Assessment of cognitive function in heart failure patients.

BACKGROUND: Research on the cognitive capacity of heart failure patients is limited, with a paucity of benchmark information available for this population. It is highly likely that cognitive deficits affect patients' understanding of disease and treatment requirements, as well as limiting their functional capacity and ability to implement treatment plans, and undertake self-care. AIMS: The purpose of this study was to establish a comprehensive neurocognitive profile of the heart failure patient through systematic neurocognitive assessment and to determine whether an association existed between severity of heart failure and cognitive abilities. METHODS: Thirty-eight patients were recruited from the heart failure patient databases of two metropolitan hospitals in Melbourne, Australia. Participants were individually assessed using four standardised, internationally recognised neuropsychological tests that examined current and premorbid intelligence, memory and executive functioning. RESULTS: Although there was no significant decline from premorbid general intellectual function, other specific areas of deficit, including impaired memory and executive functioning, were identified. There were no significant correlations between heart failure severity and the neurocognitive measures used. CONCLUSION: The results support the need to recognise cognitive impairment in people with heart failure and to develop an abbreviated method of assessing cognitive function that can be easily implemented in the clinical setting. Identifying cognitive deficits in this population will be useful in guiding the content and nature of treatment plans to maximise adherence and minimise worsening of heart failure symptoms.     

脑卒中后情感淡漠与执行功能障碍、抑郁的相关性分析

目的:探讨急性脑卒中患者卒中后情感淡漠的发生,评价卒中后情感淡漠与抑郁、认知功能障碍、执行功能障碍的关系.方法:连续搜集于住院治疗的符合入组标准的急性脑卒中患者,采用淡漠评定量表-临床医生使用版本(AES-C)于起病后第2周对患者进行评估,根据有无伴发情感淡漠,将患者分为两组,比较两组间临床资料、MoCA、MMSE、HAMD、MDRS I/P评分是否存在显著性差异.评价AES-C评分和情感、认知、执行功能量表评分的相关性.结果:共有65例患者入组,其中22例(33.8%)患者存在情感淡漠症状.伴情感淡漠组患者MDRS I/P评分明显低于无伴情感淡漠组(25.2±2.5 vs.31.9±5.0 P<0.01),Pearson相关分析显示AES-C评分与MDRS I/P评分成负相关(r=-0.54,P<0.01),AES-C评分评分与HAMD评分成正相关(r=0.27,P=0.03).结论:卒中后情感淡漠的严重程度与抑郁程度、执行功能障碍程度明显相关.     

Performance-based gait tests for acute stroke patients

OBJECTIVE: Qualitative measures may not differentiate severity of deficits after an acute or subacute stroke. The aim of this study was to contrast the utility of performance-based gait tests with qualitative measures in a sample of acute stroke patients. DESIGN: Twenty acute stroke subjects had their performance-based gait measured by gait speed, walking distance, gait energy expenditure, and gait energy cost. They were also qualitatively evaluated for cognition, functional outcomes, motor impairment, and Functional Ambulation Category. RESULTS: Strong and significant correlations were observed among performance-based gait tests. Qualitative scales indicated moderate to minimal deficits in each domain evaluated, although they were not correlated among themselves, except for Functional Ambulation Category and FIM and FIM and Mini-Mental State Exam. Functional Ambulation Category correlated with performance-based gait tests. CONCLUSIONS: Performance-based gait tests are feasible to conduct during early recovery after a stroke and allow better discrimination among the patients than qualitative measures.     

Is there a relation between neuropsychologic variables and quality of life after stroke?

OBJECTIVES: To describe the quality of life (QOL) of stroke patients and to distill neuropsychologic predictors for poor QOL. DESIGN: A cohort study in which patients were neuropsychologically assessed at a mean of 72.2 days after stroke, with follow-up at a mean of 9.8 months after stroke. SETTING: Research department of a rehabilitation center. PATIENTS: A consecutive sample of 164 stroke patients (mean age, 55.2yr) recruited from a university hospital, a regional hospital, and a rehabilitation center. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Orientation, memory, attention and concentration, visuospatial and visuoconstructive functions, language, and arithmetic skills were assessed with neuropsychologic tests. QOL was assessed with the Sickness Impact Profile (SIP). RESULTS: An overall mean SIP score +/- standard deviation of 20 +/- 11 showed that stroke has a high impact on everyday functioning. Further analyses indicated that QOL is related in particular to tests measuring spatiotemporal and/or sequential aspects of behavior. Forward/backward stepwise regression analysis (n = 106) showed that poor QOL was more likely if patients had a poor result on the Trailmaking Test (TMT) B and/or were women. CONCLUSION: The predictive value of the TMT is most effective and very useful because the TMT is a short and economical procedure. However, the gender-related aspects of recovery deserve more attention, as does the possible bias that can be caused by the composition of a measurement. Further research is needed to refine predictive models that are needed to facilitate the development of more adequate, individual rehabilitation programs.     

