A comparative evaluation of the short orientation memory concentration test of cognitive impairment

Differences in Daily Activity Performance Between Inpatient Rehabilitation Facility and Home Among Stroke Survivors

BACKGROUND

Stroke survivors are one of the largest consumer groups of rehabilitation services. Despite improvement in daily activities while in inpatient rehabilitation, many have difficulty performing daily activities at home after discharge. The difference in performance between a standard clinical context and at home is poorly understood.

OBJECTIVE

To better understand differences in activity performance during transition from inpatient rehabilitation facility (IRF) to home, we examined daily activity performance scores from 2 different environments (IRF and home) at the same time point (discharge).

METHODS

This was a cross-sectional analysis using baseline data from a randomized controlled trial. Participants were stroke survivors aged ≥50 who planned to discharge home from the IRF. The Functional Independence Measure and Section GG codes (both converted to International Classification of Functioning, Disability, and Health scores) were conducted per protocol first at home and then in the IRF at discharge (≤3 days apart, order not randomized).

RESULTS

Among 57 participants, activity scores at home were significantly worse than scores at IRF discharge. Over 40% of participants had discharge scores indicating no-to-mild impairment for shower/tub transfer, walking, and going up/down stairs, while home visit scores indicated moderate-to-complete impairment for those activities. The greatest differences in scores were for shower/tub transfer (median difference 1.5, 95% CI 1.00-2.00) and going up/down stairs (median difference 1.50, 95% CI 1.00-2.00).

CONCLUSION

The environment plays an important role in stroke survivors' functioning at home. Future studies should further examine how the environment impacts activity performance upon returning home following stroke.

Prevention at home in older persons with (pre-)frailty: analysis of participants' recruitment and characteristics of the randomized controlled PromeTheus trial

BACKGROUND

The "PromeTheus" trial is evaluating a home-based, multifactorial, interdisciplinary prevention program for community-dwelling (pre-)frail older adults. These individuals often suffer from reduced participation, which can complicate the recruitment and enrollment in a clinical trial.

AIMS

The aim of this study was to evaluate different recruitment strategies and differences in participant characteristics in relation to these strategies.

METHODS

This cross-sectional study used baseline data from the randomized-controlled PromeTheus trial, in which community-dwelling (pre-)frail older persons (Clinical Frailty Scale [CFS] 4-6 pt., ≥ 70 years) were recruited via general practitioners ("GP recruitment") or flyers, newspaper articles, and personalized letters ("direct recruitment"). Differences in the sociodemographic, clinical, physical, functional, mobility-related, psychological and social characteristics were analyzed in relation to the recruitment strategy.

RESULTS

A total of 385 participants (mean age = 81.2, SD 5.9 years; women: n = 283, 73.5%) were enrolled, of which 60 (16%) were recruited by GPs and 325 (84%) through direct recruitment. Participants recruited via GPs had significantly higher subjective frailty levels (CFS), were more often physically frail (Fried Frailty Phenotype), and showed lower physical capacity (Short Physical Performance Battery), participation (disability component of the short version of the Late-Life Function and Disability Instrument), and life-space mobility (Life-Space Assessment) compared to those recruited via the direct approach (p = 0.002-0.026). Costs per randomized participant were 94€ for the GP recruitment strategy and €213 for the direct recruitment strategy.

CONCLUSION

Different strategies may be required to successfully recruit (pre-)frail home-living older adults into preventive programs. Direct recruitment strategies, in which potential participants are directly informed about the prevention program, seem to be more promising than GP recruitment but may result in enrolment of persons with less functional impairment and higher recruitment costs.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00024638. Registered on March 11, 2021.

Association of geriatric measures and global frailty with cognitive decline after allogeneic hematopoietic cell transplantation in older adults

INTRODUCTION

Allogeneic hematopoietic cell transplantation (alloHCT) is increasingly offered to older adults, and its potential impact on cognition in this population is understudied. This work aims to evaluate the ability of cancer-specific geriatric assessments (cGA) and a global frailty index based on accumulation of deficits identified in the cGA to predict the risk of cognitive decline after alloHCT in older adults.

MATERIALS AND METHODS

AlloHCT recipients aged 50 years or older completed a cGA, including a cognitive evaluation by the Blessed Orientation Memory Concentration (BOMC) test, at baseline prior to alloHCT and then at 3, 6, and 12 months after transplant. Baseline frailty was assessed using a deficit accumulation frailty index (DAFI) calculated from the cGA. A multinomial logit model was used to examine the association between predictors (individual cGA measures, DAFI) and the following three outcomes: alive with stable or improved cognition, alive with cognitive decline, and deceased. In post-hoc analyses, analysis of variance was used to compare BOMC scores at baseline, 3, 6, and 12 months across frailty categories.

RESULTS

In total, 148 participants were included, with a median age of 62 (range 50-76). At baseline, 12% had cognitive impairment; at one year, 29% of survivors had improved BOMC scores, 33% had stable BOMC, and 37% had worse BOMC. Prior to transplant, 25% were pre-frail and 11% were frail. Individual baseline cGA measures were not associated with cognitive change at one year as assessed by BOMC. Adjusting for age, sex, and education, those who were frail at baseline were 7.4 times as likely to develop cognitive decline at one year than those who were non-frail, although this finding did not reach statistical significance (95% confidence interval [CI] 0.74-73.8, p = 0.09). The probability of being alive with stable/improved cognition at 12 months for the non-frail, pre-frail, and frail groups was 43%, 34%, and 8%, respectively.

DISCUSSION

Baseline geriatric measures and frailty were not significantly associated with cognitive change as assessed by BOMC in adults aged 50 or older after alloHCT. However, the study was underpowered to detect clinically meaningful differences, and future work to elucidate potential associations between frailty and cognitive outcomes is warranted.

Translation and concurrent validity, sensitivity and specificity of Chinese version of Short Orientation Memory Concentration Test in people with a first cerebral infarction

Purpose

This study aimed to translate the English version of the Short Orientation-Memory-Concentration (SOMC) test into a Chinese version, denoted the C-SOMC test, and to investigate the concurrent validity, sensitivity, and specificity of the C-SOMC test against a longer and widely used screening instrument in people with a first cerebral infarction.

Methods

An expert group translated the SOMC test into Chinese using a forward-backward procedure. Eighty-six participants (67 men and 19 women, mean age = 59.31 ± 11.57 years) with a first cerebral infarction were enrolled in this study. The validity of the C-SOMC test was determined using the Chinese version of Mini Mental State Examination (C-MMSE) as the comparator. Concurrent validity was determined using Spearman's rank correlation coefficients. Univariate linear regression was used to analyze items' abilities to predict the total score on the C-SOMC test and the C-MMSE score. The area under the receiver operating characteristic curve (AUC) was used to demonstrate the sensitivity and specificity of the C-SOMC test at various cut-off values distinguishing cognitive impairment from normal cognition.

Results

The total score for the C-SOMC test and the score for item 1 on this test exhibited moderate-to-good correlations with the C-MMSE score, with respective ρ-values of 0.636 and 0.565 (P < 0.001). The scores for each of items 2, 4, 5, 6, and 7 yielded fair correlations with C-MMSE score, with ρ-value from 0.272 to 0.495 (P < 0.05). The total score on the C-SOMC test and the item score were good predictors (adjusted R² = 0.049 to 0.615) of the C-MMSE score, and six items were good predictors (adjusted R² = 0.134 to 0.795) of the total score. The AUC was 0.92 for the C-SOMC test. A cut-off of 17/18 on the C-SOMC test gave optimal performance: correct classification of 75% of participants, with 75% sensitivity and 87.9% specificity.

Conclusion

The C-SOMC test demonstrated good concurrent validity, sensitivity and specificity in a sample of people with a first cerebral infarction, demonstrating that it could be used to screen for cognitive impairment in stroke patients.

Characteristics of a Danish Post-COVID Cohort Referred for Examination due to Persistent Symptoms Six Months after Mild Acute COVID-19

BACKGROUND

Post-COVID Clinics were recommended for patients with persistent symptoms following COVID-19, but no specific tests were suggested for evaluation. This study aimed to present a post-COVID clinic patient cohort and evaluate the use of a post-COVID symptom questionnaire (PCQ) score.

METHODS

Patients were referred from a population of approximately 1 million citizens. PCQ and standardized health scales were registered. Descriptive analyses were performed to assess the prevalence of symptoms, and correlation analyses was undertaken to asses convergent and discriminant trends between PCQ scores and health scales.

