Moderate-severe Cognitive Impairment Research Articles

Abstract 7445: Association between C-reactive protein and cognitive impairment in IDH-mutant gliomas

Abstract Cognitive impairment is common in primary brain tumor (PBT) patients, as a result of the disease and secondary damage from directed and systemic therapy. Recently, the risk in patients with IDH-mutant gliomas and role of interconnectivity of the tumor with neurons and the tumor microenvironment has heightened interest in exploration of biomarkers of impairment to inform care. Here, we investigate Montreal Cognitive Assessment (MoCA) scores and peripheral blood levels of C-reactive protein (CRP) in a cross-sectional cohort of 47 adult IDH-mutant PBT patients enrolled in a natural history study (NHS, NCT02851706: PI T. Armstrong). MoCA raw scores (range 0-30) were dichotomized (≤ 25 = cognitive dysfunction). Baseline CRP was quantified in banked serum samples in duplicate using (V-Plex/Vascular Injury Panel-2, Meso Scale Discovery [MSD], Rockville, MD) in a QuickPlex SQ 120 instrument (MSD). Lab personnel were blinded to diagnosis and clinical status. To reduce skewness in CRP raw values, we used log transformation. Descriptive statistics, Pearson’s correlation, and logistic regression were conducted using IBM SPSS and SAS Statistics software. The sample was predominately male (62%), white (70%), with high-grade gliomas (III/IV) (68%) and an average age at diagnosis of 36 years (SD: 9; median: 34; range: 20-53). The mean MoCA score was 25 (SD: 5; median: 26; range: 11-30). Dichotomizing MoCA scores showed that less than half (43%) of participants exhibited moderate-severe (≤ 25) cognitive impairment. MoCA binary group was negatively correlated with levels of CRP (r=-0.42, p<.003). The log mean concentration of CRP was higher in participants with cognitive impairment (7.99, SD=0.47 vs 7.57, SD=0.45, p<.003) than those without impairment. Finally, when controlling for age and sex, CRP remained predictive of cognitive impairment (OR 8.18, 95% CI 1.70,39.23). Higher levels of CRP were associated with lower MoCA scores in a cross-sectional sample of patients with IDH-mutant gliomas, suggesting an association between the severity of inflammation and cognitive impairment in IDH-mutant glioma patients. Further analysis in large, more diverse longitudinal cohorts will be needed to validate these findings in this population and compare to those with IDH-WT tumors and develop predictive models to inform biomarker development. Citation Format: McKenzie C. Kauss, Michelle L. Wright, Dhaivat Raval, Emory Hsieh, Kaitlynn Slattery, Terri S. Armstrong, Tito R. Mendoza, Vivian A. Guedes. Association between C-reactive protein and cognitive impairment in IDH-mutant gliomas [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7445.

Prevalence of urinary incontinence and associated factors in nursing homes: a multicentre cross-sectional study

BackgroundUrinary incontinence (UI) is a common geriatric syndrome with high health and socio-economic impacts in nursing home (NH) residents.ObjectivesTo estimate the prevalence and types of UI and its associated factors in older people living in NHs in Central Catalonia (Spain). We also determined the proportion of residents who were receiving behavioural strategies to prevent/manage UI.Design and settingCross-sectional study in 5 NHs conducted from January to March 2020.MethodsWe included consenting residents aged 65 + permanently living in the NHs. Residents who were hospitalized, in a coma or palliative care were excluded. UI was assessed using Section H of the Minimum Data Set. Sociodemographic and health-related variables were examined. Descriptive, bivariate, and multivariate (logistic regression) analyses were performed.ResultsWe included 132 subjects (82.6% women), mean age of 85.2 (SD = 7.4) years. The prevalence of UI was 76.5% (95% CI: 68.60-82.93). The most common type was functional UI (45.5%), followed by urgency UI (11.4%). Only 46.2% of residents received at least one behavioural strategy to manage UI. Most sedentary behaviour (SB) variables presented a p-value lower than 0.001 in the bivariate analyses, but none remained in the final model. Moderate-severe cognitive impairment (OR = 4.44, p =.003), anticholinergic activity (OR = 3.50, p =.004) and risk of sarcopenia using SARC-F (OR = 2.75, p =.041) were associated with UI.ConclusionsThe prevalence of UI was high in this sample of NH residents compared to the literature, yet less than half received prompted voiding as a strategy to prevent/reduce UI.UI was associated with cognitive impairment, anticholinergic activity, and risk of sarcopenia.

