Caroline M. van Heugten

Cognitive impairments in survivors of out-of-hospital cardiac arrest: A systematic review

OBJECTIVE To describe the current evidence on the frequency and nature of cognitive impairments in survivors of out-of-hospital cardiac arrest. DESIGN Systematic review. DATA SOURCES Pubmed, Embase, PsychInfo and Cinahl (1980-2006). No language restriction was imposed. REVIEW METHODS The following inclusion criteria were used: participants had to be survivors of out-of-hospital cardiac arrest, 18 years or older, and there had to be least one cognitive outcome measure with a follow-up of 3 months or more. Case reports and qualitative studies were excluded. The articles were screened on title, abstract and full text by two reviewers. All selected articles were reviewed and assessed by two reviewers independently using a quality criteria list. RESULTS Out of the 286 articles initially identified, 28 were selected for final evaluation. There was a high heterogeneity between the studies with regard to study design, number of participants, outcome measures and duration of follow-up. In general, the quality of the articles appeared low, with a few positive exceptions. The reported frequency of cognitive impairments in survivors of out-of-hospital cardiac arrest ranged from 6% to 100%. Memory problems were the most common cognitive impairment, followed by impairments in attention and executive functioning. Three high-quality prospective studies found that cognitive problems occurred in about half of the survivors of out-of-hospital cardiac arrest. CONCLUSION There are few good studies on the frequency of cognitive impairments after out-of-hospital cardiac arrest. However, cognitive problems, in particular memory problems, seem common in survivors of out-of-hospital cardiac arrest.

Efficacy and usability of assistive technology for patients with cognitive deficits: a systematic review

Objective: To determine the efficacy of portable electronic aids such as personal digital assistants (PDAs), pagers or mobile phones for patients with cognitive deficits by means of a systematic review. The usability of these aids is also briefly discussed. Data sources: PubMed, CINAHL, PsychINFO, EMBASE and MEDLINE were searched up to February 2009. The references of identified and relevant articles were scanned to find additional relevant titles. Review methods: Papers referring to ‘electronic aids’, ‘cognition’ and ‘brain injury’ were included. The population had to be adult and have cognitive impairments as a result of acquired brain injury. Outcome measures were change in cognitive or occupational performance or the level of participation in daily life. The criteria of Cicerone et al. were used to evaluate the quality of the retrieved studies. Results: Twenty-eight papers presenting 25 studies were reviewed. The total number of participants was 423. Most identified papers described case reports or non-randomized clinical trials. Only one randomized controlled trial was identified, in which the NeuroPage proved effective in supporting prospective memory. Other kinds of assistive technology such as PDAs and voice recorders showed positive results in supporting retrospective and prospective memory. Conclusion: The efficacy of assistive technology in general is not yet sufficiently studied in randomized controlled trials, although promising results has been reported. Furthermore, several survey studies established that both potential users and clinicians have optimistic expectations about the usability of assistive technology.

The prevalence of osteoarthritis of the intact hip and knee among traumatic leg amputees

OBJECTIVE To determine the prevalence of osteoarthritis (OA) in the knee and/or hip of the intact leg among traumatic leg amputees compared with the general population and its relationship with amputation level, time since amputation, age, and mobility. DESIGN Cross-sectional observational study. SETTING Outpatient population of 2 Dutch rehabilitation centers. PARTICIPANTS Patients (N=78) with a unilateral traumatic transtibial amputation, knee disarticulation, or transfemoral amputation of at least 5 years ago; ability to walk with a prosthesis; older than 18 years of age; and able to understand Dutch. Patients were excluded if they had bilateral amputations, other pathologies of the knee or hip, or central neurologic pathologies. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The prevalence of OA. RESULTS The prevalence of knee OA was 27% (men 28.3%, women 22.2%) and hip OA was 14% (men 15.3%, women 11.1%). This was higher compared with the general population (knee OA men 1.58%, women 1.33%, hip OA men 1.13%, women 0.98%, age adjusted). No significant relationships between the prevalence of OA and level of amputation, time since amputation, mobility, and age were found. CONCLUSIONS The prevalence of OA is significantly greater for both the knee and hip in the traumatic leg amputee population. No specific risk factors were identified. Although no specific risk factors in this specific population could be identified, it might be relevant to apply commonly known strategies to prevent OA as soon as possible after the amputation.

