A Conceptual Model of Cognitive Deficits in Chronic Heart Failure

PURPOSE: To describe a conceptual model to guide studies of cognitive deficits among patients with heart failure. ORGANIZING FRAMEWORK: The conceptual framework of cognitive deficits in chronic heart failure is based on theoretical and empirical literature about (a) the pathophysiology of heart failure, (b) the pathophysiology of cognitive deficits, and (c) health-related quality of life. Other variables that may cause or contribute to cognitive deficits include age, the relative contributions of multiple comorbid conditions, hypertension, and depressive symptoms. Covariates that might influence cognitive deficits (medications, gender, and education) are also included in the model. The most prominent cognitive deficits are believed to occur in domains of attention, working memory, memory, learning, executive function, and psychomotor speed. The main outcome variable is health-related quality of life, which is believed to be influenced by circulatory insufficiency and cognitive deficits. CONCLUSIONS: The conceptual model described in this paper is a framework for testing cognitive deficits that occur in heart failure. After validation through empirical testing, the model may be useful in developing interventions for patients with heart failure whose care is complicated by cognitive deficits.     

Executive function deficits in acute stroke

OBJECTIVES: To establish the frequency of executive dysfunction during acute hospitalization for stroke and to examine the relationship of that dysfunction to stroke severity and premorbid characteristics. DESIGN: Inception cohort study. SETTING: Inpatient wards at a Veterans Affairs hospital. PARTICIPANTS: Consecutive sample of inpatients with radiologically or neurologically confirmed stroke. Final sample included 47 patients screened for aphasia and capable of neuropsychologic testing. Two nonstroke inpatient control samples (n=10 each) with either transient ischemic attack (TIA) or multiple stroke risk factors were administered the same research procedure and tests. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Composite cognitive impairment ratio (CIR), calculated from 8 scores indicative of executive function on 6 neuropsychologic tests by dividing number of tests completed into the number of scores falling below cutoff point, defined as 1.5 standard deviations below normative population mean. RESULTS: Stroke patients had a mean CIR of .61, compared with .48 for TIAs and .44 for stroke-risk-only. Analysis of variance revealed that CIRs of stroke-risk-only patients but not TIAs were lower than those of the stroke patients (P=.02). Impairment frequencies were at least 50% for stroke patients on most test scores. The Symbol Digit Modalities Test (75% impairment) and a design fluency measure distinguished stroke from nonstroke patients. CIR was not related to stroke severity in the stroke patient sample, but was related to estimated premorbid intelligence. CONCLUSIONS: Executive function deficits are common in stroke patients. The data suggest that limitations in information processing due to these deficits may require environmental and procedural accommodations to increase rehabilitation benefit.     

The cerebellum and cognitive function: Implications for rehabilitation

Objective: To characterize the cognitive effects of isolated cerebellar lesions.Design: Review of two inpatient cases.Setting: The rehabilitation unit of a tertiary general hospital.Patients or Other Participants: Two patients with acute ischemic strokes who had solitary cerebellar infarcts.Interventions: Assessment with standard neuropsychological tests. Scores were compared with patients' premorbid levels and standardized test norms. A classical conditioning eyeblink paradigm was performed.Main Outcome Measures: Neuropsychological measures of intellectual and executive functions, learning and memory, visual-spatial abilities, language functioning, fine motor speed, and dexterity.Results: Test findings suggested lesion-associated deficits in higher aspects of cognition (visuospatial reasoning, verbal and visual memory, and intellectual and executive functions). These functions are not usually associated with the fundamentally motoric role of the cerebellum.Conclusions: (1) Lesions in the cerebellum can be associated with impairments in higher cognitive functioning. (2) Such effects may be severe enough for a diagnosis of dementia under current diagnostic criteria. (3) These rehabilitation patients may benefit from comprehensive cognitive examination to determine if cognitive effects will detract from their participation. (4) Further research is needed to localize which cerebellar areas affect which cognitive abilities.     

