Novel neurodigital interface reduces motion sickness in virtual reality

Virtual reality (VR) is a computer-created 3D environment with a focus on realistic scenes and pictures created for entertainment, medical and/or educational and training purposes. One of the major side effects of VR immersion reported in the scientific literature, media and social media is Visually Induced Motion Sickness (VIMS), with clinical symptoms such as disorientation, nausea, and oculomotor discomfort. VIMS is mostly caused by the discrepancy between the visual and vestibular systems and can lead to dizziness, nausea, and disorientation. In this study, we present one potential novel solution to combat motion sickness in VR, showcasing a significant reduction of nausea in VR users employing the META Quest 2 headsets in conjunction with a whole-body controller. Using a neurodigital approach, we facilitate a more immersive and comfortable VR experience. Our findings indicate a marked reduction in VR-induced nausea, paving the way to promote VR technology for broader applications across various fields.

Lost in space(s): Multimodal neuroimaging of disorientation along the Alzheimer's disease continuum

Orientation is a fundamental cognitive faculty and the bedrock of the neurologic examination. Orientation is defined as the alignment between an individual's internal representation and the external world in the spatial, temporal, and social domains. While spatial disorientation is a recognized hallmark of Alzheimer's disease (AD), little is known about disorientation beyond space in AD. This study aimed to explore disorientation in spatial, temporal, and social domains along the AD continuum. Fifty-one participants along the AD continuum performed an ecological orientation task in the spatial, temporal, and social domains while undergoing functional MRI. Disorientation in AD followed a three-way association between orientation domain, brain region, and disease stage. Specifically, patients with early amnestic mild cognitive impairment exhibited spatio-temporal disorientation and reduced brain activity in temporoparietal regions, while patients with AD dementia showed additional social disorientation and reduced brain activity in frontoparietal regions. Furthermore, patterns of hypoactivation overlapped different subnetworks of the default mode network, patterns of fluorodeoxyglucose hypometabolism, and cortical atrophy characteristic of AD. Our results suggest that AD may encompass a disorder of orientation, characterized by a biphasic process manifesting as early spatio-temporal and late social disorientation. As such, disorientation may offer a unique window into the clinicopathological progression of AD. SIGNIFICANCE STATEMENT: Despite extensive research into Alzheimer's disease (AD), its core cognitive deficit remains a matter of debate. In this study, we investigated whether orientation, defined as the ability to align internal representations with the external world in spatial, temporal, and social domains, constitutes a core cognitive deficit in AD. To do so, we used PET-fMRI imaging to collect behavioral, functional, and metabolic data from 51 participants along the AD continuum. Our findings suggest that AD may constitute a disorder of orientation, characterized by an early spatio-temporal disorientation and followed by late social disorientation, manifesting in task-evoked and neurodegenerative changes. We propose that a profile of disorientation across multiple domains offers a unique window into the progression of AD and as such could greatly benefit disease diagnosis, monitoring, and evaluation of treatment response.

Neuropsychiatric involvement in juvenile-onset systemic lupus erythematosus: A multicenter study

INTRODUCTION

Neuropsychiatric (NP) involvement is a restricted area in juvenile-onset systemic lupus erythematosus (jSLE).

AIM

To investigate the prevalence, demographic and clinical features, and outcomes of the neurological involvement in the Turkish jSLE population.

METHODS

This study was based upon 24 referral centers' SLE cohorts, multicenter and multidisciplinary network in Turkey. Patient data were collected by a case report form which was standardized for NP definitions according to American Collage of Rheumatology (ACR). Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) neuropsychiatric part was used to determine NP damage. Variables were evaluated Ward's hierarchical clustering analyses, univariate, and multivariate logistic regression analyses.

RESULTS

A hundred forty-nine of 1107 jSLE patients had NP involvement (13.5%). The most common NPSLE findings were headache (50.3%), seizure (38.3%), and acute confusional state (33.6%). Five clusters were identified with all clinical and laboratory findings. The first two clusters involved neuropathies, demyelinating diseases, aseptic meningitis, and movement disorder. Cluster 3 involved headache, activity markers and other SLE involvements. Idiopathic intracranial hypertension, cerebrovascular disease, cognitive dysfunction, psychiatric disorders and SLE antibodies were in the fourth, and acute confusional state was in the fifth cluster. In multivariate analysis, APA positivity; OR: 2.820, (%95CI: 1.002-7.939), P: 0,050, plasmapheresis; OR: 13.804 (%95CI: 2.785-68.432), P: 0,001, SLEDAI scores; OR: 1.115 (%95CI: (1.049-1.186), P: 0,001 were associated with increased risk for neurologic sequelae.

CONCLUSION

We detected the prevalence of juvenile NPSLE manifestations in Turkey. We have identified five clusters that may shed light pathogenesis, treatment and prognosis of NP involvements. We also determined risk factors of neurological sequelae. Our study showed that new definitions NP involvements and sequelae for childhood period are needed.

