Robert Fucetola

Age and neuropsychologic function in schizophrenia: a decline in executive abilities beyond that observed in healthy volunteers

BACKGROUND Kraepelin originally conceptualized schizophrenia as a degenerative brain disorder. It remains unclear whether the illness is characterized by a static encephalopathy or a deterioration of brain function, or periods of each condition. Assessments of cognitive function, as measured by neuropsychologic assessment, can provide additional insight into this question. Few studies of patients with schizophrenia have investigated the effect of aging on executive functions, in an extensive neuropsychologic battery across a wide age range, compared to healthy volunteers. METHODS We examined the interaction of aging and neuropsychologic function in schizophrenia through a cross-sectional study in patients (n = 87) and healthy control subjects (n = 94). Subjects were divided into three age groups (20-35, 36-49, and 50-75), and performance on an extensive neuropsychologic battery was evaluated. RESULTS Compared to control subjects, patients with schizophrenia demonstrated similar age-related declines across most neuropsychologic functions, with the exception of abstraction ability, in which significant evidence of a more accelerated decline was observed. CONCLUSIONS These results are consistent with previous reports indicating similar age effects on most aspects of cognition in patients with schizophrenia and healthy adults, but they support the hypothesis that a degenerative process may result in a more accelerated decline of some executive functions in older age in schizophrenia.

Preexisting cognitive impairment in women before cardiac surgery and its relationship with C-reactive protein concentrations

Preoperative cognitive state is seldom considered when investigating the effects of cardiac surgery on cognition. In this study we sought to determine the prevalence of cognitive impairment in women scheduled for cardiac surgery using nonhospitalized volunteers as a reference group and to examine the relationship between C-reactive protein levels and cognitive impairment. Psychometric testing was performed in 108 postmenopausal women scheduled for cardiac surgery and in 58 nonhospitalized control women. High sensitivity C-reactive protein levels were measured in the surgical patients. Preoperative cognitive impairment was defined as >2 sd lower scores on ≥2 tests compared with the controls. Cognitive impairment was present in 49 of 108 (45%) patients. C-reactive protein levels were higher for patients with compared with those without cognitive impairment (median, 8.1 mg/L versus 4.7 mg/L; P = 0.04). Based on multivariate logistic regression analysis, patient age, lower attained level of education, type 2 diabetes mellitus, and prior myocardial infarction identified risk for cognitive impairment (P < 0.05) but C-reactive protein levels did not (P = 0.09). In conclusion, cognitive impairment is prevalent in women before cardiac surgery. C-reactive protein levels are increased in women with this condition but the relationship between this inflammatory marker and preexisting cognitive impairment is likely secondary to the acute phase reactant serving as a marker for other predisposing conditions.

Age- and dose-dependent glucose-induced increases in memory and attention in schizophrenia

Glucose is the principal energy substrate for the brain, and alterations in glucose availability can alter neuronal function, including cognitive performance. Investigators have previously demonstrated glucose-induced memory and attentional improvements in humans, including a previous report from this group in subjects with schizophrenia. However, the age- and dose-dependence of this effect in schizophrenia has not been addressed. This within-subjects, double-blind experiment evaluated the cognitive effects of placebo-controlled, multiple fixed-dose oral glucose administration (0 g, 25 g, 50 g, 75 g) in younger and older patients with schizophrenia (n = 20) and healthy age-matched controls (n = 20). Each dose condition was administered on a different morning after a 9-h fast, with cognitive testing and plasma sampling following dose administration on each day. Older patients demonstrated dose-dependent improvements in recall performance on a spatial delayed response task and reaction time on a delayed match to sample task, while younger patients had decreases in attentional performance at the 75-g dose compared to placebo. As in previous reports, patients demonstrated higher plasma glucose and insulin concentrations than controls in response to fixed glucose dosing. The results provide further evidence that glucose and/or insulin can regulate brain functions relevant to memory and attention, and suggest that systemic changes in glucose regulation in schizophrenia deserve further study.