脑卒中运动功能障碍的局部一致性fMRI研究

目的:运用静息态功能性磁共振成像探究不同程度运动功能障碍脑卒中的脑局部一致性(regional homogeneity,ReHo)变化。方法:对单侧皮质下脑卒中患者(其中轻度和重度运动功能障碍患者各13例)和13例健康志愿者分别进行静息态功能磁共振成像检查。分别计算三组被试的全脑ReHo值,运用双样本t检验得到组间的差异脑区,进一步将差异脑区的ReHo值与临床上肢运动功能评分及手腕运动功能评分作相关性分析。结果:与健康对照组比较,轻度组病灶同侧皮质下的尾状核和丘脑的ReHo显著减小,辅助运动区及病灶对侧颞下回、梭状回及小脑的ReHo显著增高。重度组病灶同侧的初级运动皮质、扣带前回、颞下回、脑岛、枕中回及丘脑的ReHo显著减小,病灶对侧额上回、颞下回及小脑的ReHo显著增高。患者子组比较,重度组病灶同侧枕中回和病灶对侧颞上回的ReHo均显著低于轻度组,其中枕中回的ReHo值与上肢和"手+腕"FMA(Fugl-Meyer Assessment)评分显示正相关(分别为r=0.647,r=0.682,P<0.001),颞上回的ReHo值亦与上肢和"手+腕"FMA评分显示正相关(分别为r=0.646,r=0.718,P<0.001)。结论:单侧皮质下脑卒中运动功能障碍静息态神经功能活动异常与运动功能严重程度密切相关,主要涉及邻近病灶的皮质下组织和远离病灶的脑皮质。其中一些脑区的ReHo值与患者运动功能评分存在相关性,或许说明ReHo分析可以作为评估卒中患者运动功能障碍的一个重要影像学指标。     

BrainHQ视觉训练改善脑卒中患者执行功能的效果分析

目的:观察BrainHQ视觉训练对脑卒中患者执行功能障碍的康复效果。方法:收集唐山市工人医院康复医院脑卒中执行功能障碍患者72例,采用分层随机的方法分为对照组(n=36)和干预组(n=36),对照组进行常规康复,干预组在对照组的基础上加用BrainHQ视觉训练,每次30min,5次/周,共4周。干预前及干预4周后,分别采用执行缺陷综合征行为学评价测验(BADS)对上述两组患者进行执行功能评测。结果:两组干预前BADS评分无显著性差异(P0.05),干预4周后,干预组较对照组的BADS子测验及总标准分均有所提高,差异有显著性意义(P0.01或P0.05)。结论:BrainHQ视觉训练可改善脑卒中患者的执行功能。     

Functional implications of ipsilesional motor deficits after unilateral stroke

OBJECTIVE: To investigate the functional impact of ipsilesional motor deficits after unilateral stroke and the best predictors of those deficits. DESIGN: Observational cohort. SETTING: Primary care Veterans Affairs and private medical center. PARTICIPANTS: Volunteer right-handed sample; stroke patients with left (LHD) or right hemisphere damage (RHD) a mean of 3.9 to 5.2 years poststroke and able-bodied participants who were tested using their left (LAB) or right hand. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Jebsen-Taylor Hand Function Test (JHFT). RESULTS: Ipsilesional JHFT performance was impaired to the same extent in the LHD and RHD groups. LHD patients with apraxia had poorer scores on the JHFT than LHD patients without apraxia and the LAB group. Regression analyses showed that severity of apraxia was the best predictor of JHFT performance for the LHD group and that right (ipsilesional) motor performance (grip strength, finger tapping) was the best predictor of JHFT performance for the RHD group. CONCLUSIONS: Ipsilesional deficits are present on simulated activities of daily living after LHD or RHD, suggesting that rehabilitation after stroke should include the ipsilesional arm and that ipsilesional limb apraxia is a better predictor of ipsilesional functional motor skills after LHD than aphasia or simple motor skills (grip strength, finger tapping). These findings suggest that limb apraxia should be assessed more routinely after stroke of the left hemisphere.     

