The role of physical exercise and rehabilitation in delirium

Two-year trajectory of functional recovery and quality of life in post-intensive care syndrome: a multicenter prospective observational study on mechanically ventilated patients with coronavirus disease-19

BACKGROUND

Post-intensive care syndrome (PICS) affects the quality of life (QOL) of survivors of critical illness. Although PICS persists for a long time, the longitudinal changes in each component and their interrelationships over time both remain unclear. This multicenter prospective study investigated the 2-year trajectory of PICS and its components as well as factors contributing to deterioration or recovery in mechanically ventilated patients with coronavirus disease 2019 (COVID-19), and also attempted to identify possible countermeasures.

METHODS

Patients who survived COVID-19 requiring mechanical ventilation completed questionnaires on the Barthel index, Short-Memory Questionnaire, Hospital Anxiety and Depression Scale, and EuroQol 5 dimensions 5-level every six months over a two-year period. Scores were weighted to account for dropouts, and the trajectory of each functional impairment was evaluated with alluvial diagrams. The prevalence of PICS and factors impairing or restoring function were examined using generalized estimating equations considering trajectories.

RESULTS

Among 334 patients, PICS prevalence rates in the four completed questionnaires were 72.1, 78.5, 77.6, and 82.0%, with cognitive impairment being the most common and lower QOL being noted when multiple impairments coexisted. Physical function and QOL indicated that many patients exhibited consistent trends of either recovery or deterioration. In contrast, cognitive function and mental health revealed considerable variability, with many patients showing fluctuating ratings in the later surveys. Delirium was associated with worse physical and mental health and poor QOL, while prolonged ventilation was associated with poor QOL. Living with family was associated with the recovery of all functions and QOL, while extracorporeal membrane oxygenation (ECMO) was associated with the recovery of cognitive function and mental health.

CONCLUSIONS

Critically ill patients had PICS for a long period and followed different trajectories for each impairment component. Based on trajectories, known PICS risk factors such as prolonged ventilation and delirium were associated with impaired recovery, while ECMO and the presence of family were associated with recovery from PICS. In critically ill COVID-19 patients, delirium management and family interventions may play an important role in promoting recovery from PICS.

TRIAL REGISTRATION NUMBER

UMIN000041276, August 01, 2020.

Age-Specific Changes in Physical Function in Patients with Acute Decompensated Heart Failure

Cardiac rehabilitation (CR) improves physical function in patients with acute decompensated heart failure (ADHF) and frailty. However, few studies have assessed physical function through multiple measures during hospitalization; moreover, the effect of age remains unclear. This study aimed to evaluate age-specific changes in physical function during the acute-phase treatment period in patients with ADHF. Patients with ADHF hospitalized between June 2018 and June 2023, who were aged ≥ 60 years and underwent CR, were included in the study. Physical function assessments at admission and discharge included grip strength, quadriceps isometric strength, short physical performance battery (SPPB), gait speed, and frailty. Changes in physical function from admission to discharge were assessed. The mean age of the 531 patients was 79.8 ± 9.0 years and 58% were male. Physical function at admission and discharge significantly decreased with age according to all measures. In patients aged ≥ 90 years, quadriceps isometric strength (0.27 ± 0.11 kgf/BW kg) and the SPPB score (4.5 ± 3.6 points) were severely impaired at admission. However, no significant differences were observed in changes in physical function according to age; the improvement in the SPPB score tended to increase with age (+1.7 ± 1.9, +2.3 ± 2.1, +2.2 ± 2.4, and +2.3 ± 1.8, in the 60-69-, 70-79-, 80-89-, and ≥ 90-year age groups, respectively). The improvement in frailty was similar in all groups. Although physical function declined with age, the changes in physical function were similar in patients with ADHF at any age above 60 years who underwent CR.

Implementation of Function Focused Care for Acute Care Using the Evidence Integration Triangle

BACKGROUND

The purpose of this study was to test the impact of Function Focused Care for Acute Care Using the Evidence Integration Triangle (FFC-AC-EIT) on hospitalized patients living with dementia.