Unravelling nonverbal cognitive performance in acquired aphasia

Background: Nonverbal cognitive constructs are not well understood in patients with acquired aphasia due to stroke. The relative contribution of aphasia, particularly receptive language impairment, to nonverbal function is rarely quantified in studies, although it is assumed to be substantial. Aims: The purpose of the present study was first to investigate the factor structure of some of the WAIS‐III and WMS‐III nonverbal tasks in patients with acquired aphasia due to stroke using confirmatory factor‐analytic techniques. Second, we sought to determine the degree to which aphasia severity (both auditory comprehension and oral expression), as measured by the Language Competency Index (LCI) of the Boston Diagnostic Aphasia Examination (Goodglass et al., 2001), would account for variance in nonverbal cognitive task performance. Methods & Procedures: The present study investigated the factor structure of widely used nonverbal cognitive tasks in 136 patients with aphasia due to single left hemisphere stroke, and sought to determine the degree to which language impairment accounted for nonverbal skill. Outcomes & Results: A single factor model representing nonverbal (perceptual) constructs provided the best model fit to the data. The underlying factor structure of nonverbal constructs in patients with aphasia mirrors the structure observed in healthy adults. Although the correlations between language impairment measures and nonverbal skills were moderate, language competence accounted for a minority (about a quarter) of the variance in nonverbal skills. Conclusions: We conclude that impairment in nonverbal cognitive ability is not fully explained by language competence in people with aphasia.

Aphasia severity, semantics, and depression predict functional communication in acquired aphasia

Background: The functional communication deficits that result from aphasia are well known, although contributing factors have not been systematically studied. Although overall aphasia severity is directly related to communication ability, the contribution of cognitive and mood factors is less understood. Aims: This study attempted to identify predictors of functional communication in patients with acquired aphasia at various points post‐unilateral left hemisphere stroke. Methods & Procedures: A total of 57 patients with aphasia due to left hemisphere stroke completed a comprehensive battery of aphasia diagnostic, neuropsychological, mood, and functional communication measures. Significant predictors of functional communication were identified with multiple hierarchical regression analysis. Outcomes & Results: Over and above the contribution of aphasia severity, depression (sadness and anger), semantic processing, and reading comprehension accounted for a significant amount of variance in functional communication. Working memory, phonologic processing, and other mood states were not predictive. Conclusions: Aphasia severity, depression, semantic impairment, and reading comprehension may be most relevant to functional communication in people with acquired aphasia.

Neuropsychological issues in the assessment of refugees and victims of mass violence.

Brain injury, stressor severity, depression, premorbid vulnerabilities, and PTSD are frequently intertwined in trauma populations. This interaction is further complicated when the neuropsychologist evaluates refugees from other cultures. In addition, the observed psychiatric symptoms reported in refugees and victims of mass violence may in fact not be the primary features of PTSD and depression but psychiatric symptoms secondary to the effects of traumatic brain injury. This paper reviews the occurrence of starvation, torture, beatings, imprisonment, and other head injury experiences in refugee and POW populations to alert treators to the presence of chronic and persistent neuropsychiatric morbidity, with implications for psychosocial adjustment. The concept of fixed neural loss may also interact with environmental and emotional stresses, and a model of neuropsychological abnormalities triggered by traumatic events and influenced by subsequent stress will also be considered. Neuropsychologists working with refugees play an important role in assessing the possibility of traumatic brain injury with tools that are relatively culture-fair.

Neurocognitive Outcomes Are Not Improved by 17β-Estradiol in Postmenopausal Women Undergoing Cardiac Surgery