RESULTS

Of 547 patients, 447 accepted inclusion. The median age was 47 years and 12% of the patients were hospitalized. At a median of 6.3 (IQR 4.4-9.9) months after the onset of symptoms, 82% of the patients reported both physical exhaustion and concentration difficulties. Functional disability and extreme fatigue were reported as moderate to severe by 33% and 62% of the patients, respectively. The PCQ score correlated significantly with each of the standardized health scales.

CONCLUSION

Patients referred to a Post-COVID Clinic were previously generally healthy. At the time of diagnosis, they reported multiple symptoms with severely affected health. The PCQ score could be used as valid measure of Post-COVID severity.

A multifactorial interdisciplinary intervention to prevent functional and mobility decline for more participation in (pre-)frail community-dwelling older adults (PromeTheus): study protocol for a multicenter randomized controlled trial

Background

Age-related decline in physical capacity can lead to frailty, associated with an increased vulnerability to adverse health outcomes and greater healthcare utilization. In an aging population, effective strategies to prevent physical decline and frailty, and preserve independence are needed. Prevention programs for vulnerable community-dwelling older adults are, however, often not yet established and implemented in routine practice. Research on the feasibility, implementation, and (cost-)effectiveness of multifactorial, interdisciplinary intervention programs that take advantage of available services of healthcare providers is also limited. The main aim of this study is to evaluate the effectiveness of such an intervention program (PromeTheus) to prevent functional and mobility decline for more participation in community-dwelling (pre-)frail older adults.

Methods

The study is designed as a three-center, randomized controlled trial with a 12-month intervention period. Four hundred community-dwelling (pre-)frail (Clinical Frailty Scale score 4–6) older adults (≥70 years) will be randomized in a 1:1 ratio to the intervention group (IG) or the control group (CG). The IG will receive the PromeTheus program consisting of obligatory home-based physical exercises (Weight-bearing Exercise for Better Balance) accompanied by physiotherapists and facultative counseling services (person-environment-fit, coping with everyday life, nutrition, group-based activities) delivered via existing healthcare structures (e.g., social workers, nutritionists). The CG will receive usual care and a one-time counseling session on recommendations for physical activity and nutrition. Primary outcomes assessed at months 6 and 12 are the function component of the Late-Life Function and Disability Instrument and the University of Alabama at Birmingham Life-Space Assessment. Secondary outcomes are disability, physical capacity and activity, frailty, nutritional status, falls, fear of falling, health status, and psychosocial components. Process and economic evaluations are also conducted. Primary statistical analyses will be based on the intention-to-treat principle.

Discussion

Compared to usual care, the PromeTheus program is expected to result in higher function and mobility, greater independence and lower need for care, and more participation. As the PromeTheus program draws on existing German healthcare structures, its large-scale translation and delivery will be feasible, if evidence of (cost-)effectiveness and successful implementation can be demonstrated.

Trial registration

German Clinical Trials Register, . Registered on March 11, 2021.

Unmet needs of family caregivers of hospitalized older adults preparing for discharge home

Objectives

To describe unmet needs of caregivers of hospitalized older adults during the transition from hospital back home, and identify subgroups with different needs.

Methods

Patients and family caregivers were recruited from an acute care hospital in Montreal, Canada. Measures included Instrumental Activities of Daily Living (IADL), Hospital Anxiety and Depression Scale (HADS), Zarit burden scale, and Family Inventory of Needs. Dimensions of unmet needs were explored with principal component analysis; regression tree models were used to identify subgroups with different unmet needs.

Results

A total of 146 patient-caregiver dyads were recruited. Three categories of caregiver unmet needs were identified: patient medical information; role clarity and support; and reassurance. Caregiver subgroups with highest unmet needs were those with high burden of care plus depressive symptoms ( n = 46) and those caring for patients with low IADL scores ( n = 10).

Discussion

Caregivers with high burden and depression are those with the greatest unmet needs during the care transition.

Brief Cognitive Tests in the Case of Dementia and Alzheimer's Disease Early Diagnosis

Nowadays, Alzheimer's disease (AD) diagnosis is considered to be a crucial and extremely complex process. Nevertheless, psychometric tools, like Mini-Mental State Evaluation (MMSE), are used to address cognitive function assessment and clinical evaluation processes. However, MMSE's sensitivity in the diagnosis of mild cognitive impairment is debatable in terms of education, age, or nationality. Typical psychometric tools with the use of "paper and pencil" methods combined with physiology measurements are proposed in order to enhance validity and effectiveness in the case of Alzheimer's disease cognitive deficits. The objective of this review study is to highlight the effectiveness of brief cognitive tests (BCT) in the case of dementia and Alzheimer's disease screening. Authors' future work will focus on the application of BCT in MCI diagnosis and evaluation.

Association between a cognitive screening test and severe chemotherapy toxicity in older adults with cancer

INTRODUCTION

Cognitive impairment (CI) increases chemotherapy toxicity risk with need to understand this association utilizing publicly available short screening tools. We evaluated this utilizing a lower threshold on a short screening tool in older adults with cancer.

MATERIALS AND METHODS

We analyzed data from the Cancer and Aging Research Group (CARG) Chemotherapy Toxicity Risk tool (CARG score) development and validation cohorts (n = 703), which recruited adults age ≥ 65 with cancer from academic centers. Cognition was evaluated with the Blessed Orientation-Memory-Concentration test (BOMC). Patients with BOMC score ≥ 11 were excluded. Utilizing cut-points for older adults, we considered moderate BOMC scores (5-10) as potential CI. Logistic regression was used for analysis.

RESULTS

Patient baseline characteristics included: mean age 73; 85% white; 63% college or higher education; 250 (36%) potential CI; 385 (55%) severe toxicity. Patients with potential CI were more likely non-white (p ≤ 0.01) and to have high school or lower education (p ≤ 0.01) and high CARG score (p = 0.04). Potential CI was associated with increased severe toxicity risk (OR = 1.54, p ≤ 0.01). After adjusting for CARG score, this association became nonsignificant (OR = 1.35; p = 0.08). Among patients with lower education (n = 258; 36.7%), potential CI remained associated with severe toxicity, even after adjusting for CARG score (OR = 1.87, p = 0.03).

CONCLUSIONS

Our findings suggest potential cognitive impairment, defined by BOMC score 5-10, in older adults with cancer and lower education is associated with increased severe toxicity risk. Future studies are needed to validate these findings. Healthcare providers should consider cognitive testing before treatment for these vulnerable patients.

Rapid in-person cognitive screening in the preoperative setting: Test considerations and recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI)

There are few cognitive screening tools appropriate for fast-paced settings with limited staffing, and particularly in preoperative evaluation clinics. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in neuropsychology, geriatric medicine, and anesthesiology to conduct a review of the literature and compile a comprehensive list of cognitive screening tools used within primary care and preoperative settings. This Recommendations Statement: 1. summarizes a review of the literature on existing cognitive screening tools used within preoperative settings; 2. discusses factors to consider when selecting cognitive screening tools in a preoperative environment; and 3. includes a work flow diagram to guide use of these screening measures. Methodology involved searching peer-reviewed literature for 29 cognitive screening tools which were identified from the literature that fit inclusion criteria. Of these 29, seven tests have been used in preoperative settings and are discussed. These seven had an average administration time ranging from one to ten minutes. Memory, language, and attention were the most commonly evaluated cognitive domains. Most had adequate sensitivity and specificity to detect cognitive impairment/dementia. While information on the psychometric properties of these tools is limited, the tools discussed are appropriate for lay examiners, are short in duration, and accessible for free or at a low cost. We describe factors that must be considered prior to instrument selection.

Rapid In-Person Cognitive Screening in the Preoperative Setting: Test Considerations and Recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI)

There are few cognitive screening tools appropriate for fast-paced settings with limited staffing, and particularly in preoperative evaluation clinics. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in neuropsychology, geriatric medicine, and anesthesiology to conduct a review of the literature and compile a comprehensive list of cognitive screening tools used within primary care and preoperative settings. This Recommendations Statement: 1. summarizes a review of the literature on existing cognitive screening tools used within preoperative settings; 2. discusses factors to consider when selecting cognitive screening tools in a preoperative environment; and 3. includes a work flow diagram to guide use of these screening measures. Methodology involved searching peer-reviewed literature for 29 cognitive screening tools which were identified from the literature that fit inclusion criteria. Of these 29, seven tests have been used in preoperative settings and are discussed. These seven had an average administration time ranging from one to ten minutes. Memory, language, and attention were the most commonly evaluated cognitive domains. Most had adequate sensitivity and specificity to detect cognitive impairment/dementia. While information on the psychometric properties of these tools is limited, the tools discussed are appropriate for lay examiners, are short in duration, and accessible for free or at a low cost. We describe factors that must be considered prior to instrument selection.