METHODS

This was a clustered randomized clinical trial including 12 hospitals from two states and 455 patients living with dementia. Hospitals were randomized to FFC-AC-EIT versus FFC Education Only. The mean age of the participants was 82.5 (SD = 8.5), the majority were women (62.6%), White (65.3%), married (64.4%), and had 3.0 (SD = 2.4) comorbidities. Outcome measures included the Barthel Index; the Physical Activity Survey, the Confusion Assessment Method Short Form (CAM-S), the Neuropsychiatric Inventory (NPI), and the Pain Assessment in Advanced Dementia.

RESULTS

At discharge, both groups improved in function and physical activity, patients in the intervention group had less increase in pain than those in the control group (β = -0.58, 95% confidence interval [95% CI] (-0.89, -0.26), p < 0.001). There were no group differences in behavioral symptoms or delirium. At 1 month post-discharge there was a significant improvement in function (β = 5.55, 95% CI [0.36, 10.75], p = 0.036) and physical activity (β = 3.07, 95% CI [1.87, 4.28], p < 0.001).

CONCLUSIONS

Exposure to information about function focused care may help staff in acute care settings maintain and increase function and physical activity for older patients living with dementia during the hospital stay and help facilitate an increase in function and physical activity after discharge.

Postoperative delirium in geriatric orthopedic and trauma patients: Care begins preoperatively!

Delirium is a common and serious neuropsychiatric syndrome affecting older adults, particularly after surgery. It manifests in three forms: hypoactive, hyperactive, and mixed, with symptoms ranging from lethargy and inattention to agitation and confusion. Delirium is often misdiagnosed or overlooked, especially in its hypoactive form, which can delay treatment and worsen patient outcomes. Distinguishing delirium from dementia is crucial, as delirium is typically reversible with prompt intervention. This article, presented in a case study format, explores the assessment and management of delirium in postoperative patients, highlighting the use of validated tools such as the Delirium Elderly at Risk (DEAR) and the Confusion Assessment Method (CAM). Early identification of at-risk patients and timely screening are critical for improving outcomes. Non-pharmacological interventions, including reorientation, sleep hygiene, sensory aids, early mobilization, and family involvement, play a vital role in preventing and managing delirium. The article emphasizes the importance of nurses in detecting early signs of delirium and implementing preventative measures. A multidisciplinary approach, integrating ongoing screening, patient-centered care, and non-pharmacological strategies, is essential for reducing the incidence and severity of delirium. Early detection and appropriate management can significantly improve recovery and reduce long-term complications, promoting better outcomes in older adults undergoing surgery.

Delirium and frailty in older adults: Clinical overlap and biological underpinnings

Frailty and delirium are two common geriatric syndromes sharing several clinical characteristics, risk factors, and negative outcomes. Understanding their interdependency is crucial to identify shared mechanisms and implement initiatives to reduce the associated burden. This literature review summarizes scientific evidence on the complex interplay between frailty and delirium; clinical, epidemiological, and pathophysiological commonalities; and current knowledge gaps. We conducted a PubMed systematic search in June 2023, which yielded 118 eligible articles out of 991. The synthesis of the results-carried out by content experts-highlights overlapping risk factors, clinical phenotypes, and outcomes and explores the influence of one syndrome on the onset of the other. Common pathophysiological mechanisms identified include inflammation, neurodegeneration, metabolic insufficiency, and vascular burden. The review suggests that frailty is a risk factor for delirium, with some support for delirium associated with accelerated frailty. The proposed unifying framework supports the integration and measurement of both constructs in research and clinical practice, identifying the geroscience approach as a potential avenue to develop strategies for both conditions. In conclusion, we suggest that frailty and delirium might be alternative-sometimes coexisting-manifestations of accelerated biological aging. Clinically, the concepts addressed in this review can help approach older adults with either frailty or delirium from a different perspective. From a research standpoint, longitudinal studies are needed to explore the hypothesis that specific pathways within the biology of aging may underlie the clinical manifestations of frailty and delirium. Such research will pave the way for future understanding of other geriatric syndromes as well.