Background and Purpose— Neurocognitive dysfunction is an important source of patient morbidity and mortality after cardiac surgery that may disproportionately affect postmenopausal women. 17&bgr;-Estradiol limits the extent of ischemic neuronal injury in a variety of experimental models. The purpose of this study was to evaluate whether perioperative administration of 17&bgr;-estradiol to postmenopausal women reduces the frequency of neurocognitive dysfunction after cardiac surgery. Methods— One hundred seventy-four postmenopausal women not on estrogen replacement therapy who were undergoing primary coronary artery bypass graft surgery and/or valve surgery with cardiopulmonary bypass were prospectively randomized to receive in a double-blinded manner either 17&bgr;-estradiol or placebo beginning the day before surgery and continuing for 5 days postoperatively. The patients were evaluated before and after surgery with the National Institutes of Health Stroke Scale and a psychometric test battery. Results— There were no differences in the frequency of neurocognitive dysfunction (primary outcome) between patients randomized to perioperative 17&bgr;-estradiol (n=86) and those randomized to placebo (n=88) 4 to 6 weeks after surgery (17&bgr;-estradiol, 22.4% versus placebo, 21.4%, P=0.45). The mean scores on tests of psychomotor speed were worse in women in the 17&bgr;-estradiol group than in the placebo group at the 4- to 6-week (P=0.005) postoperative testing sessions. Conclusions— Perioperative treatment with 17&bgr;-estradiol did not result in improved neurocognitive outcomes in postmenopausal women undergoing cardiac surgery.

Distorted visual feedback effects on drawing in Parkinson's disease

We investigated the effects of distorted visual feedback on the drawing performance of a group with Parkinsons disease (PD) and a control group. Twenty older healthy adults and 20 PD patients copied figures onto a digitizer tablet with a pen under normal and distorted visual feedback conditions. PD patients were less able than controls to adjust the size of their drawing to compensate for distortions in visual feedback. The effect was particularly pronounced when patients were required to draw smaller than normal. Nevertheless, with practice. PD patients showed a similar degree of improvement in size as controls, although they did not match the control groups level of performance. Overall, these findings support the notion that PD may have specific difficulty adjusting to a change in gain (or discrepancy) between visual and kinesthetic feedback when they must alter the size of their drawing. These findings point to the putative role of the basal ganglia in adjusting for the intermodal discrepancy between sensory feedback, and re-scaling the size of movements.

Prediction of Discharge Walking Ability From Initial Assessment in a Stroke Inpatient Rehabilitation Facility Population

OBJECTIVES To (1) determine which clinical assessments at admission to an inpatient rehabilitation facility (IRF) most simply predict discharge walking ability, and (2) identify a clinical decision rule to differentiate household versus community ambulators at discharge from an IRF. DESIGN Retrospective cohort study. SETTING IRF. PARTICIPANTS Two samples of participants (n=110 and 159) admitted with stroke. INTERVENTIONS A multiple regression determined which variables obtained at admission (age, time from stroke to assessment, Motricity Index, somatosensation, Modified Ashworth Scale, FIM, Berg Balance Scale, 10-m walk speed) could most simply predict discharge walking ability (10-m walk speed). A logistic regression determined the likelihood of a participant achieving household (<0.4m/s) versus community (≥0.4-0.8m/s; >0.8m/s) ambulation at the time of discharge. Validity of the results was evaluated on a second sample of participants. MAIN OUTCOME MEASURE Discharge 10-m walk speed. RESULTS Admission Berg Balance Scale and FIM walk item scores explained most of the variance in discharge walk speed. The odds ratio of achieving only household ambulation at discharge was 20 (95% confidence interval [CI], 6-63) for sample 1 and 32 (95% CI, 10-96) for sample 2 when the combination of having a Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 was present. CONCLUSIONS A Berg Balance Scale score of ≤20 and a FIM walk item score of 1 or 2 at admission indicates that a person with stroke is highly likely to only achieve household ambulation speeds at discharge from an IRF.

The brain recovery core: Building a system of organized stroke rehabilitation and outcomes assessment across the continuum of care

This Special Interest article describes a multidisciplinary, interinstitutional effort to build an organized system of stroke rehabilitation and outcomes measurement across the continuum of care. This system is focused on a cohort of patients who are admitted with the diagnosis of stroke to our acute facility, are discharged to inpatient and/or outpatient rehabilitation at our free-standing facility, and are then discharged to the community. This article first briefly explains the justification, goals, and purpose of the Brain Recovery Core system. The next sections describe its development and implementation, with details on the aspects related to physical therapy. The article concludes with an assessment of how the Brain Recovery Core system has changed and improved delivery of rehabilitation services. It is hoped that the contents of this article will be useful in initiating discussions and potentially facilitating similar efforts among other centers.