Jean Saunders

Motor Symptoms in 100 Patients With Delirium Versus Control Subjects : Comparison of Subtyping Methods

BACKGROUND Different motor presentations of delirium may represent clinically meaningful subtypes. OBJECTIVE Authors sought to evaluate delirium phenomena. METHOD They used three non-validated delirium psychomotor subtype schemas, applied to a palliative-care population. Their unique items were merged to comprise a 30-item Delirium Motor Checklist (DMC) used to collect data, rate each schema, and determine subtype frequencies in 100 consecutive DSM-IV delirium patients and 52 medically-matched control subjects without delirium. The Delirium Rating Scale-Revised-98 (DRS-R98) assessed delirium severity, and subtype categorization using its two motor items was compared with the scale that used the psychomotor schema. RESULTS In delirium, motor disturbance was present in 100% by DMC versus 92% by DRS-R98 motor items; the DMC motor items also significantly distinguished delirium from control subjects. Motor subtype classification (hyperactive, hypoactive, mixed, and none) varied among the four methods, with low concordance across all four methods and 76% concordance for pairwise comparisons. The DRS-R-98 identified the most hypoactive delirium cases. CONCLUSION Motor disturbances are common in delirium, although whether they represent clinical subtypes is confounded by methodological issues. New motor subtyping methods are needed that are validated in other medical populations, use matched control subjects, and have higher sensitivity and specificity for pure motor features.

Cystatin C improves the detection of mild renal dysfunction in older patients

Background: Conventional estimates of glomerular dysfunction, including serum creatinine and creatinine clearance, are inadequate in older people. In this study we have compared the diagnostic accuracy of a novel test of kidney disease, cystatin C, against these markers in older patients with a range of renal function. Methods: Fifty-three patients (mean age 79.6 years, range 69-92 years) with a variety of medical diagnoses were recruited via outpatient clinics. Exclusion criteria included active rheumatoid disease, known current malignancy, renal replacement therapy/renal transplantation and cognitive impairment. 51Cr-EDTA was used as the reference method against which the other markers of glomerular filtration rate were compared using regression analyses. Results: The best fit with glomerular filtration rate was given by Cockcroft and Gault calculated clearance (R 2 = 0.83), followed by serum cystatin C (R 2 = 0.79), serum creatinine (R 2 = 0.76) and creatinine clearance (R 2 = 0.73). The accuracy for glomerular filtration rate prediction was poor for all markers. Serum cystatin C detected nearly all patients with mild renal impairment whereas serum creatinine only detected half of these cases. Regression modelling predicted that the upper limit of normal for serum cystatin C would be exceeded as glomerular filtration rate fell below 64 mL/min/1.73 m2, compared with 44 mL/min/1.73 m2 for serum creatinine. Conclusion: Serum cystatin C is a simple and sensitive screening test for kidney dysfunction in older people.

A comparison of neuropsychiatric and cognitive profiles in delirium, dementia, comorbid delirium-dementia and cognitively intact controls

Purpose Delirium and dementia have overlapping features that complicate differential diagnosis. Delirium symptoms overshadow dementia symptoms when they co-occur, but delirium phenomenology in comorbid cases has not been compared to both conditions alone. Methods Consecutive adults with DSM-IV delirium, dementia, comorbid delirium-dementia and cognitively intact controls were assessed using the Revised Delirium Rating Scale (DRS-R98) and Cognitive Test for Delirium (CTD). Results Delirium and comorbid delirium-dementia groups had comparable DRS-R98 and CTD total scores, which were greater than in dementia or control groups. On the DRS-R98, multiple non-cognitive symptoms, inattention and disorientation were more severe in delirium groups compared with dementia-alone. Patients with dementia differed from both delirium groups on the CTD test of attention. Spatial span backwards was significantly lower in all patients with cognitive impairment (delirium, comorbid delirium-dementia, dementia alone) compared to controls, whereas spatial span forwards distinguished delirium groups from dementia. Conclusions Delirium phenomenology is similar with or without comorbid dementia. A wide range of neuropsychiatric symptoms distinguish delirium from dementia. Spatial span forward is disproportionately diminished in delirium suggesting usefulness as a differentiating screening test.