EMERGENCY DEPARTMENT USE AMONG OLDER ADULTS RECEIVING MEDICAID HOME- AND COMMUNITY-BASED SERVICES

Abstract Medicaid-funded home and community-based services (HCBS) for older adults aim to prolong independent living despite physical and cognitive disabilities. Medicaid-eligible HCBS populations are racially and ethnically heterogeneous, with multiple chronic conditions. Clinical threats to continued independent living among older adult HCBS recipients include acute illnesses, injuries, and exacerbations of chronic conditions, which could trigger a pathway of emergency department (ED) visits, hospitalization, and long-term nursing home admission. Despite its importance in the pathway from independent living, little is known about the rate of, or risk factors for, ED use in this target population. Accordingly, we determined predictors of ED use in a statewide cohort (N=5,651) in Connecticut’s Medicaid HCBS program for adults age >65, who were clinically assessed using a uniform tool between April 2020-March 2021. ED use, (0 vs 1+ visits), was ascertained over 12 months following clinical assessment using Medicare and Medicaid claims data. Predictor variables were racial and ethnic group, primary language, age, sex, educational attainment level, dementia diagnosis or moderate-severe cognitive impairment, depressive symptom severity, and Charlson comorbidity index. Cohort members were 76% female, 30% Hispanic, 15% non-Hispanic Black, 4% non-Hispanic Asian, 33% age >85. Forty-one percent had 1+ ED visits. Multivariate logistic regression analyses revealed that ED use was associated with (adjusted odds ratios p<0.05): high school education, more severe depressive symptoms, and more chronic conditions. Non-Hispanic Asian individuals had lowest ED visit likelihood. ED use among older adults receiving Medicaid HCBS might be reduced if depressive symptoms and multiple chronic conditions are optimally managed.

P154: Mild Behavioral Impairment (MBI) in a sample of general population aged > 55: associations with degree of cognitive impairment.

Objective:The present study aims to determine the prevalence estimates of MBI and specific MBI domains in a large sample of the general population, by degree of cognitive impairment (CI).Method:A representative community sample of individuals aged 55+ (n=4803) (ZARADEMP Study) was studied. MBI, and specific MBI domains, were assessed according to ISTAART-AA MBI criteria, using the Geriatric Mental State (GMS). In accordance with these criteria, clinically significant anxiety, depression, and dementia were excluded. For the standardized degree of CI Perneczky et al. ́s criteria were applied: normal (MMSE 30), questionable (MMSE 26-29), mild CI (MMSE 21-25), moderate-severe CI (MMSE <21).Results:The prevalence of MBI, and specifically the domain Decrease Motivation (DM), increased progressively and significantly by degree of CI, the differences being significant between all cognitive groups. After control by age and education, DM was 2- and 4.5-times more frequent in subjects with mild CI (10.6%) and moderate-severe CI (18.3%), respectively, than in cognitive normal (5.8%). Affective Dysregulation (AD) was 1.7-times more frequent in mild CI (26.4%) (vs 20.4% in normal). Impulsive Dyscontrol (ID) was 2- and 7.9-times more frequent in mild CI (8%) and moderate-severe CI (23.5%) than in cognitive normal (4.7%). And Abnormal Perception and Thoughts (APT) was 6-times more frequent in moderate-severe CI (10%) (vs 1.4% in cognitive normal).Conclusion:Our results confirm an increase of MBI prevalence across the spectrum of CI. However, each specific domain of MBI shows a different pattern of association with CI. Our results support the relevance of studying MBI domains independently.

Functional Status of Patients over 65 Years Old Intervened on for a Hip Fracture One Year after the Operation.

Evaluation of the functional status one year after a hip fracture surgery and the influence of sarcopenia and other clinical factors at the time of admission. Prospective observational study with 135 patients over 65 years of age. Functional status of basic (modified Katz) and instrumental activities (Lawton and Brody) and walking ability (Functional Ambulation Classification, FAC) was measured on admission, at discharge, and telephonically one year later. The risk or positive screening of sarcopenia (SARC-F) and cognitive status (Pfeiffer), as well as clinical variables, were evaluated. 72% of patients are women; 36% have a risk of sarcopenia (Sarc-F ≥ 4), and 43% have moderate-severe cognitive impairment (Pfeiffer ≥ 5). Walking capacity at one year was closer to the values at admission more often in women than in men (0.2 ± 1.3 points vs. 0.9 ± 1.6; p = 0.001), as well as in patients without risk of sarcopenia versus sarcopenic patients (0.3 ± 1.2 points vs. 0.7 ± 1.7; p = 0.001), although their evolution did not show significant differences (p = 0.183). Instrumental activities after one year have not been recovered (1.7 ± 2.5 points; p = 0.032), and patients at risk of sarcopenia showed worse values (1.7 ± 1.9 points vs. 3.7 ± 2.7; p < 0.001) and worse evolution (p = 0.012). The evolution of basic activities varied according to the risk of sarcopenia (0.6 ± 1.4 points vs. 1.4 ± 2.1; p = 0.008). Functional status at one year is related to the functional status at admission, the positive screening of sarcopenia, sex, and cognitive impairment of the patient. Knowing at the time of admission an estimate of the functional status at one year will help to reinforce the individual treatment of patients with a worse prognosis.

