Elizabeth R. Skidmore

Cognitive and affective predictors of rehabilitation participation after stroke.

OBJECTIVE To examine associations between cognitive and affective impairments and rehabilitation participation during stroke rehabilitation. DESIGN Secondary analyses of stroke patients who received acetylcholinesterase inhibitors during inpatient rehabilitation. SETTING University-affiliated inpatient rehabilitation facilities. PARTICIPANTS Patients (N=44) admitted to inpatient stroke rehabilitation with impairment in attention, memory, or executive functions. INTERVENTIONS Secondary analysis of patients receiving inpatient stroke rehabilitation care plus random assignment to one of two acetylcholinesterase inhibitors or no drug at rehabilitation admission. MAIN OUTCOME MEASURES Correlations between measures of cognitive (Digit Span, Hopkins Verbal Learning Test, Executive Interview) and affective impairments (Hamilton Rating Scale for Depression, Apathy Evaluation Scale) and participation (Pittsburgh Rehabilitation and Participation Scale) were examined. Significant correlates of participation were examined in a linear multiple regression model. RESULTS Executive functions and depressive symptoms were significant correlates of participation. After controlling for baseline disability, executive functions predicted participation, but depressive symptoms did not (F(4,32)=9.35; R(2)=.54, P<.001). CONCLUSIONS These findings are an important first step toward understanding potentially modifiable clinical factors that contribute to rehabilitation participation and overall functional status after rehabilitation. A better understanding of cognitive impairment and rehabilitation participation may be used to develop strategies for improving functional outcomes after stroke.

Onset of Depression in Elderly Persons After Hip Fracture: Implications for Prevention and Early Intervention of Late‐Life Depression

OBJECTIVES: To identify predictors of onset of major depressive disorder (MDD) and of depressive symptoms in subjects who suffered a hip fracture.

Association of the Serotonin Transporter Gene-Linked Polymorphic Region (5-HTTLPR) Genotype With Depression in Elderly Persons After Hip Fracture

OBJECTIVE The authors examined the serotonin transporter gene-linked polymorphic region (5-HTTLPR) as a predictor of major depressive disorder and depressive symptoms after hip fracture, a common stressful medical event. METHODS This was a prospective, observational study of 23 elderly rehabilitation-hospital patients during their inpatient stay. Depressive symptoms were assessed by Hamilton Rating Scale for Depression (Ham-D) and PRIME-MD. Subjects were also genotyped for 5-HTTLPR. RESULTS Survival analysis showed that genotype significantly predicted time-to-major depressive episode. Subjects with an s allele (genotype s/l or s/s) had significantly higher Ham-D scores over 14 weeks of follow-up than those with the l/l genotype. CONCLUSION Depressive symptoms and major depressive disorder in elderly persons after a stressful medical event may be associated with 5-HTTLPR genotype. This finding requires confirmation in a larger sample.

Cognitive-Motor Interference During Functional Mobility After Stroke: State of the Science and Implications for Future Research

Cognitive-motor interference (CMI) is evident when simultaneous performance of a cognitive task and a motor task results in deterioration in performance in one or both of the tasks, relative to performance of each task separately. The purpose of this review is to present a framework for categorizing patterns of CMI and to examine the specific patterns of CMI evident in published studies comparing single-task and dual-task performance of cognitive and motor tasks during gait and balance activities after stroke. We also examine the literature for associations between patterns of CMI and a history of falls, as well as evidence for the effects of rehabilitation on CMI after stroke. Overall, this review suggests that during gait activities with an added cognitive task, people with stroke are likely to demonstrate significant decrements in motor performance only (cognitive-related motor interference), or decrements in both motor and cognitive performance (mutual interference). In contrast, patterns of CMI were variable among studies examining balance activities. Comparing people poststroke with and without a history of falls, patterns and magnitude of CMI were similar for fallers and nonfallers. Longitudinal studies suggest that conventional rehabilitation has minimal effects on CMI during gait or balance activities. However, early-phase pilot studies suggest that dual-task interventions may reduce CMI during gait performance in community-dwelling stroke survivors. It is our hope that this innovative and critical examination of the existing literature will highlight the limitations in current experimental designs and inform improvements in the design and reporting of dual-task studies in stroke.

Abbreviated Environmental Enrichment Enhances Neurobehavioral Recovery Comparably to Continuous Exposure After Traumatic Brain Injury

Background. Environmental enrichment (EE) is a complex living milieu that has been shown to enhance functional recovery versus standard (STD) housing after experimental traumatic brain injury (TBI) and therefore may be considered a rodent correlate of rehabilitation. However, the typical EE paradigm consists of continuous exposure to enrichment after TBI, which is inconsistent with the limited time frame in clinical rehabilitation. Objective. To determine whether abbreviated EE (ie, rehabilitation-relevant dose response) confers benefits similar to typical EE after TBI. Methods. Adult male rats received either a controlled cortical impact (2.8 mm depth at 4 m/s) or sham injury and were then randomly assigned to TBI + EE, TBI + EE (2 hours), TBI + EE (4 hours), TBI + EE (6 hours), TBI + STD, and respective sham controls. Motor (beam balance/beam walk) and cognitive (Morris water maze) performance was assessed on postoperative days 1 to 5 and 14 to 19, respectively. Results. The TBI + EE (2 hours) and TBI + EE (4 hours) groups were not statistically different from the TBI + STD group in any behavioral assessment. In contrast, the TBI + EE (6 hours) group exhibited significant enhancement of motor and cognitive performance when compared with the TBI + STD group, as well as the TBI + EE (2 hours) and TBI + EE (4 hours) groups (P < .003), and did not differ from the TBI + EE (typical) group. Conclusions. These data demonstrate that abbreviated EE (6 hours) produces motor and cognitive benefits similar to continuous EE after TBI and thus may be considered a dose-relevant rehabilitation paradigm.