Effects of Exercise Intervention for the Management of Delirium in Hospitalized Older Adults: A Randomized Clinical Trial

OBJECTIVE

Delirium is a serious neuropsychiatric syndrome frequently occurring in hospitalized older adults, for which pharmacological treatments have shown limited effectiveness. Multicomponent physical exercise programs have demonstrated functional benefits; however, the impact of exercise on the course of delirium remains unexplored. The aim of this study was to investigate the effect of an individualized, multicomponent exercise intervention on the evolution of delirium and patient outcomes.

DESIGN

A single-center, single-blind randomized controlled trial.

SETTING AND PARTICIPANTS

Medical inpatients with delirium in an acute geriatric unit of a tertiary public hospital.

METHODS

Thirty-six patients (mean age 87 years) were recruited and randomized into 2 groups. The control group received usual care and the intervention group received individualized physical exercise (1 daily session) for 3 consecutive days. Primary endpoints were the duration and severity of delirium (4-AT, Memorial Delirium Assessment Scale) and change in functional status [Barthel Index, Short Physical Performance Battery, Hierarchical Assessment of Balance and Mobility (HABAM), and handgrip strength]. Secondary endpoints included length of stay, falls, and health outcomes at 1- and 3-month follow-up.

RESULTS

The intervention group showed more functional improvement at discharge (HABAM, P = .015) and follow-up (Barthel, P = .041; Lawton P = .027). Less cognitive decline was observed at 1 and 3 months (Informant Questionnaire on Cognitive Decline in the Elderly, P = .017). Exercise seemed to reduce delirium duration by 1 day and contribute to delirium resolution at discharge, although findings did not reach statistical significance. No exercise-related adverse events occurred.

CONCLUSION AND IMPLICATIONS

Findings suggest that individualized exercise in acutely hospitalized older patients with delirium is safe, may improve delirium course and help preserve post-hospitalization function and cognition.

Impact of AI-Powered Solutions in Rehabilitation Process: Recent Improvements and Future Trends

Rehabilitation is an important and necessary part of local and global healthcare services along with treatment and palliative care, prevention of disease, and promotion of good health. The rehabilitation process helps older and young adults even children to become as independent as possible in activities of daily life and enables participation in useful living activities, recreation, work, and education. The technology of Artificial Intelligence (AI) has evolved significantly in recent years. Many activities related to rehabilitation have been getting benefits from using AI techniques. The objective of this review study is to explore the advantages of AI for rehabilitation and how AI is impacting the rehabilitation process. This study aims at the most critical aspects of the rehabilitation process that could potentially take advantage of AI techniques including personalized rehabilitation apps, rehabilitation through assistance, rehabilitation for neurological disorders, rehabilitation for developmental disorders, virtual reality rehabilitation, rehabilitation of neurodegenerative diseases and Telerehabilitation of Cardiovascular. We presented a survey on the newest empirical studies available in the literature including the AI-based technology helpful in the Rehabilitation process. The novelty feature included but was not limited to an overview of the technological solutions useful in rehabilitation. Seven different categories were identified. Illustrative examples of practical applications were detailed. Implications of the findings for both research and practice were critically discussed. Most of the AI applications in these rehabilitation types are in their infancy and continue to grow while exploring new opportunities. Therefore, we investigate the role of AI technology in rehabilitation processes. In addition, we do statistical analysis of the selected studies to highlight the significance of this review work. In the end, we also present a discussion on some challenges, and future research directions.

Gender, Pain, and Function Associated With Physical Activity After Hospitalization in Persons Living With Dementia

BACKGROUND

The purpose of this study was to identify factors that are associated with physical activity after hospitalization in persons living with dementia.

METHODS

Multiple linear regressions were conducted to test factors associated with objective activity levels (sedentary, low, moderate, and vigorous) among 244 patients living with dementia from a randomized controlled trial.

RESULTS

Within 48 hours of hospital discharge, time in sedentary behavior was associated with increased pain (β=0.164, P =0.015). Time in low activity was associated with less pain (β=-0.130, P =0.049) and higher physical function (β=0.300, P =<0.001). Time in moderate activity was associated with increased physical function (β=0.190, P =0.008) and male gender (β=0.155, P =0.016). No significant associations of potential factors were found with time in vigorous activity.

