medications, and time since transplantation. The findings show that cognitive impairment is common after lung transplantation and should be subject to rehabilitation and psychological resilience strategies.

Psychosocial dimensions of hand transplantation: lessons learned from solid organ transplantation

PURPOSE OF REVIEW

The present review examines psychosocial factors emerging as predictive of clinical outcomes among solid organ transplant (SOT) recipients, with possible extensions to vascular composite allograft (VCA) and hand transplantation, in particular. The Chauvet Workgroup report and International Society of Heart and Lung Transplantation consensus guidelines are used to delineate areas of commonality between SOT and VCA, as well as unique features contributing to post-VCA psychosocial risk.

RECENT FINDINGS

Increasing evidence suggests that depression, cognitive function, and other posttransplant psychosocial factors consistently associate with clinical risk in SOT. However, the mechanisms precipitating these psychosocial risk factors are likely diverse in their cause, with large individual differences across SOT and VCA. Transdiagnostic dimensions may serve as mechanistic factors, increasing the risk of adverse clinical outcomes and suggesting potential treatment strategies for risk mitigation. Psychosocial dimensions including psychological flexibility, self-efficacy, and posttraumatic growth are discussed as potential contributory factors.

SUMMARY

Psychosocial factors hold importance in predicting posttransplant clinical outcomes. Emerging transdiagnostic factors may provide insight into mechanisms and potential treatments.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Alterations of the default mode network and cognitive impairments in patients with chronic obstructive pulmonary disease

Background and objectives

Cognitive impairment is a common extrapulmonary comorbidity in COPD patients. The default mode network (DMN) plays a critical role in maintaining the normal activities of humans, and its function can be evaluated by resting state functional magnetic resonance imaging. The aim of this study was to investigate the correlations between cognition and function changes of the DMN in COPD patients.

Methods

One hundred and thirteen eligible participants including 30 control subjects and 83 COPD patients matched for demographic characteristics were recruited. All participants performed cognitive function tests and underwent resting state functional magnetic resonance imaging.

Results

The total cognitive function scores of COPD patients were significantly different from those of control subjects (P<0.05) and worsened with the degree of airflow obstruction. The activated brain regions in the DMN of COPD patients were less than those of normal controls. Six activated brain regions in the DMN were found to develop significantly different functional connectivity (FC) values among the subjects. Meanwhile, the FC values of the left posterior cingulate cortex and left hippocampus correlated well with cognitive functions and pulmonary function.

Conclusion

COPD patients have cognitive impairments that correlate well with disease severity. FC changes in activated brain regions in the DMN may predict cognitive impairment, and the left posterior cingulate cortex and left hippocampus may be important brain regions related to cognitive impairment in COPD patients.

[Chronic cerebral ischemia in obstructive pulmonary diseases]

Chronic obstructive pulmonary disease (COPD) is one of the main causes of disease and death incidences worldwide. Different organs and systems are involved in COPD activating tissue hypoxia. It affects especially tissue functioning with the high level of intensity of metabolic processes, and the nervous system suffers first. Neuroimaging studies show white and grey matter damage and cerebral atrophy, which may clinically manifest themselves in different neurological symptoms depended on vascular system lesions, and cognitive and affective impairments. Despite of its potential importance, encephalopathy in COPD remains a little-studied concomitant pathology. Application of cytoprotective drugs is pathogenetically justified in this case and must be included in COPD complex therapy. In particular, the inclusion of mexicor in the treatment of patients with chronic pulmonary heart increases the efficacy of treatment of the main and associated diseases (chronic cerebral ischemia, cardiac insufficiency and arrhythmia).

Clinical effects of cognitive impairment in patients with chronic obstructive pulmonary disease