Rehabilitation Referral for Patients With Irreversible Vision Impairment Seen in a Public Safety-Net Eye Clinic

Importance

The prevalence of irreversible vision impairment in the United States is expected to increase by 2050. Vision rehabilitation is the primary treatment option. Clinical trials have established its efficacy in improving quality of life. Yet studies indicate that patients experience many barriers to accessing low-vision care.

Objectives

To examine the rate of referral for low-vision rehabilitation services by resident and attending ophthalmologists for adults with irreversible vision impairment and to assess the knowledge, attitudes, and beliefs of patients about vision rehabilitation.

Design, Setting, and Participants

Cross-sectional study with enrollment from June 20, 2016, to January 31, 2017, of 143 adults 18 years or older seen in a publicly funded, comprehensive eye clinic in Jefferson County, Alabama, and having 1 or both eyes with irreversible vision impairment (visual acuity was defined as 20/60 or worse) per the electronic health record.

Exposures

Demographic characteristics; patient questionnaire on knowledge, attitudes, and beliefs about vision rehabilitation; general cognitive status (Short Orientation-Memory-Concentration test); depressive symptoms (Patient Health Questionnaire-9); health literacy (Rapid Estimate of Adult Literacy in Medicine, Revised [REALM-R]); and self-reported difficulty in everyday activities.

Main Outcomes and Measures

Proportion of patients with irreversible vision impairment who were referred by ophthalmologists to low-vision rehabilitation services per the electronic health record.

Results

Of 143 patients enrolled with irreversible vision impairment in 1 or both eyes, the mean (SD) age was 55.4 (11.1) years and 68 (47.6%) were women. Most patients were African American (123 [86.0%]), uninsured (88 [61.5%]), and unemployed (92 [64.3%]); on average, they had normal cognitive status, minor depressive symptoms, and limited health literacy. As noted in the electronic health record, the rate of referral for low-vision rehabilitation services was 11.4% for patients with irreversible bilateral vision impairment (4 of 35 patients) and 1.9% for those with unilateral impairment (2 of 108). Most patients with bilateral (31 of 34 [91.2%]) and unilateral (90 of 97 [92.8%]) impairment indicated that they were bothered by their vision impairment, and most reported difficulty with reading (33 of 34 patients [97.1%] who were bilaterally impaired vs 85 of 104 [81.7%] who were unilaterally impaired).

Conclusions and Relevance

Results of this study suggest a need to better educate ophthalmologists and residents in ophthalmology about referrals to low-vision rehabilitation services for patients with irreversible vision impairment.

Development, Reliability, and Validity of the Multiple Errands Test Home Version (MET–Home) in Adults With Stroke

OBJECTIVE. Our objective was to perform initial psychometric analysis of the Multiple Errands Test Home Version (MET–Home), which was designed to assess the influence of poststroke executive dysfunction on in-home task performance.

METHOD. We examined the reliability and validity of the MET–Home in adults with stroke (n = 23) and individually matched control participants (n = 23). All participants completed a series of assessments during a single in-home visit.

RESULTS. Notable differences in MET-Home subscores were discovered between participants with stroke and control participants. Participants with stroke omitted more tasks, broke more rules, passed by tasks more often, and were less efficient than matched control participants. The MET–Home demonstrated evidence of adequate internal consistency, excellent interrater reliability, and significant moderate associations with several tests.

CONCLUSION. This preliminary study suggests that the MET–Home differentiates between adults with stroke and matched control participants. The MET–Home provides evidence of initial reliability and validity among adults with stroke.

Postoperative cognitive decline: the nurse's role in identifying this underestimated and misinterpreted condition

BACKGROUND

postoperative cognitive changes can increase morbidity and mortality, demand for postoperative care and social and health costs, and can lead to dementia.

AIM

this article discusses perioperative variables that can be used to identify patients who are more vulnerable to experiencing cognitive decline after surgery. It also highlights some screening tools that could be useful for early detection and for planning nursing care.

METHOD

a literature search was conducted using the Medline, CINAHL, PsychINFO and Cochrane Library databases from 2010 to 2018. Google Scholar was also consulted. The reference lists of relevant articles covering postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) were reviewed for further relevant papers.

CONCLUSION

assessment and evaluation of a patient's cognitive resources before and after surgery can lead to clinical interventions to support the person's coping mechanisms; health professionals can reduce the short- and long-term effects of cognitive decline. Screening tools could be used as part of a strategy to minimise postoperative cognitive changes.

Self-management support in primary care is associated with improvement in patient activation

OBJECTIVES

To examine: 1) whether patient characteristics predict perceived self-management support (usefulness of information and collaborative care planning) by primary care providers after six months, and 2) the association between perceived self-management support and patient activation at 6 months METHODS: We conducted a secondary analysis among 120 primary care patients aged 40 and over with a chronic physical condition and comorbid depressive symptoms who participated in a randomized controlled trial of a coaching intervention for depression self-management. Activation was measured at baseline (T0) and 6 months (T1). Self-management support was captured at T1 for physical and mood problems.

RESULTS

The sample of analysis was 120 patients who completed all relevant measures. At T1, the perceived usefulness of information for mood self-management was independently associated with activation. More severe depressive symptoms at T0 predicted lower perceived usefulness of chronic condition self-management information at T1. Lower T0 mental health-related quality of life predicted lower perceived usefulness of mood self-management information at T1.

CONCLUSIONS

Perceived informational support for mood self-management may contribute to increased activation. Patients with more severe mental health symptoms or impairment perceive that they receive less useful self-management information from their care team.

PRACTICE IMPLICATIONS

Care teams should determine whether patients with mood problems need greater self-management support.

Quality of Life and Symptom Burden in Cancer Patients Admitted to An Acute Palliative Care Unit

This paper describes the quality of life and symptom burden of 211 cancer patients admitted to an acute palliative care unit (PCU) in a comprehensive cancer centre. Participants completed the McGill Quality of Life Questionnaire (MQOL), Edmonton Symptom Assessment Scale (ESAS), Short Orientation-Memory-Concentration Test, and Palliative Performance Scale within 24 hours of admission to the PCU. The mean MQOL total was 6.1±1.4, and the mean single-item scale score was 4.9±2.4. The mean total ESAS score was 36.3±15.8, with a median of six reported symptoms. Women and younger patients reported a lower quality of life (QoL) and a higher symptom burden. Regression and correlational analyses highlighted the importance of the existential and psychological domains to overall QoL. These findings emphasize the need for interdisciplinary, collaborative approaches to managing the complex physical, psychosocial, and existential needs of cancer patients admitted to acute PCUs.

Novel mHealth App to Deliver Geriatric Assessment-Driven Interventions for Older Adults With Cancer: Pilot Feasibility and Usability Study

Background

Older patients with cancer are at an increased risk of adverse outcomes. A geriatric assessment (GA) is a compilation of reliable and validated tools to assess domains that are predictors of morbidity and mortality, and it can be used to guide interventions. However, the implementation of GA and GA-driven interventions is low due to resource and time limitations. GA-driven interventions delivered through a mobile app may support the complex needs of older patients with cancer and their caregivers.

Objective

We aimed to evaluate the feasibility and usability of a novel app (TouchStream) and to identify barriers to its use. As an exploratory aim, we gathered preliminary data on symptom burden, health care utilization, and satisfaction.

Methods

In a single-site pilot study, we included patients aged ≥65 years undergoing treatment for systemic cancer and their caregivers. TouchStream consists of a mobile app and a Web portal. Patients underwent a GA at baseline with the study team (on paper), and the results were used to guide interventions delivered through the app. A tablet preloaded with the app was provided for use at home for 4 weeks. Feasibility metrics included usability (system usability scale of >68 is considered above average), recruitment, retention (number of subjects consented who completed postintervention assessments), and percentage of days subjects used the app. For the last 8 patients, we assessed their symptom burden (severity and interference with 17-items scored from 0-10 where a higher score indicates worse symptoms) using a clinical symptom inventory, health care utilization from the electronic medical records, and satisfaction (6 items scored on a 5-point Likert Scale for both patients and caregivers where a higher score indicates higher satisfaction) using a modified satisfaction survey. Barriers to use were elicited through interviews.

Results

A total of 18 patients (mean age 76.8, range 68-87) and 13 caregivers (mean age 69.8, range 38-81) completed the baseline assessment. Recruitment and retention rates were 67% and 80%, respectively. The mean SUS score was 74.0 for patients and 72.2 for caregivers. Mean percentage of days the TouchStream app was used was 78.7%. Mean symptom severity and interference scores were 1.6 and 2.8 at preintervention, and 0.9 and 1.5 at postintervention, respectively. There was a total of 27 clinic calls during the intervention period and 15 during the postintervention period (week 5-8). One patient was hospitalized during the intervention period (week 1-4) and two patients during the postintervention period (week 5-8). Mean satisfaction scores of patients and caregivers with the mobile app were 20.4 and 23.4, respectively. Barriers fell into 3 themes: general experience, design, and functionality.