Use of assistive technology in cognitive rehabilitation: Exploratory studies of the opinions and expectations of healthcare professionals and potential users

Objective: To provide recommendations for the successful implementation of Assistive Technology (AT) in cognitive rehabilitation by investigating the attitudes towards AT of professionals, individuals with acquired brain injury (ABI) and their caregivers in two exploratory studies. Method: A total of 147 professionals in cognitive rehabilitation filled out a web-based survey. Fifteen patients with ABI and 14 caregivers were interviewed. Results: Most professionals were willing to use AT in the future, although only 27% used AT currently in a treatment setting. Professionals with AT experience were more positive than those without about the potential of AT and their own ability to use it in their treatment programmes. Most patients and caregivers were positive about using AT in the future, still, only a minority currently used AT. Refusal to reimburse AT devices by health insurance companies appeared an important barrier for a more widespread use. Conclusions: Although enthusiasm about AT was evident in both studies, a lack of progress in the implementation of AT was noted. This could be improved by promoting knowledge and hands-on experience of professionals who work in rehabilitation centres. More evidence on the efficacy of AT is required to improve coverage of AT devices by insurance companies.

Coping styles in relation to cognitive rehabilitation and quality of life after brain injury.

This study investigated the changes in coping styles of patients with acquired brain injury who underwent cognitive rehabilitation, and the effects of these changes on their quality of life. Participants were 110 patients in the chronic phase post-injury, who underwent outpatient cognitive rehabilitation according to current guidelines and standards. Coping style (Utrecht Coping List) was measured at the start of rehabilitation (T0) and repeated at least 5 months later (T1). Coping style was related to quality of life measured at T1 (Life Satisfaction Questionnaire and Stroke-Adapted Sickness Impact Profile). Results indicated that active problem-focused coping styles decreased and passive emotion-focused coping styles increased significantly between T0 and T1. Furthermore, the study showed that increases in active problem-focused coping styles and decreases in passive emotion-focused coping styles predicted a higher quality of life in the long term. These changes in coping styles are adaptive for the adjustment process in the chronic phase post-injury. Overall however, most participants showed maladaptive changes in coping styles. Implications for cognitive rehabilitation are therefore discussed.

Assessment of apraxia: inter-rater reliability of a new apraxia test, association between apraxia and other cognitive deficits and prevalence of apraxia in a rehabilitation setting:

Objective: To investigate the inter-rater reliability of a new apraxia test. Furthermore to examine the association of apraxia with other neuropsychological impairments and the prevalence of apraxia in a rehabilitation setting on the basis of the new test. Design: Cross-sectional cohort study, involving 100 patients with a first stroke admitted to a rehabilitation centre in the Netherlands. Measures: General patient characteristics and stroke-related aspects. Cognitive screening involving apraxia, visuospatial scanning, abstract thinking and reasoning, memory, attention, planning and aphasia. Results: The indices for inter-rater agreement range from excellent to poor. Significant correlations are found between apraxia and visuospatial scanning, memory, attention, planning and aphasia. The patients with apraxia perform significantly worse than the patients without apraxia on memory, the time needed to complete the tests for scanning and attention, and aphasia. The prevalence of apraxia is 25.3% in the total group, 51.3% in the left hemisphere stroke patients and 6.0% in the right hemisphere stroke patients. Patients with and without apraxia do not differ significantly concerning age, gender and type of stroke. Conclusion: The apraxia test has been shown to be a reliable instrument. Apraxia is often associated with aphasia, memory problems and mental slowness. This study shows that on the basis of the apraxia test, the prevalence of apraxia among patients in the rehabilitation centre is high, especially among patients with left hemisphere lesions.

The practical use of goal attainment scaling for people with acquired brain injury who receive cognitive rehabilitation

Objective: To examine the feasibility of and clinical experiences with goal attainment scaling when used for the evaluation of cognitive rehabilitation in people with acquired brain injury. Design: A prospective observational longitudinal study. Setting: A 21-week cognitive rehabilitation programme and a cognitive programme with varying length in two different Dutch rehabilitation centres. Subjects: Forty-eight consecutive patients with acquired brain injury enrolled during a 15-month period. Interventions: Cognitive rehabilitation programme. Main measure: Goal attainment scaling; the number of goals was counted; time to set goals was recorded; the number of different domains in which goals were set was counted; goal attainment scaling score was calculated at baseline, one week after the end of the cognitive rehabilitation programme and at six months follow-up; clinical experiences that could be useful for both clinical and research practice were recorded. Results: The mean (SD) age of the patients was 46.1 (10.7) years; 29 (60%) were male; 186 goals were set with a mean (SD) number of 4 (1) goals per patient. It was possible to set at least three realistic goals per patient within 30 minutes. Most goals were set in the cognitive domain (i.e. memory and attention), followed by the behavioural domain (i.e. fatigue and aggression). Conclusion: It proved possible to set three goals within an acceptable time-frame, to involve patients in the goal-setting procedure, to set realistic goals, and to set goals within relevant domains. Based on clinical experiences, goal attainment scaling is less feasible for research when patients lack insight, or suffer from comorbidity or mood problems.