Confusion and Hallucination in a Geriatric Patient. Pitfalls of a Rare Differential: Case Report of an Anti-LGI1-Encephalitis

Background

Confusion and hallucinations in geriatric patients are frequent symptoms and typically associated with delirium, late-life psychosis or dementia syndromes. A far rarer but well-established differential in patients with rapid cognitive deterioration, acute psychosis, abnormal movements and seizures is autoimmune encephalitis. Exemplified by our case we highlight clinical and economic problems arising in management of geriatric patients with cognitive decline and psychotic symptoms.

Case Presentation

A 77-year-old female caucasian patient with an unremarkable medical history was hospitalized after a fall in association with diarrhea and hyponatremia. Upon adequate therapy, disorientation and troubled short-term memory persisted. Within a week the patient developed visual hallucinations. Basic blood and urine samples and imaging (cranial computed tomography and magnetic resonance imaging) were unremarkable. With progressive cognitive decline, amnestic impairment, word finding difficulty and general apathy, psychiatric and neurologic expertise was introduced. Advanced diagnostics did not resolve a final diagnosis; an electroencephalogram showed unspecific generalized slowing. Extended clinical observation revealed visual hallucinations and faciobrachial dystonic seizures. A treatment with anticonvulsants was initiated. Cerebrospinal fluid ultimately tested positive for voltage-gated potassium channel LGl1 (leucine-rich-inactivated-1) antibodies confirming diagnosis of autoimmune anti-LGI1 encephalitis. Immediate immunotherapy (high-dose glucocorticoids and administration of intravenous immunoglobulin G) led to a rapid improvement of the patient’s condition. After immunotherapy was tapered, the patient had one relapse and completely recovered with reintroduction of glucocorticoids and initiation of therapy with rituximab.

Conclusion

Rapidly progressive dementia in geriatric patients demands a structured and multidisciplinary diagnostic approach. Accurate management and financially supportable care is a major issue in rare diseases such as anti-LGI1-encephalitis. Education and awareness about autoimmune encephalitis of all physicians treating a geriatric population is important in order to involve expertise and establish treatment within reasonable time.

Postural Control and Psychophysical State Following of Flight Simulator Session in Novice Pilots

Flight simulators can cause side effects usually called simulator sickness. Scientific research proves that postural instability can be an indicator of the occurrence of simulator sickness symptoms. This study aims to assess changes of postural control and psychophysical state in novice pilots following 2-h exposure to simulator conditions. The postural sway was quantified based on variables describing the displacement of the Center of Pressure (COP) generated in a quiet stance with eyes open (EO) and closed (EC). The psychophysical state was assessed using the Simulator Sickness Questionnaire (SSQ). The research was carried out in a group of 24 novice pilots who performed procedural and emergency flight exercises in the simulator at Instrument Meteorological Conditions. Each subject was examined twice: immediately before the simulator session (pre-exposure test), and just after the session (post-exposure test). The differences in postural stability between pre- and post-exposure to simulator conditions were assessed based on the normalized Romberg quotients, calculated for individual variables. The lower median values of all Romberg quotients confirmed the decreasing difference between the measures with eyes open and with eyes closed in the post-exposure tests. After the flight simulator session in both measurements (EO and EC) the values of the length of sway path (SP), the mean amplitude (MA), the sway area (SA) have changed. The visual contribution to postural sway control was reduced. The median values for all SSQ scores (total, nausea, oculomotor, and disorientation scales) were significantly higher in post-exposure tests. The largest increase was noted in the oculomotor SSQ scores (from 7.6 ± 7.6 to 37.9 ± 26.5). Over 50% of pilots participating in this study expressed symptoms typical of simulator sickness connected with visual induction: fatigue, eyestrain, difficulty focusing and difficulty concentrating. The severity of oculomotor and disorientation symptoms were rated as moderate (total SSQ score of more than 25 and <60). This study concludes that changes noted in the postural control and psychophysical state of the studied pilots after exposure to the flight simulator confirm the occurrence of the simulator sickness symptoms. Although, we did not find significant correlation of postural stability with SSQ scores.

Predictors for Falls among Hospital Inpatients with Impaired Mobility

Gait and balance disturbances have been shown to predispose to falls in hospital. We aimed to investigate the patient characteristics associated with an unsafe gait and to determine what features predispose to falling in this group of hospital inpatients. In a prospective open observational study we studied 825 patients admitted for rehabilitation following acute medical illness or a surgical procedure. The patient's gait was assessed with the 'get up and go' test and classified into one of four categories-normal; abnormal but safe with or without mobility aids; unsafe; or unable. 72.6% of patients were assessed as having an unsafe gait. The factors independently associated with an unsafe gait were confusion, abnormal lower limbs, hearing defects and the use of tranquillizers. Patients with an unsafe gait who fell were more likely than the non-fallers within the group to have had falls in the past (85.3% versus 73.8%) and to be confused (66.2% versus 34.1%). Patients with both these characteristics had a 37.5% chance of falling compared with 15.4% in patients with one and 11.2% in patients with none of these characteristics. The presence of confusion and a history of falls identifies those patients who are at greatest risk of falls. Such patients might be the focus of special efforts at falls prevention.

Syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) in a patient with confusional symptoms, diffuse EEG abnormalities, and bilateral vasospasm in transcranial Doppler ultrasound: A case report and literature review

INTRODUCTION

HaNDL syndrome (transient headache and neurological deficits with cerebrospinal fluid lymphocytosis) is characterised by one or more episodes of headache and transient neurological deficits associated with cerebrospinal fluid lymphocytosis. To date, few cases of HaNDL manifesting with confusional symptoms have been described. Likewise, very few patients with HaNDL and confusional symptoms have been evaluated with transcranial Doppler ultrasound (TCD). TCD data from patients with focal involvement reveal changes consistent with vasomotor alterations.

DEVELOPMENT

We present the case of a 42-year-old man who experienced headache and confusional symptoms and displayed pleocytosis, diffuse slow activity on EEG, increased blood flow velocity in both middle cerebral arteries on TCD, and single-photon emission computed tomography (SPECT) findings suggestive of diffuse involvement, especially in the left hemisphere.

CONCLUSIONS

To our knowledge, this is the first description of a patient with HaNDL, confusional symptoms, diffuse slow activity on EEG, and increased blood flow velocity in TCD. Our findings suggest a relationship between cerebral vasomotor changes and the pathophysiology of HaNDL. TCD may be a useful tool for early diagnosis of HaNDL.

Falls, physical limitations, confusion and memory problems in people with type II diabetes, undiagnosed diabetes and prediabetes, and the influence of vitamins A, D and E

AIMS

To examine the association between type II diabetes, prediabetes and undiagnosed diabetes with falls, physical limitations, confusion and memory problems, and to evaluate the effects of vitamins A, D and E levels on the associations.

METHODS

Data from 37,973 participants of the National Health and Nutrition Examination Survey was analyzed.

RESULTS

The participants' mean age was 46±17years, 20% had diabetes of which 17% were unaware of their condition (undiagnosed diabetes), and 21% had prediabetes. Diabetes was significantly associated with falls, difficulties in stooping, crouching, kneeling, completing house chores, getting in and out bed, standing and sitting for long periods, reaching over head, grasping, holding objects, and attending social events. The association between diabetes and confusion or memory problems was stronger for those diagnosed before age 40. Memory problems were reported only by people with diabetes with lower vitamin D levels. Vitamin A and E levels did not modify the association between diabetes and falls or any of the physical functions, confusion or memory problems. Prediabetes was only associated with difficulty standing for long periods.

CONCLUSIONS

Diabetes was associated with falls, difficulties in physical functioning and attending social events. Vitamin D levels modified the effects on confusion and memory problems.

Daily episodes of confusion · altered behavior · chronic sleep deprivation · Dx?

His neurologic exam was normal. Family history was positive for a cousin with narcolepsy but negative for seizures and obstructive sleep apnea. Polysomnography revealed moderate OSA with minimal oxygen desaturation. Inpatient video EEG monitoring captured several of the events that the patient and his wife had described; the patient seemed "uninhibited" in his behavior. His EEG, cardiac telemetry, oxygen saturation, blood pressure, and serum glucose level remained normal.

[The acute management of agitation]

Agitation in psychiatry is defined as "a request to which an answer cannot be deferred". If some types of controllable agitation can be solved by human means or psychotropic drugs, others may require the intervention of intensivists who will contribute to the onset of crisis resolution. In addition, an organic aetiology must be carefully excluded a before considering a psychiatric origin of agitation, especially in patients with no psychiatric history and in the elderly. Indeed, acute agitation can hide serious somatic traps and be life threatening.

Development of a questionnaire on everyday navigational ability to assess topographical disorientation in Alzheimer's disease

We developed a Questionnaire on Everyday Navigational Ability (QuENA) to detect topographical disorientation (TD) in patients with Alzheimer's disease (PwAD). In the QuENA, 3 items were designed to assess landmark agnosia, 2 for egocentric disorientation, 3 for heading disorientation, and 2 for inattention. The PwAD and their caregivers rated QuENA according to which TD symptoms would occur. Regarding the construct validity, confirmatory factor analysis showed that the caregiver version of the QuENA fits the proposed TD model well but the patient version does not. Regarding the internal consistency, the Cronbach's α for the caregiver version was 0.91 and that for the patient version was 0.87. A discrepancy existed between the appraisal of navigational abilities by PwAD and by caregivers, and it was correlated with the number of getting lost (GL) events. The caregiver version of QuENA is a feasible, reliable, and valid instrument to assess TD and it also discriminates well between the PwAD with GL and those without.

Symptom clusters in advanced cancer

CONTEXT

Patients with advanced cancer often experience multiple concurrent symptoms. Few studies have explored symptom clusters (SCs) in this population.

OBJECTIVES

The aim of the present study was to explore SCs in advanced cancer, evaluate the characteristics associated with various clusters, and determine their relationship to survival.

METHODS

This study included patients in the palliative care program of the Hospital Universitario La Paz from 2003 to 2005. The Edmonton Symptom Assessment System and a supplement including 13 other symptoms were used to detect symptoms. Principal component analysis was performed to determine symptom relationships and compare SCs with associated parameters.