The relationship between neuropsychologic function and level of caregiver supervision at 1 year after traumatic brain injury

OBJECTIVES: To evaluate distribution of levels of caregiver supervision at 1 year after traumatic brain injury, and to determine neuropsychologic predictors of supervision level. DESIGN: Prospective longitudinal design, concurrent measurement of neuropsychologic function and supervision level. SETTING: Seventeen Traumatic Brain Injury Model Systems centers. PARTICIPANTS: A total of 563 adults tested at 1 year postinjury; and a subgroup of 452 studied for neuropsychologic function in the absence of impairment in mobility or basic self-care, as assessed by high FIM instrument motor scores. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Supervision level measured by scores on Supervision Rating Scale (SRS). RESULTS: Two thirds (69%) of the sample was rated as independent of supervision. Participants without significant dysfunction on motor FIM were grouped into supervision groups differing in intensity of time commitment from caregiver (independent, moderate supervision, heavy supervision). In univariate analyses, groups differed on demographic variables (education, race, productivity prior to injury), duration of altered consciousness, and all but 1 neuropsychologic measure. A binomial regression model (complementary log-log model) revealed that supervision at 1 year was predicted by education and scores on the Trail Making Test Part B and digits backward. CONCLUSIONS: Findings confirm the importance of preinjury status and measures of working memory and cognitive flexibility in predicting functional independence after TBI. The SRS appears prone to ceiling effects in persons followed prospectively after moderate to severe TBI.     

Executive dysfunction is associated with self-care confidence in patients with heart failure

AimTo explore differences in self-care maintenance, management and confidence levels between American heart failure (HF) patients with and without executive dysfunction.BackgroundEvidence indicates some aspect of cognitive impairment is prevalent in up to 75% of the HF patient population. Moreover, cognitive impairment has been identified as a barrier to adequate self-care contributing to poor outcomes. There is limited understanding of the role executive function, a domain of cognitive performance, has on self-care behaviors for patients with HF.MethodThis secondary analysis examined the role of executive function, measured by the Clock Drawing Test (CDT), in relation to self-care measures. The Self Care of Heart Failure Index v6.2 (SCHFI v6.2) was used to measure self-care maintenance, management, and confidence.ResultsParticipants had a mean age of 75.1 ± 12.5 years, identified as male (59.4%), with New York Heart Association (NYHA) class III (57.3%). Executive function impairment was present in 28% of the sample. Comparison of self-care maintenance and management scores between the two groups were not significant. However, participants with executive dysfunction demonstrated an average self-care confidence score of 48.6 ± 23.3, while participants with no executive function impairment demonstrated a higher average self-care confidence score of 61.5 ± 18.4. Differences in self-care confidence scores between the groups were statistically significant (p = .014).ConclusionsHF self-care confidence is considered a moderator of self-care behaviors. Understanding the influence executive function has on self-care confidence may lead to a better understanding of those needing greater support with self-care behaviors.     

People with stroke living in the community: Attention deficits,balance, ADL ability and falls

PURPOSE: To describe levels of attention deficits among people with stroke living in the community and explore relationships between attention, balance, function and falls. METHOD: Forty-eight mobile community-dwelling people with stroke (30 men, 18 women, mean age 68.4 +/- 11.2) were recruited to this cross-sectional investigation through General Practitioners. Twenty-six participants had a right, 21 a left hemisphere infarction and one had a brain stem lesion; mean time since stroke was 46 months (range five to 204). Participants' were interviewed about fall-events; attention, balance and function were assessed using standardised tests. RESULTS: Visual inattention was identified in five participants (10%), deficits of sustained attention in 15 (31%), auditory selective attention in nine (19%), visual selective attention in 17 (35%) and divided attention deficits in 21 participants (43%). Sustained and divided attention scores correlated with balance, ADL ability and fall-status (p < 0.01). The balance and function of subjects with normal attention were better than those with abnormal scores (p < 0.01). Analysis of variance revealed differences between repeat-fallers and non-fallers with no near-falls for divided attention, balance and ADL ability (p < 0.01). CONCLUSIONS: Attention deficits were common among this sample; sustained and divided attention deficits correlated with functional impairments and falls, highlighting that attention deficits might contribute to accident prone behaviour and falling.     

Neuropsychologic outcome at one-month postinjury

Neuropsychologic outcome at one-month postinjury was investigated in a group of 102 adult patients with head injury representing a broad spectrum of severity. A group of friends of the patients with head injury was selected for comparison purposes. A comprehensive battery of measures assessing various abilities determined the adequacy of neuropsychological functions. Results support the following conclusions: head injury is associated with early deficits observable on measures assessing a broad spectrum of functions, ranging from simple to complex and motoric to abstraction skills; use of appropriate control groups is essential for determining head injury related deficits; the degree of neuropsychologic deficits depends on the severity of head injury; and the severity indices of time to following commands and depth of coma relate more closely and systematically to adequacy of one-month neuropsychologic outcome than does retrospectively assessed posttraumatic amnesia.     