Role of Social Support in Predicting Caregiver Burden

OBJECTIVE To examine the unique contribution of social support to burden in caregivers of adults aging with spinal cord injury (SCI). DESIGN Secondary analyses of cross-sectional data from a large cohort of adults aging with SCI and their primary caregivers. SETTING Multiple community locations. PARTICIPANTS Caregivers of community-dwelling adults aging with SCI (n=173) were interviewed as part of a multisite randomized controlled trial. The mean age ± SD of caregivers was 53±15 years and of care-recipients, 55±13 years. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The primary outcome was caregiver burden measured with the Abridged Version of the Zarit Burden Interview. A hierarchical multiple regression analysis examined the effects of social supports (social integration, received social support, and negative social interactions) on burden in caregivers of adults aging with SCI while controlling for demographic characteristics and caregiving characteristics. RESULTS After controlling for demographic characteristics and caregiving characteristics, social integration (β=-.16, P<.05), received social support (β=-.15, P<.05), and negative social interactions (β=.21, P<.01) were significant independent predictors of caregiver burden. CONCLUSIONS Findings demonstrate that social support is an important factor associated with burden in caregivers of adults aging with SCI. Social support should be considered for assessments and interventions designed to identify and reduce caregiver burden.

Memantine for late-life depression and apathy after a disabling medical event: a 12-week, double-blind placebo-controlled pilot study.

Preclinical data suggests that memantine, a noncompetitive glutamate N‐methyl‐ D‐aspartate‐receptor blocker used for the treatment of moderate to severe Alzheimers disease, could reduce depressive and amotivated behavior occurring in the context of psychosocial stress. Therefore, we examined whether memantine could reduce depressive symptoms and amotivation manifesting in older adults after a disabling medical event, thereby improving their functional recovery.

The feasibility of meta-cognitive strategy training in acute inpatient stroke rehabilitation: Case report

Meta-cognitive strategy training may be used to augment inpatient rehabilitation to promote active engagement and subsequent benefit for individuals with cognitive impairments after stroke. We examined the feasibility of administering a form of meta-cognitive strategy training, Cognitive Orientation to daily Occupational Performance (CO-OP), during inpatient rehabilitation. We trained an individual with cognitive impairments after right hemisphere stroke to identify performance problems, set self-selected goals, develop plans to address goals, and evaluate performance improvements. To assess feasibility, we examined the number of meta-cognitive training sessions attended, the number of self-selected goals, and changes in goal-related performance. We also examined changes in rehabilitation engagement and disability. The participant used the meta-cognitive strategy to set eight goals addressing physically oriented, instrumental, and work-related activities. Mean improvement in Canadian Occupational Performance Measure Performance Scale scores was 6.1. Pittsburgh Rehabilitation Participation Scale scores (measuring rehabilitation engagement) improved from 3.2 at admission to 4.9 at discharge. Functional Independence Measure scores (measuring disability) improved from 68 at admission, to 97 at discharge. Performance Assessment of Self-Care Skills scores improved from 1.1 at admission to 2.9 at discharge. The results indicate that meta-cognitive strategy training was feasible during inpatient rehabilitation and warrants further evaluation to determine its effectiveness.

An Open-Label Pilot Study of Acetylcholinesterase Inhibitors to Promote Functional Recovery in Elderly Cognitively Impaired Stroke Patients

Background: Impairments in cognition and motivationare common after stroke and predict poor functional recovery. Pharmacological agents that enhance cognition and/or diminish apathy may, when combined with traditional rehabilitative efforts, improve functional recovery. We investigated the feasibility of using acetylcholinesterase inhibitors in older patients with acute post-stroke cognitive impairment and examined their effects on functional recovery. Methods: This 12-week open-label study prospectively treated ischemic stroke survivors aged ≧60 years who were undergoing inpatient rehabilitation and who had cognitive impairment in one or more domains (memory, attention or executive function). Participants received galantamine (maximum dose 24 mg/day) or donepezil (maximum dose 10 mg/day). Physical function was assessed using the Functional Independence Measure–motor subscale (FIM-motor); participants’ functional gains were compared to those of a matched historical comparator group. Changes in cognition and apathy were also assessed. Since donepezil and galantamine have different pharmacologic profiles, they were examined separately. Results: Forty participants started study medication; 14 participants terminated prematurely. Donepezil-treated participants experienced a 14-point greater improvement in the FIM-motor score compared to either galantamine-treated participants or the historical comparator group (repeated measures mixed model, group × time interaction p < 0.0001). Change in apathy, but not in cognition, was also associated with change in the FIM-motor score. Conclusions: In this open-label study, participants receiving donepezil had better functional recovery than participants receiving galantamine or the historical comparators. This improvement may reflect efficacy at the starting dose for donepezil but not galantamine. A randomized trial is in progress.

Comparison of Surface and Ultrasound Localization to Identify Forearm Flexor Muscles for Botulinum Toxin Injections

To determine if ultrasound (US) localization is equivalent to surface landmark localization to identify botulinum toxin injection targets for forearm muscle spasticity.