Caisa Hofgren

Cognitive Function in Survivors of Out-of-Hospital Cardiac Arrest After Target Temperature Management at 33°C Versus 36°C

Background— Target temperature management is recommended as a neuroprotective strategy after out-of-hospital cardiac arrest. Potential effects of different target temperatures on cognitive impairment commonly described in survivors have not been investigated sufficiently. The primary aim of this study was to evaluate whether a target temperature of 33°C compared with 36°C was favorable for cognitive function; the secondary aim was to describe cognitive impairment in cardiac arrest survivors in general. Methods and Results— Study sites included 652 cardiac arrest survivors originally randomized and stratified for site to temperature control at 33°C or 36°C within the Target Temperature Management trial. Survival until 180 days after the arrest was 52% (33°C, n=178/328; 36°C, n=164/324). Survivors were invited to a face-to-face follow-up, and 287 cardiac arrest survivors (33°C, n=148/36°C, n=139) were assessed with tests for memory (Rivermead Behavioural Memory Test), executive functions (Frontal Assessment Battery), and attention/mental speed (Symbol Digit Modalities Test). A control group of 119 matched patients hospitalized for acute ST-segment–elevation myocardial infarction without cardiac arrest performed the same assessments. Half of the cardiac arrest survivors had cognitive impairment, which was mostly mild. Cognitive outcome did not differ (P>0.30) between the 2 temperature groups (33°C/36°C). Compared with control subjects with ST-segment–elevation myocardial infarction, attention/mental speed was more affected among cardiac arrest patients, but results for memory and executive functioning were similar. Conclusions— Cognitive function was comparable in survivors of out-of-hospital cardiac arrest when a temperature of 33°C and 36°C was targeted. Cognitive impairment detected in cardiac arrest survivors was also common in matched control subjects with ST-segment–elevation myocardial infarction not having had a cardiac arrest. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01946932.

Individual Placement and Support in Sweden—A randomized controlled trial

Abstract Background: Currently there is no evidence on the effectiveness of Individual Placement and Support (IPS) in Sweden. Aims: To determine the effectiveness of IPS on vocational outcomes among people with severe mental illness (SMI) in a Swedish context. A secondary aim was to evaluate a community integration effect. Methods: A randomized controlled trial with a parallel design was used. Mental health outpatients with SMI were randomized to IPS or traditional vocational rehabilitation (TVR) services. The allocation status was assessor-blinded. The primary outcome was competitive employment. All vocational outcomes were collected continuously, and socio-demographic and clinical variables at baseline, 6 and 18 months. The trial is registered with ClinicalTrials.gov: NCT00960024. Results: One hundred and twenty participants were randomized. Eighty seven per cent were assessed after 6 months, and 73% after 18 months. IPS was more effective than TVR in terms of gaining employment at 18-month follow-up (46% vs. 11%; difference 36%, 95% CI 18–54), along with the amount of working hours and weeks, longer job tenure periods and income. Cox regression analysis showed that IPS participants gained employment five times quicker than those in TVR. Ninety per cent of the IPS participants became involved in work, internships or education, i.e. activities integrated in mainstream community settings, while 24% in the TVR group achieved this. Conclusions: IPS is effective in a Swedish context in terms of gaining employment and becoming integrated within the local community. The welfare system presented obstacles for gaining competitive employment directly and it was indicated that internships delayed time to first competitive employment.

Return to work after acquired brain injury: facilitators and hindrances observed in a sub-acute rehabilitation setting.

OBJECTIVES There is great variability in the rate of return to work for persons who have suffered from brain injury. The aims of this study was: 1) to describe employment status of persons with stroke or traumatic brain injury, one year after the incident and 2) to investigate the impact of injury/stroke severity, length of stay, the ability to perform activities of daily living and cognitive function on return to work. PARTICIPANTS AND METHODS Information was collected from 72 persons; 48 with a diagnosis of stroke and 24 with a traumatic brain injury. All patients had attended to a Rehabilitation Centre with inpatient and outpatient facilities. Data of the above mentioned variables was gathered retrospectively and information about employment status was retrieved from the medical records. RESULTS After one year, 13 persons (approximately 18%), 5 with a stroke and 8 with a traumatic brain injury (one with mild brain injury, 9 with moderate and 3 persons with severe injuries) had returned to work. They had significantly shorter length of stay at the rehabilitation hospital and were younger than those that did not return to work. Somewhat better results at the neuropsychological screening were seen among those that returned to work, although with a significant difference only in the subscale assessing affect. Some persons with severe injury returned to work, while a majority of those with mild brain injury did not. CONCLUSION Traumatic brain injury, younger age and less need of rehabilitation were associated with a higher rate of returning to work. Patients with stroke were older and seem to need more support in order to be successful in work return. It is of importance to reach primary rehabilitation goals, such as being ADL independent, as this was also favourable for work return. The impact of injury severity seemed complex and should to be further explored. Persons with mild brain injury should be followed-up with respect to work return. An important cognitive factor was ability to perceive and express affective responses, reflecting the need of social skills in todays work-life.