RESULTS

In total, 406 patients were included, 61% men and 39% women. The median age was 66.4 (range 18-95). The most common primaries were gastrointestinal (35%), lung (25%), genitourinary (8%), breast (5%), and head and neck (5%) carcinomas. The following clusters were identified: confusion (cognitive impairment, agitation, urinary incontinence), neuropsychological (anxiety, depression, and insomnia), anorexia-cachexia (anorexia, weight loss, and tiredness), and gastrointestinal (nausea and vomiting). The presence of these SCs was influenced by primary cancer site, gender, age, and performance status. Survival was related to the number of SCs present in a given patient: zero SC, 52 days; one SC, 38 days; two SCs, 23 days; and three to four SCs, 19 days; P < 0.001.

CONCLUSION

Different SCs can be identified in patients with advanced cancer. These SCs are influenced by primary cancer site, gender, age, and Eastern Cooperative Oncology Group performance status, and they can have prognostic value.

[Surgical emergencies in elderly patients]

Surgical emergencies represent a diverse combination of common and particularly severe pathologies in elderly patients. This severity is due in part to concurrent comorbidities and sometimes atypical clinical presentations, causing delay in diagnosis and treatment.

Hospital-based descriptive study of symptomatic hyponatremia in elderly patients

BACKGROUND

Hyponatremia is a common electrolyte disturbance in the hospitalized elderly sick patients. There is no existing record for profiling of symptomatic hyponatremia in elderly Indian subjects.

OBJECTIVES

To study clinical features and etiology of hyponatremia in elderly hospitalized patients. To classify severity of hyponatremia in hospitalized elderly

METHODS

All elderly patients admitted to ICU with serum sodium level < =125 mmol/L were included in study.

RESULTS

100 patients with symptomatic hyponatremia (serum sodium < =125 mmol/L) were studied. The CNS symptoms included drowsiness, lethargy, confusion, seizures and coma. There was female preponderance of cases (55%). The common co-morbid conditions were Hypertension (69%) and diabetes mellitus (51%). Females tolerated hyponatremia better than males with mortality of 9.09% in females and 33.33% in males (p = 0.0026). The common cause of Hyponatremia was SIADH (30) followed by drugs of which diuretics was the major contributor.

CONCLUSION

Hyponatremia was more common in females and they seemed to better tolerate it than their male counterparts. Diuretics should be used with caution in elderly.

Drug-induced confusional states: the usual suspects?

BACKGROUND

Acute confusional state (ACS) is a frequent reason for hospital admission. This study examines retrospectively the frequency by which individual drugs were found responsible for ACS.

RESULTS

Drug-induced ACS was found in 65 (18.8%) of 346 hospital admissions for acute confusion. The most frequent causative substances were dopaminergic drugs in Parkinsonian patients (24.2%), diuretics (15.1%), tricyclic or tetracyclic antidepressants (13.6%) and benzodiazepines (13.6%). Almost half of the patients were demented, and in one-third of these, dementia had not been diagnosed hitherto.

CONCLUSION

The data suggest that diuretics by way of causing hyponatraemia are as relevant a cause of ACS as dopaminergic or anticholinergic substances.

Racial/ethnic differences in stroke awareness among veterans

OBJECTIVE

To examine racial/ethnic differences in stroke recognition and knowledge of appropriate first action if someone was having a stroke.

METHODS

We examined data from 36,150 veterans from the 2003 Behavioral Risk Factor Surveillance System (BRFSS). Respondents indicated recognition of five stroke warning signs/symptoms and first action they would take if someone were having a stroke. Multiple logistic regression was used to assess the independent effect of race/ethnicity on stroke recognition and appropriate first action, controlling for relevant covariates.

RESULTS

Most respondents recognized at least one warning sign: 96% recognized sudden confusion or trouble speaking; 97% recognized sudden facial, arm, or leg weakness; 88% recognized sudden vision loss; 94% recognized sudden trouble walking; and 80% recognized sudden headache; 86% recognized calling 911 as the appropriate first action. However, only 17% recognized all five warning signs/symptoms, and only 15% recognized all five warning signs/symptoms and would call 911 as the first action. In multivariate models with Whites as reference, Hispanics (OR .34, 95% CI .22-.51) and Others (OR .68, 95% CI .50-.92) were less likely to recognize all five stroke warning signs/symptoms. Hispanics (OR .37, 95% CI .24-.58) and Others (OR .68, 95% CI .48-.96) were less likely to recognize all five warning signs/symptoms and call 911 as the first action.

CONCLUSIONS

Most veterans recognize individual stroke warning signs, but very few recognize all five and would take appropriate action to call 911 in the event of a stroke. Low rates of stroke recognition and taking appropriate action are more pronounced in racial/ethnic minority veterans.

Preliminary derivation of a Nursing Home Confusion Assessment Method based on data from the Minimum Data Set

OBJECTIVES

To develop a Nursing Home Confusion Assessment Method (NH-CAM) for diagnosing delirium using items found on the Minimum Data Set (MDS) and to compare its performance with that of the delirium Resident Assessment Protocol (RAP) trigger and to an additive score of six of the RAP items.

DESIGN

Retrospective cohort study using MDS and Medicare claims data.