Neuropsychological performance, impulsivity, and comorbid psychiatric illness in patients with pathological gambling undergoing treatment at the CORE Inpatient Treatment Center

INTRODUCTION: Pathologic gambling is a disorder with features that implicate abnormal functioning in brain regions involved in addiction, mood, anxiety, and impulse control disorders. Our goal was to examine brain function with neurocognitive tasks that target these brain regions in patients with pathologic gambling. METHODS: Patients were evaluated for comorbid psychiatric disorders, impulsivity, and performance on reversal-learning and reward-based decision-making cognitive tasks. RESULTS: Patients had higher impulsivity scores and significant deficits on both cognitive tasks compared with controls. All subjects also had comorbid psychiatric disorders, including mood, anxiety, psychotic, and substance abuse. CONCLUSION: The cognitive deficits and impulsivity are consistent with abnormal activity in orbitofrontal-limbic networks. The high level of comorbidity is consistent with the overall severity in these inpatients undergoing treatment, and adds weight to the concept of a fundamental abnormality in this network.     

Cognitive rehabilitation following anterior communicating artery aneurysm bleeding: a case report

The present case report documents the successful rehabilitation of a severely amnesic anterior communicating artery aneurysm patient. The patient was able to return to his premorbid high-level occupation after significant improvement in executive functioning, moderate improvement in visual memory, modest improvement in immediate verbal memory, and minimal improvement in delayed verbal memory. An interdisciplinary approach to rehabilitation was utilized in conjunction with empirically based intervention strategies. The implications of improved executive functions versus memory functions for successful rehabilitation are discussed.     

Cognitive functions among Hong Kong Chinese people with schizophrenia

Persons with schizophrenia show deficits in a variety of cognitive domains including executive function, attention, memory and language. Similar interest in studying the impact of cognitive deficits on the everyday functioning of people with schizophrenia has been documented. This study examined the cognitive functioning among Hong Kong Chinese schizophrenic patients compared with other patient groups, and its relationship with functional outcome, especially in the social aspect. Results indicated that schizophrenic patients presented with mild cognitive problems compared with neurosurgical and demented patients. Initial support was found in relating cognitive functions, as measured by Neurobehavioral Cognitive Status Examination, with functional outcome as measured by Functional Independence Measures. The implication for community rehabilitation is also discussed.     

An overview of nonpathological geroneuropsychology: implications for nursing practice and research

One aspect of successful aging is maintaining cognitive functioning, which includes both subjective cognitive functioning and objective cognitive functioning even in lieu of subtle cognitive deficits that occur with normal, nonpathological aging. Age-related cognitive deficits emerge across several domains including attention, memory, language, speed of processing, executive, and psychomotor, just to name a few. A primary theory explaining such cognitive deficits is cognitive reserve theory; it posits that biological factors such as demyelination and oxidative stress interfere with neuronal communication, which eventually produces observable deficits in cognitive functioning. Therefore, it is important to maintain or improve cognitive reserve to augment cognitive functioning in later life. This article provides a general overview of the principles of geroneuropsychology along with implications for nursing practice and research.     

The Neurocognitive Effects of Type 1 Diabetes Mellitus in Children and Young Adults With and Without Hypoglycemia

Type 1 Diabetes Mellitus is one of the most common illnesses found in children under the age of 18 as well as in young adults. Symptoms of this disease, including those with and without severe hypoglycemia, create abnormal blood glucose levels along with abnormal insulin levels. These abnormal chemical levels have been associated with neurocognitive deficits in memory, attention, motor skills, visuospatial abilities and executive functioning. In this paper, available literature on the central nervous system changes associated with the effects of insulin-dependent diabetes on school-aged children and young adults is reviewed. Implications for learning as well as a neurobiological cause of executive function deficits are discussed.     