The aim of this study was to evaluate the clinical effects of cognitive impairment in patients with chronic obstructive pulmonary disease (COPD). A total of 91 patients with stable moderate to very severe COPD were included in this study. Cognitive functions of the patients were evaluated using the mini-mental state examination (MMSE) tool and clock-drawing test. The Brody’s Instrumental Activities of Daily Living (IADL) Questionnaire; COPD assessment test (CAT); body mass index, airflow obstruction, dyspnea, and exercise capacity (BODE); and Charlson comorbidity index were assessed. The patients were divided into two groups as those who were diagnosed with cognitive impairment (group 1, n = 16) and those with normal cognitive functions (group 2, n = 75). Group 1 had a lower arterial partial pressure of oxygen , shorter 6-min walking distance, and higher arterial partial pressure of carbon dioxide (PaCO₂) than group 2 (p = 0.01, p = 0.024, p = 0.018, respectively). In group 1, the IADL score was lower, and CAT and BODE scores were higher than group 2 (p = 0.002, p = 0.037, p = 0.012, respectively). When we considered all the patients, there was an independent correlation between the IADL score and MMSE score (p = 0.03). This study revealed that COPD patients with cognitive impairment may have more hypoxemia and limited activities of daily living.

Cognitive deficits in obstructive sleep apnea: Insights from a meta-review and comparison with deficits observed in COPD, insomnia, and sleep deprivation

Obstructive sleep apnea (OSA) is a nocturnal breathing disorder that is associated with cognitive impairment. The primary determinants of cognitive deficits in OSA are thought to be sleep disruption and blood gas abnormalities. Cognitive impairment is also seen in other disorders that are characterised primarily by sleep disturbance (e.g., sleep restriction/deprivation, insomnia) or hypoxia/hypercarbia (e.g., chronic obstructive pulmonary disease (COPD)). Assessment of the cognitive deficits observed in these other disorders could help better define the mechanisms underlying cognitive deficits in OSA. This study utilised meta-review methodology to examine the findings from systematic reviews and meta-analyses of the effects of untreated OSA, COPD, insomnia, and sleep deprivation on cognitive function in adults, compared with norms or controls. Eighteen papers met inclusion criteria: seven in OSA, two in insomnia, five in COPD, and four in sleep deprivation. OSA and COPD were both accompanied by deficits in attention, memory, executive function, psychomotor function, and language abilities, suggesting that hypoxia/hypercarbia may be an important determinant of deficits in these domains in OSA. Both OSA and sleep deprivation studies were accompanied by deficits in attention and memory, suggesting that short-term sleep disturbance in OSA may contribute to deficits in these domains. Visuospatial deficits were unique to OSA, suggesting the contribution of a mechanism other than sleep disturbance and hypoxia/hypercarbia to this problem. Our findings suggest that the cognitive deficits associated with untreated OSA are multidimensional, with different physiological disturbances responsible for differing cognitive problems.

Neurocognitive Function and Health-Related Quality of Life in Pediatric Korean Survivors of Medulloblastoma

The neurocognitive function and quality of life of 58 Korean survivors of childhood medulloblastoma were assessed after surgery, cranial radiation and chemotherapy. All patients were evaluated with a battery of neurocognitive function tests and the Pediatric Functional Assessment of Cancer Therapy-Brain Tumor Survivors, which consists of self-report questionnaires on quality of life. The mean full-scale intelligence quotient (IQ), verbal IQ, and performance IQ scores were 90.2, 97.1, and 84.16, respectively. The mean memory quotient (MQ) score was 86.78, which was within 1 standard deviation of the average score of 100. Processing speed, attention, and executive function showed mild to moderate deficits. Intelligence, memory, executive function, visuospatial function, and simple motor function were significantly lower in the patients diagnosed before 8 years of age compared with those diagnosed after 8. The cognitive deficits in the patients diagnosed at younger ages might be related to earlier exposure to craniospinal irradiation and chemotherapy. The patient and parent proxy evaluations of attention, fine motor function, and quality of life did not differ. We found significant neurocognitive changes in a wide range of neurocognitive functional domains in Korean survivors of childhood medulloblastoma. Long-term follow-up studies of survivors of childhood medulloblastoma beginning at the time of their first diagnosis are required to better understand the deficits exhibited by survivors of childhood medulloblastoma, so that intervention strategies and treatment refinements that reduce the long-term neurocognitive decline can be developed.

Lifestyle and Self-Management by Those Who Live It: Patients Engaging Patients in a Chronic Disease Model

BACKGROUND

Patients pursuing organ transplantation have complex medical needs, undergo comprehensive evaluation for possible listing, and require extensive education. However, transplant patients and their supports frequently report the need for more lifestyle and self-management strategies for living with organ transplantation.

