Do patients with severe poststroke communication difficulties have a higher incidence of falls during inpatient rehabilitation? A retrospective cohort study

Background: Falls in hospital are common and serious complications of stroke. Associations have been found between communication disorders and increased rates of falls, but have received relatively little consideration as a risk factor for falls among stroke survivors.

Objectives: To investigate whether there is an association between severe communication impairment and falls among patients receiving inpatient rehabilitation after stroke.

Methods: A retrospective audit of 149 records of consecutive patients admitted to an inpatient rehabilitation facility after stroke over a two-year period was conducted. The relationship between falls and severe communication impairment was explored using (1) direct comparison of falls in patients with and without functional communication for the inpatient ward environment and (2) multivariate logistic regression to examine factors that may predict falls, including presence or absence of functional communication. In each analysis, falls were examined both as a binary outcome (fall or no fall), and the rate of falls per day.

Results: The 32 patients in the sample (21.7%) who were unable to communicate their basic needs were almost twice as likely to fall in hospital as those with functional communication (RR 1.94, 95% CI 1.15 to 3.24). Several commonly assessed factors were not significant predictors of falls (including falls history, polypharmacy, and cognitive impairment) in this population. Lack of functional communication was the strongest independent predictor of falls rate.

Conclusions: Findings suggest that severe communication disorders may be under recognized as a falls risk factor after stroke.     

Motor dual-tasking deficits predict falls in Parkinson's disease: A prospective study

IntroductionFalls severely affect lives of Parkinson's disease (PD) patients. Cognitive impairment including dual-tasking deficits contribute to fall risk in PD. However, types of dual-tasking deficits preceding falls in PD are still unclear.MethodsWalking velocities during box-checking and subtracting serial 7s were assessed twice a year in 40 PD patients over 2.8 ± 1.0 years. Fourteen patients reported a fall within this period (4 excluded fallers already reported falls at baseline). Their dual-task costs (DTC; mean ± standard deviation) 4.2 ± 2.2 months before the first fall were compared with 22 patients never reporting falls. ROC analyses and logistic regressions accounting for DTC, UPDRS-III and disease duration were used for faller classification and prediction.ResultsOnly walking/box-checking predicted fallers. Fallers showed higher DTC for walking while box-checking, p = 0.029, but not for box-checking while walking, p = 0.178 (combined motor DTC, p = 0.022), than non-fallers. Combined motor DTC classified fallers and non-fallers (area under curve: 0.75; 95% confidence interval, CI: 0.60–0.91) with 71.4% sensitivity (95%CI: 41.9%–91.6%) and 77.3% specificity (54.6%–92.2%), and significantly predicted future fallers (p = 0.023). Here, 20.4%-points higher combined motor DTC (i.e. the mean difference between fallers and non-fallers) was associated with a 2.6 (1.1–6.0) times higher odds to be a future faller.ConclusionMotor dual-tasking is a potentially valuable predictor of falls in PD, suggesting that avoiding dual task situations as well as specific motor dual-task training might help to prevent falls in PD. These findings and their therapeutic relevance need to be further validated in PD patients without fall history, in early PD stages, and with various motor-motor dual-task challenges.     

Natural history of falls in a population-based cohort of patients with Parkinson's disease: An 8-year prospective study

BackgroundProspective long-term studies of falls in Parkinson's disease (PD) are scarce.ObjectiveTo examine the development of falls over 8 years in a population-based cohort of ambulatory patients with PD, and to investigate predictors of future falls in non-fallers at baseline.MethodsAll patients were examined at baseline and after 4 and 8 years, including the UPDRS, MMSE, Montgomery and Aaberg Depression Rating Scale, Functional Comorbidity Index, and a clinical dementia interview. Logistic regression models were applied to investigate baseline risk factors for future falls. A total of 211 patients were included at baseline, whereas 121 and 64 were re-examined at 4 and 8 years, respectively.ResultsThe prevalence of falls increased from 41% (87 of 211) at baseline to 72% (46 of 64) after 8 years of prospective follow-up (disease duration 16.2 ± 4.8 years). Forty-seven non-falling patients at baseline completed all study visits, of these 68% (n = 32) changed fall status during follow-up. Predictive variables for current falling after 4 years were rare or occasional freezing of gait (OR 6.6, 95% CI 1.2–36.9), higher levodopa equivalent doses and more severe speech and axial impairment (both OR 1.3, 95% CI 1.0–1.7) in non-fallers at baseline. Higher baseline age was the only risk factor for current falling after 8 years.ConclusionsNearly ¾ of the PD cohort reported falling after 8 years of follow-up. Disease-specific gait and axial impairments were the major risk factors for future falls in non-fallers at baseline. This has implications for patient education and management.     