Life after survival: long-term daily life functioning and quality of life of patients with hypoxic brain injury as a result of a cardiac arrest

Objectives : To determine the level of daily functioning and quality of life of patients with hypoxic brain injury after a cardiac arrest and to investigate the predictive value of the duration of coma and post-traumatic amnesia in long-term functioning. Design : A retrospective cohort study. Setting : A Dutch rehabilitation centre. Subjects : Thirty-two patients with hypoxic brain injury caused by a cardiac arrest 2—7 years ago, who were admitted to a brain injury rehabilitation programme. Main outcome measures : Cognitive Failures Questionnaire (CFQ), Frenchay Activities Index (FAI), Impact on Participation and Autonomy Questionnaire (IPAQ) and Quality of Life after Brain Injury questionnaire (QOLIBRI). Data on duration of coma and post-traumatic amnesia were retrieved from medical files. Results : A significant association was found between duration of coma, complaints of cognitive functioning (r = 0.57, P < 0.05) and quality of life after brain injury (r = —0.70, P < 0.01). Duration of post-traumatic amnesia was associated with both daily functioning (r = —0.70, P < 0.01) and quality of life (r = —0.70, P < 0.01). Furthermore complaints of cognitive functioning were associated with both the level of participation in society (r = 0.76, P < 0.01) and quality of life (r = 0.77, P < 0.01). Conclusions : Long-term outcome of patients with hypoxic brain injury after a cardiac arrest shows that this group is limited in cognitive and daily functioning, participation and quality of life. Based on the duration of coma and post-traumatic amnesia, an estimation of daily life functioning and quality of life 2—7 years after a cardiac arrest can be made.

Psychosocial functioning of spouses in the chronic phase after stroke: Improvement or deterioration between 1 and 3 years after stroke?

OBJECTIVE To describe the psychosocial functioning of spouses of stroke patients at 1 and 3 years after stroke and identify predictors of substantial negative change in psychosocial functioning. METHODS Prospective study (N=119). Five domains of psychosocial functioning were assessed: burden, life satisfaction, depression, harmony in the relationship and social support. We used paired t-tests to describe changes and identified substantial changes using an Effect Size of 0.5 as the cut-off point. RESULTS Fifty-one percent reported significant burden, 46% were dissatisfied with life and 51% reported depressive symptoms 1 year after the stroke. Changes in psychosocial functioning between 1 and 3 years post stroke were reported by 27%-57% of the spouses. Although burden improved, life satisfaction, social support and harmony in the relationship deteriorated significantly. The percentage of spouses with depressive symptoms remained stable. Spouses with young children were at risk of deteriorating psychosocial functioning. CONCLUSIONS A large proportion of spouses experience serious caregiver burden, depression and decreased life satisfaction, 1 year as well as 3 years after the stroke, and harmony in the relationship, social support and life satisfaction decline over time. PRACTICE IMPLICATIONS Rehabilitation programmes should give more attention to the relationship with the patients partner, family life and the maintenance of a support network.

Efficacy of Time Pressure Management in Stroke Patients With Slowed Information Processing : A Randomized Controlled Trial

UNLABELLED Winkens I, Van Heugten CM, Wade DT, Habets EJ, Fasotti L. Efficacy of Time Pressure Management in stroke patients with slowed information processing: a randomized controlled trial. OBJECTIVE To examine the effects of a Time Pressure Management (TPM) strategy taught to stroke patients with mental slowness, compared with the effects of care as usual. DESIGN Randomized controlled trial with outcome assessments conducted at baseline, at the end of treatment (at 5-10wk), and at 3 months. SETTING Eight Dutch rehabilitation centers. PARTICIPANTS Stroke patients (N=37; mean age +/- SD, 51.5+/-9.7y) in rehabilitation programs who had a mean Barthel score +/- SD at baseline of 19.6+/-1.1. INTERVENTION Ten hours of treatment teaching patients a TPM strategy to compensate for mental slowness in real-life tasks. MAIN OUTCOME MEASURES Mental Slowness Observation Test and Mental Slowness Questionnaire. RESULTS Patients were randomly assigned to the experimental treatment (n=20) and to care as usual (n=17). After 10 hours of treatment, both groups showed a significant decline in number of complaints on the Mental Slowness Questionnaire. This decline was still present at 3 months. At 3 months, the Mental Slowness Observation Test revealed significantly higher increases in speed of performance of the TPM group in comparison with the care-as-usual group (t=-2.7, P=.01). CONCLUSIONS Although the TPM group and the care-as-usual group both showed fewer complaints after a 3-month follow-up period, only the TPM group showed improved speed of performance on everyday tasks. Use of TPM treatment therefore is recommended when treating stroke patients with mental slowness.