SETTING

Free-standing NHs in urban markets in the 48 contiguous U.S. states.

PARTICIPANTS

Long-stay residents who returned to their NHs after acute hospitalizations between April and September 2000 (N=35,721).

MEASUREMENTS

Mortality and rehospitalization rates within 90 days of readmission to the NH from the hospital.

RESULTS

Almost one-third (31.8%) of the residents were identified as having delirium according to the RAP; 1.4% had full delirium, 13.2% had Subsyndromal II delirium, and 17.2% had Subsyndromal I delirium. More-severe NH-CAM scores were associated with greater risks of mortality and rehospitalization. NH-CAM levels were strong independent risk factors for survival and rehospitalization in a Cox model (hazard ratios ranging from 1.5 to 1.9 for mortality and 1.1 to 1.3 for rehospitalization) adjusting for cognitive and physical function, diagnoses, inpatient care parameters, care preferences, and sociodemographic factors.

CONCLUSION

The NH-CAM successfully stratified NH residents' risk of mortality and rehospitalization. If validated clinically, the NH-CAM may be useful in care planning and in further research on the determinants and consequences of delirium in the NH.

Electroconvulsive monotherapy in confusion psychosis: a potential standard regimen?

We report on the successful use of continuation electroconvulsive therapy (ECT) as prophylactic treatment of relapse in a case of confusion psychosis. The 20-year-old patient exacerbated in an almost annual rhythm and had been characterized as pharmacologically treatment-resistant since he failed to respond to any psychopharmacological therapy including sufficient clozapine as well as mood-stabilizing and sedating pharmacological treatments. After the diagnosis of confusion psychosis, the patient received ECT as monotherapy and showed a marked reduction of symptoms. Continuation ECT was then conducted for 7 months after the patient was discharged from hospital. Two years later, our patient is still in remission while continuation ECT has been tapered; no prophylactic psychotropic medication was prescribed in the last 2 years. Implications of this case on the therapy of confusion psychosis as well as on the diagnostic classification of confusion psychosis within our current systems are discussed.

Assessment and treatment of childhood topographical disorientation: A case study

Topographical disorientation refers to individuals who are unable to find their way around large-scale environments in a normal manner. Childhood topographical disorientation is rarely investigated or reported. Treatment of topographical disorientation is also rare with only one reported treatment study in an adult (Davis & Coltheart, 1999) and no known description of treatment in a child. This paper reports a detailed case analysis of CA, a 6-year-old child with topographical disorientation, and a description of a treatment programme focused on training orientation in the school environment. Assessment of CA revealed mild to moderate visual agnosia in conjunction with severe impairments in general spatial learning and memory, topographical new learning and memory, and a total inability to learn new topographical routes. CA was also unable to use a mental image of his environment, a simple visual plan of his environment or a simple visual map, but was able to follow verbally mediated topographical instructions. The treatment programme focused on improving CA's topographical orientation in the school environment. The programme first involved training in recognition of major school buildings and landmarks and then focused on practical training in route finding along commonly used routes in the school environment. Clear benefits from treatment were evident. The assessment and treatment methods employed provide practical and useful ideas for management of this condition in other children.

A multivariate fall risk assessment model for VHA nursing homes using the minimum data set

OBJECTIVES

The purpose of this study was to develop a multivariate fall risk assessment model beyond the current fall Resident Assessment Protocol (RAP) triggers for nursing home residents using the Minimum Data Set (MDS).

DESIGN

Retrospective, clustered secondary data analysis.

SETTING

National Veterans Health Administration (VHA) long-term care nursing homes (N = 136).

PARTICIPANTS

The study population consisted of 6577 national VHA nursing home residents who had an annual assessment during FY 2005, identified from the MDS, as well as an earlier annual or admission assessment within a 1-year look-back period.

MEASUREMENT

A dichotomous multivariate model of nursing home residents coded with a fall on selected fall risk characteristics from the MDS, estimated with general estimation equations (GEE).

RESULTS

There were 17 170 assessments corresponding to 6577 long-term care nursing home residents. The increased odds ratio (OR) of being classified as a faller relative to the omitted "dependent" category of activities of daily living (ADL) ranged from OR = 1.35 for "limited" ADL category up to OR = 1.57 for "extensive-2" ADL (P < .0001). Unsteady gait more than doubles the odds of being a faller (OR = 2.63, P < .0001). The use of assistive devices such as canes, walkers, or crutches, or the use of wheelchairs increases the odds of being a faller (OR = 1.17, P < .0005) or (OR = 1.19, P < .0002), respectively. Foot problems may also increase the odds of being a faller (OR = 1.26, P < .0016). Alzheimer's or other dementias also increase the odds of being classified as a faller (OR = 1.18, P < .0219) or (OR=1.22, P < .0001), respectively. In addition, anger (OR = 1.19, P < .0065); wandering (OR = 1.53, P < .0001); or use of antipsychotic medications (OR = 1.15, P < .0039), antianxiety medications (OR = 1.13, P < .0323), or antidepressant medications (OR = 1.39, P < .0001) was also associated with the odds of being a faller.