CONCLUSIONS

Our findings suggest that managing or reducing pain, encouraging individual functional level, and gender could influence time spent in physical activity after acute hospitalization in persons living with dementia.

Perioperative interventions to improve early mobilisation and physical function after hip fracture: a systematic review and meta-analysis

BACKGROUND

Perioperative interventions could enhance early mobilisation and physical function after hip fracture surgery.

OBJECTIVE

Determine the effectiveness of perioperative interventions on early mobilisation and physical function after hip fracture.

METHODS

Ovid MEDLINE, CINAHL, Embase, Scopus and Web of Science were searched from January 2000 to March 2022. English language experimental and quasi-experimental studies were included if patients were hospitalised for a fractured proximal femur with a mean age 65 years or older and reported measures of early mobilisation and physical function during the acute hospital admission. Data were pooled using a random effect meta-analysis.

RESULTS

Twenty-eight studies were included from 1,327 citations. Studies were conducted in 26 countries on 8,192 participants with a mean age of 80 years. Pathways and models of care may provide a small increase in early mobilisation (standardised mean difference [SMD]: 0.20, 95% confidence interval [CI]: 0.01-0.39, I2 = 73%) and physical function (SMD: 0.07, 95% CI 0.00 to 0.15, I2 = 0%) and transcutaneous electrical nerve stimulation analgesia may provide a moderate improvement in function (SMD: 0.65, 95% CI: 0.24-1.05, I2 = 96%). The benefit of pre-operative mobilisation, multidisciplinary rehabilitation, recumbent cycling and clinical supervision on mobilisation and function remains uncertain. Evidence of no effect on mobilisation or function was identified for pre-emptive analgesia, intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, occupational therapy training or nutritional supplements.

CONCLUSIONS

Perioperative interventions may improve early mobilisation and physical function after hip fracture surgery. Future studies are needed to model the causal mechanisms of perioperative interventions on mobilisation and function after hip fracture.

Post-stroke delirium and challenges for the rehabilitation setting: A narrative review

INTRODUCTION

Post-stroke delirium (PSD) is a common yet underrecognized complication following stroke, with its effect on stroke rehabilitation being the subject of limited attention. The objective of this narrative review is to provide an overview of core issues in PSD including epidemiology, diagnostic challenges, and management considerations, with an emphasis on the rehabilitation phase.

METHODS

Ovid Medline and Google Scholar were searched through February 2023 using keywords related to delirium, rehabilitation, and the post-stroke period. Only studies conducted on adults (≥18 years) and written in the English language were included.

RESULTS

PSD affects approximately 25% of stroke patients, and often persists well into the post-acute phase, with a negative impact on rehabilitation outcomes including lengths of stay, function, and cognition. Certain stroke and patient characteristics can help predict risk for PSD. The diagnosis of delirium becomes more challenging when superimposed on stroke deficits (such as attentional impairment or other cognitive, psychiatric, or behavioural disorders), leading to underdiagnosis, overdiagnosis, or misdiagnosis. Particularly in patients with post-stroke language or cognitive disorders, common screening tools are less accurate. The multidisciplinary rehabilitation team should be involved in management of PSD as rehabilitative activities can be beneficial for patients who can participate safely. Addressing barriers to effective delirium care at various levels of the health care system can improve rehabilitation trajectories for these patients.

CONCLUSIONS

PSD is a disease entity commonly encountered in the rehabilitation setting, but it is challenging to diagnose and manage. New delirium screening tools and management approaches specific for the post-stroke and rehabilitation settings are needed.

Heart rate response and recovery during exercise predict future delirium risk-A prospective cohort study in middle- to older-aged adults

BACKGROUND

Delirium is a neurocognitive disorder characterized by an abrupt decline in attention, awareness, and cognition after surgical/illness-induced stressors on the brain. There is now an increasing focus on how cardiovascular health interacts with neurocognitive disorders given their overlapping risk factors and links to subsequent dementia and mortality. One common indicator for cardiovascular health is the heart rate response/recovery (HRR) to exercise, but how this relates to future delirium is unknown.