Interaction of Cognitive Distortions and Cognitive Deficits in the Formulation and Treatment of Obsessive–Compulsive Behaviours in a Woman with an Intellectual Disability

Aims This case study describes the formulation and cognitive–behavioural treatment (CBT) of obsessive–compulsive thoughts and behaviours in a woman with an intellectual disability. The report aimed to distinguish the cognitive deficits that reflect her disability from the cognitive distortions integral to her obsessive–compulsive disorder. Case study Hence, we present one account of the cognitive–behavioural interventions aimed at correcting the cognitive distortions, and a separate account of the modifications necessary to compensate for specific cognitive deficits, which include impairments not only of ‘cognitive therapy skills’, but also of aspects of memory and executive functioning skills. Discussion We suggest that this analysis may provide a rational approach to the problem of simplifying CBT to meet the needs of people with intellectually disabilities, by identifying more clearly the specific adaptations that are needed by a particular individual. We also discuss the assessment of cognitive deficits that might impact on CBT, and some implications of this approach for research and training.     

Outcome after traumatic brain injury: pathway analysis of contributions from premorbid, injury severity, and recovery variables

OBJECTIVE: To examine the relationship of premorbid variables, injury severity, and cognitive and functional status to outcome 1 year after traumatic brain injury (TBI) and to assess the feasibility of multivariate path analysis as a way to discover those relationships. DESIGN: Prospective, longitudinal. SETTINGS: Level I trauma center, acute inpatient rehabilitation hospital. PATIENTS: One hundred seven subjects (87 men, 20 women; mean age, 33.91 +/- 14.2 yr) who had experienced severe TBI, typically from motor vehicle crashes. INTERVENTIONS: Acute medical and rehabilitation care. MAIN OUTCOME MEASURES: Disability Rating Scale, Community Integration Questionnaire, and return to employment. Evaluated in acute rehabilitation, and at 6 and 12 months' postinjury. RESULTS: Path analyses revealed that premorbid factors had significant relationships with injury severity, functional skills, cognitive status, and outcome; injury severity affected cognitive and functional skills; and cognitive status influenced outcome. No significant relationships were found between injury severity and emotional status, injury severity and outcome, emotional status and outcome, and functional skills and outcome. CONCLUSIONS: Multivariate analysis is important to understanding outcome after TBI. Injury severity, as measured in this study, is less important to 12-month outcome than the premorbid status of the person and the difficulties (particularly cognitive deficits) exhibited at follow-up 6 months after the trauma.     

Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002

OBJECTIVE: To update the previous evidence-based recommendations of the Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 1998 through 2002. DATA SOURCES: PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, and reasoning combined with each of the terms rehabilitation, remediation, and training. Reference lists from identified articles were reviewed and a bibliography listing 312 articles was compiled. STUDY SELECTION: One hundred eighteen articles were initially selected for inclusion. Thirty-one studies were excluded after detailed review. Excluded articles included 14 studies without data, 6 duplicate publications or follow-up studies, 5 nontreatment studies, 4 reviews, and 2 case studies involving diagnoses other than TBI or stroke. DATA EXTRACTION: Articles were assigned to 1 of 7 categories reflecting the primary area of intervention: attention; visual perception; apraxia; language and communication; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria. DATA SYNTHESIS: Of the 87 studies evaluated, 17 were rated as class I, 8 as class II, and 62 as class III. Evidence within each area of intervention was synthesized and recommendations for practice standards, practice guidelines, and practice options were made. CONCLUSIONS: There is substantial evidence to support cognitive-linguistic therapies for people with language deficits after left hemisphere stroke. New evidence supports training for apraxia after left hemisphere stroke. The evidence supports visuospatial rehabilitation for deficits associated with visual neglect after right hemisphere stroke. There is substantial evidence to support cognitive rehabilitation for people with TBI, including strategy training for mild memory impairment, strategy training for postacute attention deficits, and interventions for functional communication deficits. The overall analysis of 47 treatment comparisons, based on class I studies included in the current and previous review, reveals a differential benefit in favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition. Future research should move beyond the simple question of whether cognitive rehabilitation is effective, and examine the therapy factors and patient characteristics that optimize the clinical outcomes of cognitive rehabilitation.     