OBJECTIVES

First, to explore feasibility of a successful, patient-run transplant lifestyle educational group (Transplant Living Community), designed to complement medical care and integrated into the clinical setting; and second, to report the major themes of patients' and supports' qualitative and quantitative feedback regarding the group.

METHODS

Informal programmatic review and patient satisfaction surveys.

RESULTS

A total of 1862 patient satisfaction surveys were disseminated and 823 were returned (response rate, 44.2%). Patients and their supports reported positive feedback regarding the group, including appreciation that the volunteer was a transplant recipient and gratitude for the lifestyle information. Five areas were associated with the success of Transplant Living Community: 1) a "champion" dedicated to the program and its successful integration into a multidisciplinary team; 2) a health care environment receptive to integration of a patient-led group with ongoing community development; 3) a high level of visibility to physicians and staff, patients, and supports; 4) a clearly presented and manageable lifestyle plan ("Play Your ACES"(a) [Attitude, Compliance, Exercise, and Support]), and 5) a strong volunteer structure with thoughtful training with the ultimate objective of volunteers taking ownership of the program.

CONCLUSION

It is feasible to integrate a sustainable patient-led lifestyle and self-management educational group into a busy tertiary care clinic for patients with complex chronic illnesses.

Cognitive status among patients with chronic obstructive pulmonary disease

PURPOSE

We investigated the association between cognitive impairment and chronic obstructive pulmonary disease (COPD), taking into account demographic and clinical variables evaluated during routine practice.

PATIENTS AND METHODS

We performed a post hoc analysis of a cross-sectional study that included subjects with stable COPD. Sociodemographic and clinical information was recorded using the Body mass index, airflow Obstruction, Dyspnea and Exacerbations index and the Charlson comorbidity index. Cognitive performance was studied by the mini-mental state examination, with a score less than 27 indicating clinical impairment. Depressive symptoms, physical activity, and quality of life (EuroQoL-5 dimensions and COPD Assessment Test) were also evaluated.

RESULTS

The analysis included 940 subjects. The prevalence of cognitive impairment was 39.4%. Multivariate logistic regression models revealed that cognitive impairment was associated with educational level (odds ratio [OR] =0.096, 95% confidence interval [CI] =0.011-0.447) and poorer quality of life measured by the EuroQoL-5 dimensions social tariff (OR =0.967, 95% CI =0.950-0.983). When questionnaires were not included in the analysis, cognitive impairment was associated with educational level (OR =0.063, 95% CI =0.010-0.934), number of exacerbations (OR =11.070, 95% CI =1.450-84.534), Body mass index, airflow Obstruction, Dyspnea and Exacerbations index score (OR =1.261, 95% CI =1.049-1.515), and the Charlson comorbidity index (OR =1.412, 95% CI =1.118-1.783).

CONCLUSION

Cognitive impairment is common in COPD and is associated with low educational level, higher disease severity, and increased comorbidity. This could have therapeutic implications for this population.

Driving performance in patients with chronic obstructive lung disease, interstitial lung disease and healthy controls: a crossover intervention study

Introduction

Cognitive deficits in patients suffering from chronic obstructive pulmonary disease (COPD) have been described and hypoxaemia has been addressed as a possible cause. Cognitive functions in patients with interstitial lung disease (ILD) are not well studied. These patients are taking part in everyday traffic, but little is known regarding their driving performance. This study was conducted to determine the driving performance in patients with COPD and ILD, respectively compared to healthy controls using a driving simulator. Additionally, the effect of oxygen supply was addressed.

Methods

16 patients with COPD (8 receivers and 8 non-receivers of long-term oxygen therapy (LTOT)), 8 patients with ILD (consisting of idiopathic interstitial pneumonias) and 8 healthy controls were tested in a driving simulator. Each test lasted 45 min. In the oxygen intervention part of the study the patients were randomised to receive oxygen therapy in the first or second test and acted as their own controls.

Results

Patients with COPD had significantly impaired driving performance when comparing SD from the centre of the road and number of off-road events to controls. Patients with COPD receiving LTOT performed significantly worse than those not receiving LTOT when comparing SD and worse than the patients with ILD when comparing SD and off-road events. Patients with ILD performed similarly to controls (SD: LTOT 2.39*; no LTOT 0.69*; ILD 0.37; controls 0.36; *p<0.05. Off-road: LTOT 226.67*; no LTOT 78.92*; ILD 40.00; controls 25.78; *p<0.05). Oxygen therapy had no effect on driving performance.