Conclusions

TouchStream is feasible and usable for older patients on cancer treatment and their caregivers. Future studies should evaluate the effects of the TouchStream on symptoms and health care utilization in a randomized fashion.

Adaptation and validation into Portuguese language of the six-item cognitive impairment test (6CIT)

BACKGROUND

The six-item cognitive impairment test (6CIT) is a brief cognitive screening tool that can be administered to older people in 2-3 min.

OBJECTIVE

To adapt the 6CIT for the European Portuguese and determine its psychometric properties based on a sample recruited from several contexts (nursing homes; universities for older people; day centres; primary health care units).

METHOD

The original 6CIT was translated into Portuguese and the draft Portuguese version (6CIT-P) was back-translated and piloted. The accuracy of the 6CIT-P was assessed by comparison with the Portuguese Mini-Mental State Examination (MMSE). A convenience sample of 550 older people from various geographical locations in the north and centre of the country was used.

RESULTS

The test-retest reliability coefficient was high (r = 0.95). The 6CIT-P also showed good internal consistency (α = 0.88) and corrected item-total correlations ranged between 0.32 and 0.90. Total 6CIT-P and MMSE scores were strongly correlated. The proposed 6CIT-P threshold for cognitive impairment is ≥10 in the Portuguese population, which gives sensitivity of 82.78% and specificity of 84.84%. The accuracy of 6CIT-P, as measured by area under the ROC curve, was 0.91.

CONCLUSION

The 6CIT-P has high reliability and validity and is accurate when used to screen for cognitive impairment.

Geriatric assessment-driven polypharmacy discussions between oncologists, older patients, and their caregivers

OBJECTIVES

Polypharmacy (PP) and potentially inappropriate medications (PIM) are common in older adults with cancer, increasing the risk of adverse outcomes. Approaches to identifying and addressing PP/PIM are needed.

MATERIALS AND METHODS

Patients ≥70 years with advanced cancer were enrolled in this cluster-randomized study. All underwent geriatric assessment (GA), and oncologists randomized to the intervention arm received GA-driven recommendations; no information was provided to oncologists at usual care sites. For patients with PP (≥5 medications or ≥1 high-risk medication), clinic visits with treating oncologists were audiorecorded and transcribed, and discussions regarding PP/PIM identified. Quality of provider response was coded as dismissed, mentioned, acknowledged, or addressed.

RESULTS

Forty patient transcripts were analyzed (20 per arm). More discussions occurred in the intervention group (n = 81) versus the usual care group (n = 51). More concerns per patient were brought up in the intervention group (4.1 vs. 2.6, p = 0.07). Physician-initiated discussions were higher in the intervention group (73% vs. 49%, p = 0.006). More PP concerns were "addressed" in the intervention group (59% vs. 45%, p = 0.1). Oncology supportive care medication concerns were more often addressed in the usual care group (58% vs. 18%, p = 0.008), but medication management concerns were addressed more commonly in the intervention group (38% vs. 79%, p = 0.003).

CONCLUSION

In this secondary analysis, a GA-driven intervention increased PP discussions, particularly about total number of medications and medication management. PP/PIM concerns were more commonly addressed in the intervention group, except for the subset of conversations about supportive care medications.

Social and clinical determinants of preferences and their achievement at the end of life: prospective cohort study of older adults receiving palliative care in three countries

Background

Achieving choice is proposed as a quality marker. But little is known about what influences preferences especially among older adults. We aimed to determine and compare, across three countries, factors associated with preferences for place of death and treatment, and actual site of death.

Methods

We recruited adults aged ≥65-years from hospital-based multiprofessional palliative care services in London, Dublin, New York, and followed them for >17 months. All services offered consultation on hospital wards, support for existing clinical teams, outpatient services and received funding from their National Health Service and/or relevant Insurance reimbursements. The New York service additionally had 10 inpatient beds. All worked with and referred patients to local hospices. Face-to-face interviews recorded most and least preferred place of death, treatment goal priorities, demographic and clinical information using validated questionnaires. Multivariable and multilevel analyses assessed associated factors.

Results

One hundred and thirty eight older adults (64 London, 59 Dublin, 15 New York) were recruited, 110 died during follow-up. Home was the most preferred place of death (77/138, 56%) followed by inpatient palliative care/hospice units (22%). Hospital was least preferred (35/138, 25%), followed by nursing home (20%) and home (16%); hospice/palliative care unit was rarely least preferred (4%). Most respondents prioritised improving quality of life, either alone (54%), or equal with life extension (39%); few (3%) chose only life extension. There were no significant differences between countries. Main associates with home preference were: cancer diagnosis (OR 3.72, 95% CI 1.40–9.90) and living with someone (OR 2.19, 1.33–3.62). Adults with non-cancer diagnoses were more likely to prefer palliative care units (OR 2.39, 1.14–5.03). Conversely, functional independence (OR 1.05, 1.04–1.06) and valuing quality of life (OR 3.11, 2.89–3.36) were associated with dying at home. There was a mismatch between preferences and achievements – of 85 people who preferred home or a palliative care unit, 19 (25%) achieved their first preference.

Conclusion

Although home is the most common first preference, it is polarising and for 16% it is the least preferred. Inpatient palliative care unit emerges as the second most preferred place, is rarely least preferred, and yet was often not achieved for those who wanted to die there. Factors affecting stated preferences and met preferences differ. Available services, notably community support and palliative care units, require expansion. Contrasting actual place of death with capacity for meeting patient and family needs may be a better quality indicator than simply ‘achieved preferences’.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0648-4) contains supplementary material, which is available to authorized users.

Associations of sleep disturbance with physical function and cognition in older adults with cancer

PURPOSE

Although sleep disturbances are common in older adults, studies evaluating the prevalence of sleep disturbance and its influence on functional outcomes in older adults with cancer are few. In this study, we examined the prevalence of sleep disturbance and its association with physical function and cognition in older adults with cancer.

METHODS

This is a cross-sectional study of patients who were referred and evaluated in the Specialized Oncology Care & Research in the Elderly (SOCARE) clinics at the Universities of Rochester and Chicago from May 2011 to October 2015. All patients underwent a geriatric assessment (GA) as part of their routine evaluation. Our final study cohort included patients who completed a sleep assessment and consented to the study. We collected demographics (age, sex, race, marital status, and education level) and clinical characteristics (depression, comorbidity, cancer type, and stage) from the GA and medical chart reviews. Presence of sleep disturbance was self-reported (yes/no). Physical function was assessed using Instrumental Activities of Daily Living (IADLs), physical activity (PA) survey, falls in the preceding 6 months, and Short Physical Performance Battery (SPPB). Cognition was screened using the Blessed Orientation-Memory-Concentration Test (impairment >4) or Montreal Cognitive Assessment (impairment <26). Bivariate and multivariable analyses were used to examine the associations between sleep disturbance with functional outcomes and cognition.

RESULTS

We included 389 older patients. The prevalence of sleep disturbance was 40%. Sixty-eight percent had ≥1 IADL impairment, 76% had PA limitation, 37% had ≥1 fall, 70% had impairment on SPPB, and 47% screened positive for cognitive impairment. On bivariate analyses, sleep disturbance was associated with IADL impairment (odds ratio [OR] 1.96, 95% confidence interval [CI] 1.23-3.13, P = 0.005), and PA limitation (OR 2.43, 95% CI 1.38-4.28, P = 0.002). The associations remained significant on multivariable analyses. Sleep disturbance was not significantly associated with falls, impairment on SPPB, and performance on the cognitive screen.

CONCLUSION

Sleep disturbance was associated with IADL impairment and PA limitation. It is important for oncologists to inquire about sleep problems, and these patients should also be screened for functional impairment if sleep disturbance was present.

Baseline Psychological Treatment Reduces the Effect of Coaching in a Randomised Trial of a Depression Self-Care Intervention

OBJECTIVE

To explore the effects of baseline psychological and antidepressant medication treatment in a trial of lay telephone coaching in a low-intensity, supported depression self-care intervention.

METHOD

A single blind, individually randomised, pragmatic trial was conducted among primary care adults with chronic physical conditions and comorbid depressive symptoms. Eligible subjects were randomised to receive a depression self-care toolkit with (intervention group) or without (control group) telephone coaching provided by trained lay coaches. For this brief communication, a secondary analysis of the trial data focused on the effects of baseline psychological and antidepressant treatments on mental health outcomes (Patient Health Questionnaire 9 [PHQ-9], SF-12 Mental Component Summary [MCS], Generalized Anxiety Disorder 7 [GAD-7]) and satisfaction with the intervention.