The association between serum uric acid and cognitive performance in patients with ischemic stroke is modified by estimated glomerular filtration rate

The relationship between serum uric acid (SUA) and poor cognitive performance in patients with ischemic stroke is unclear. We hypothesized that the severity of renal function mediates the association between SUA and cognitive dysfunction.A retrospective analysis of 608 patients with ischemic stroke was conducted between 2016 and 2020. SUA was obtained from inpatient medical records. Global cognitive function via mini-mental state exam (MMSE) and Montreal Cognitive Assessment (MoCA) was determined one month after hospital discharge. The relationship between SUA and cognitive function was assessed by multiple linear and logistic regression analyses. Patients had a mean age of 66.6 years (SD: 4.1 years), and 52% were male. The mean SUA level was 298.6 ± 75.4 μmol/L. SUA increases were significantly positively associated with lower MMSE and MoCA scores and increased risk of moderate-severe cognitive impairment one month after stroke (p < 0.01), even after adjusting for factors including age, gender, BMI, diabetes and hypertension history. Adding a term for estimated glomerular filtration rate (eGFR) attenuated these associations such that SUA was no longer associated with cognitive performance. A fully adjusted stronger negative association between SUA and cognitive performance was found in those who had lower eGFR, with a significant eGFR interaction for MMSE (p-interaction = 0.016) and MoCA (p-interaction = 0.005). In patients with ischemic stroke, SUA showed an inverse association with cognitive function among those who have lower eGFR. The renal function might mediate the association between SUA and cognitive dysfunction.

Longitudinal clinical outcomes, cognitive impairment, and mood symptoms in anti-NMDAR encephalitis (P5-5.006)

<h3>Objective:</h3> To characterize longitudinal outcomes in anti-NMDA receptor (anti-NMDAR) encephalitis. <h3>Background:</h3> Outcomes in anti-NMDAR encephalitis are poorly understood but may be influenced by factors not adequately captured using the modified Rankin Scale (mRS). <h3>Design/Methods:</h3> This retrospective, observational cohort study examined outcome measures (mRS and clinical assessment scale in autoimmune encephalitis, CASE) in adults with anti-NMDAR-IgG in CSF at hospital discharge and long-term follow-up. Linear and logistic regression modeled outcomes. Mixed models examined predictor effects by time. Subgroups with evaluations for cognitive impairment (CI) (Montreal Cognitive Assessment or Mini-Mental State Examination) &gt;6 months from symptom onset and depression (Patient Health Questionnaire-9) and anxiety (General Anxiety Disorder-7) within 1 year of long-term follow-up were reported. Spearman correlations were examined between mood and final CASE scores. <h3>Results:</h3> Thirty-eight patients (76.3% female, median disease onset age=28 years, IQR=22–36) were included. The majority received first-(97.4%) and second-line (68.4%) immunosuppressants at a median of 3.9 weeks (IQR=2.1–9.7). Median/mean mRS and CASE were 4 (IQR=3–5) and 12.7 (SD=7) at baseline and 2 (IQR=1–3) and 4 (SD=4.1) at long-term follow-up (median=70 weeks, IQR=51–174). Both improved from baseline (p&lt;0.001). At hospital discharge (median=10 weeks, IQR=6–17), predictors of higher CASE and mRS scores included: dysautonomia, coma/lethargy, seizures/status epilepticus, and intensive care unit admission (p&lt;0.05). At long-term follow-up, only onset weakness predicted higher mRS scores (OR=5.62, CI 1.02–30.90, p=0.047). Seizures were uncommon (3%). Psychiatric morbidity was the main contributor to final CASE scores (mean=1.3, SD=0.94). In subgroup analyses, moderate-severe CI (50%), depression (29.5%), and anxiety (41.6%) were frequent. There was a correlation between depression (r=0.65, p&lt;0.01) and anxiety (r=0.79, p&lt;0.01) measures with final CASE memory sub-scores. <h3>Conclusions:</h3> Different clinical factors predict early versus long-term outcomes in anti-NMDAR encephalitis. Only onset weakness predicts long-term disability by mRS. Long-term CI and mood symptoms were frequently noted. Highlighting a complex interplay, mood symptoms correlated with CASE memory sub-scores. <b>Disclosure:</b> Dr. Morgan has nothing to disclose. Ms. Li has nothing to disclose. Nicholas Thompson has nothing to disclose. Dr. Rae-Grant has received publishing royalties from a publication relating to health care. Dr. Rae-Grant has received publishing royalties from a publication relating to health care. Dr. Abbatemarco has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for EMD Serono. Dr. Abbatemarco has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Horizon. Dr. Abbatemarco has received personal compensation in the range of $5,000-$9,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genentech . The institution of Dr. Abbatemarco has received research support from Horizon. Dr. Punia has nothing to disclose. Dr. Hantus has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Eisai. Dr. Hantus has received personal compensation in the range of $0-$499 for serving as a Consultant for UCB. Rachel Galioto has nothing to disclose. Dr. Kunchok has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Genentech. Dr. Kunchok has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Horizon therapeutics . Dr. Kunchok has received personal compensation in the range of $10,000-$49,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Neurology.