METHODS

Electrocardiogram data were examined in 38,740 middle- to older-aged UK Biobank participants (mean age = 58.1 years, range: 40-72 years; 47.3% males) who completed a standardized submaximal exercise stress test (15-s baseline, 6-min exercise, and 1-min recovery) and required hospitalization during follow-up. An HRR index was derived as the product of the heart rate (HR) responses during exercise (peak/resting HRs) and recovery (peak/recovery HRs) and categorized into low/average/high groups as the bottom quartile/middle 2 quartiles/top quartile, respectively. Associations between 3 HRR groups and new-onset delirium were investigated using Cox proportional hazards models and a 2-year landmark analysis to minimize reverse causation. Sociodemographic factors, lifestyle factors/physical activity, cardiovascular risk, comorbidities, cognition, and maximal workload achieved were included as covariates.

RESULTS

During a median follow-up period of 11 years, 348 participants (9/1000) newly developed delirium. Compared with the high HRR group (16/1000), the risk for delirium was almost doubled in those with low HRR (hazard ratio = 1.90, 95% confidence interval (95%CI): 1.30-2.79, p = 0.001) and average HRR (hazard ratio = 1.54, 95%CI: 1.07-2.22, p = 0.020)). Low HRR was equivalent to being 6 years older, a current smoker, or ≥3 additional cardiovascular disease risks. Results were robust in sensitivity analysis, but the risk appeared larger in those with better cognition and when only postoperative delirium was considered (n = 147; hazard ratio = 2.66, 95%CI: 1.46-4.85, p = 0.001).

CONCLUSION

HRR during submaximal exercise is associated with future risk for delirium. Given that HRR is potentially modifiable, it may prove useful for neurological risk stratification alongside traditional cardiovascular risk factors.

Post hip fracture orthogeriatric care-a Canadian position paper addressing challenges in care and strategies to meet quality indicators

INTRODUCTION

Osteoporosis is a major disease state associated with significant morbidity, mortality, and health care costs. Less than half of the individuals sustaining a low energy hip fracture are diagnosed and treated for the underlying osteoporosis.

OBJECTIVE

A multidisciplinary Canadian hip fracture working group has developed practical recommendations to meet Canadian quality indicators in post hip fracture care.

METHODS

A comprehensive narrative review was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections and develop recommendations. These recommendations are based on the best evidence available today.

CONCLUSION

Recommendations are anticipated to reduce recurrent fractures, improve mobility and healthcare outcomes post hip fracture, and reduce healthcare costs. Key messages to enhance postoperative care are also provided.

Low Skeletal Muscle Mass and the Incidence of Delirium in Hospitalized Older Patients: A Systematic Review and Meta-Analysis of Observational Studies

Background

Both low skeletal muscle mass and delirium are prevalent in older hospitalized patients, while their associations are unclear. This systematic review and meta-analysis aim to investigate the associations between low skeletal muscle mass and the incidence of delirium in hospitalized patients.

Methods

The PubMed, Web of Science, and Embase were searched for relevant studies published before May 2022, and we conducted this systematic review and meta-analysis according to the PRISMA and MOOSE guidelines. The summary odds ratios (OR) and 95% confidence intervals (CI) were estimated, and subgroup analyses were also conducted according to the age and major surgeries.

Results

Finally, nine studies with 3 828 patients were included. The pooled result showed no significant association between low skeletal muscle mass and the incidence of delirium (OR 1.69, 95% CI 0.85 to 2.52). However, sensitivity analysis suggested that one study caused a significant alteration of the summary result, and the meta-analysis of the remaining 8 studies showed that low skeletal muscle mass was significantly associated with an 88% increased incidence of delirium (OR 1.88, 95% CI 1.43 to 2.33). Furthermore, subgroup analyses indicated that low skeletal muscle mass was associated with a higher incidence of delirium in patients ≥75 years old or undergoing major surgeries instead of those <75 years old or without surgeries, respectively.

Conclusions

Hospitalized patients with low skeletal muscle mass might have higher incidence of delirium, particularly in those of older age and undergoing major surgeries. Therefore, great attention should be paid to these patients.