Two years after cardiac arrest; cognitive status, ADL function and living situation

Purpose: To describe cognitive function, activities of daily living (ADL), housing and return to work after cardiac arrest (CA) and examine the prognostic value of early assessments. Method: Two years after CA 22 persons were assessed with the Barrow Neurological Screen for Higher Cerebral Functions (BNIS) and the Functional Independence Measure (FIM™). Data on early assessments of neurological status (The National Institute of Health Stroke Scale, NIHSS), mental status (the Mini Mental State Examination, MMSE) and ADL ability (FIM™) were retrieved. Results: Sixty-four per cent were living in their own home, 36% lived in sheltered accommodation and 29% of those of working age had returned to work. Cognitive dysfunction was noted in 95% according to neuropsychological screen. Four persons living in own homes were in need of assistance in social-cognitive ADL. All those in sheltered accommodation needed help in ADL; one was independent in motor functions. This need for assistance was reflected at initial assessments by a higher degree of neurological deficits, cognitive dysfunctions and dependency in ADL activities. Conclusion: The majority had persistent cognitive dysfunctions. Persons in sheltered accommodation were dependent for ADL. Early evaluation is important for understanding and planning for future need for assistance and care, having realistic goals.

Application and validation of the barrow neurological institute screen for higher cerebral functions in a control population and in patient groups commonly seen in neurorehabilitation.

OBJECTIVE To determine whether the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) can differentiate brain-dysfunctional patients from controls. DESIGN A case-control study. SUBJECTS A total of 92 controls and 120 patients from a neuro-rehabilitation clinic with a diagnosis of: right and left hemisphere stroke, traumatic brain injury, Parkinsons disease or anoxic brain damage. METHODS The BNIS has a maximum total score of 50 points, < 47 indicates cognitive dysfunction. Group comparisons and exploration of variables influencing the BNIS total score were made. RESULTS A significant difference was found between the control group and the total patient group for the BNIS total score and for the subscales (p < 0.0005). Sensitivity was 88% and specificity 78%. Presence of disease and educational level had the greatest influence on the results of the BNIS. Patients with Parkinsons disease were shown to be the least cognitively affected and those with anoxic brain damage the most affected. CONCLUSION The BNIS has potential value as a screening instrument for cognitive functions and is sufficiently sensitive to differentiate brain-dysfunctional patients from a control population. It appears to be applicable in a neurological rehabilitation setting, and can be used early in the process, giving a baseline cognitive functional level.

Individual placement and support illustrated in the Swedish welfare system: A case study

Individual Placement and Support (IPS) results in more people with severe mental illness obtaining employment in comparison to traditional vocational rehabilitation approaches. The implementation challenges of IPS vary across countries and contexts. However, the implications for IPS delivery and thus the IPS principles have not been studied in Sweden, which this embedded case study aims to investigate. The study was bounded by a single case, which was equivalent to the implementation of IPS in a Swedish city over 18 months. Data was collected from multiple units of information and consisted of interviews, documents and audio materials. A content analysis was used. The results showed that the first four IPS principles were challenged by the welfare system. Work capacity, in terms of amount of working hours per week, was evaluated differently in IPS and in the welfare systems prevocational services. In addition, the type of welfare benefit was decisive for IPS delivery and could be withdrawn if the IPS participant did not enter the prevocational rehabilitation situated within the welfare service. The differences of vocational approaches as experienced by professionals led to frustration, but also positive statements regarding how to increase integration between the welfare services and IPS. The authors discuss the tangible result and suggestive recommendations are made.

Support and process in individual placement and support: a multiple case study.

OBJECTIVE This multiple case study investigated support and process in the Individual Placement and Support (IPS) approach from individual client, longitudinal, and Person-Environment-Occupation (PEO) model perspectives. PARTICIPANTS Five IPS-participants, or cases, with severe mental illness (SMI) who worked a minimum of 4 hours a week entered the study. METHODS A multiple data collection method was used over a period of 12 months and included IPS-vocational profiles and plans as well as various instruments and questionnaires concerning socio-demographics, work performance, limitations, and accommodations. Both within- and across-case analyses were performed. RESULTS The IPS-process concerned job search support, job-matches (PEO-match), and adjustment of the PEO-match by providing accommodations by on- and off-worksite support. All participants had limitations concerning social interactions and handling symptoms/tolerating stress. Several accommodations were made for the same limitations, mostly directed towards the social environment. Prior work experience, disclosure, and not being in an acute phase of illness seemed important to the support provided. CONCLUSIONS This study has visualised the support and process in IPS and provided a theoretical framework, the PEO-model, to detect limitations and provide IPS-support. The organization of IPS-support and methods of providing it to individuals may be important for job tenure and employment success.