CONCLUSIONS

This national study in one of the largest managed healthcare systems in the United States has empirically confirmed the relative importance of certain risk factors for falls in long-term care settings. The model incorporated an ADL index and adjusted for case mix by including only long-term care nursing home residents. The study offers clinicians practical estimates by combining multiple univariate MDS elements in an empirically based, multivariate fall risk assessment model.

Fatigue and related human factors in the near crash of a large military aircraft

INTRODUCTION

During approach to a remote island location, a U.S. Air Force heavy-airlift aircraft was flown into an aerodynamic stall, resulting in the loss of more than 4000 ft of altitude, with the crew recovering the aircraft just before impact would have occurred.

METHODS

An analysis of the mishap was conducted through a review of non-privileged USAF mishap data, cockpit voice recordings, flight data records, and interviews of the aircrew involved. A thorough examination of fatigue-related factors was conducted, including computerized fatigue modeling.

RESULTS

The crew traveled over 11,000 mi in a westward direction over a 6-d period. They had been on duty for nearly 21 h on the day of the mishap, with minimal in-flight rest. The pilots were late beginning their descent for landing, and a minor aircraft malfunction distracted the crew, contributing to channelized attention and degraded situational awareness. A breakdown in crew communication and failure to adequately monitor and interpret true aircraft state culminated in loss of aircraft control. Analysis of the crew's work/rest schedule confirmed that multiple elements of fatigue were present during this mishap, including acute and cumulative fatigue, circadian disruptions, and sleep inertia. Additionally, reduced situational awareness and spatial disorientation, exacerbated by the underlying fatigue, were causal in this mishap.

DISCUSSION

This mishap highlights the importance of maintaining a high degree of situational awareness during long-haul flights with a continuing need to address issues regarding spatial disorientation, proper application of human engineering principles in modern cockpits, and mitigation of aircrew fatigue factors.

The transient syndrome of headache with neurological deficits, cerebrospinal fluid pleocytosis and acute confusional state: a case report

The syndrome of transient Headache and Neurological Deficits with cerebrospinal fluid Lymphocytosis (HaNDL) now referred to in the IHS ICHD-II code 7.8, is only infrequently accompanied by a confusional state and severe agitation. We report the case of a 34-year-old man who suffered from three episodes of headache with transient focal neurological deficits that were consistent with HaNDL but that were accompanied by an intense, confusional agitated state that required admission, in the first episode, in a psychiatric unit.

[Accidental death of disoriented persons in long term care facilities]

Five cases of accidental death occurring in connection with physical restraints in long-term care facilities are reported. The position in which the deceased were found, autopsy findings, police investigations as well as the evaluation of each case under criminal law are described. The investigations by the prosecution as well as the attention of the public media have meanwhile contributed to an improvement of the technical standards and a reduction of the risk in applying such restraints under the Law on Medical Devices.

Predictors of falling in elderly hospital patients

A prospective study was conducted to determine whether a brief clinical assessment conducted soon after admission can accurately identify older people who fall while staying in an acute hospital. Eighty-eight non-bedfast patients aged 80-99 years took part in the study. Within 3 days of admission, these patients were assessed for the following measures: impaired orientation on the MMSE, psychoactive medication use, evidence of stroke, and impaired ability on the Get-Up-and-Go-test. The major presenting condition for each patient was also recorded. Patients were then followed up to determine whether they fell while in hospital. Impaired orientation on the MMSE, evidence of previous cerebrovascular accident, and major presenting conditions of falls and confusion were significantly associated with falls while in hospital. There was also a trend indicating that psychoactive medication use was elevated in the fallers. In contrast, there was no difference in the proportion of fallers and non-fallers who had impaired ability in the Get-Up-and-Go-test. Of the 15 patients who fell, 13 had two or more risk factors, and after controlling for possible confounding factors of age, sex and length of stay, the presence of two-plus risk factors remained strongly and significantly associated with falls (adjusted OR = 13.43; 95% CI = 1.91 - 94.40). The findings indicate that a simple screening protocol can accurately identify patients at risk of falling while in hospital.

Delirium in the intensive care unit

Delirium in the intensive care unit (ICU) is a complex, common, and problematic condition that interferes with healing and recovery. It leads to higher morbidity and mortality and extended hospital stays. The aging population older than 65, and more likely to develop delirium, is the fastest growing population in the United States and is increasingly seen in the ICU. Delirium is often unrecognized and misdiagnosed, which leads to mistreatment or lack of appropriate treatment. This article discusses the definition of delirium, pathogenesis, clinical practice guidelines, newer assessment tools for ICU, and nursing interventions directed toward prevention and early identification of delirium.