Electrophysiological changes in poststroke subjects with depressed mood: A quantitative EEG study

Background

We aimed to explore the electrophysiological changes in poststroke subjects with depressed mood.

Methods

Resting‐state electroencephalogram (EEG) signals of 16 electrodes in 35 poststroke depressed, 24 poststroke nondepressed, and 35 age‐matched healthy control subjects were analyzed by means of spectral power analysis, a quantitative EEG measurement of different frequency bands. The relationship among depressed mood, functional status, lesion side, and poststroke time was assessed by using variance and Spearman correlation analysis. Multiple analysis of variance was used to compare the differences among the 3 groups. Binary logistic regression analysis was used to establish a regression model to predict depressed mood in stroke subjects and to explore the association between depression and EEG band power. Receiver operating characteristic curves were used to estimate the ability of spectral power selected by binary logistic regression to indicate depressed mood in stroke subjects.

Results

We found that the hemisphere in which the lesion was located and the time since stroke onset had no effect on depressed mood. Only the patient's functional status was related to emotional symptoms. Quantitative EEG analysis revealed increased delta, theta, and beta2 power in stroke subjects with depressed mood, particularly in temporal regions. The theta and beta2 power in the right temporal area were shown to be highly sensitive to depressed mood, and these parameters showed good discriminatory ability for depressed subjects following stroke.

Conclusion

Depressed mood after stroke is associated with functional status. Quantitative EEG parameters may be a useful tool in timely screening for depressed mood after stroke.     

脑卒中后抑郁患者血清促肾上腺皮质激素研究

目的：研究脑卒中后抑郁（poststroke depression,PSD）患者血清促肾上腺皮质激素（ACTH）水平变化,探讨PSD患者的内分泌指标变化。方法：采用放射免疫法对59例PSD患者（PSD组）、36例无PSD患者（无PSD组）及43名正常人（对照组）的血清ACTH水平进行检测;并观察29例PSD患者抗抑郁治疗后血清ACTH水平变化。结果：治疗前PSD组血清ACTH水平显著高于无PSD组（P〈0．01）和对照组（P〈0．01）;治疗后,PSD抗抑郁治疗组与PSD无抗抑郁治疗组相比,汉密尔顿抑郁量表（HAMD）评分（P〈0．01）和ACTH水平（P〈0．01）均显著降低。在治疗前PSD组及在治疗后的PSD抗抑郁治疗组和PSD无抗抑郁治疗组中,HAMD评分与血清ACTH水平呈显著性正相关。结论：PSD患者血清ACTH水平明显升高并且与抑郁程度相关,提示PSD患者可能有内分泌功能的变化。     

A combined approach of bedside clinical examination and flexible endoscopic evaluation of swallowing in poststroke dysphagia: A pilot study

Background:

As with most neurologic conditions, stroke involves impairment of the swallowing mechanism. This could be a spectrum of issues, the worst of which is aspiration. At the same time, the prolonged presence of a naso-gastric tube (NGT) has its own morbidity. Flexible endoscopic evaluation of swallowing (FEES) is one reliable method to assess the structural and functional status of the oropharynx and larynx, during the swallowing process.

Objective:

To study the utility of FEES in decision-making with respect to resumption of oral intake in stroke patients. To document the findings of FEES in stroke patients, and to look for correlations between these and the site of stroke.

Materials and Methods:

Protocol insertion of naso-gastric tube in all stroke patients, at presentation. Initial assessment by a neurologist and swallowing therapist, depending on cognitive status of the patient. All patients underwent MRI Brain with diffusion weighted sequences. After detailed clinical examination, they underwent swallow exercises under the supervision of a trained swallowing therapist. The decision to remove NGT was taken clinically by the combined decision of neurologist and swallowing therapist. Then all patients underwent FEES by the ENT surgeon. The final decision for NGT removal was taken as per the FEES findings.

Result:

Sixteen stroke patients underwent the FEES procedure during a period of six months. The oropharyngeal and laryngeal findings varied depending on the area of stroke involvement. Of these, change in decision regarding swallowing rehabilitation or NGT removal was needed in four patients, following the FEES findings.