Plasma Lipoprotein-Associated Phospholipase A2 Affects Cognitive Impairment in Patients with Cerebral Microbleeds.

The plasma lipoprotein-associated phospholipase A2 (Lp-PLA2) is an inflammatory biomarker of cerebral microbleeds (CMBs) and may be related to the occurrence, development, and prognosis of cognitive impairment. The present study aimed to investigate the impact of plasma Lp-PLA2 level on the cognitive impairment in patients with CMBs. In this study, 213 patients with CMBs confirmed by 3.0 T brain magnetic resonance imaging (MRI) were analyzed. Lp-PLA2 levels were determined by magnetic particle chemiluminescence immunoassay technology, and cognitive function was assessed using the Montreal Cognitive Assessment Scale (MoCA). The cognitive functions of patients with CMBs were divided into three groups according to the MoCA scale, including normal cognition (NC), mild cognitive impairment (MCI), and moderate-severe cognitive impairment (MSCI). Clinical, laboratory and radiological data of the three groups were analysed. The relationship between plasma Lp-PLA2 and MoCA score in patients with CMBs was investigated through rank correlation analysis and multivariate regression analysis, and receiver operating characteristic (ROC) curve was used to evaluate the diagnostic value of Lp-PLA2. CMBs were detected in 213 (30.2%) of 705 patients who underwent 3.0 T MRI. Multiple comparisons showed that plasma Lp-PLA2 in patients with CMBs with normal cognitive scores was significantly lower than that in the other two groups with cognitive impairment (p < 0.05). In the single factor correlation analysis, high level of plasma Lp-PLA2 was negatively correlated with the decrease of MoCA score in patients with CMBs (r =-0.389, p < 0.01). Multivariate regression analysis showed that high plasma Lp-PLA2 was an independent risk factor for a low MoCA score in patients with CMBs (odds ratio [OR]=1.014; 95% confidence interval [CI], 1.002-1.026; p=0.025). A high level of plasma Lp-PLA2 is positively correlated with the generation of cognitive impairment in patients with CMBs and negatively correlated with the degree of impairment. Plasma Lp-PLA2 is an important indicator of cognitive impairment in patients with CMBs and may provide a therapeutic target for preventing CMB-induced cognitive impairment.

Plasma Concentrations of Neurofilament Light Chain Protein and Brain-Derived Neurotrophic Factor as Consistent Biomarkers of Cognitive Impairment in Alcohol Use Disorder.

For a long time, Substance Use Disorders (SUDs) were not considered a component in the etiology of dementia. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders introduced substance-induced neurocognitive disorders, incorporating this notion to clinical practice. However, detection and monitoring of neurodegenerative processes in SUD patients remain a major clinical challenge, especially when early diagnosis is required. In the present study, we aimed to investigate new potential biomarkers of neurodegeneration that could predict cognitive impairment in SUD patients: the circulating concentrations of Neurofilament Light chain protein (NfL) and Brain-Derived Neurotrophic Factor (BDNF). Sixty SUD patients were compared with twenty-seven dementia patients and forty healthy controls. SUD patients were recruited and assessed using the Psychiatric Research Interview for Substance and Mental (PRISM) and a battery of neuropsychological tests, including the Montreal Cognitive Assessment test for evaluation of cognitive impairment. When compared to healthy control subjects, SUD patients showed increases in plasma NfL concentrations and NfL/BDNF ratio, as well as reduced plasma BDNF levels. These changes were remarkable in SUD patients with moderate-severe cognitive impairment, being comparable to those observed in dementia patients. NfL concentrations correlated with executive function and memory cognition in SUD patients. The parameters "age", "NfL/BDNF ratio", "first time alcohol use", "age of onset of alcohol use disorder", and "length of alcohol use disorder diagnosis" were able to stratify our SUD sample into patients with cognitive impairment from those without cognitive dysfunction with great specificity and sensibility. In conclusion, we propose the combined use of NfL and BDNF (NfL/BDNF ratio) to monitor substance-induced neurocognitive disorder.

