Michael A. Fearing

The Confusion Assessment Method: A Systematic Review of Current Usage

OBJECTIVES: To examine the psychometric properties, adaptations, translations, and applications of the Confusion Assessment Method (CAM), a widely used instrument and diagnostic algorithm for identification of delirium.

Persistent Delirium Predicts Greater Mortality

OBJECTIVES: To examine the association between persistent delirium and 1‐year mortality in newly admitted post‐acute care (PAC) facility patients with delirium who were followed regardless of residence.

PHENOMENOLOGICAL SUBTYPES OF DELIRIUM IN OLDER PERSONS: PATTERNS, PREVALENCE, AND PROGNOSIS

BACKGROUND Delirium is an acute confusional state that is common, preventable, and life-threatening. OBJECTIVE The authors investigated the phenomenology of delirium severity as measured with the Memorial Delirium Assessment Scale among 441 older patients (age 65 and older) admitted with delirium in post-acute care. METHODS Using latent class analysis, they identified four classes of psychomotor-severity subtypes of delirium: 1) hypoactive/mild; 2) hypoactive/severe; 3) mixed, with hyperactive features/severe; and 4) normal/mild. RESULTS Among those with dementia (N=166), the hypoactive/mild class was associated with a higher risk of mortality. Among those without dementia (N=275), greater severity was associated with mortality, regardless of psychomotor features, when compared with the normal/mild class. CONCLUSION The data suggest that instruments measuring delirium severity and psychomotor features provide important prognostic information and should be integrated into the assessment of delirium.

Hippocampus, amygdala, and basal ganglia morphometrics in children after moderate-to-severe traumatic brain injury.

While closed head injury frequently results in damage to the frontal and temporal lobes, damage to deep cortical structures, such as the hippocampus, amygdala, and basal ganglia, has also been reported. Five deep central structures (hippocampus, amygdala, globus pallidus, putamen, and caudate) were examined in 16 children (eight males, eight females; aged 9–16y), imaged 1 to 10 years after moderate‐to‐severe traumatic brain injury (TBI), and in 16 individually‐matched uninjured children. Analysis revealed significant volume loss in the hippocampus, amydala, and globus pallidus of the TBI group. Investigation of relative volume loss between these structures and against five cortical areas (ventromedial frontal, superomedial frontal, lateral frontal, temporal, and parieto‐occipital) revealed the hippocampus to be the most vulnerable structure following TBI (i.e. greatest relative difference between the groups). In a separate analysis excluding children with focal hippocampal abnormalities (e.g. lesions), group differences in hippocampal volume were still evident, suggesting that hippocampal damage may be diffuse rather than focal.

Diffuse damage in pediatric traumatic brain injury: a comparison of automated versus operator-controlled quantification methods.

This investigation had two main objectives: 1) to assess the comparability of volumes determined by operator-controlled image quantification with automated image analysis in evaluating atrophic brain changes related to traumatic brain injury (TBI) in children, and 2) to assess the extent of diffuse structural changes throughout the brain as determined by reduced volume of a brain structure or region of interest (ROI). Operator-controlled methods used ANALYZE software for segmentation and tracing routines of pre-defined brain structures and ROIs. For automated image analyses, the open-access FreeSurfer program was used. Sixteen children with moderate-to-severe TBI were compared to individually matched, typically developing control children and the volumes of 18 brain structures and/or ROIs were compared between the two methods. Both methods detected atrophic changes but differed in the magnitude of the atrophic effect with the best agreement in subcortical structures. The volumes of all brain structures/ROIs were smaller in the TBI group regardless of method used; overall effect size differences were minimal for caudate and putamen but moderate to large for all other measures. This is reflective of the diffuse nature of TBI and its widespread impact on structural brain integrity, indicating that both FreeSurfer and operator-controlled methods can reliably assess cross-sectional volumetric changes in pediatric TBI.