Combined analyses of thalamic volume, shape and white matter integrity in first-episode schizophrenia

The thalamus has been considered to be integral to the pathophysiology of schizophrenia. To determine whether its anatomical abnormalities may be associated with cognitive deficits in the onset of schizophrenia, we assessed thalamic volume, shape, white matter integrity, and their correlations with cognition in patients with first-episode schizophrenia. T1-weighted magnetic resonance and diffusion tensor (DT) images were collected in 49 healthy comparison controls (CON) and 32 patients with FES (FES). Large deformation diffeomorphic metric mapping (LDDMM) algorithms were used to delineate and assess the thalamic shape from MRI scans. The thalamic white matter integrity was quantified by fractional anisotropy (FA) and mean diffusivity (MD) averaged over the thalamus using DTI. Our analysis revealed that FES did not differ from CON in FA and MD but did differ markedly from them in the thalamic volume and shape. Patients with FES also performed poorly in spatial working memory and executive tasks. The correlation study found that regional thalamic shapes highly correlate with the two cognitive scores in the entire sample and healthy comparison controls but not in patients with FES even though no correlation was found between the thalamic volumes with the two cognitive scores in any group. Left thalamic FA was correlated with spatial working memory deficits in FES. Our findings suggest that thalamic volume and shape abnormalities are evident at the onset of FES prior to thalamic abnormal white matter integrity. Altered microstructural white matter integrity assessed using DTI may not be apparent in FES but may be observed as the disease progresses. Cognitive deficits related to spatial working memory and executive functioning in FES were observed in the context of loss of their normal relationship with the thalamic shapes, that is, regionally-specific thalamic shape compression is associated with poor performance in executive functioning and spatial working memory.     

Integrative group-based cognitive rehabilitation efficacy in multiple sclerosis: a randomized clinical trial

Purpose: This study aimed to determine the efficacy of the integrative group-based cognitive rehabilitation programme, REHACOP, on improving cognitive functions in multiple sclerosis (MS).

Methods: Fourty-two MS patients were randomized to the treatment programme REHACOP (n?=?21) or waiting list control condition (n?=?21). The REHACOP group received cognitive rehabilitation in group format for three months focused on attention, processing speed, learning and memory, language, executive functioning, and social cognition. Patients completed a neuropsychological assessment at baseline and follow-up, which included tests of attention, processing speed, working memory, verbal memory, verbal fluency, and executive functioning. Repeated measures multivariate analysis of covariance (MANCOVA) was used to determine the efficacy of the cognitive rehabilitation programme.

Results: Group?×?Time interactions revealed significant improvements in the REHACOP group as compared with the control group for processing speed (p?=?0.011, n_p²?=?0.16), working memory (p?=?0.014, n_p²?=?0.15), verbal memory (p?=?0.025, n_p²?=?0.13), and executive functioning (p?=?0.024, n_p²?=?0.13), showing medium–large effect sizes.

Conclusions: Patients receiving REHACOP showed improvements in several cognitive domains. This preliminary study thus provides evidence supporting the efficacy of this integrative group-based cognitive rehabilitation intervention in MS. Future research should confirm these findings, examine the impact of the treatment on everyday life functioning and explore the presence of brain changes associated with cognitive rehabilitation.

• Implications for rehabilitation

• This study provides initial evidence for integrative group-based cognitive rehabilitation efficacy in MS patients through the implementation of the REHACOP cognitive rehabilitation programme.

• Patients received cognitive rehabilitation for three months (3 one-hour-sessions per week) focused on training attention, learning and memory, language, executive functioning, and social cognition.

• Patients attending REHACOP sessions showed medium to large and statistically significant improvements in processing speed, working memory, verbal memory, and executive functioning.

     

Postoperative variation in neurocognitive and functional status in elderly hip fracture patients