The development and testing of the PATCOA to assess pain in confused older adults

The purposes of this study were to develop and evaluate the psychometric properties of an instrument with nonverbal cues to assess pain in confused older adults, and to describe the differences among selected demographic variables and scores on the pain and confusion measures. The Pain Assessment Tool in Confused Older Adults (PATCOA) was evaluated with 116 cognitively intact older adults undergoing orthopedic surgery. The interrater reliability for each nonverbal cue ranged from 56.5% to 100%, and the Spearman correlations were .16 to 1.00. Nine nonverbal pain cues were subjected to exploratory factor analysis. Four components explained 69.83% variance. Older adults reported significantly higher levels of pain on the visual analog scale, yet age was not related to the nonverbal pain cues. Women reported significantly more pain than did men. No significant gender differences were found regarding the display of nonverbal pain cues and the level of acute confusion, or with race and self-report of pain, display of nonverbal pain cues, or level of confusion. The development and testing of the PATCOA are initial steps that contribute to our knowledge about acute pain assessment in confused older adults.

Recorded delirium in a national sample of elderly inpatients: potential implications for recognition

This retrospective study examined delirium and related confusional diagnoses recorded in patients older than age 60 discharged from Veterans Affairs (VA) acute inpatient units nationally in 1996 (n = 267,947). Only 4% of patients had delirium or related confusional diagnoses recorded. Patients with recorded delirium had significantly higher mortality than did those without recorded delirium or those with other confusional diagnoses ("organic psychoses"); the most common delirium types were dementia with delirium and alcohol intoxication/withdrawal delirium. Organic psychoses patients had the longest lengths of stay and significantly more admissions to nonmedical/surgical units and discharges to nursing homes; almost 20% were African American. The recorded rate of delirium in the VA health system likely underestimates true prevalence and possibly reflects nonrecognition of delirium in many older veterans. Certain motoric and etiologic types of delirium may be more commonly diagnosed and recorded. Future research should prospectively examine recognition of motoric and etiologic delirium subtypes and racial differences in delirium diagnoses.

Loss of spatial learning in a patient with topographical disorientation in new environments

The case is described of a patient who, following cerebral hypoxia, developed severe difficulty in orienting himself in new environments in the context of a mild global amnesic syndrome. Some episodes he related suggested that his main difficulty was remembering the spatial/directional value of landmarks he recognised. A neuroradiological examination documented severe bilateral atrophy of the hippocampi associated with atrophic changes in the cerebral hemispheres, most marked in the dorsal regions. Neuropsychological and experimental evaluation showed a severe deficit of spatial learning with substantially preserved ability to learn verbal and visual-object information. He was also virtually unable to learn a route in a maze task based exclusively on spatial data, but the availability of visual cues substantially improved his learning. Finally, he performed within normal limits on various tests investigating knowledge acquired premorbidly regarding famous buildings, routes in the town he had been living in since childhood, and geography. Topographical disorientation may be subtended by a specific difficulty in storing the spatial/directional value of visual landmarks in novel environments. The hippocampus appears to be involved in the acquisition of new topographical spatial knowledge.

[Confused states as predictors of epileptic seizures during and after cerebrovascular accident]

The state of mental confusion is described as an dependent risk factor in development of early and late epileptic-onset seizures following CVI. The aim of this paper is to determine the influence of confused state as possible predictor of symptomatic seizures in the course and following CVI.

MATERIAL AND METHODS

The patients who were treated in The Department of Neurology for early and late-onset seizures in the course and following CVI in the period between 1.1.1989 and 31.12.1998.

RESULTS

We had total number of 106 patients with symptomatic seizures, 56 in the group of late-onset and 50 in the group of early seizures. 52.8% of the patients have a registered state of mental confusion at the admission to hospital (in the stage of acute CVI), 19.2% of patients had a clear sensorium. Disorder of consciousness of the type of coma was registered in 27.4% of the patients. There was statistically significant increase of the occurrence of mental confusion in the group of patients with late-onset seizures, 62.5% while there was a statistically significant increase of coma in conditions related to type, frequency and outcome of seizures. We can conclude that mental confusion has significant influence of the occurrence of late-onset seizures while it does not influence the type and frequency of seizures.

Behaviors and outcomes of acute confusion in hospitalized patients

The purpose of this study was to describe behaviors associated with acute confusion (AC) in hospitalized patients and to determine whether acutely confused patients experience more adverse outcomes compared with their nonconfused counterparts. Using a prospective design, 117 subjects were followed throughout hospital stay. Subjects who developed AC were more likely to fall, be incontinent, have a urinary catheter, and experience functional decline. Mortality was higher in subjects with AC. Contrary to popular belief, acutely confused patients exhibited decreased psychomotor activity. Nurses can be trained to recognize AC using a standardized protocol to improve outcomes for this vulnerable population.

Promoting positive outcomes for elderly persons in the hospital: prevention and risk factor modification

The hospitalized elderly are at an increased risk for poor outcomes such as increased length of stay, readmissions, functional decline, and iatrogenic complications, as compared with other age groups. Research related to the hospitalized elderly has identified factors associated with poor outcomes. Nurses and other healthcare team members may be able to identify elderly patients at risk for poor outcomes and target modifiable factors to minimize their negative impact. Clinical experience and research validate the conclusion that multidimensional, preventive risk factor modification balanced with acute illness treatment can result in positive outcomes for elderly patients.