Telephone Interview for Cognitive Status: Creating a crosswalk with the Mini-Mental State Examination

Brief cognitive screening measures are valuable tools for both research and clinical applications. The most widely used instrument, the Mini‐Mental State Examination (MMSE), is limited in that it must be administered face‐to‐face, cannot be used in participants with visual or motor impairments, and is protected by copyright. Screening instruments such as the Telephone Interview for Cognitive Status (TICS) were developed to provide a valid alternative, with comparable cut‐point scores to rate global cognitive function.

Basal ganglia lesions following carbon monoxide poisoning

Primary objectives: Carbon monoxide (CO) is the most common cause of poisoning and may result in basal ganglia lesions. This study reviewed the literature of carbon monoxide poisoning and basal ganglia lesions and prospectively assessed the prevalence of basal ganglia lesions in a cohort of patients with CO poisoning. Research design: Literature review and prospective cohort study. Methods: This study conducted a comprehensive review of the literature and assessed 73 CO-poisoned patients for basal ganglia lesions on sequential MR scans. Magnetic resonance scans were obtained on day 1, 2 weeks and 6 months post-CO poisoning. Results: The literature review found basal ganglia lesions occur in 4–88% of subjects. Only one patient was found with globus pallidus lesions at 2 weeks and 6 months following CO poisoning, that were not present on the initial day 1 MR scan. Conclusions: Basal ganglia lesions, including lesions of the globus pallidus, may be less common than previously reported.

Morphometric MRI findings in the thalamus and brainstem in children after moderate to severe traumatic brain injury.

Generalized whole brain volume loss is well documented in moderate to severe traumatic brain injury. Whether this atrophy occurs in the thalamus and brainstem has not been systematically studied in children. Magnetic resonance imaging (MRI) quantitative analysis was used to investigate brain volume loss in the thalamus and brainstem in 16 traumatic brain injury subjects (age range 9-16 years) compared with 16 age and demo-graphically matched controls. Based on multiple analysis of covariance, controlling for age and head size, reduced volume in the thalamus and the midbrain region of the brainstem were found. General linear model analyses revealed a relation between processing speed on a working memory task and midbrain and brain stem volumes. Reduced volume in thalamic and brainstem structures were associated with traumatic brain injury. Reduction in midbrain and thalamic volume is probably a reflection of the secondary effects of diffuse axonal injury and reduction in cortical volume from brain injury.

Participation in Activity and Risk for Incident Delirium

OBJECTIVES: To examine the mediating role between educational attainment and risk for incidence delirium of activity participation and to examine the contribution of participation in specific activities to the development of delirium.

Autopsy-confirmed Alzheimer's disease versus clinically-diagnosed Alzheimer's disease in the Cache County Study on Memory and Aging: A comparison of quantitative MRI and Neuropsychological Findings

Atrophy of specific, regional, and generalized brain structures occurs as a result of the Alzheimers disease (AD) process. Comparing AD patients with histopathological confirmation of the disease at autopsy to those without autopsy but who were clinically diagnosed using the same antemortem criteria will provide further evidence of the utility and accuracy of neuropsychological assessments at the time of diagnosis, as well as the efficacy of quantitative magnetic resonance imaging (qMRI) in demonstrating gross neuropathological changes associated with the disease. The Cache County Study of Aging provides a unique opportunity to determine how closely AD subjects with only the clinical diagnosis match similarly diagnosed AD subjects but with postmortem confirmation of the disease. qMRI volumes of various brain structures, as well as neuropsychological outcome measures from an expanded battery, were obtained in 31 autopsy-confirmed AD subjects and 45 clinically diagnosed AD subjects. Of the various qMRI variables examined, only total temporal lobe volume was different, where those with postmortem confirmation had reduced volume. No significant differences between the two groups were found with any of the neuropsychological outcome measures. These findings confirm the similarity in neuroimaging and neuropsychological assessment findings between those with just the clinical diagnosis of AD and those with an autopsy-confirmed diagnosis in the moderate-to-severe stage of the disease at the time of diagnosis.