The Influence of Prior Functional Status on Self-Care Improvement During a Skilled Nursing Facility Stay

Older adults' prior health status can influence their recovery after a major illness. We investigated the association between older adults' independence in self-care tasks prior to a skilled nursing facility (SNF) stay and their self-care function at SNF admission, discharge, and the change in self-care function during an SNF stay. Retrospective study of 100% national CMS data files from October 1, 2018, to December 31,2019. The sample included 616,073 Medicare fee-for-service beneficiaries who were discharged from an SNF between October 1, 2018, and December 31,2019. The admission Minimum Data Set (MDS) was used to determine residents' prior ability (independent, some help, dependent) to complete self-care tasks before the current illness, exacerbation, or injury. Seven self-care tasks from MDS Section GG were used to calculate total scores (range 7-42 points) for self-care at admission, discharge, and the change in self-care between admission and discharge. Most residents (62.0%) were independent, 35.3% needed some help, and 2.64% were dependent in self-care prior to SNF admission. Nearly 25% of residents with urinary incontinence, 28.8% with bowel incontinence, and 31.7% with moderate-severe cognitive impairment were independent in self-care prior to SNF admission compared with approximately 70% of residents without these conditions. Compared with residents who were dependent in self-care prior to SNF admission, those who were independent or needed some help had significantly higher self-care total scores at admission (5.67 vs 4.21 points, respectively) and discharge (6.44 vs 3.82 points, respectively) and exhibited greater improvement in self-care (3.48 vs 1.62 points, respectively). Our findings are evidence that the new MDS item for a resident's independence in self-care tasks before SNF admission is a valid measure of their prior self-care function. This is clinically useful information and should be considered when developing rehabilitation goals.

The Effects of the 2020 COVID-19 Lockdown on Mood, Behavior, and Social and Cognitive Functioning in Older Long-Term Care Residents.

ObjectivesWe aimed to explore the effects of the Dutch COVID-19 lockdown (March 20–May 25, 2020) on mood, behavior, and social and cognitive functioning of older residents of long-term care facilities (LTCFs) prospectively.DesignMixed methods: historically controlled longitudinal cohort study and focus groups.Setting and ParticipantsResidents of Dutch LTCFs.MethodsResidents who were assessed during and prior to the lockdown were compared to residents of the same wards with 2 assessments prior to the lockdown. We used mixed models and generalized estimating equation analyses to explore differences in changes in mood, withdrawal and aggressive behavior, loneliness and conflict, and cognition and delirium. We also explored whether the effect of the lockdown differed for different subgroups. In 2 online focus groups, LTCF care professionals, ranging from care staff to physicians, reflected on their experiences of the effect of the lockdown and the cohort study results.ResultsThe lockdown group of 298 residents was compared to the control group of 625 residents. Self-reported mood symptoms showed a slightly greater increase during the lockdown. During the first half of the lockdown, the level of conflict with other residents decreased whereas it increased in the control group. The subgroup with moderate-severe cognitive impairment showed a decrease in withdrawal during the lockdown, whereas the group with no-mild cognitive impairment showed a statistically nonsignificant relative increase. Professionals described great individual variation in the effects of the lockdown on residents. Facilities attempted to preserve the experienced positive effects, for example, by promoting tranquility in shared rooms and continuing to organize individualized ward-based activities.Conclusions and ImplicationsWe did not find clinically relevant negative effects of the lockdown on mood, behavior, and social and cognitive functioning in older residents of LTCFs at the group level. Possibly, staff mitigated the negative effects at the group level. Meanwhile, they learned lessons that they continue to apply to enhance resident well-being.

Sliding scale insulin use in a national cohort study of nursing home residents with type 2 diabetes.

Guidelines discourage sliding scale insulin (SSI) use after the first week of a nursing home (NH) admission. We sought to determine the prevalence of SSI and identify factors associated with stopping SSI or transitioning to another short-acting insulin regimen. In an observational study from October 1, 2013, to June 30, 2017 of non-hospice Veterans Affairs NH residents with type 2 diabetes and an NH admission over 1 week, we compared the weekly prevalence of SSI versus two other short-acting insulin regimens - fixed dose insulin (FDI) or correction dose insulin (CDI, defined as variable SSI given alongside fixed doses of insulin) - from week 2 to week 12 of admission. Among those on SSI in week 2, we examined factors associated with stopping SSI or transitioning to other regimens by week 5. Factors included demographics (e.g., age, sex, race/ethnicity), frailty-related factors (e.g., comorbidities, cognitive impairment, functional impairment), and diabetes-related factors (e.g., HbA1c, long-acting insulin use, hyperglycemia, and hypoglycemia). In week 2, 21% of our cohort was on SSI, 8% was on FDI, and 7% was on CDI. SSI was the most common regimen in frail subgroups (e.g., 18% of our cohort with moderate-severe cognitive impairment was on SSI vs 5% on FDI and 4% on CDI). SSI prevalence decreased steadily from 21% to 16% at week 12 (p for linear trend <0.001), mostly through stopping SSI. Diabetes-related factors (e.g., hyperglycemia) were more strongly associated with continuing SSI or transitioning to a non-SSI short-acting insulin regimen than frailty-related factors. SSI is the most common method of administering short-acting insulin in NH residents. More research needs to be done to explore why sliding scale use persists weeks after NH admission and explore how we can replace this practice with safer, more effective, and less burdensome regimens.