Reversibility of delirium in terminally ill patients and predictors of mortality

In this study, factors related to reversibility and mortality in consecutive cases of Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) delirium [n = 121] occurring in palliative care patients were evaluated. Delirium was assessed with the revised Delirium Rating Scale (DRS-R98) and Cognitive Test for Delirium (CTD). Patients were followed until recovery from delirium or death. In all, 33 patients (27%) recovered from delirium before death. Mean time until death was 39.7 ± 69.8 days in patients with reversible delirium [n = 33] versus 16.8 ± 10.0 days in those with irreversible delirium [n = 88; P < 0.01]. DRS-R98 and CTD scores were higher in irreversible delirium (P < 0.001) with greater disturbances of sleep, language, long-term memory, attention, vigilance and visuospatial ability. Irreversible delirium was associated with greater disturbance of CTD attention and higher DRS-R98 visuospatial function. Survival time was predicted by CTD score (P < 0.001), age (P = 0.01) and organ failure (P = 0.01). Delirium was not necessarily a harbinger of imminent death. Less reversible delirium involved greater impairment of attention, vigilance and visuospatial function. Survival time is related to age, severity of cognitive impairment and evidence of organ failure.

Dance for People With Parkinson Disease: What Is the Evidence Telling Us?

OBJECTIVES (1) To appraise and synthesize the literature on dance interventions for individuals with Parkinson disease (PD); (2) to provide information regarding the frequency, intensity, duration, and type of dance used in these programs; and (3) to inform the development of future studies evaluating dance interventions in this population. DATA SOURCES Eight databases (MEDLINE, Cumulative Index to Nursing and Allied Health Literature [CINAHL], the Allied and Complementary Medicine Database [AMED], SPORTDiscus, PubMed, PubMed Central, Sage, and ScienceDirect) were electronically searched in April 2014. The references lists from the included articles were also searched. STUDY SELECTION Studies retrieved during the literature search were reviewed by 2 reviewers independently. Suitable articles were identified by applying inclusion criteria. DATA EXTRACTION Data regarding participants and the frequency, intensity, duration, and type of dance form used were extracted. The effect that each dance program had on defined outcomes and the feasibility of each program were also reviewed. DATA SYNTHESIS Thirteen articles were identified. The quality of studies varied, and methodological limitations were evident in some. The evidence evaluated suggests that two 1-hour dance classes per week over 10 to 13 weeks may have beneficial effects on endurance, motor impairment, and balance. CONCLUSIONS Dance may be helpful for some people with PD. This article provides preliminary information to aid clinicians when implementing dance programs for people with PD. Higher-quality multicenter studies are needed to determine the effect of other dance genres and the optimal therapy volume and intensity.

Impact of critical social empowerment on psychological empowerment and job satisfaction in nursing and midwifery settings

AIM To test an expanded model of empowerment which specifies the relationships between structural, psychological, critical social empowerment and job satisfaction. BACKGROUND There is evidence that structural empowerment predicts psychological empowerment and these two dimensions of empowerment are independent predictors of job satisfaction. This study explored a third dimension of empowerment-- critical social empowerment--and its impact on psychological empowerment and job satisfaction. METHOD A predictive, non-experimental design in a sample of 306 nurses and midwives in Ireland using the Conditions of Work Effectiveness Questionnaire, the Psychological Empowerment Questionnaire, a researcher developed tool to measure critical social empowerment and a job satisfaction questionnaire. RESULTS While both structural and critical social empowerment were significant independent predictors of psychological empowerment and job satisfaction, critical social empowerment was the stronger predictor. CONCLUSIONS The findings support the inclusion of the critical social dimension of empowerment in the understanding of empowerment. IMPLICATIONS FOR NURSING MANAGEMENT Managers at all levels must attend to critical social empowerment as well as structural empowerment in order to increase job satisfaction, retention and engagement of highly qualified committed nurses and midwives.

Protein Supplementation at Breakfast and Lunch for 24 Weeks beyond Habitual Intakes Increases Whole-Body Lean Tissue Mass in Healthy Older Adults