Regaining independence in the performance of activities of daily living (ADL) is a nursing priority in the postoperative care of hip fracture patients, though often impeded by a temporary yet reversible decrease in cognitive status postoperatively. This study investigated the incidence and evolution of decreased cognitive status in geriatric hip fracture patients from admission through to the fifth postoperative day, and the relationship between cognitive abilities and functional (ADL) status. Twenty-six elderly hip fracture patients (f: 21, m: 5) with a mean age of 79·5 years ( SD =8·2) admitted to the emergency room of an academic medical centre were monitored longitudinally from admission until the fifth postoperative day regarding neurocognitive status and ADL status, as measured by the mini-mental state exam (MMSE; including subscales of memory, linguistic ability, concentration and psychomotor executive skills) and an adapted version of the Katz ADL-scale, respectively. Patients were categorized on the basis of cognitive status as follows: no cognitive impairment (MMSE≥24), moderate (MMSE≤23 but ≥18) and severe impairment (MMSE≤17). Nineteen of the 26 patients (73·1%) showed cognitive impairment (MMSE≤23) at some point in time before and/or after surgery. Some improvement in cognitive status was observed yet only selectively across patient cohorts and neurocognitive dimensions. Cognitive status, especially memorial ability and psychomotor executive skills, seemed to be most vulnerable to becoming impaired after hip fracture surgery. A relationship was found between cognitive and functional status, specifically, strong associations between memory and psychomotor skills relative to ADL and modest associations between linguistic ability and concentration relative to ADL. Further, patients with decreased cognitive status postoperatively remained more ADL-dependent than non-impaired patients. This study underscores the importance of a systematic assessment of the cognitive status of elderly hip fracture patients and linking these observations to functional ability in order to enhance the postoperative rehabilitation of this patient group.     

Impact of perceived cognitive impairment in breast cancer survivors

PurposeCognitive impairment is commonly reported by breast cancer survivors, yet little is known regarding its impact on quality of life. The purpose of this study was to obtain a better understanding of breast cancer survivors' experiences of perceived cognitive impairment, its trajectory, and its impact on relationships, daily functioning, work and overall life satisfaction after breast cancer diagnosis and treatment.MethodsThe results are based on qualitative interviews with 22 breast cancer survivors who reported cognitive impairment and who were at least 1 year post-chemotherapy treatment. Interviews were recorded, transcribed verbatim, and analyzed using a content analysis approach.ResultsBreast cancer survivors' primarily expressed concerns in 6 major domains including: short-term memory, long-term memory, speed of processing, attention and concentration, language and executive functioning. Concerns emerged as salient after treatment ended as other problems resolved. All of the survivors found these impairments frustrating, and some also reported these changes as detrimental to their self-confidence and social relationships. Employed survivors reported working harder to perform tasks and use of compensatory strategies to complete work tasks. Validation of perceived cognitive impairment by family, friends, and healthcare providers was perceived as important to adjustment.ConclusionsPerceived cognitive deficits have broad implications for the well-being of breast cancer survivors. Study findings underscore the broad consequences of this symptom, provide direction for theory development, measurement selection, and additional intervention targets. A greater understanding of cognitive impairment in breast cancer survivors may lead to the development of effective treatment of this symptom.     

Mindfulness,Obsessive–Compulsive Symptoms,and Executive Dysfunction

Recent investigations have included mindfulness as a component of intervention for OCD. However, the extent to which processes underlying OCD interfere with mindfulness has not been examined. Limited research has examined neuropsychological functions as mechanisms to explain different levels of mindfulness across individuals. Research in OCD highlights impairment in visual/spatial working memory as possible unique deficits; these and other components of executive functioning may also be important for mindfulness. Participants (N = 103) exceeding clinical cutoffs on measures of OCD, depressive, or generalized anxiety symptoms, or were healthy controls, completed a self-report measure of mindfulness and computerized measures of working memory and cognitive inhibition. Results demonstrated the OCD group scored significantly lower than the anxiety and control groups on some facets of mindfulness. The OCD group performed significantly worse on visual but not spatial working memory compared to verbal working memory. Additionally, the OCD group showed significantly poorer performance on all working memory tasks compared to the control group but not in comparison to other groups. There were no significant differences between the OCD group and the depression group on any measure. Finally, regression models examining working memory and cognitive inhibition as predictors of mindfulness found some support for two of the five facets of mindfulness, though the individual predictors were not significant. Implications are discussed in the context of mindfulness and executive functioning in OCD in terms of future research and treatment.     