Unravelling the complex interactions between self-awareness, cognitive change, and mood at 6-months post-stroke using the Y-shaped model

ABSTRACT We investigated the relationships between cognitive change following stroke, awareness of cognitive impairments, and mood to further understanding of change processes influencing psychological outcomes post-stroke in line with the “Y-shaped” process model. Patients (n = 143; M age = 73 years, SD = 13.73; 74 males) were assessed at 3-weeks (T1) and 6-months (T2) post-stroke and had completed the Oxford Cognitive Screen (T1 and T2), the Cognitive Failures Questionnaire (CFQ; T2), and the Hospital Anxiety and Depression Scale (HADS; T2). An ANCOVA controlling for disability relating to activities of daily living (ADL) revealed that awareness of cognitive impairment was significantly lower in participants with moderate-severe cognitive impairment. Regression analysis indicated that greater awareness of cognitive impairment and reduced independence in ADL were associated with greater emotional distress at T2. Cognitive improvement was associated with lower emotional distressat T2. Contrary to the awareness hypothesis, moderation analyses suggest that this effect was largest for those most cognitively impaired at T1. Findings emphasize the importance of monitoring stroke patients’ capacity to be self-aware when assessing and formulating long-term post-stroke distress and have potential implications for improving long-term emotional status in those most cognitively impaired post-stroke, e.g., through psychoeducation, cognitive rehabilitation, and emotional support.

Detection of factors influencing circadian rhythms on Intensive Care inpatients and hospitalization: Protocol for an observational study.

Identify the prevalence of circadian health disorders in ICU and hospitalized patients. Stablish the relationship of the circadian system with light, temperature, noise and nursing activities. Commonly, self-assessment through subjective questionnaires is used for research about sleep quality. However, more reliable and valid measures should be applied objectively to find out the real prevalence of the problem. There is a negative relationship between circadian rhythms and hospitalization. In this study, we will analyse sleep patterns and hospital environments to implement measures to improve the quality of care related to sleep. Descriptive observational study. It is estimated that 975 patients from 13 hospitals need to be recruited from ICU and hospitalization units. The sample should meet the following criteria: Patients over 18 admitted to ICU and medical units, length of stay between 96-148hr, with no visual, hearing or moderate-severe cognitive impairment.Variables: Sleep variables are collected with an electronic device (named Kronowise® and Kronobed®), circadian and infrared light exposure, environmental noise, temperature, unit structural characteristics, nursing care (from 0 to 6 a.m.) and, characteristics of hospitalization period. The study, registered on Clinical Trials, initiated in December 2019 and it will continue up to December 2022. Using objective and subjective measures of sleep and circadian rhythms, this study will shed light on the factors that negatively affect the hospitalized patients' sleep quality and circadian health. The ultimate goal is to design hospital guidelines to minimize the adverse effects on the dependent variables studied. Arguably, these guidelines will contribute to reducing the risk of these alterations and it will also serve to improve the nursing activities. We expect to obtain adequate results for the creation of a protocol to improve the circadian health, quality of care and health outcomes related to sleep in patients.

Variables asociadas con mortalidad en una población de pacientes mayores de 80 años y con algún grado de dependencia funcional, hospitalizados por COVID-19 en un Servicio de Geriatría

ObjectiveThe SARS-CoV-2 pandemic conditions high mortality rates in hospitalized elderly. Currently, a few studies include octogenarian patients and none of them analyze the impact of functional status on this health outcome. Our objective is to describe the characteristics of patients older than 80 years hospitalized for coronavirus disease 2019 (COVID-19), to determine the mortality rate and to identify associated factors. Material and methodsProspective observational study carried out on patients over 80 years admitted for COVID-19 in a Geriatrics Service. Sociodemographic, clinical, functional, mental, analytical, radiological, therapeutic and healthcare variables were collected. The factors associated with in-hospital lethality were analyzed by bivariate analysis. Results58 cases with laboratory-confirmed COVID-19 were included, mean age 88.3 ± 5.4 years, 69% women, 65.5% moderate-severe cognitive impairment and previous Barthel index 40.66 ± 36. The main symptoms were fever (60,3%), dyspnea (53.4%) and deterioration of functional condition (50%). The most frequent comorbidities were cardiovascular disease (75.9%), hypertension (HT) (74.1%) and chronic kidney disease (CKD) (50%). A mortality rate of 41,4% was detected and the associated factors were: severe functional dependence (OR = 3.8 [1.2-12.2]), moderate-severe cognitive impairment (OR = 4.9 [1-25.4]) and CKD (OR = 3.2 [1.1-9.7]). ConclusionHigh mortality rates are observed in older patients hospitalized for COVID-19, with a higher risk of dying in those with severe functional dependence or cognitive impairment. These findings reinforce the value of Geriatric Assessment to develop strategies to adapt diagnostic and therapeutic decision-making and to optimize care for elderly patients in the event of a new epidemic outbreak.

