Ketki D. Raina

Patterns of Mild Cognitive Impairment After Treatment of Depression in the Elderly

OBJECTIVES Late-life depression (LLD) is associated with persistent cognitive impairment in a subset of individuals. The purpose of this study was to 1) examine the frequency and characteristics of cognitive diagnoses (Mild Cognitive Impairment [MCI], dementia) among remitted elderly depressed subjects and 2) to compare the prevalence rate and correlates of cognitive diagnoses with those of comparison subjects. DESIGN Crosssectional. SETTING Outpatient geriatric mental health clinic. PARTICIPANTS The authors examined cognitive diagnoses among 109 subjects age 65 and older, after depression treatment response and 65 never-depressed, age- and education-equated comparison subjects. MEASUREMENTS Cognitive diagnoses were independently established by the University of Pittsburghs Alzheimers Disease Research Center. Bivariate and multivariate analyses were conducted to examine the role of specific risk factors for cognitive diagnosis among depressed subjects. RESULTS Relative to comparison subjects, nearly twice as many depressed subjects were diagnosed with MCI or dementia (48% versus 28%). Of the 109 depressed subjects, 38% were diagnosed with MCI (63% amnestic, 37% nonamnestic). The majority of amnestic MCI subjects (85%) had the multiple domain subtype. Age, but not age of onset or lifetime depression duration, predicted cognitive diagnosis. CONCLUSIONS Despite adequate depression treatment response, 48% of remitted depressed subjects had a cognitive diagnosis. Of the 38% diagnosed with MCI, there was high representation among both the amnestic and the nonamnestic subtypes, suggesting heterogeneity in cognitive course and outcomes in LLD.

Unique Contribution of Fatigue to Disability in Community-Dwelling Adults With Traumatic Brain Injury

OBJECTIVE To examine the unique contribution of fatigue to self-reported disability in community-dwelling adults with traumatic brain injury (TBI). DESIGN A cross-sectional cohort design. SETTING Community dwellings. PARTICIPANTS Adults (N=50) with a history of mild to severe TBI were assessed. INTERVENTION Not applicable. MAIN OUTCOME MEASURES This study assessed the contribution of fatigue (Modified Fatigue Impact Scale) to disability (Mayo-Portland Adaptability Inventory), controlling for executive functions (Frontal Systems Behavior Scale), depression status (major depression in partial remission/current major depression/depressive symptoms or no history of depression), and initial injury severity (uncomplicated mild, complicated mild, moderate, or severe). RESULTS Fatigue was found to contribute uniquely to the variance in self-reported disability (β=.47, P<.001) after controlling for injury severity, executive functions, and depression status. The overall model was significant (F(4,45)=17.32, P<.001) and explained 61% of the variance in self-reported disability, with fatigue alone accounting for 12% of the variance in self-reported disability (F(1,45)=13.97, P<.001). CONCLUSIONS Fatigue contributes uniquely to disability status among community-dwelling adults with chronic TBI, independent of injury severity, executive functions, and depression. Addressing fatigue through targeted interventions may help to improve self-perceived disability in this population.

Functional Outcomes: One Year after a Cardiac Arrest

Objective. The study aim was to characterize the time-course of recovery in impairments, activity limitations, participation restrictions, disability, and quality of life during the first year after cardiac arrest. Secondarily, the study described the associations between the instruments used to measure each of these domains. Methods. Measures of global disability (Cerebral Performance Category, CPC, Modified Rankin Scale, mRS), quality of life, activity limitations, participation restrictions, and affective and cognitive impairments were administered to 29 participants 1, 6, and 12 months after cardiac arrest. Results. Global measures of disability indicated recovery between one month and one year after cardiac arrest (mean CPC: 2.1 versus 1.69,  P < 0.05; mean mRS: 2.55 versus 1.83, P < 0.05). While global measures of disability were moderately associated with participation, they were poorly associated with other measures. The cohort endorsed depressive symptomatology throughout the year but did not have detectable cognitive impairment. Conclusions. Recovery from cardiac arrest is multifaceted and recovery continues for months depending upon the measures being used. Measures of global disability, reintegration into the community, and quality of life yield different information. Future clinical trials should include a combination of measures to yield the most complete representation of recovery after cardiac arrest.