Conclusions

Patients with ILD performed similarly to controls in the driving simulator, whereas patients with COPD showed decreased driving performance, especially those receiving LTOT. Doctors should be aware of this when renewing the driving license of patients with COPD. Oxygen therapy showed no effect on driving performance.

Trial registration number

NCT02125916

Neurocognitive changes after lung transplantation

RATIONALE

Neurocognitive impairments are associated with reduced quality of life and may adversely affect medical compliance, but their prevalence after lung transplantation has not been extensively studied.

OBJECTIVES

To examine the frequency of neurocognitive impairment after lung transplantation and to examine perioperative factors affecting post-transplant neurocognitive function.

MEASUREMENTS AND MAIN RESULTS

We performed serial assessments of neurocognitive function in a consecutive series of 47 subjects who received transplants between March 2013 and November 2013 (45% women; mean age, 53.5 ± 17.2 yr). Neurocognitive function was assessed using a composite measure including the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) total score and Trail Making Test parts A and B obtained before transplant, at hospital discharge, and 3 months after discharge. The presence of neurocognitive impairment was assessed using the Montreal Cognitive Assessment Battery (MoCA), and in-hospital delirium was assessed using the Confusion Assessment Method. Results demonstrated that neurocognitive performance initially worsened among non-cystic fibrosis patients and improved over follow-up (P = 0.002). Time effects were strongest on Trail Making Test part B (P < 0.001) and the RBANS (P = 0.054). Participants who exhibited delirium during their hospitalization showed poorer performance during follow-up assessments (P = 0.006). Examination of cognitive impairment rates demonstrated that 21 participants (45%) exhibited neurocognitive impairment (MoCA < 26) before lung transplant, whereas 27 (57%) participants exhibited impairment after transplantation, and 19 (57%) participants continued to neurocognitive impairment during a 3-month follow-up.

CONCLUSIONS

Neurocognitive impairments are prevalent among lung transplant candidates and appear to worsen in some patients after transplant. Delirium during hospitalization is associated with worse neurocognitive function after transplant among patients without cystic fibrosis.

Cognitive function, mental health, and health-related quality of life after lung transplantation

RATIONALE

Cognitive and psychiatric impairments are threats to functional independence, general health, and quality of life. Evidence regarding these outcomes after lung transplantation is limited.

OBJECTIVES

Determine the frequency of cognitive and psychiatric impairment after lung transplantation and identify potential factors associated with cognitive impairment after lung transplantation.

METHODS

In a retrospective cohort study, we assessed cognitive function, mental health, and health-related quality of life using a validated battery of standardized tests in 42 subjects post-transplantation. The battery assessed cognition, depression, anxiety, resilience, and post-traumatic stress disorder (PTSD). Cognitive function was assessed using the Montreal Cognitive Assessment, a validated screening test with a range of 0 to 30. We hypothesized that cognitive function post-transplantation would be associated with type of transplant, cardiopulmonary bypass, primary graft dysfunction, allograft ischemic time, and physical therapy post-transplantation. We used multivariable linear regression to examine the relationship between candidate risk factors and cognitive function post-transplantation.

MEASUREMENTS AND MAIN RESULTS

Mild cognitive impairment (score, 18-25) was observed in 67% of post-transplant subjects (95% confidence interval [CI]: 50-80%) and moderate cognitive impairment (score, 10-17) was observed in 5% (95% CI, 1-16%) of post-transplant subjects. Symptoms of moderate to severe anxiety and depression were observed in 21 and 3% of post-transplant subjects, respectively. No transplant recipients reported symptoms of PTSD. Higher resilience correlated with less psychological distress in the domains of depression (P < 0.001) and PTSD (P = 0.02). Prolonged graft ischemic time was independently associated with worse cognitive performance after lung transplantation (P = 0.001). The functional gain in 6-minute-walk distance achieved at the end of post-transplant physical rehabilitation (P = 0.04) was independently associated with improved cognitive performance post-transplantation.