RESULTS

In total, 223 patients were randomised, and 165 (74.0%) completed both 3- and 6-month follow-ups. There were 2 significant interactions of baseline treatment and study group for 6-month mental health outcomes. A significant benefit of coaching on 6-month PHQ-9 was seen only among participants who were not receiving baseline psychological treatment. A smaller interaction was found for baseline antidepressant medications and 6-month mental health. There was a significant main effect for baseline psychological treatment and lower 6-month satisfaction.

CONCLUSIONS

Depressed patients receiving baseline psychological treatment may not benefit from lay coaching offered as part of a low-intensity depression self-care intervention.

Family members' or friends' involvement in self-care for patients with depressive symptoms and co-morbid chronic conditions

OBJECTIVES

To describe the support that patients reported receiving from family or friends (F/F) while participating in a self-care intervention for depressive symptoms; examine associations between patient-reported F/F support and use of self-care materials; and describe F/F perceptions of involvement in a subsample of F/F.

METHODS

One hundred eighty-nine of 223 (85%) patients aged 40+ with chronic physical conditions and co-morbid depressive symptoms participating in a randomized self-care intervention trial, completed structured telephone surveys at three months about the F/F support received. Ten F/F participated in post study qualitative interviews on the support provided.

RESULTS

30%, 44%, and 91% of patients reported overall F/F support with self-care, F/F involvement with the self-care intervention and emotional support, respectively. 61% felt positively and 10% felt negatively or conflicted with F/F support. F/F involvement in the self-care intervention was the only variable associated with patient use of self-care materials when examined alongside all F/F support variables (Proportional Odds Ratio = 1.21; 95% C.I. = 1.01, 1.45). F/F perceived less involvement in the self-care intervention than patients.

DISCUSSION

Patients engaged in a self-care intervention for depressive symptoms use more self-care materials when they perceive F/F involvement in the intervention. Patients and F/F may perceive involvement differently and benefit from discussions about potential F/F roles.

Examining interference of different cognitive tasks on voluntary balance control in aging and stroke

This study compared the effect of semantic and working memory tasks when each was concurrently performed with a voluntary balance task to evaluate the differences in the resulting cognitive-motor interference (CMI) between healthy aging and aging with stroke. Older stroke survivors (n = 10), older healthy (n = 10) and young adults (n = 10) performed the limits of stability, balance test under single task (ST) and dual task (DT) with two different cognitive tasks, word list generation (WLG) and counting backwards (CB). Cognitive ability was evaluated by recording the number of words and digits counted while sitting (ST) and during balance tasks (DT). The balance and cognitive costs were computed using [(ST-DT)/ST] × 100 for all the variables. Across groups, the balance cost was significantly higher for the older stroke survivors group in the CB condition than older healthy (p < 0.05) and young adult groups (p < 0.05) but was similar between these two groups for the WLG task. Similarly, the cognitive cost was significantly higher in older stroke survivors than in older healthy (p < 0.05) and young adults (p < 0.01) for both the cognitive tasks. The working memory task resulted in greater CMI than the semantic one, and this difference seemed to be most apparent in older stroke survivors. Young adults showed the least CMI, with a similar performance on the two memory tasks. On the other hand, healthy aging and stroke impact both semantic and working memory. Stroke-related cognitive deficits may further significantly decrease working memory function.

Falls-risk post-stroke: Examining contributions from paretic versus non paretic limbs to unexpected forward gait slips

Community-dwelling stroke survivors show a high incidence of falls with unexpected external perturbations during dynamic activities like walking. Previous evidence has demonstrated the importance of compensatory stepping to restore dynamic stability in response to perturbations in hemiparetic stroke survivors. However, these studies were limited to either stance perturbations or perturbation induced under the unaffected limb. This study aimed to compare the differences, if any, between the non-paretic and paretic sides in dynamic stability and protective stepping strategies when exposed to unexpected external perturbation during walking. Twenty hemiparetic subjects experienced an unexpected forward slip during walking on the laboratory walkway either on the paretic (n=10) or the nonparetic limb (n=10). Both groups demonstrated a backward loss of balance with a compensatory stepping response, with the nonparetic-side slip group resorting mainly to an aborted step response (60%) and the paretic-side slip group mainly exhibiting a recovery step response (90%). Although both groups showed an equal incidence of falls, the nonparetic-side slip group demonstrated a higher stability at recovery step touchdown, resulting from lower perturbation magnitudes (slip displacement and velocity) compared to the paretic-side slip group. The results indicate that the paretic side had difficulty initiating and executing a successful stepping response (nonparetic-side slip) and also in reactive limb control while in stance (paretic-side slip). Based on these results it is suggested that intervention strategies for fall-prevention in chronic stroke survivors should focus on paretic limb training for both reactive stepping and weight bearing for improving balance control for recovery from unpredictable perturbations during dynamic activities such as walking.

Activation and Self-Efficacy in a Randomized Trial of a Depression Self-Care Intervention

OBJECTIVES

In a sample of primary care participants with chronic physical conditions and comorbid depressive symptoms: to describe the cross-sectional and longitudinal associations of activation and self-efficacy with demographic, physical and mental health status, health behaviors, depression self-care, health care utilization, and use of self-care tools; and to examine the effects of a depression self-care coaching intervention on these two outcomes. Design/Study Setting. A secondary analysis of activation and self-efficacy data collected as part of a randomized trial to compare the effects of a telephone-based coached depression self-care intervention with a noncoached intervention. Activation (Patient Activation Measure) was measured at baseline and 6 months. Depression self-care self-efficacy was assessed at baseline, at 3 months, and at 6 months.

PRINCIPAL FINDINGS

In multivariable cross-sectional analyses (n = 215), activation and/or self-efficacy were associated with language, birthplace, better physical and mental health, individual exercise, specialist visits, and antidepressant nonuse. In longitudinal analyses (n = 158), an increase in activation was associated with increased medication adherence; an increase in self-efficacy was associated with use of cognitive self-care strategies and increases in social and solitary activities. There were significant improvements from baseline to 6 months in activation and self-efficacy scores both among coached and noncoached groups. The self-care coaching intervention did not affect 6-month activation or self-efficacy but was associated with quicker improvement in self-efficacy.

CONCLUSIONS

Overall, the results for activation and self-efficacy were similar, although self-efficacy correlated more consistently than activation with depression-specific behaviors and was responsive to a depression self-care coaching intervention.

A randomized trial of a depression self-care toolkit with or without lay telephone coaching for primary care patients with chronic physical conditions

OBJECTIVE

The aim of this study was to compare outcomes of use of a depression self-care toolkit with and without lay telephone coaching among primary care patients 40 years and older with depressive symptoms and comorbid chronic physical conditions.

METHOD

A single blind, individually randomized, pragmatic trial of a depression self-care toolkit (Toolkit) with or without lay telephone coaching was conducted among primary care adults with depressive symptoms and comorbid chronic physical conditions. Eligible patients were randomized to receive the Toolkit with (intervention) or without (control) telephone coaching provided by trained lay coaches. The primary outcome was depression severity [Patient Health Questionnaire (PHQ-9)] at 6 months. Secondary outcomes were self-efficacy, satisfaction, and use of health services at 6 months.

RESULTS

A total of 223 patients were randomized, and 172 (77.1%) completed 6-month follow-ups. PHQ-9 scores improved significantly in both groups over the 6-month follow-up; the differences in PHQ-9 scores between intervention and control groups were statistically significant at 3 months [effect size = 0.43; 95% confidence interval (CI) = 0.15-0.70] but not at 6 months (effect size = 0.23; 95% CI = -0.04-0.59). Patients with moderate depression severity (PHQ-9 10-19) and high self-efficacy at baseline were most likely to benefit from the intervention. There was no significant effect of the intervention on the secondary outcomes.

CONCLUSIONS

The incremental value of lay telephone coaching of a Toolkit appears short-lived. Targeting of coaching to those with moderate depression severity may be indicated.

Reactive Balance in Individuals With Chronic Stroke: Biomechanical Factors Related to Perturbation-Induced Backward Falling

BACKGROUND

An effective compensatory stepping response is the first line of defense for preventing a fall during sudden large external perturbations. The biomechanical factors that contribute to heightened fall risk in survivors of stroke, however, are not clearly understood. It is known that impending sensorimotor and balance deficits poststroke predispose these individuals to a risk of fall during sudden external perturbations.

