Grace Campbell

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.

An integrative review of factors associated with falls during post-stroke rehabilitation.

Purpose: Our aims were to evaluate evidence of risk factors for falls among patients in stroke rehabilitation and to offer recommendations for clinical practice and future research. Method: We conducted an integrative review of the literature published from 1990 to 2009 that describes empirical investigations of risk factors for post-stroke falls during inpatient rehabilitation. We searched Medline, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo, and Embase databases, using the search terms “accidental falls,”“fall risk,”“risk factors,”“risk assessment,”“stroke,” and “cerebrovascular disorders.” We extracted information regarding study design, sample, potential risk factors, analytic methods, findings, and limitations from the 14 articles that met our inclusion criteria, and we rated the level of evidence for each study. Findings: Available empirical evidence points to impaired balance, visuospatial hemineglect, and impaired performance of activities of daily living as risk factors for falls during inpatient rehabilitation for stroke. Associations between falls and cognitive function, incontinence, visual field deficits, and stroke type were less clear, while relationships between falls and age, gender, stroke location, and impaired vision and hearing were not supported. Conclusions: The relatively sparse literature pertaining to risk factors for falls among stroke rehabilitation inpatients indicates that deficits affecting balance, perception, and self-care significantly increase the likelihood of falls. Particularly intriguing is the less well established role of post-stroke cognition in falls in this population. A conceptual model is needed to guide scientific inquiry and clinical practice in this area. Clinical Relevance: When clinicians in the inpatient stroke rehabilitation setting evaluate which patients are at greatest risk to fall, stroke-specific risk factors such as impaired balance, visuospatial hemineglect, and self-care deficits may be better predictors than more general risk factors such as age, incontinence, and sensory impairments. Patients with these stroke-specific deficits may benefit from the use of aggressive fall prevention interventions.

Symptom Identification in the Chronically Critically Ill

Ascertaining the symptom experience of chronically critically ill (CCI) patients is difficult because of communication impairment and fluctuations in patient cognition and physiologic conditions. The use of checklist self-report ratings is hampered by the inability of most CCI patients to respond verbally to symptom queries. In addition to the communication problems caused by mechanical ventilation, the apparently diverse idioms of symptom expression add to the potential for miscommunication regarding symptom experience. Although patient communication impairment is a major barrier to symptom identification, symptom assessment and treatment are fundamental components of nursing care for CCI. This article reviews and describes the unique constellation of symptoms experienced by many critically ill patients. We report our observations of symptom communication among CCI patients and nurses and discuss inconsistency in the language of symptom expression among nurses and patients. Clinically applicable strategies to improve nurse-patient symptom communication and suggestions for refinement of symptom assessment in chronic critical illness are provided.

SYMPTOM COMMUNICATION DURING CRITICAL ILLNESS: THE IMPACT OF AGE, DELIRIUM, AND DELIRIUM PRESENTATION

Symptom communication is integral to quality patient care. Communication between patients and nurses in the intensive care unit (ICU) is complicated by oral or endotracheal intubation and fluctuating neurocognitive status or delirium. We report the (a) prevalence of delirium and its subtypes in non-vocal, mechanically ventilated, critically ill patients; (b) impact of age on delirium; and (c) influence of delirium and age on symptom communication. Videorecorded interactions between patients (N = 89) and nurses (N = 30) were analyzed for evidence of patient symptom communication at four time points across 2 consecutive days. Delirium was measured at enrollment and following sessions. Delirium prevalence was 23.6% at enrollment and 28.7% across sessions. Participants age >60 were more likely to be delirious on enrollment and during observational sessions. Delirium was associated with self-report of pain, drowsiness, and feeling cold. Patients were significantly less likely to initiate symptom communication when delirious. Symptom identification should be carefully undertaken in older adults with or without delirium.

Usability of a Wearable Camera System for Dementia Family Caregivers

Health care providers typically rely on family caregivers (CG) of persons with dementia (PWD) to describe difficult behaviors manifested by their underlying disease. Although invaluable, such reports may be selective or biased during brief medical encounters. Our team explored the usability of a wearable camera system with 9 caregiving dyads (CGs: 3 males, 6 females, 67.00 ± 14.95 years; PWDs: 2 males, 7 females, 80.00 ± 3.81 years, MMSE 17.33 ± 8.86) who recorded 79 salient events over a combined total of 140 hours of data capture, from 3 to 7 days of wear per CG. Prior to using the system, CGs assessed its benefits to be worth the invasion of privacy; post-wear privacy concerns did not differ significantly. CGs rated the system easy to learn to use, although cumbersome and obtrusive. Few negative reactions by PWDs were reported or evident in resulting video. Our findings suggest that CGs can and will wear a camera system to reveal their daily caregiving challenges to health care providers.