CONCLUSIONS

Mild cognitive impairment was present in the majority of patients after lung transplantation. Prolonged allograft ischemic time may be associated with cognitive impairment. Poor physical performance and cognitive impairment are linked, and physical rehabilitation post-transplant and psychological resilience may be protective against the development of long-term impairment. Further study is warranted to confirm these potential associations and to examine the trajectory of cognitive function after lung transplantation.

[Cognitive impairment in patients with COPD: a review]

COPD (Chronic Obstructive Pulmonary Disease) is a respiratory disease characterized by progressive and largely irreversible airway limitation and extrapulmonary problems. The prevalence of COPD increases with age. Mental health problems, including cognitive capacity limitations, occur frequently. Patients with COPD may have problems with cognitive functioning, either globally or in single cognitive domains, such as information processing, attention and concentration, memory, executive functioning and self-regulation. Possible causes are hypoxemia, hypercapnia, exacerbations and decreased physical activity. Cognitive problems in these patients may be related to structural brain abnormalities, such as gray matter pathologic changes and the loss of white matter integrity. Because of the negative impact on health and daily life, it is important to assess cognitive functioning in patients with COPD in order to optimize patient-oriented treatment and to reduce personal discomfort, hospital admissions and mortality.

Neurobehavioral functioning and survival following lung transplantation

BACKGROUND

Neurobehavioral functioning is widely recognized as being an important consideration in lung transplant candidates, but little is known about whether these factors are related to clinical outcomes. The present study examined the relationship of neurobehavioral functioning, including measures of executive function and memory, depression, and anxiety, to long-term survival among lung transplant recipients.

METHODS

The sample was drawn from 201 patients who underwent transplantation at Duke University and Washington University who participated in a dual-site clinical trial investigating medical and psychosocial outcomes in transplant candidates with end-stage lung disease. All patients completed the Beck Depression Inventory-II (BDI-II) and Spielberger State-Trait Anxiety Inventory at baseline and again after 12 weeks, while a subset of 86 patients from Duke University also completed neurocognitive testing. Patients were followed for survival up to 12 years after completing baseline assessments.

RESULTS

One hundred eleven patients died over a mean follow-up of 10.8 years (SD=0.8). Baseline depression, anxiety, and neurocognitive function were examined as predictors of posttransplant survival, controlling for age, 6-min walk distance, FEV, and native disease; education and cardiovascular risk factors were also included in the model for neurocognition. Lower executive function (hazard ratio [HR]=1.09, P=.012) and memory performance (HR=1.11, P=.030) were independently associated with greater mortality following lung transplant. Although pretransplant depression and anxiety were not predictive of mortality, patients who scored>13 on the BDI-II at baseline and after 3 months pretransplant had greater mortality (HR=1.85 [95% CI, 1.04, 3.28], P=.036).

CONCLUSIONS

Neurobehavioral functioning, including persistently elevated depressive symptoms and lower neurocognitive performance, was associated with reduced survival after lung transplantation.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00113139; URL: www.clinicaltrials.gov.

Physical activity and cognitive function in individuals over 60 years of age: a systematic review

BACKGROUND

It is unclear whether physical activity in later life is beneficial for maintenance of cognitive function. We performed a systematic review examining the effects of exercise on cognitive function in older individuals, and present possible mechanisms whereby physical activity may improve cognition.

METHODS

Sources consisted of PubMed, Medline, CINAHL, the Cochrane Controlled Trials Register, and the University of Washington, School of Medicine Library Database, with a search conducted on August 15, 2012 for publications limited to the English language starting January 1, 2000. Randomized controlled trials including at least 30 participants and lasting at least 6 months, and all observational studies including a minimum of 100 participants for one year, were evaluated. All subjects included were at least 60 years of age.

RESULTS

Twenty-seven studies met the inclusion criteria. Twenty-six studies reported a positive correlation between physical activity and maintenance or enhancement of cognitive function. Five studies reported a dose-response relationship between physical activity and cognition. One study showed a nonsignificant correlation.

CONCLUSION

The preponderance of evidence suggests that physical activity is beneficial for cognitive function in the elderly. However, the majority of the evidence is of medium quality with a moderate risk of bias. Larger randomized controlled trials are needed to clarify the association between exercise and cognitive function and to determine which types of exercise have the greatest benefit on specific cognitive domains. Despite these caveats, the current evidence suggests that physical activity may help to improve cognitive function and, consequently, delay the progression of cognitive impairment in the elderly.