Mild and marked executive dysfunction and falls in people with Parkinson’s disease

BackgroundExecutive dysfunction and risk of falling are hallmarks of Parkinson’s disease (PD). However, it is unclear how executive dysfunction predisposes people with PD to falling.ObjectivesTo: (i) identify sensorimotor, balance, and cardiovascular risk factors for falls that discriminate between those with normal executive function and those with mild and marked executive dysfunction in people with PD and (ii) determine whether mild and marked executive dysfunction are significant risk factors for falls when adjusting for PD duration and severity and freezing of gait (FOG).MethodsUsing the Frontal Assessment Battery, 243 participants were classified into normal executive function (n = 87), mild executive dysfunction (n = 100), and marked executive dysfunction (n = 56) groups. Participants were asked if they had episodes of FOG in the last month and were assessed with the Movement Disorders Society – Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), the Hoehn and Yahr Scale, the physiological profile assessment, and tests of orthostatic hypotension, coordinated stability, and gait and were then followed-up prospectively for falls for 32–52 weeks.ResultsSeveral PD-specific (elevated Hoehn and Yahr stage, higher MDS-UPDRS scale scores, a history of FOG, Postural Instability and Gait Difficulty subtype, and longer PD duration), sensorimotor (poor vision, knee extension weakness, slow simple reaction time), and balance (greater postural sway and poor controlled leaning balance) factors discriminated among the normal executive function and mild and marked executive dysfunction groups. Fall rates (mean ± SD) differed significantly among the groups (normal executive function: 1.0 ± 1.7; mild executive dysfunction: 2.8 ± 5.2; marked executive dysfunction: 4.7 ± 7.3) with the presence of both mild and marked executive dysfunction identified as significant risk factors for falls when adjusting for three measures of PD severity (Hoehn and Yahr scale scores, disease duration, and FOG).ConclusionsSeveral PD-specific, sensorimotor, and balance factors differed significantly among the normal, mild, and marked executive dysfunction groups and both mild and marked executive dysfunction were identified as independent risk factors for falls in people with PD.     

Geriatric depression, medical diagnosis, and functional recovery during acute rehabilitation

OBJECTIVE: To examine and compare the prevalence and functional impact of depressive symptoms for older adult stroke and nonstroke rehabilitation inpatients. DESIGN: Case-control study examining functional outcome using a 2 (stroke, nonstroke) by 2 (depression, no depression) design. SETTING: Urban hospital rehabilitation unit. PARTICIPANTS: A total of 509 rehabilitation inpatients (age, > or = 60 y) were included and grouped by diagnosis of stroke (n=207) and nonstroke (n=302). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Geriatric Depression Scale and FIM instrument. Analysis of covariance procedures examined the impact of depressive symptoms on discharge functional ability controlling for age, sex, admission functional ability, and hospital length of stay. RESULTS: Prevalence of depressive symptoms was similar for stroke (31.8%) and nonstroke (31.5%) and negatively associated with functional ability at discharge for both groups. Overall, the stroke and nonstroke groups did not differ significantly with respect to functional recovery. CONCLUSIONS: Depression, and its impact on acute rehabilitation, is significantly related to functional recovery but does not differ in its frequency or impact for stroke patients. Because depressive symptoms do not appear to discriminate across diagnostic groups, routine screening for depression is recommended for all rehabilitation inpatients.     

Marked improvement of neuropsychological impairment in a patient with chronic obstructive pulmonary disease after lung volume reduction surgery

This paper reports a case of a 71-year-old pulmonary emphysema patient with neuropsychological impairments that were markedly improved 6 months after he underwent lung volume reduction surgery (LVRS). He also underwent pulmonary rehabilitation before and after surgery. He was suspected of having memory impairment and attention disorder when he was referred for rehabilitation. The neuropsychologic test showed a general cognitive impairment, attention disorder, and verbal memory impairment. Magnetic resonance imaging showed moderate atrophy of the left hippocampal area, cortex, and lacunae infarction in the periventricular area. Interestingly, scores of the neuropsychologic test, as well as severity of dyspnea and lung function, remarkably improved 6 months after LVRS. These results suggested that the neuropsychological impairments in pulmonary emphysema patients can be improved after lung reduction surgery.     

Cognitive deficits in spinal cord injury: epidemiology and outcome.