Conclusions:

FEES is an easy, efficient and reliable method to evaluate the swallowing status in stroke patients. In combination with good bedside clinical examination and swallow exercises, it can be a good tool in assessing patients with post- stroke dysphagia. Post-stroke rehabilitation and prevention of aspiration pneumonia can be effectively done with the help of FEES.     

Dance-based exergaming for upper extremity rehabilitation and reducing fall-risk in community-dwelling individuals with chronic stroke. A preliminary study

Background: Post-stroke, individuals demonstrate persistent upper extremity (UE) motor impairments that impact functional movements and change-in-support strategies essential for recovery from postural instability. OBJECTIVES: This study primarily aims to quantify the effect of dance-based exergaming (DBExG) intervention on improving paretic UE movement control. The secondary aim is to assess if these improvements in UE movement control if observed, could partially account for improved fall-risk.

Methods: Thirteen adults with chronic stroke received DBExG training using the commercially available Kinect dance gaming “Just Dance 3”. Surface electromyography of shoulder muscle activity during the stand-reaching task and UE shoulder kinematics for a dance trial were recorded. Changes in balance control were determined using the Activities-specific Balance Confidence scale [ABC] and Timed-Up-and-Go test [TUG].

Results: Post-training, participants demonstrated improvements in shoulder muscle activity in the form of performance (reaction time, burst duration, and movement time) and production outcomes (peak acceleration) (p < .05). There was also a post-training increase in shoulder joint excursion (Ex) and peak joint angles (∠) during dance trials (p < .05). Participants exhibited positive post-intervention correlations between ABC and shoulder joint Ex [R² of 0.43 (p < .05)] and between TUG and peak joint ∠ [R² of 0.51 (p < .05)]. CONCLUSION: Findings demonstrated the beneficial effect of DBExG for improving UE movement and the training-induced gains were also positively correlated with improvements in fall-risk measures in people with chronic stroke. Thus, DBEx training could be used as a meaningful clinical application for this population group.     

Clinical milestones in Parkinson's disease: A 7-year population-based incident cohort study

IntroductionClinical staging of Parkinson's disease (PD) is important for patient management and prognosis. The non-motor and functional features visual hallucinations, recurrent falls, dementia and nursing home placement are currently not included in clinical staging schemes, but have been suggested as clinical milestones with important prognostic implications in advanced PD. In this study, we sought to evaluate the potential of these four milestone events for clinical staging and prognosis during the early years of the disease.MethodsWe recruited 185 patients with incident PD and monitored prospectively every six months through seven years for emergence and consequences of four clinical milestones.ResultsOne or more milestones were reached in 53.0%. Of the patients who reached the milestones, visual hallucinations appeared after a median of 3.3 (interquartile range 1.3–4.9) years from diagnosis, recurrent falls after 3.8 (2.8–5.2) years, dementia after 4.0 (2.1–4.8) years and nursing home placement after 5.4 (3.9–6.7) years. Presence of any milestone was associated with occurrence of other milestones (relative risks 1.9–6.3; all p ≤ 0.001). Experiencing two or more milestones increased the risk of death during the study (relative risk 2.7, p = 0.03).ConclusionsIn early PD, visual hallucinations, recurrent falls, dementia and nursing home placement appear closely interrelated, possibly reflecting a shared neuropathological disease stage. All events convey important and sinister information on PD status and prognosis and are relatively easily accessible during routine clinical consultations. Therefore, they appear highly useful as clinical PD milestones and could possibly be incorporated into a novel disease rating scale.     

Multiple sleep–wake disturbances after stroke predict an increased risk of cardio-cerebrovascular events or death: A prospective cohort study

Background and purpose

Contradictory evidence on the impact of single sleep-wake-disturbances (SWD), such as sleep-disorderd breating (SDB) or insomnia, in patients with stroke, on the risk of subsequent cardio- and cerebrovascular events (CCE) and death, exists. Very recent studies in the general population suggest that the presence of multiple SWD increases cardio-cerebrovascular risk. Hence, the aim of this study was to asssess whether a novel score capturing the burden of multiple SWD, a so called "sleep burden index", is predictive for subsequent CCE including death in a prospectively followed cohort of stroke patients.