OBJECTIVE

The purpose of this study was to examine the mechanism of fall risk in survivors of chronic stroke when exposed to sudden, slip-like forward perturbations in stance.

DESIGN

This was a cross-sectional study.

METHODS

Fourteen individuals with stroke, 14 age-matched controls (AC group), and 14 young controls (YC group) were exposed to large-magnitude forward stance perturbations. Postural stability was computed as center of mass (COM) position (XCOM/BOS) and velocity (ẊCOM/BOS) relative to the base of support (BOS) at first step lift-off (LO) and touch-down (TD) and at second step TD. Limb support was quantified as vertical hip descent (Zhip) from baseline after perturbation onset.

RESULTS

All participants showed a backward balance loss, with 71% of the stroke group experiencing a fall compared with no falls in the control groups (AC and YC groups). At first step LO, no between-group differences in XCOM/BOS and ẊCOM/BOS were noted. At first step TD, however, the stroke group had a significantly posterior XCOM/BOS and backward ẊCOM/BOS compared with the control groups. At second step TD, individuals with stroke were still more unstable (more posterior XCOM/BOS and backward ẊCOM/BOS) compared with the AC group. Individuals with stroke also showed greater peak Zhip compared with the control groups. Furthermore, the stroke group took a larger number of steps with shorter step length and delayed step initiation compared with the control groups.

LIMITATIONS

Although the study highlights the reactive balance deficits increasing fall risk in survivors of stroke compared with healthy adults, the study was restricted to individuals with chronic stroke only. It is likely that comparing compensatory stepping responses across different stages of recovery would enable clinicians to identify reactive balance deficits related to a specific stage of recovery.

CONCLUSIONS

These findings suggest the inability of the survivors of stroke to regain postural stability with one or more compensatory steps, unlike their healthy counterparts. Such a response may expose them to a greater fall risk resulting from inefficient compensatory stepping and reduced vertical limb support. Therapeutic interventions for fall prevention, therefore, should focus on improving both reactive stepping and limb support.

Desflurane Allows for a Faster Emergence When Compared to Sevoflurane without Affecting the Baseline Cognitive Recovery Time

AIMS

We compared the effect of desflurane and sevoflurane on anesthesia recovery time in patients undergoing urological cystoscopic surgery. The Short Orientation-Memory-Concentration Test (SOMCT) measured and compared cognitive impairment between groups and coughing was assessed throughout the anesthetic.

METHODS AND MATERIALS

This investigation included 75 ambulatory patients. Patients were randomized to receive either desflurane or sevoflurane. Inhalational anesthetics were discontinued after removal of the cystoscope and once repositioning of the patient was final. Coughing assessment and awakening time from anesthesia were assessed by a blinded observer.

STATISTICAL ANALYSIS USED

Statistical analysis was performed by using t-test for parametric variables and Mann-Whitney U test for non-parametric variables.

RESULTS

The primary endpoint, mean time to eye-opening, was 5.0 ± 2.5 min for desflurane and 7.9 ± 4.1 min for sevoflurane (p < 0.001). There were no significant differences in time to SOMCT recovery (p = 0.109), overall time spent in the post-anesthesia care unit (PACU) (p = 0.924) or time to discharge (p = 0.363). Median time until readiness for discharge was 9 min in the desflurane group, while the sevoflurane group had a median time of 20 min (p = 0.020). The overall incidence of coughing during the perioperative period was significantly higher in the desflurane (p = 0.030).

CONCLUSION

We re-confirmed that patients receiving desflurane had a faster emergence and met the criteria to be discharged from the PACU earlier. No difference was found in time to return to baseline cognition between desflurane and sevoflurane.

Associations between a patient-reported outcome (PRO) measure of sarcopenia and falls, functional status, and physical performance in older patients with cancer

OBJECTIVE

In older patients with cancer, we aimed to investigate associations between a patient-reported outcome measure for sarcopenia (SarcoPRO) and the Short Physical Performance Battery (SPPB), self-reported falls, and limitations in instrumental activities of daily living (IADLs).

MATERIALS AND METHODS

Assessments were conducted as part of the initial evaluation of older, often frail, patients with cancer seen in the Specialized Oncology Care and Research in the Elderly (SOCARE) clinic. Univariate associations were evaluated using Spearman's correlation and Wilcoxon sign ranked tests. Logistic regressions were used to identify associations of clinical factors and SarcoPRO scores or SPPB scores with falls and IADL limitations.

RESULTS

In total, 174 older patients with cancer were evaluated. A moderate correlation was found between the SarcoPRO and the SPPB (ρ=0.62). After adjusting for multiple clinical factors, neither the SarcoPRO nor the SPPB were associated with falls. In contrast, both higher SarcoPRO (i.e., worse) and lower SPPB (i.e., worse) scores were associated with limitations in IADLs (odds ratio for one unit change in predictor: SarcoPRO: 1.06, p<0.0001; SPPB: 0.71, p=0.003, respectively). Models using the SarcoPRO and SPPB explained similar amounts of variability in association with IADL limitations (AUC: 0.88 vs. 0.87, respectively).

CONCLUSIONS

The SarcoPRO was moderately associated with the SPPB, an objective measure of physical performance, and was associated with limitations in IADLs. Thus, older patients with cancer who present with IADL limitations should be screened for sarcopenia. The SarcoPRO shows promise as a measure for screening as well as outcome assessment for research on sarcopenia.

The Verbal Rating Scale Is Reliable for Assessment of Postoperative Pain in Hip Fracture Patients

Background. Hip fracture patients represent a challenge to pain rating due to the high prevalence of cognitive impairment. Methods. Patients prospectively rated pain on the VRS. Furthermore, patients described the changes in pain after raising their leg, with one of five descriptors. Agreement between paired measures on the VRS at rest and by passive straight leg raise with a one-minute interval between ratings at rest and three-minute interval for straight leg raise was expressed by kappa coefficients. Reliability of this assessment of pain using the VRS was compared to the validity of assessing possible change in pain from the selected descriptors. Cognitive status was quantified by the short Orientation-Memory-Concentration Test. Results. 110 patients were included. Paired scores with maximum disagreement of one scale point reached 97% at rest and 95% at straight leg raise. Linear weighted kappa coefficients ranged from 0.68 (95% CI = 0.59–0.77) at leg raise to 0.75 (95% CI = 0.65–0.85) at rest. Unweighted kappa coefficients of agreement in recalled pain compared to agreement of paired VRS scores ranged from 0.57 (95% CI = 0.49–0.65) to 0.36 (95% CI = 0.31–0.41). Interpretation. The VRS is reliable for assessment of pain after hip fracture. The validity of intermittent questioning about possible change in pain intensity is poor.

A randomized trial of a depression self-care toolkit with or without lay telephone coaching for primary care patients with chronic physical conditions

OBJECTIVE

The aim of this study was to compare outcomes of use of a depression self-care toolkit with and without lay telephone coaching among primary care patients 40 years and older with depressive symptoms and comorbid chronic physical conditions.

METHOD

A single blind, individually randomized, pragmatic trial of a depression self-care toolkit (Toolkit) with or without lay telephone coaching was conducted among primary care adults with depressive symptoms and comorbid chronic physical conditions. Eligible patients were randomized to receive the Toolkit with (intervention) or without (control) telephone coaching provided by trained lay coaches. The primary outcome was depression severity [Patient Health Questionnaire (PHQ-9)] at 6 months. Secondary outcomes were self-efficacy, satisfaction, and use of health services at 6 months.

RESULTS

A total of 223 patients were randomized, and 172 (77.1%) completed 6-month follow-ups. PHQ-9 scores improved significantly in both groups over the 6-month follow-up; the differences in PHQ-9 scores between intervention and control groups were statistically significant at 3 months [effect size = 0.44; 95% confidence interval (CI) = 0.16-0.72] but not at 6 months (effect size = 0.24; 95% CI = -0.01 to 0.60). Patients with moderate depression severity (PHQ-9 10-19) and high self-efficacy at baseline were most likely to benefit from the intervention. There was no significant effect of the intervention on the secondary outcomes.

CONCLUSIONS

The incremental value of lay telephone coaching of a Toolkit appears short-lived. Targeting of coaching to those with moderate depression severity may be indicated.