Effect of Bisphosphonates on Fracture Outcomes Among Frail Older Adults.

Bisphosphonates are seldom used in frail, older adults, in part due to lack of direct evidence of efficacy in this population and increasing concerns about safety. We estimated the effects of bisphosphonates on hip fractures, nonvertebral fractures, and severe esophagitis among frail, older adults. Population-based retrospective cohort using 2008 to 2013 linked national Minimum Data Set assessments; Online Survey Certification and Reporting System records; and Medicare claims. US nursing homes (NHs). Long-stay NH residents 65 years and older without recent osteoporosis medication use (N = 24,571). Bisphosphonate initiators were 1:1 propensity score matched to calcitonin initiators (active comparator). Hospitalized hip fracture, nonvertebral fracture, and esophagitis outcomes were measured using part A claims. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated, controlling for over 100 baseline characteristics. The matched cohort included 5209 new bisphosphonate users and an equal number of calcitonin users (mean age [SD] = 85 [8] years; 87% female; 52% moderate-severe cognitive impairment). Over a mean follow-up of 2.5 (SD = 1.7) years, 568 residents (5.5%) had a hip fracture, 874 (8.4%) had a nonvertebral fracture, and 199 (1.9%) had a hospitalized esophagitis event. Users of bisphosphonates were less likely than calcitonin users to experience hip fracture (HR = 0.83; 95% CI = 0.71-0.98), with an average gain in time without fracture of 28.4 days (95% CI = 6.0-50.8 days). Bisphosphonate and calcitonin users had similar rates of nonvertebral fracture (HR = 0.91; 95% CI = 0.80-1.03) and esophagitis events (HR = 1.11; 95% CI = 0.84-1.47). The effects of bisphosphonates on fractures and esophagitis were generally homogeneous across subgroups, including those defined by age, sex, history of prior fracture, and baseline fracture risk. Use of bisphosphonates is associated with a meaningful reduction in hip fracture among frail, older adults, but little difference in nonvertebral fracture or severe esophagitis. J Am Geriatr Soc 67:768-776, 2019.

Prevalencia de delirium mediante la escala Memorial Delirium Assessment Scale (MDAS) en pacientes oncológicos avanzados ingresados en una Unidad de Cuidados Paliativos. Factores de riesgo, reversibilidad y tratamiento recibido

IntroductionDelirium is a common symptom in patients with advanced cancer, despite being under diagnosed and therefore not appropriately treated. Its correct identification using scales and the detection of the possible risk factors is critical to improve symptoms control. ObjectiveTo determine the prevalence of delirium using the Memorial Delirium Assessment Scale (MDAS) as a screening and diagnostic tool, to assess the reversibility of episodes and to identify its risk factors. MethodProspective and observational study of patients diagnosed with advanced oncologic disease, consecutively admitted to a Palliative Care Unit (PCU), during a period of 4 months with follow-up of same until discharge or death. Patients with moderate-severe cognitive impairment and agony status were excluded. Delirium screening was performed on admission and weekly with the MDAS scale. The possible risk factors, treatment and reversibility of the episode during the week after its detection were assessed. ResultsWe included 90 of the 124 oncology patients who were hospitalized during the study period. The prevalence of delirium was 75%, 29% of the cases were diagnosed on admission, and 71% were diagnosed during admission, with the majority subtype being hypoactive (56%). Seventy-three percent of the episodes constituted a terminal event and 27% were reversed or improved. The main precipitating factors were drugs (98.8%): opioids, steroids and benzodiazepines; followed by infections (46%) and dehydration (28%). The main predisposing factor was a history of depression/anxiety/insomnia (72%).Hypercalcaemia was more frequent in patients with reversible delirium (P=.04). The primary treatment was hydration (69%), followed by a reduction of drugs, antibiotics and rotation of opioids, which is more common in patients admitted in delirium (P=.003). The main drugs administered were haloperidol (81%), midazolam (81%) and levomepromazine (54%); the latter two drugs more frequently in patients who died in delirium. Exitus occurred in 95.5% of patients with delirium compared to 65% of patients without delirium (p <0.001), with no difference in either group in the length of stay. ConclusionsDelirium is a prevalent symptom in oncology patients hospitalized in a PCU and its main risk factors are drugs. The episode is more frequently resolved in patients with hypercalcaemia. The reversibility in our sample was lower than in other series, possibly due to the high percentage of patients diagnosed with delirium on admission and who died during the same episode.