BACKGROUND Key areas of research on the preservation of lean tissue mass (LTM) during aging are determinations of the protein requirement and optimal protein intake at meals. OBJECTIVE The aim of this study was to determine the effect of protein supplementation at breakfast and lunch for 24 wk beyond habitual intakes on whole-body LTM in healthy adults aged 50-70 y. METHODS In a single-blinded, randomized, controlled design, 60 healthy older men and women (aged 61 ± 5 y) with a body mass index (in kg/m(2)) of 25.8 ± 3.6 consumed either 0.165 g/kg body mass of a milk-based protein matrix (PRO) or an isoenergetic, nonnitrogenous maltodextrin control (CON) at breakfast and midday meals, the lower protein-containing meals of the day, for 24 wk. Dual-energy X-ray absorptiometry was used to measure the change in LTM. RESULTS After the intervention, protein intake in the PRO group increased from 0.23 ± 0.1 to 0.40 ± 0.1 g/kg for breakfast and from 0.31 ± 0.2 to 0.47 ± 2 g/kg for the midday meal. In response, LTM increased by 0.45 (95% CI: 0.06, 0.83) kg in the PRO group compared with a decrease of 0.16 (95% CI: -0.49, 0.17) kg in the CON group (P = 0.006). Appendicular LTM accounted for the majority of the difference in LTM, increasing by 0.27 (95% CI: 0.05, 0.48) kg in the PRO group compared with no change in the CON group (P = 0.002). CONCLUSIONS Protein supplementation at breakfast and lunch for 24 wk in healthy older adults resulted in a positive (+0.6 kg) difference in LTM compared with an isoenergetic, nonnitrogenous maltodextrin control. These observations suggest that an optimized and balanced distribution of meal protein intakes could be beneficial in the preservation of lean tissue mass in the elderly. This trial was registered at clinicaltrials.gov as NCT02529124.

A multi-centre retrospective study of rituximab use in the treatment of relapsed or resistant warm autoimmune haemolytic anaemia.

This retrospective analysis assessed the response, safety and duration of response to standard dose rituximab 375 mg/m2 weekly for four weeks as therapy for patients with primary or secondary warm autoimmune haemolytic anaemia (WAIHA), who had failed initial treatment. Thirty‐four patients received rituximab for WAIHA in seven centres in the Republic of Ireland. The overall response rate was 70·6% (24/34) with 26·5% (9/34) achieving a complete response (CR). The time to response was 1 month post‐initiation of rituximab in 87·5% (21/24) and 3 months in 12·5% (3/24) of patients. The median duration of follow‐up was 36 months (range 6–90 months). Of the patients who responded, 50% (12/24) relapsed during follow up with a median time to next treatment of 16·5 months (range 6–60 months). Three patients were re‐treated with rituximab 375 mg/m2 weekly for four weeks at relapse and responded. There was a single episode of neutropenic sepsis. Rituximab is an effective and safe treatment for WAIHA but a significant number of patients will relapse in the first two years post treatment. Re‐treatment was effective in a small number of patients, suggesting that intermittent pulse treatment or maintenance treatment may improve long‐term response.

Exercise in the community for people with multiple sclerosis--a follow-up of people with minimal gait impairment.

Background: Although there are many studies evaluating exercise interventions, few studies have evaluated the effect at follow-up. Objectives: This paper presents follow-up data for participants who completed the exercise interventions in a large randomised controlled trial. Methods: One hundred twenty-one people with multiple sclerosis (MS) with minimal gait impairment who completed 10 weeks of community-based exercise interventions were evaluated by a blinded assessor 12 weeks after the intervention. The primary outcome measure was the Multiple Sclerosis Impact Scale-29 version 2 (MSIS-29,v2) physical component. Other outcomes were the MSIS-29 psychological component, the Modified Fatigue Impact Scale (MFIS) and the 6-minute walk test (6MWT) distance. Results: The positive effect on the physical impact of MS was not maintained from baseline to follow-up (−1.6, 95% CI −0.8, 4.0, p=0.189). The psychological impact and the impact of fatigue remained significantly improved (−3.5, 95% CI −6.1, −1.0, p = 0.006 and −4.68, 95% CI −6.9, −2.5, p < 0.001, respectively). There was no time effect for the 6MWT (f = 1.76, p = 0.179) although the trend suggests reversal of the benefits gained from the physiotherapist (PT)- and fitness instructor (FI)-led intervention. Conclusion: The maintained benefit on the psychological impact of MS and fatigue may have important personal and socioeconomic consequences; however, it is important to find ways to maintain the physical benefits of exercise over the long term.

A magnetic resonance imaging‐based study of retropubic haematoma after sling procedures: preliminary findings

To determine, using magnetic resonance imaging (MRI), the incidence of retropubic haematoma and any associated clinically significant effects after a xenograft (porcine dermis) sling (XS) or the tension‐free vaginal tape (TVT) procedure.