[Drug treatment is beneficial also for elderly patients with Parkinson disease. Important to consider also other co-existing diseases]

Parkinson's disease is a relatively common disorder in elderly patients. With carefully performed treatment a considerable improvement can be seen also in patients of high age. L-dopa as well as other antiparkinsonian drugs should be used in lower doses than those subscribed for younger patients. Cognitive decline implies a certain risk for mental confusion, in which case the dose of the causing agent has to be lowered or the treatment interrupted.

Risk factors for falls and injuries in a long-term care facility in Ontario

OBJECTIVE

To identify risk factors for falls and injuries among seniors living in a long-term care facility.

METHOD

Case-control study of 335 residents living at St. Joseph's Villa, Dundas, Ontario. Cases were defined as residents who fell between July 1, 1996 and June 30, 1997; controls were those who did not fall. To identify risk factors for injury, cases were defined as those with completed incident injury forms and controls as those without.

RESULTS

The most important risk factors for falls included: having fallen in the past three months; residing in a secured unit; living in the facility for two or more years; having the potential to cause injury to others; and having an illness, disease or behaviour that may cause a fall. The most important risk factor for injury among those who fell was altered mental state.

CONCLUSION

The risk factors identified may be helpful to those planning falls prevention initiatives within long-term care settings.

[Nonconvulsive status epilepticus of frontal origin. A case report]

INTRODUCTION

Nonconvulsive status epilepticus (NCSE) of frontal origin is a form of partial status epilepticus which has rarely been well-documented. The inespecificity of the symptoms contribute frequently to its misinterpretation being the EEG the most useful tool to make an accurate diagnosis.

CLINICAL CASE

We report a 53-year-old woman who suffered from two generalized tonic-clonic seizures secondary to a left frontal hematoma in 1994. Onset of treatment with carbamazepine was followed by a complete control of seizures. After remaining seizure-free during four years, antiepileptic therapy was discontinued. By June 1999, she presented with a prolonged confusional state having a generalized tonic-clonic seizure at the emergency room. At that moment, a computed tomography (CT) scan was normal. Generalized seizures were controlled with phenytoin, however, the patient remained confused having occasionally episodes of turning of the head and eyes to the right side. Ictal EEG examination showed recurrent bilateral frontopolar, frontocentral and frontotemporal epileptiform discharges with a left frontal focal onset. The diagnosis of NCSE of frontal origin was made. Despite several anticonvulsant combinations, confusional state remained unchanged and she was transferred to the intensive care unit for sedation with propofol and mydazolam. On the following days, she experienced a marked improvement and EEG showed a few frontal spikes and sharp waves but without evidence of electrographic status epilepticus. The patient was finally discharged and remains seizure-free on phenytoin therapy.

CONCLUSIONS

Our clinical and EEG findings are in keeping with the diagnosis of NCSE of frontal origin. A severe confusional state was the most prominent symptom and EEG was essential for the diagnosis.

[Usefulness of the EEG recording in the diagnosis of cyclosporin A-induced encephalopathy]

INTRODUCTION

Cyclosporine A is one of the immunosuppressors most frequently used to prevent transplant rejection. Neurotoxicity is one of the complications often associated with it. These complications include acute encephalopathy, lethargy, confusion state, tremor, headache, motor disorders, visual changes and epileptic crises amongst others, even when blood levels are at what are considered to be 'therapeutic' levels.

CLINICAL CASES

We present the EEG anomalies found in 3 transplant patients (two liver transplants and on double lung transplant) to whom cyclosporin A had been given and who presented with status epilepticus. The EEG recordings showed paroxystic discharges of focal onset in the temporo-occipital areas. They were mainly correlated with the clinical findings of oculomotor and eyelid disorders.

CONCLUSION

The topography of the neurophysiological findings supports--as do the other clinico-radiological findings--localization preferably to the posterior areas of cerebral dysfunction associated with cyclosporin A. Although the physiopathological origin of the encephalopathy of patients treated with cyclosporin A seems to correspond to multiple factors, we wish to point out the diagnostic usefulness of the identification of EEG changes localized to the temporo-occipital areas in the recognition of the neurotoxic syndrome in these patients.

Community-acquired Staphylococcus aureus bacteraemia in patients who do not abuse intravenous drugs

Despite advances in antimicrobial therapy and intensive care support, Staphylococcus aureus continues to cause significant morbidity and mortality. We studied community-acquired S. aureus bacteraemia in a population where intravenous drug abuse is extremely uncommon, prospectively reviewing all such patients (n = 113) admitted to Groote Schuur Hospital from February 1986 to January 1991. Overall mortality was 35%. Factors associated with poor outcome were: confusion on presentation, failure to mount a febrile response, acute renal failure, adult respiratory distress syndrome, shock, endocarditis, disseminated intravascular coagulation and platelet count of < 100 x 10(9)/l. Only confusion, acute renal failure and shock were independently associated with death by stepwise regression analysis. Skin infections were the most commonly identified source of bacteraemia (22%), but in 58% of patients the source was not determined. Twenty-six percent of patients were diabetic. Almost all patients (90%) developed one or more complications. In those who survived, therapy was generally prolonged, with a median of 70 days and range of 7-393 days, depending on the associated complications. Community-acquired S. aureus bacteraemia is a serious condition associated with a high complication rate and mortality.