Methods

Patients with acute ischemic stroke or transient ischemic attack (TIA) were prospectively recruited. Four SWD were analyzed: (i) SDB with respirography; (ii) insomnia (defined using the insomnia severity index [ISI]); (iii) restless legs syndrome (RLS; defined using the International RLS Study Group rating scale); and (iv) self-estimated sleep duration at 1 and 3 months. A “sleep burden index”, calculated using the mean of z-transformed values from assessments of these four SWD, was created. The occurrence of CCE was recorded over a mean ± standard deviation (SD) follow-up of 3.2 ± 0.3 years.

Results

We assessed 437 patients (87% ischemic stroke, 13% TIA, 64% males) with a mean ± SD age of 65.1 ± 13.0 years. SDB (respiratory event index ≥ 5/h) was present in 66.2% of these patients. Insomnia (ISI ≥ 10), RLS and extreme sleep duration affected 26.2%, 6.4% and 13.7% of the patients 3 months post-stroke. Seventy out of the 437 patients (16%) had at least one CCE during the follow-up. The sleep burden index was associated with a higher risk for subsequent CCE, including death (odds ratio 1.80 per index unit, 95% confidence interval 1.19–2.72; p = 0.0056).

Conclusion

The presence of multiple SWDs constitutes a risk for subsequent CCE (including death) within the first 3 years following stroke. Larger systematic studies should assess the utility of the sleep burden index for patients' risk stratification in clinical practice.     

Effects of sleep duration and weekend catch-up sleep on falling injury in adolescents: a population-based study

ObjectiveThis population-based study aimed to determine the effects of sleep deprivation and compensatory weekend catch-up sleep on the risk of falls in adolescents.MethodsData from the 2013 Korean Youth Risk Behavior Web-based Survey on 57,225 adolescents were investigated. Demographic, socioeconomic, sleep-related, health-related behavioral, and psychological variables were compared between fallers (n = 7346) and non-fallers (n = 49,879). Multivariate logistic regression analysis using a hierarchical model was carried out to identify sleep-related factors (eg, sleep duration, longer weekend catch-up sleep) independently contributing to the risk of falls.ResultsCompared to non-fallers, fallers were associated with a shorter sleep duration (p = 0.001) and later bedtimes on weekdays and weekends (p < 0.001). An average sleep duration of ≤ 5 h (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.12–1.34) and of 6 h (OR 1.12, CI 1.03–1.21) were associated with an increased risk of falls. By contrast, an average sleep duration of ≥ 9 h (OR 0.90, CI: 0.82–0.99) and longer weekend catch-up sleep (OR 0.94, CI: 0.89–0.99) were associated with a decreased risk of falls.ConclusionOur results corroborate previous suggestions that short sleep duration is a major risk factor for falls among adolescents. Moreover, our study provided a novel finding that longer sleep duration and longer weekend catch-up sleep may have a protective effect against falls. Our findings have important public health implications that modifying school schedules to increase sleep duration could reduce unintentional falls and injuries in school-aged adolescents.     

Cardiovascular autonomic neuropathy and falls in Parkinson disease: a prospective cohort study

Journal of Neurology - Falls represent one of the main complications of Parkinson’s disease (PD), significantly lowering quality of life. Cardiovascular autonomic neuropathy (cAN) is one of...     

A review of balance and gait capacities in relation to falls in persons with intellectual disability

Limitations in mobility are common in persons with intellectual disabilities (ID). As balance and gait capacities are key aspects of mobility, the prevalence of balance and gait problems is also expected to be high in this population. The objective of this study was to critically review the available literature on balance and gait characteristics in persons with ID. Furthermore, the consequences of balance and gait problems in relation to falls were studied, as well as the trainability of balance and gait in persons with ID. The systematic literature search identified 48 articles to be included in this review. The literature consistently reports that balance and gait capacities are affected in persons with ID compared to their age-matched peers. These problems start at a young age and remain present during the entire lifespan of persons with ID, with a relatively early occurrence of age-related decline. From these results a conceptual model was suggested in which the development of balance and gait capacities in the ID population across the life span are compared to the general population. Regarding the second objective, our review showed that, although the relationship of balance and gait problems with falls has not yet been thoroughly investigated in persons with ID, there is some preliminary evidence that these aspects are also important in the ID population. Finally, this review demonstrates that balance and gait are potentially trainable in persons with ID. These results suggest that falls might be prevented with ID-specific exercise interventions.