Reclaiming the worker role: Perceptions of people with mental illness participating in IPS

Abstract Objective: People with severe mental illness are often successful in gaining work when participating in the evidence-based Individual Placement and Support (IPS) approach. Little evidence exists on how starting work is perceived by IPS participants. This qualitative study aimed to explore how IPS participants perceived working and the work environment to impact on their work performance. Methods: Nineteen participants starting work in mainstream work settings were interviewed. Questions from the Work Environment Impact Scale were used and data was analysed by content analysis. The participants strove to fit in by coping with environmental demands and adapting to their worker role. Results: Work was perceived as having a positive impact on their daily life, although starting work was perceived as a challenge and the mental illness affected work performance. Personal strategies were needed in order to cope. They perceived both supportive and demanding factors in their work environments, such as the employers support and the social atmosphere among colleagues. Conclusion: The study showed that it is vital to focus on the individuals own strategies for adapting to the worker role when designing the support, as well as to develop collaborative relationships with employers and to optimize the match between the individual and the demands of the work environment.

Cognitive impact of traumatic axonal injury (TAI) and return to work.

Objective: Axonal injury (AI) after traumatic brain injury (TBI) is often overlooked as an explanation for cognitive complaints when no damage is detected by computed tomography. The purpose was to assess cognition during the 12 months following a TBI and suspected traumatic axonal injury (TAI). Methods: The sample included 17 patients younger than 65 years old, however one died. In the acute phase and at 6 and 12 months, cognition, reaction time, psychomotor performance and finger tapping speed were assessed. Working memory and work status were added at 12 months. Acute MRI findings were recorded. Results: After 1 year, all patients still showed cognitive dysfunction. A recovery had been noted at 6 months, but a cognitive decline was indicated for the majority at 12 months. The sick-listed patients had TAI located in the corpus callosum and the brainstem. They were cognitively more impaired and in more areas than the four patients who had returned to work. Conclusion: Cognitive screening can identify the long-term impact of TAI identified by conventional MRI, used as a routine clinical technique. For rehabilitation and for insurance-related matters, these injuries must be taken seriously, as a deterioration over time might occur. Further research is needed.

Return to Work and Participation in Society After Out-of-Hospital Cardiac Arrest

Background: The aim of this study was to describe out-of-hospital cardiac arrest (OHCA) survivors’ ability to participate in activities of everyday life and society, including return to work. The specific aim was to evaluate potential effects of cognitive impairment. Methods and Results: Two hundred eighty-seven OHCA survivors included in the TTM trial (Target Temperature Management) and 119 matched control patients with ST-segment–elevation myocardial infarction participated in a follow-up 180 days post-event that included assessments of participation, return to work, emotional problems, and cognitive impairment. On the Mayo-Portland Adaptability Inventory-4 Participation Index, OHCA survivors (n=270) reported more restricted participation In everyday life and in society (47% versus 30%; P<0.001) compared with ST-segment–elevation myocardial infarction controls (n=118). Furthermore, 27% (n=36) of pre-event working OHCA survivors (n=135) compared with 7% (n=3) of pre-event working ST-segment–elevation myocardial infarction controls (n=45) were on sick leave (odds ratio, 4.9; 95% confidence interval, 1.4–16.8; P=0.01). Among the OHCA survivors assumed to return to work (n=135), those with cognitive impairment (n=55) were 3× more likely (odds ratio, 3.3; 95% confidence interval, 1.2–9.3; P=0.02) to be on sick leave compared with those without cognitive impairment (n=40; 36%, n=20, versus 15%, n=6). For OHCA survivors, the variables that were found most predictive for a lower participation were depression, restricted mobility, memory impairment, novel problem-solving difficulties, fatigue, and slower processing speed. Conclusions: OHCA survivors reported a more restricted societal participation 6 months post-arrest, and their return to work was lower compared with ST-segment–elevation myocardial infarction controls. Cognitive impairment was significantly associated with lower participation, together with the closely related symptoms of fatigue, depression, and restricted mobility. These predictive variables may be used during follow-up to identify OHCA survivors at risk of a less successful recovery that may benefit from further support and rehabilitation. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01946932.