The Stroke Assessment of Fall Risk (SAFR): predictive validity in inpatient stroke rehabilitation:

Objective: To evaluate relative accuracy of a newly developed Stroke Assessment of Fall Risk (SAFR) for classifying fallers and non-fallers, compared with a health system fall risk screening tool, the Fall Harm Risk Screen. Design and setting: Prospective quality improvement study conducted at an inpatient stroke rehabilitation unit at a large urban university hospital. Participants: Patients admitted for inpatient stroke rehabilitation (N = 419) with imaging or clinical evidence of ischemic or hemorrhagic stroke, between 1 August 2009 and 31 July 2010. Interventions: Not applicable. Main outcome measure(s): Sensitivity, specificity, and area under the curve for Receiver Operating Characteristic Curves of both scales’ classifications, based on fall risk score completed upon admission to inpatient stroke rehabilitation. Results: A total of 68 (16%) participants fell at least once. The SAFR was significantly more accurate than the Fall Harm Risk Screen (p < 0.001), with area under the curve of 0.73, positive predictive value of 0.29, and negative predictive value of 0.94. For the Fall Harm Risk Screen, area under the curve was 0.56, positive predictive value was 0.19, and negative predictive value was 0.86. Sensitivity and specificity of the SAFR (0.78 and 0.63, respectively) was higher than the Fall Harm Risk Screen (0.57 and 0.48, respectively). Conclusions: An evidence-derived, population-specific fall risk assessment may more accurately predict fallers than a general fall risk screen for stroke rehabilitation patients. While the SAFR improves upon the accuracy of a general assessment tool, additional refinement may be warranted.

Overcoming Practical Challenges to Conducting Clinical Research in the Inpatient Stroke Rehabilitation Setting

Abstract Background: There is a shortage of published empirical studies conducted in acute inpatient stroke rehabilitation, though such studies are greatly needed in order to shed light on the most efficacious inpatient stroke rehabilitation interventions. The inherent challenges of inpatient research may dissuade researchers from undertaking this important work. Objective: This paper describes our institutions experience devising practical solutions to research barriers in this setting. Method: Through concentrated efforts to overcome research barriers, such as by cultivating collaborative relationships and capitalizing on unanticipated benefits, we successfully facilitated conduct of five simultaneous inpatient stroke studies. Results: Tangible benefits realized include increased effectiveness of research participant identification and enrollment, novel collaborative projects, innovative clinical care initiatives, and enhanced emotional and practical support for patients and their families. We provide recommendations based on lessons learned during our experience, and discuss benefits of this collaboration for our research participants, clinical staff, and the research team.

Wearable Technology to Garner the Perspective of Dementia Family Caregivers

Family caregivers of individuals with dementia typically have limited opportunity during brief clinical encounters to describe the dementia-related behaviors and interactions they find difficult to handle. Lack of objective data depicting the nature, intensity, and impact of these manifestations of the underlying disease further constrains the extent to which strategies recommended by nurses or other health care providers can be tailored to the situation. The current article describes a prototype wearable camera system used to gather image and voice data from the caregivers perspective in a pilot feasibility intervention study conducted with 18 caregiving dyads. Several scenarios are presented that include salient events (i.e., behaviors or interactions deemed difficult by the caregiver or identified as concerning by the research team during screening) captured in the resulting video. The current authors anticipate future wearable camera systems and software will automate screening for salient events, providing new tools for assessment and intervention by nurses.

Stroke Unit Fall Prevention: An Interdisciplinary, Data‐Driven Approach

Situation: Frustration came over me as I shuffled through the file cabinet looking for the folder containing the blank incident report forms. As a manager, I felt that the entire stroke team had failed in the eyes of the patient and his loved ones. I dr eaded making yet another telephone call to a patient’s family to tell them that their loved one had fallen while performing a transfer with staf f. Moreover, the clinical team was becoming frustrated as well. They wer e highly trained, caring staf f dedicated to teaching patients to safely incr ease their independence, yet patients continued to fall during transfers. How can we accomplish safe, therapeutic transfers? Furthermore, how should we communicate these techniques to all staff in all disciplines? We need to identify an ef fective process to minimize transfer-related falls.

Cancer and treatment-related symptoms are associated with mobility disability in women with ovarian cancer: A cross-sectional study

OBJECTIVE To examine the prevalence of symptom-related mobility disability and identify specific symptoms and other factors associated with mobility disability among a national sample of ovarian cancer (OC) survivors. METHODS Descriptive, correlational secondary analysis of a National Ovarian Cancer Coalition mailed survey of women with a history of OC (n=713). We used the Symptom Representation Questionnaire (SRQ), the MD Anderson Symptom Inventory (MDASI) Interference Scale, and medical and demographic information to determine prevalence of symptom-related mobility disability. We constructed a multiple linear regression model to determine the relative contributions of specific symptoms and other factors to mobility disability. RESULTS A majority of the sample (60.0%) reported symptom-related mobility disability. Independent predictors included: > one comorbidity (β=0.112, p=0.001), active OC (β=0.111, p=0.037), abdominal bloating (β=0.097, p=0.006), fatigue (β=0.314, p<0.001), lack of appetite (β=0.072, p=0.045), numbness/tingling (β=0.134, p<0.001), and pain (β=0.194, p<0.001). The model explained 41.5% of the variance in symptom-related mobility disability (R2=0.415). Unexpectedly, age (β=-0.028, p=0.412) and current chemotherapy (β=0.107, p=0.118) were not significant predictors. CONCLUSIONS Symptom-related mobility disability is common among women with OC and is associated with medical comorbidities, abdominal bloating, fatigue, lack of appetite, numbness/tingling, and pain. Longitudinal research should clarify the relationship of these symptoms to mobility disability and determine whether effective symptom management minimizes disability.