Neurocognitive Outcomes Following Successful Resuscitation from Cardiac Arrest

INTRODUCTION Cardiac arrest commonly results in varying degrees of cognitive injury. Standard outcome measures used in the cardiac arrest cohort do not rigorously evaluate for these injury patterns. We examined the utility of the Computerized Assessment for Mild Cognitive Injury (CAMCI) in cardiac arrest (CA) survivors. We hypothesized that cognitive deficits would be more severe in patients who were comatose on hospital arrival. METHODS Prospective cohort of CA survivors at a single tertiary care facility where participants received neurocognitive testing using CAMCI. CAMCI results were subdivided into memory, attention, and executive functions. Scores between subjects who were initially comatose and were not comatose following resuscitation were compared using the Mann-Whitney test. RESULTS Of 72 subjects included, the majority (N=44) were initially comatose following resuscitation with mean age of 54 (±14) years. The majority experienced a good neurologic outcome based on Cerebral Performance Category (N=47; 66%) and Modified Rankin Scale (N=38; 53%). Time from resuscitation to CAMCI testing was not associated with total CAMCI score in this cohort (Pearsons r(2) value -0.1941, p=0.20). Initially comatose and not comatose subjects did not differ in their CAMCI overall scores (p=0.33), or in any subtest areas. The not comatose cohort had 1 subtest for which there was a Moderate Risk for mild cognitive impairment (Nonverbal Accuracy), and 2 for which there was a Moderately Low Risk (Verbal Accuracy and Executive Accuracy). The Comatose cohort had 4 subtests, which were deemed Moderately Low Risk for cognitive impairment (Verbal Accuracy, Attention Accuracy, Executive Accuracy and Nonverbal Accuracy). CONCLUSIONS In-hospital CAMCI testing suggests memory, attention and executive impairment are commonly in patients following resuscitation from cardiac arrest. Outcome evaluations should test for deficits in memory, attention, and executive function.

Influence of the environment on activity performance in older women with heart failure.

Purpose. To examine the influence of the environment on activity performance in older women with heart failure living in the community. Method. The cross-sectional study included 55 older women with heart failure. Differences in activity performance collected through performance observation in the clinic and home were analysed with repeated measures ANOVAs and paired samples t-tests. Results. Overall, the influence of the environment in the clinic was neutral for activity independence, and disabling for activity safety and activity adequacy at the global level. At the domain level, functional mobility and personal care were more independent but equally safe and adequate in the clinic compared to the home, cognitively-oriented instrumental activities were less independent, safe and adequate in the clinic compared to the home, and physically-oriented instrumental activities were equally independent, but less safe and adequate in the clinic compared to the home. At the activity level, 6 activities were positively influenced by the environment in the clinic and 13 activities were negatively influenced. Conclusions. Findings suggest that the influence of the environment can be neutral, enabling, or disabling depending on the global scores or level of analysis being considered.

Extensive Brainstem Ischemia on Neuroimaging Does Not Preclude Meaningful Recovery from Locked-In Syndrome: Two Cases of Endovascularly Managed Basilar Thrombosis

We report 2 patients with angiographically demonstrated basilar artery thrombosis who received emergent intra‐arterial thrombolysis with successful recanalization of the basilar artery. In the ensuing weeks after the procedure, both patients were in a locked‐in state and had sustained large bilateral regions of pontine ischemia on brain imaging. Following aggressive supportive care and rehabilitation, outcomes obtained prospectively revealed that both patients made a remarkable recovery, becoming fully independent with Barthel scores of 20 and modified Rankin scores of 2.

Affective state and community integration after traumatic brain injury.