Effect of dual tasking on intentional vs. reactive balance control in people with hemiparetic stroke

To examine the effect of a cognitive task on intentional vs. reactive balance control in people with hemiparetic stroke (PwHS). Community-dwelling PwHS ( n = 10) and healthy, age-similar controls performed two tests, which included the Limits of Stability Test (intentional control) and the Motor Control Test (reactive control), under single-task (ST) and dual-task (DT) conditions (addition of a cognitive task). Cognitive ability was measured on a word list generation task by recording the number of words enumerated in sitting (ST; for cognition) and during the balance tasks. The difference in response time between the ST and DT, defined as the “balance cost” was obtained [(ST − DT)/ST × 100] and compared between tests and across groups. The “cognitive cost” was similarly defined and compared. For both groups, the response time under DT condition was significantly greater for intentional than the reactive balance control task, leading to a higher balance cost for this task ( P < 0.05). However, the cognitive cost was significantly greater for the intentional than the reactive balance control task for only the PwHS. DT significantly affected intentional than reactive balance control for PwHS. The significant decrease in both balance and cognitive performance under DT compared with ST conditions during intentional balance control suggests sharing of attentional resources between semantic memory and intentional balance control. Decreased performance on the cognitive task only during the reactive balance test indicates possible central nervous system's prioritization of reactive balance control over cognition.

Dynamic stability and compensatory stepping responses during anterior gait-slip perturbations in people with chronic hemiparetic stroke

To examine the control of dynamic stability and characteristics of the compensatory stepping responses to an unexpected anterior gait slip induced under the non-involved limb in people with hemi-paretic stroke (PwHS) and to examine any resulting adaptive changes in these on the second slip due to experience from prior slip exposure. Ten PwHS experienced overground slip (S1) during walking on the laboratory walkway after 5-8 regular walking (RW) trials followed by a second consecutive slip trial (S2). The slip outcome (backward loss of balance, BLOB and no loss of balance, NLOB) and COM state (i.e. its COM position and velocity) stability were examined between the RW and S1 and S1 and S2 at touchdown (TD) of non-involved limb and at liftoff (LO) of the contralateral limb. At TD there was no difference in stability between RW and S1, however at LO, subjects demonstrated a lower stability on S1 than RW resulting in a 100% backward loss of balance (BLOB) with compensatory stepping response (recovery step, RS, 4/10 or aborted step, AS, 6/10). On S2, although there was no change in stability at TD, there was a significant improvement in stability at LO with a 40% decrease in BLOB. There was also a change in step strategy with a decrease in AS response (60% to 35%, p<0.05) which was replaced by an increase in the ability to step (increased compensatory step length, p<0.05) either via a recovery step or a walkover step. PwHS have the ability to reactively control COM state stability to decrease fall-risk upon a novel slip; prior exposure to a slip did not significantly alter feedforward control but improved the ability to use such feedback control for improved slip outcomes.

Suitability of the 6CIT as a screening test for dementia in primary care patients

OBJECTIVES

To map the suitability of the Six Item Cognitive Impairment Test's (6CIT) as a screening instrument for dementia in primary care and to assess its feasibility, reliability, and validity in a real-world setting.

METHOD

The present study was part of a population-based prospective trial aimed at reducing the incidence of stroke and dementia. The 6CIT was administered by general practitioners (GPs) at routine examinations every two years. Incidence of dementia was obtained from health insurance records. Psychometric qualities of the 6CIT were evaluated for two different cut-offs.

RESULTS

At baseline, 72 GPs examined 3908 patients. In total, 528 patients were diagnosed with new dementia. Less than 1% of the tests were not completed. Internal consistency (Cronbach's alpha), stability over time (Pearson's r), and the agreement between successive tests (Cohen's kappa) reached values of 0.58, 0.62, and 0.45, respectively. Sensitivity and specificity reached values of 0.49 and 0.92 at the 7/8 cut-off and of 0.32 and 0.98 at the 10/11 cut-off, respectively. Patients with dementia had significantly higher mean error scores than patients without dementia. High scores at baseline posed a more than fourfold risk of being diagnosed with dementia.

CONCLUSION

The 6CIT's psychometric properties in a real-world setting suggest that the test is not suited as a routine screening instrument. Factors inherent to screening in primary care likely contributed to its low reliability and validity. This highlights the need for training GPs in the conduct of cognitive screening before such procedures can be implemented on a routine basis.

Walking Ability and Its Relationship to Self-Rated Health in Later Life

This study investigated the relationship between self-assessed overall health (SRH) and walking ability among older adults (n = 239) gauged using three well-established measures of walking ability ("normal" and "fast" walking speeds, and perceived walking difficulty). Logistic regression models adjusted for health, behavioral, and sociodemographic variables were used to estimate the relationship between the three measures of walking ability and SRH. Walking ability was significantly associated with SRH; notably, only normal walking speed discriminated between participants in all three SRH comparisons (good versus poor/bad, good versus fair, or excellent versus good). Health care providers, family, and friends should be attentive to reduced walking speed or complaints about difficulty walking because these are harbingers of health decline.

A feasibility study of a telephone-supported self-care intervention for depression among adults with a comorbid chronic physical illness in primary care

Objective We assessed the feasibility and acceptability to patients of a telephone-supported self-care intervention for depression among adults aged 40 years or over with one of six targeted chronic physical illnesses and comorbid depressive symptoms in family practice settings. Methods An open, uncontrolled trial (feasibility study) was conducted among patients treated in Montreal family practices. Eligible patients were aged 40 years or over, had one or more of the targeted chronic physical illnesses for at least 6 months (arthritis, hypertension, diabetes, heart disease, asthma and chronic obstructive pulmonary disease) and were evaluated as having at least mild depressive symptoms (a score of ≥ 5 on the 9-item Patient Health Questionnaire, PHQ-9). Participants received a package of six self-care tools (information booklet, video, Internet programme, action plan, workbook and mood-monitoring tool) with telephone support by a lay coach for up to 6 months. Results In total, 63 eligible patients provided written consent and completed the baseline interview; 57 (90%) and 55 (87%) patients completed 2-month and 6-month follow-up interviews, respectively. The mean number of telephone calls made by coaches to participants was 10.5 (SD 4.0), and the average length of these calls was 10.6 minutes. At the 6-month follow-up, 83.6% of the participants reported that one or more of the tools were helpful. Clinically significant improvements were seen in depressive symptoms (as assessed by the PHQ-9) at 6 months, with an effect size of 0.88 (95% CI, 0.55, 1.14). Conclusion A telephone-supported self-care intervention for depression was feasible, was acceptable to patients, and was associated with a significant 6-month improvement in depressive symptoms. A randomised trial of this intervention is justified.

Sleep disturbance in women before myocardial infarction

OBJECTIVE

The study objective was to describe the prevalence and correlates of sleep disturbances among women who retrospectively reported sleep disturbance before their myocardial infarction (MI). MI is frequently unrecognized in women because they may have only vague symptoms, such as sleep disturbance. Describing correlates of sleep disturbance before MI may assist in recognizing women at risk for coronary heart disease.

METHODS

A secondary analysis was performed of a dataset derived from 15 sites.

RESULTS

Of 1270 women experiencing initial MI, 632 reported new onset of or worsening sleep disturbance before MI. Prevalence was similar across racial groups. Women reporting prodromal sleep disturbance were more likely to be older, to be heavier, and to report cognitive changes (adjusted odds ratio [OR], 1.47), new or increasing anxiety (adjusted OR, 2.21), and unusual fatigue (adjusted OR, 2.16).

CONCLUSION

Subjective reports of sleep disturbance preceding MI seem to be prevalent in women of all races and may be an important warning sign for MI in women.

Screening for cognitive impairment in older general hospital patients: comparison of the Six-Item Cognitive Impairment Test with the Mini-Mental State Examination

OBJECTIVE

To investigate the performance and usability of the Six-Item Cognitive Impairment Test (6CIT) as a screening instrument for cognitive impairment in older, general hospital inpatients/outpatients.

METHOD

In 253 general hospital patients aged ≥ 70 years, diagnostic accuracy of the 6CIT and time required to administer it were assessed using the Mini-Mental State Examination (MMSE) as the criterion standard.

RESULTS

The (negative) correlation between the 6CIT and the MMSE was very high (r = -0.82). Optimal comparability was found using a MMSE cutoff of ≤19 for lower and ≤23 for higher educated patients, at a cutoff of ≥11 on the 6CIT that was not sensitive to educational level. The sensitivity of the 6CIT was 0.90 and the specificity was 0.96, whereas the positive predictive value was 0.83 and the negative predictive value was 0.98. The area under the curve was 0.95. The mean administration time was 5.8 min for the MMSE and 2.5 min for the 6CIT (p ≤ 0.01).

CONCLUSIONS

Diagnostic accuracy of the 6CIT was high. As the 6CIT is not sensitive to educational level, does not require advanced language skills, only takes a few minutes to administer and is very easy to use, it appears to be a suitable screening instrument for cognitive impairment in older patients in the general hospital.