Cognitive deficits are common among patients with acute spinal cord injury (SCI), but reported prevalence figures vary because of different methods of study. Factors associated with cognitive deficits in patients with SCI include age, educational background, history of learning disability, chronic alcohol and substance abuse, and concomitant or recurrent traumatic brain injury. Psychologic testing of patients with and without cognitive deficits indicates that impaired psychosocial adjustment and adaptation are more frequent in SCI patients who have evidence of cognitive deficits. Various associations have been found between neuropsychologic test performance and major depression. Cognitive functioning and premorbid educational level appear to be associated with medical stability, the patient's ability to assimilate the necessary skills for survival and adaptation after SCI, and readmission patterns after discharge for initial inpatient rehabilitation.     

Functional outcomes of children with sickle-cell disease affected by stroke

The nature and degree of functional recovery after stroke in children with sickle-cell disease (SCD) has not been extensively investigated. The purpose of this study was to evaluate retrospectively the functional status of 14 SCD children who had had strokes and to compare them with age-matched and gender-matched SCD children who had not had strokes. By doing so, we would be able to quantify the eventual physical and cognitive functional outcomes of survivors of stroke secondary to SCD and assess the impact of stroke on these patients. These children (five boys and nine girls) with SCD and stroke(s) were 11.6 +/- 4.3 years of age (range five to 18 years). They experienced one to three strokes at a mean age of 6.1 +/- 5.2 years (range one to 17 years). A series of tests were administered to these subjects to evaluate physical and psychosocial functions. These tests were performed at least one year after the latest stroke. This study showed that all of the SCD-stroke children were physically independent. Only a few had impairments of hand functions and mild difficulties in self-care activities. However, most of these children demonstrated intellectual deficits ranging from borderline to moderate mental retardation, reduced language functions ranging from low normal to retarded range, and problems in adjustment. Intelligence quotient of the children with SCD-stroke(s) was significantly lower than those of age-matched and gender-matched nonstroke SCD children, suggesting that stroke caused an adverse effect on the cognitive functioning of these children. The results indicate that in the SCD-stroke children psychosocial deficits outweighed physical disabilities.(ABSTRACT TRUNCATED AT 250 WORDS)     

Relationship between executive functions and productivity outcomes following stroke

PURPOSE: Stroke occurs in many individuals of working age and can considerably disrupt their capacity for employment and other productive activities. Few studies have examined the relationship between loss of productivity and cognitive impairment, particularly deficits in executive function. The present study examined whether performance on tests of executive function is related to employment and productivity at 12-months follow-up. METHOD: Twenty-seven individuals (mean age = 47.3 years, SD = 10.7) on average 2.1 years (SD = 1.6) post-stroke were recruited from hospital and community rehabilitation services and administered a theory-driven battery of executive function tests (i.e. Health and Safety sub-test, FAS Test, Five-Point test, Key Search Test and Tinkertoy Test). A 12-month follow-up assessment of employment outcome ('employed' or 'unemployed') and productivity (measured by the Sydney Psychosocial Reintegration Scale) was conducted. RESULTS: A series of between-group comparisons identified that a measure of purposive behaviour and self-regulation (i.e. the Tinkertoy Test) best distinguished between the employed and unemployed groups (p < 0.01) irrespective of time since injury and neglect. Level of post-stroke productivity was significantly correlated with measures of planning (p < 0.05), self-monitoring (p < 0.01) and self-regulation (p < 0.05), as well as time since injury (p < 0.05) and functional status (p < 0.01). CONCLUSIONS: These findings highlight the importance of routinely assessing executive functions to guide cognitive rehabilitation interventions following stroke.     

Short-duration robotic therapy in stroke patients with severe upper-limb motor impairment

Chronic motor deficits in the upper limb (UL) are a major contributor to disability following stroke. This study investigated the effect of short-duration robot-assisted therapy on motor impairment, as measured by clinical scales and robot-derived performance measures in patients with chronic, severe UL impairments after stroke. As part of a larger study, 15 individuals with chronic, severe UL paresis (Fugl-Meyer < 15) after stroke (minimum 6 mo postonset) performed 18 sessions of robot-assisted UL rehabilitation that consisted of goal-directed planar reaching tasks over a period of 3 weeks. Outcome measures included the Fugl-Meyer Assessment, the Motor Power Assessment, the Wolf Motor Function Test, the Stroke Impact Scale, and five robot-derived measures that reflect motor control (aiming error, mean speed, peak speed, mean:peak speed ratio, and movement duration). Robot-assisted training produced statistically significant improvements from baseline to posttreatment in the Fugl-Meyer and Motor Power Assessment scores and the quality of motion (quantified by a reduction in aiming error and movement duration with an increase in mean speed and mean:peak speed ratio). Our findings indicate that robot-assisted UL rehabilitation can reduce UL impairment and improve motor control in patients with severe UL paresis from chronic stroke.