COgnitive-pulmonary disease

Over the past few decades, chronic obstructive lung disease (COPD) has been considered a disease of the lungs, often caused by smoking. Nowadays, COPD is regarded as a systemic disease. Both physical effects and effects on brains, including impaired psychological and cognitive functioning, have been demonstrated. Patients with COPD may have cognitive impairment, either globally or in single cognitive domains, such as information processing, attention and concentration, memory, executive functioning, and self-control. Possible causes are hypoxemia, hypercapnia, exacerbations, and decreased physical activity. Cognitive impairment in these patients may be related to structural brain abnormalities, such as gray-matter pathologic changes and the loss of white matter integrity which can be induced by smoking. Cognitive impairment can have a negative impact on health and daily life and may be associated with widespread consequences for disease management programs. It is important to assess cognitive functioning in patients with COPD in order to optimize patient-oriented treatment and to reduce personal discomfort, hospital admissions, and mortality. This paper will summarize the current knowledge about cognitive impairment as extrapulmonary feature of COPD. Hereby, the impact of smoking on cognitive functioning and the impact of cognitive impairment on smoking behaviour will be examined.

Changes in neurocognitive functioning following lung transplantation

Although neurocognitive impairment is relatively common among patients with advanced lung disease, little is known regarding changes in neurocognition following lung transplantation. We therefore administered 10 tests of neurocognitive functioning before and 6 months following lung transplantation and sought to identify predictors of change. Among the 49 study participants, native diseases included chronic obstructive pulmonary disease (n = 22), cystic fibrosis (n = 12), nonfibrotic diseases (n = 11) and other (n = 4). Although composite measures of executive function and verbal memory scores were generally within normal limits both before and after lung transplantation, verbal memory performance was slightly better posttransplant compared to baseline (p < 0.0001). Executive function scores improved in younger patients but worsened in older patients (p = 0.03). A minority subset of patients (29%) exhibited significant cognitive decline (i.e. >1 standard deviations on at least 20% of tests) from baseline to posttransplant. Patients who declined were older (p < 0.004) and tended to be less educated (p = 0.07). Lung transplantation, like cardiac revascularization procedures, appears to be associated with cognitive decline in a subset of older patients, which could impact daily functioning posttransplant.

Apolipoprotein E genotype modifies the association between midlife lung function and cognitive function in old age

BACKGROUND/AIMS

Because poor lung function may be a risk factor for cognitive decline, we aimed to test the association of respiratory function with cognitive function and dementia later in life, as well as potential effect modification by APOE epsilon4 carrier status.

METHODS

In a prospective population-based cohort study, forced vital capacity and forced expiratory flow were measured around 1965 in 857 men aged 45-64 years (394 from Finland, 208 from The Netherlands, and 255 from Italy). The Mini-Mental State Examination scores around 1990, 1995 and 2000 were analyzed using multilevel regression models and the Clinical Dementia Rating score around 1990 using multinomial logistic regression analyses.

RESULTS

Midlife lung function was positively associated with cognitive function in old age in APOE epsilon4 non-carriers, but not in carriers (p < 0.05 for interaction). In Finland and Italy, 18.6% had questionable to mild dementia and 2.8% moderate to severe dementia after 25 years of follow-up. Dementia was inversely related to midlife lung function in APOE epsilon4 non-carriers, but not in carriers (p < 0.05 for interaction).

CONCLUSIONS

Small lung volumes were prospectively associated with an increased risk for poor cognitive function and dementia in non-carriers of the APOE epsilon4 gene.

Psychiatric aspects of organ transplantation in critical care

Intensive care unit teams are a critical part of the solid organ transplant process. The psychosocial issues involved during critical periods of transplantation are important for intensive care physicians and clinicians to understand to provide comprehensive care to transplant patients. This article provides a brief overview of transplant epidemiology, followed by a review of the psychosocial issues relevant to the phases of the transplant process. Considered are the pretransplant evaluation phase, psychiatric disorders in transplant patients, and cognitive impairments and delirium with additional issues specific to particular organs. Also covered are the side effects of immunosuppressive medications and special issues arising with living donors.