Importance of neuropsychological and clinical features to predict seizure control in medically treated patients with mesial temporal epilepsy and hippocampal sclerosis.

It is not yet understood why seizures in certain patients with mesial temporal lobe epilepsy and hippocampal sclerosis (MTLE-HS) develop resistance to antiepileptic drugs (AEDs) while others achieve good seizure control with this treatment. We analyzed clinical and neuropsychological features associated with seizure control in patients with MTLE-HS who had not undergone resective surgery. We enrolled 40 patients with medically treated MTLE-HS and retrospectively collected the following data from prospective databases: sex, febrile seizures, central nervous system infection, history of head trauma, cognitive impairment, psychiatric disturbances, history of status epilepticus, age at onset of epilepsy, aura, seizure type and frequency, electroencephalography abnormalities, HS side, AEDs, global cognitive status, and neuropsychological functions such as cognitive processing speed, attention and executive functions, verbal and visual memory, language, and visuospatial ability. These factors were compared between patients who achieved seizure control (no seizures or a >50% reduction in seizure frequency) with AED treatment and those who continued with poor seizure control (increase or no change in frequency or <50% reduction) after starting treatment. The factors associated with poor seizure control in the multivariate analysis were >2seizures per month before treatment (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.2-4.8, p=0.04), moderate or severe cognitive impairment (OR 2.1, 95% CI 1.8-7.6, p=0.02), and impairment of >2 neuropsychological functions (OR 2.88, 95% CI 2-6.6, p=0.04). No associations were observed between poor seizure control and specific neuropsychological function impairment. Poor seizure control in MTLE-HS is associated with moderate-severe cognitive impairment but not with a specific profile of impairment. Recognizing poor prognostic features such as a high frequency of monthly seizures prior to starting AED treatment could help to identify patients with medically intractable MTLE-HS who may be good candidates for early epilepsy surgery.

A comparison of health expectancies over two decades in England: results of the Cognitive Function and Ageing Study I and II

SummaryBackgroundWhether rises in life expectancy are increases in good-quality years is of profound importance worldwide, with population ageing. We investigate how various health expectancies have changed in England between 1991 and 2011, with identical study design and methods in each decade.MethodsBaseline data from the Cognitive Function and Ageing Studies in populations aged 65 years or older in three geographically defined centres in England (Cambridgeshire, Newcastle, and Nottingham) provided prevalence estimates for three health measures: self-perceived health (defined as excellent–good, fair, or poor); cognitive impairment (defined as moderate–severe, mild, or none, as assessed by Mini-Mental State Examination score); and disability in activities of daily living (defined as none, mild, or moderate–severe). Health expectancies for the three regions combined were calculated by the Sullivan method, which applies the age-specific and sex-specific prevalence of the health measure to a standard life table for the same period.FindingsBetween 1991 and 2011, gains in life expectancy at age 65 years (4·5 years for men and 3·6 years for women) were accompanied by equivalent gains in years free of any cognitive impairment (4·2 years [95% CI 4·2–4·3] for men and 4·4 years [4·3–4·5] for women) and decreased years with mild or moderate–severe cognitive impairment. Gains were also identified in years in excellent or good self-perceived health (3·8 years [95% CI 3·5–4·1] for men and 3·1 years [2·7–3·4] for women). Gains in disability-free years were much smaller than those in excellent–good self-perceived health or those free from cognitive impairment, especially for women (0·5 years [0·2–0·9] compared with 2·6 years [2·3–2·9] for men), mostly because of increased mild disability.InterpretationDuring the past two decades in England, we report an absolute compression (ie, reduction) of cognitive impairment, a relative compression of self-perceived health (ie, proportion of life spent healthy is increasing), and dynamic equilibrium of disability (ie, less severe disability is increasing but more severe disability is not). Reasons for these patterns are unknown but might include increasing obesity during previous decades. Our findings have wide-ranging implications for health services and for extension of working life.FundingUK Medical Research Council.

Malnutrition and cognitive impairment as negative prognostic factors in hospitalized geriatric patients

Introduction.–Malnutrition is a commonproblemamongolderpeople and associated with reduced functional and cognitive ability. Cognitive impairment, in turn, can determine changes in dietary habits and consequent nutritional deficiencies. Patients and methods.– We administered Mini Nutritional Assessment (MNA) and Mini Mental State Examination (MMSE) to seventy-eight patients (average age 83.2 years) admitted to rehabilitation geriatric institute. All patients were evaluated at admittance;wealsoevaluated the relationshipbetweennutritional and cognitive status and discharge (home vs residential home vs hospital vs death). Results.– On admission 58% of patients had moderate-severe cognitive impairment (MMSE<18) while 82% of patients presented malnutrition (MNA<16.5). A linear regression between MMSE score and MNA values showed a close direct relationship between cognitive and nutritional status (r=0.85).