Cognitive deficits in patients with heart failure: a review of the literature

PURPOSE: Chronic heart failure (HF) and cognitive impairments (CI) are common problems in the elderly. Both are associated with increased mortality and disability, decreased quality of life, and increased health care costs. While these conditions may occur by chance in the same individual, there is increasing evidence that HF is independently associated with CI. The purpose of this article is to review and critique the literature addressing the prevalence, type, and severity of CI in HF patients, the clinical factors associated with CI, and the potential pathophysiology underlying the development of CI, and to recommend priority areas for future research. RESULTS: Memory and attention deficits are the most frequently occurring CI in this patient population, followed by slowed motor response times and difficulties in problem solving. Prevalence rates range from 30% to 80% depending upon the age of the patients and the characteristics of the sample being studied. Most patients have mild impairments, although as many as one fourth may have moderate to severe CI. The relationship between left ventricular ejection fraction and cognition is inconsistent and may be nonlinear. The pathophysiology underlying the development of CI in HF patients may be related to both cerebral infarction and cerebral hypoperfusion either alone or in combination. CONCLUSIONS: The current literature is limited by studies with sometimes small or nonrepresentative samples, few matched control studies, and lack of longitudinal data that could indicate the conditions that favor the development of CI over time. Future research needs to focus on (1) determining the types, frequency, and severity of impairments in cognitive functioning among a representative sample of HF patients, (2) explicating the pathological mechanisms and the clinical factors that underlie the development of cognitive deficits, and (3) identifying the ways CI influences quality of life. Interventions can then be developed to prevent or delay the occurrence of CI or to minimize their effect on patient self-management and quality of life.     

Relations of brain volumes with cognitive function in males 45 years and older with past lead exposure

We examined relations between brain volumes assessed by MRI and cognitive function in subjects in whom we have previously reported associations of cumulative lead dose with: (1) longitudinal declines in cognitive function; (2) smaller volumes of several regions of interest (ROIs) in the brain; and (3) increased prevalence and severity of white matter lesions. We used two complementary methods (ROI- [evaluating 20 ROIs] and voxel-wise) to examine associations between brain volumes and cognitive function using multiple linear regression. MRIs and cognitive testing were obtained from 532 former organolead workers with a mean (SD) age of 56.1 (7.7) years and a mean of 18.0 (11.0) years since the last occupational exposure to lead at the time of MRI acquisition. Cognitive testing was grouped into six domains of function (visuo-construction, verbal memory and learning, visual memory, executive functioning, eye-hand coordination, processing speed). Results indicated that larger ROI volumes were associated with better cognitive function in five of six cognitive domains, with significant associations observed for visuo-construction (15 of 20, p相似文献   

Deep Brain Stimulation as a Treatment for Neuropathic Pain: A Longitudinal Study Addressing Neuropsychological Outcomes

Deep brain stimulation (DBS) of the periventricular/periaqueductal gray area and sensory thalamus can reduce pain intensity in patients with neuropathic pain. However, little is known about its impact on quality of life, emotional well-being, and cognition. This study followed up 18 patients who had received DBS for neuropathic pain. Each participant had previously undergone psychometric evaluation of each of the above areas as part of a routine presurgical neuropsychological assessment. Commensurate measures were employed at a follow-up assessment at least 6 months postsurgery. DBS significantly improved mood, anxiety, and aspects of quality of life. Improvements correlated with reduced pain severity. However, the sample continued to show impairments in most areas when compared against normative data published on nonclinical samples. There was little change in general cognitive functioning, aside from deterioration in spatial working memory. However, improvements in pain severity were associated with less improvement (and even deterioration) on measures of executive cognitive functioning. Improvements in emotional well-being also were correlated with changes in cognition. These results suggest that DBS of the periventricular/periaqueductal gray and/or sensory thalamus improves quality of life and emotional well-being in sufferers, although there is some indication of executive dysfunction, particularly among those reporting greatest pain alleviation.PerspectiveThis article examines the neuropsychological outcomes of DBS surgery as a treatment for neuropathic pain. This intervention was found to improve pain severity, emotional well-being, and quality of life, although such benefits may be accompanied by reduced ability on tasks measuring executive functioning.