ABSTRACT Previous studies investigating the relationship between affective state and community integration have focused primarily on the influence of depression and anxiety. In addition, they have focused on frequency of participation in various activities, failing to address an individual’s subjective satisfaction with participation. The purpose of this study was to examine how affective state contributes to frequency of participation and satisfaction with participation after traumatic brain injury among participants with and without a current major depressive episode. Sixty-four community-dwelling participants with a history of complicated mild-to-severe traumatic brain injury participated in this cross-sectional cohort study. High positive affect contributed significantly to frequency of participation (&bgr; = 0.401, P = 0.001), and both high positive affect and low negative affect significantly contributed to better satisfaction with participation (F2,61 = 13.63, P < 0.001). Further investigation to assess the direction of these relationships may better inform effective targets for intervention. These findings highlight the importance of assessing affective state after traumatic brain injury and incorporating a subjective measure of participation when considering community integration outcomes.

Activities and Adaptation in Late-Life Depression: A Qualitative Study

OBJECTIVE. We sought to understand activity choices of older adults when they were depressed. METHOD. Each community-dwelling participant (n = 27) completed one semistructured interview while in recovery for at least 3 mo. but less than 7 mo. Transcripts were coded to identify relevant themes. RESULTS. Six themes emerged that explained activities participants continued while depressed, and four themes described activities they stopped. CONCLUSION. Older adults maintained many instrumental activities of daily living while depressed, and some actively adapted activities so they could continue them. Some intentionally stopped activities to direct limited energy to their highest priority activities. To guide effective intervention, it is critical for occupational therapy practitioners to complete a client-centered qualitative assessment to understand what and, most important, why activities are continued or stopped. Each theme for activities continued and activities stopped lends itself to intervention strategies.

An intervention for cardiac arrest survivors with chronic fatigue: A feasibility study with preliminary outcomes.

AIM The primary aim was to examine the feasibility of recruiting and retaining participants for an Energy Conservation+Problem Solving Therapy (EC+PST) intervention delivered over the telephone, to evaluate the acceptability of the intervention, and to assess the appropriateness of the outcome measures. The secondary aim was to evaluate the preliminary intervention effect on fatigue impact, activity performance, and participation in daily activities in post-cardiac arrest (CA) adults with chronic fatigue. METHODS This feasibility study used a prospective, pre-post experimental design. Individuals who were at least 3 months post-CA with moderate-to-severe fatigue were eligible to participate. By participating in EC+PST intervention sessions, participants learned how to apply EC strategies to solve their fatigue-related problems. Participants were assessed before and after completing the intervention using outcome measures assessing fatigue, activity performance, and participation in daily activities. RESULTS Eighteen CA survivors with chronic fatigue successfully completed the intervention and the assessments with high satisfaction. We observed a 15% recruitment rate and ceiling effects on two outcome measures of perceived-performance in daily activities. Significant decreases in the impact of physical (p=.001) and cognitive (p=.006) fatigue of CA survivors were observed with small to moderate effect sizes of r=0.23-0.25 after receiving the EC+PST intervention. CONCLUSION The delivery of EC+PST intervention over the telephone is feasible, and the intervention is highly acceptable to CA survivors with chronic fatigue. Also, the EC+PST intervention seems promising in reducing the impact of physical and cognitive fatigue of CA survivors.

Solving fatigue-related problems with cardiac arrest survivors living in the community☆

AIM The aim was to describe fatigue-related problems reported by post-cardiac arrest adults with chronic fatigue and energy conservation strategies generated using an Energy Conservation plus Problem Solving Therapy intervention. METHODS Following an introduction to the intervention process outlined in a Participant Workbook, participants engaged in the telephone intervention by identifying one to two fatigue-related problems. They then brainstormed with the interventionist to identify potential strategies to reduce fatigue, tested them, and either modified the strategies or moved to the next problem over three to five sessions. RESULTS Eighteen cardiac arrest survivors with chronic fatigue identified instrumental activities of daily living and leisure activities as fatigue-related activities more frequently than basic activities of daily living. Energy Conservation strategies used most frequently were: plan ahead, pace yourself, delegate to others, and simplify the task. CONCLUSION Post-cardiac arrest adults living in the community with chronic fatigue can return to previous daily activities by using energy conservation strategies such as planning ahead, pacing tasks, delegating tasks, and simplifying tasks.