Assessing agreement between terminally ill cancer patients' reports of their quality of life and family caregiver and palliative care physician proxy ratings

CONTEXT

Proxy ratings, if valid, may provide an alternative approach to evaluating patient quality of life (QoL) at the end of life.

OBJECTIVES

To examine agreement between terminally ill cancer patients' self-reported QoL and proxy assessment of patient QoL by their family caregiver (FCG) and palliative care physicians (PCPs) at two time points.

METHODS

Patients admitted to an acute palliative care unit and their FCGs and PCPs completed the McGill Quality of Life Questionnaire (MQOL) at Days 3 and 6 after admission. Response bias and response precision were examined at the individual and group levels. Furthermore, we examined patient factors affecting agreement and responsiveness of proxy MQOL scores to changes in patients' QoL between Days 3 and 6.

RESULTS

Statistically and clinically significant mean differences were detected between the patient and both proxy groups' reports of QoL on Day 3, with the magnitude of the differences decreasing somewhat by Day 6. Proxies underestimated patients' QoL compared with patients' self-report. Response precision based on intraclass correlation values and proportion of approximate agreement was poor to fair at both time points. Agreement was better for patients with greater physical burden and more cognitive difficulties. Proxies' responsiveness to change from Day 3 to Day 6 was low, and proxies were not able to detect minimally important changes in QoL.

CONCLUSION

The findings suggest that moderate agreement between patient and proxy ratings of QoL develops over time but that precision at the individual level, which is more clinically relevant, is less reliable. New strategies for improving proxy reliability are needed.

Early postoperative cognitive dysfunction and postoperative delirium after anaesthesia with various hypnotics: study protocol for a randomised controlled trial--the PINOCCHIO trial

Background

Postoperative delirium can result in increased postoperative morbidity and mortality, major demand for postoperative care and higher hospital costs. Hypnotics serve to induce and maintain anaesthesia and to abolish patients' consciousness. Their persisting clinical action can delay postoperative cognitive recovery and favour postoperative delirium. Some evidence suggests that these unwanted effects vary according to each hypnotic's specific pharmacodynamic and pharmacokinetic characteristics and its interaction with the individual patient.

We designed this study to evaluate postoperative delirium rate after general anaesthesia with various hypnotics in patients undergoing surgical procedures other than cardiac or brain surgery. We also aimed to test whether delayed postoperative cognitive recovery increases the risk of postoperative delirium.

Methods/Design

After local ethics committee approval, enrolled patients will be randomly assigned to one of three treatment groups. In all patients anaesthesia will be induced with propofol and fentanyl, and maintained with the anaesthetics desflurane, or sevoflurane, or propofol and the analgesic opioid fentanyl.

The onset of postoperative delirium will be monitored with the Nursing Delirium Scale every three hours up to 72 hours post anaesthesia. Cognitive function will be evaluated with two cognitive test batteries (the Short Memory Orientation Memory Concentration Test and the Rancho Los Amigos Scale) preoperatively, at baseline, and postoperatively at 20, 40 and 60 min after extubation.

Statistical analysis will investigate differences in the hypnotics used to maintain anaesthesia and the odds ratios for postoperative delirium, the relation of early postoperative cognitive recovery and postoperative delirium rate. A subgroup analysis will be used to categorize patients according to demographic variables relevant to the risk of postoperative delirium (age, sex, body weight) and to the preoperative score index for delirium.

Discussion

The results of this comparative anaesthesiological trial should whether each the three hypnotics tested is related to a significantly different postoperative delirium rate. This information could ultimately allow us to select the most appropriate hypnotic to maintain anaesthesia for specific subgroups of patients and especially for those at high risk of postoperative delirium.

Registered at Trial.gov Number

ClinicalTrials.gov: NCT00507195

Accuracy in scoring vignettes using the mini mental state examination and the short orientation memory concentration test

OBJECTIVE

To compare the accuracy in scoring of vignettes of 2 cognitive screening tests-the Mini Mental State Examination (MMSE) and the Short Orientation Memory Concentration Test (S-OMC).

DESIGN

Within group comparison.

SETTING

Academic institution.

PARTICIPANTS

A total of 74 student nurses.

METHOD

Participants received instruction on the scoring of each test and were then asked to score 6 videotaped clinical vignettes.

MAIN OUTCOME MEASURES

Scores allocated by participants on the vignettes for the MMSE and S-OMC.

RESULTS

The proportion of participants assigning the correct total score to the vignettes was low (MMSE 53.2%, S-OMC 66.7%), and the difference in accuracy between tests was significant (P = .005). The total scores that were assigned resulted in misclassification across all 4 caseness cutoffs within each test (MMSE 0.9%-5.9%; S-OMC 1.4%-2.7%). The differences in correct caseness placement between the 2 tests were significant only for the moderate impairment cutoff, where the S-OMC achieved greater correct caseness placement.

CONCLUSIONS

The high proportion of scoring mistakes overall has implications for the use of both the tests in routine clinical practice but in particular for the MMSE. An increased awareness is needed in clinical settings and among tests developers, of the likelihood of, and implications arising from, variations in scoring accuracy. In the current study, the S-OMC was scored more accurately than the MMSE.

Early postoperative cognitive recovery and gas exchange patterns after balanced anesthesia with sevoflurane or desflurane in overweight and obese patients undergoing craniotomy: a prospective randomized trial

Overweight and obese patients are at especially high risk for delayed awakening after general surgery. Whether this risk also applies to cerebral neurosurgical procedures remains unclear. This study evaluated early postoperative cognitive recovery and gas exchange patterns, after balanced anesthesia with sevoflurane or desflurane, in overweight and obese patients undergoing craniotomy for supratentorial expanding lesions. Fifty-six patients were consecutively enrolled, and randomly assigned to 1 of 2 study groups to receive balanced anesthesia with sevoflurane or desflurane. Cognitive function was evaluated with the Short Orientation Memory Concentration Test and the Rancho Los Amigos Scale and gas exchange patterns (pH, PaO2, and PaCO2) were recorded in all patients at 5 time-points: preoperatively and postoperatively, after patients reached an Aldrete score >or=9, at 15, 30, 45, and 60 minutes. Preoperative cognitive status was similar in the 2 treatment groups. Early postoperative cognitive recovery was more delayed and Short Orientation Memory Concentration Test scores at 15 and 30 minutes postanesthesia were lower in patients receiving sevoflurane-based anesthesia than in those receiving desflurane-based anesthesia (21.5+/-3.5 vs. 14.9+/-3.5) (P<0.005) and (26.9+/-0.7 vs. 21.5+/-1.4) (P<0.005), and the postoperative Rancho Los Amigos Scalegrade 8 showed a similar trend (25/28 patients 89% vs. 8/28 patients 28% (P<0.005) and 28/28 patients (100% vs. 13/28 patients 46%) (P<0.005). Similarly, gas-exchange analysis showed higher PaCO2 at 15 and 30 minutes and lower pH up to 45 minutes postextubation in patients receiving sevoflurane-based anesthesia. In overweight and obese patients undergoing craniotomy desflurane-based anesthesia allows earlier postoperative cognitive recovery and reversal to normocapnia and normal pH.

Chronic kidney disease is associated with incident cognitive impairment in the elderly: the INVADE study

BACKGROUND

Limited data exist regarding the relationship between decreased renal function and cognitive impairment.

METHODS

A total of 3679 participants of the Intervention Project on Cerebrovascular Diseases and Dementia in the Community of Ebersberg (INVADE) composed the community-based cohort study. Measures of renal function were estimated using the Cockcroft-Gault equation and divided into normal, mild and moderate-to-severe impaired renal function (creatinine clearance >or=60, 45-59 and <45 mL/min/1.73 m(2), respectively). The main outcome measures were cognitive impairment at baseline and new cognitive impairment after a 2-year follow-up. Cognitive function was measured using the 6-Item Cognitive Impairment Test (6CIT). Multiple logistic regression analysis was used to assess the association between renal function and cognitive impairment.

RESULTS

At baseline, 396 participants (10.8%) had cognitive impairment. After the 2-year follow-up, 194 participants (6.2%) developed new cognitive impairment. The incidence of cognitive impairment across the groups with normal renal function, mild and moderate-to-severe kidney disease at baseline were 5.8, 9.9 and 21.5%, respectively. Multiple logistic regression analysis after adjustment for possible confounders including traditional cardiovascular risk factors showed a significant association for participants with moderate-to-severe kidney disease at baseline to develop new cognitive impairment after the 2-year follow-up [odds ratio: 2.14 (95% confidence interval: 1.18-3.87), P = 0.01].

CONCLUSIONS

In summary, moderate-to-severe impaired renal function is associated with incident cognitive impairment after 2 years in a large cohort of elderly subjects.