Micronutrient Deficiency and Its Potential Role in Delirium Onset in Older Adults: A Systematic Review

BACKGROUND AND OBJECTIVES

One of the pathogenetic hypotheses of delirium is the "neuroinflammatory theory" with consequent neurotoxicity of brain connectivity networks. Micronutrients may play a significant role in the prevention of neuroinflammation. This systematic review addresses the role of micronutrients in the development of delirium in older populations.

METHODS

The EBSCO, Cochrane, PubMed, and Web of Science databases were searched for articles on delirium and micronutrients. The methodological quality of the studies included in the review was evaluated with the Newcastle-Ottawa Scales for observational studies and for case-control studies.

RESULTS

1326 papers were identified from the searches, 7 of which met the inclusion criteria (see section 2.3). All the papers included were written in English. Delirium was predominantly secondary to post-operative dysfunction or acute medical conditions. By altering the production of neurotransmitters resulting in an imbalance, and by reducing their immunomodulatory role with a consequent increase in inflammatory oxidative stress, micronutrient deficiency seems to be associated with an increased incidence of delirium.

CONCLUSIONS

This review supports the existence of an association between micronutrient deficiency (i.e. cobalamin, thiamine, and vitamin D) and an increased incidence of delirium, with a greater prevalence in hospitalized patients.

Type 2 Diabetes Mellitus with Tight Glucose Control and Poor Pre-Injury Stair Climbing Capacity May Predict Postoperative Delirium: A Secondary Analysis

(1) Background: Previous evidence demonstrates that tight glycemic control and good physical function could reduce the risk of delirium. This study aimed to investigate whether the occurrence of postoperative delirium (POD) in older hip fracture surgery patients is associated with preoperative glycemic control factors or pre-injury physical performance. (2) Methods: Three-hundred and nine individuals aged over 65 years and scheduled for hip fracture surgery were included at a single center. Glycemic control factors and pre-injury physical performance were assessed preoperatively. The presence of delirium was assessed using the Confusion Assessment Method on postoperative hospitalization days. Univariate and multivariable logistic regression models and a risk prediction model of POD were established. (3) Results: Among the 309 patients, 52 (16.83%) experienced POD during the hospital stay. The numbers of pre-injury physical performance and type 2 diabetes mellitus (T2DM) patients were significantly different in the POD and non-POD groups. The multivariable model showed that development of delirium was significantly explained by preoperative fasting blood glucose (FBG) (OR 0.804, p = 0.004), stair climbing (OR 0.709, p = 0.003), T2DM (odds ratio (OR) 3.654, p = 0.001), and age-adjusted Charlson comorbidity index (ACCI) (OR 1.270, p = 0.038). The area under the receiver operating characteristic curve (AUROC) of the risk prediction model including those covariates was 0.770. (4) Conclusions: More older T2DM patients develop POD after hip fracture surgery than patients without T2DM. A simple assessment of preoperative FBG and pre-injury stair climbing capacity may identify those at high risk for the development of POD. Higher preoperative FBG and good pre-injury stair climbing capacity are protective factors for POD.

Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

Low-intensity extracorporeal shock wave therapy promotes recovery of sciatic nerve injury and the role of mechanical sensitive YAP/TAZ signaling pathway for nerve regeneration

Background:

Histological and functional recovery after peripheral nerve injury (PNI) is of significant clinical value as delayed surgical repair and longer distances to innervate terminal organs may account for poor outcomes. Low-intensity extracorporeal shock wave therapy (LiESWT) has already been proven to be beneficial for injured tissue recovery on various pathological conditions. The objective of this study was to explore the potential effect and mechanism of LiESWT on PNI recovery.

Methods:

In this project, we explored LiESWT's role using an animal model of sciatic nerve injury (SNI). Shockwave was delivered to the region of the SNI site with a special probe at 3 Hz, 500 shocks each time, and 3 times a week for 3 weeks. Rat Schwann cells (SCs) and rat perineurial fibroblasts (PNFs) cells, the two main compositional cell types in peripheral nerve tissue, were cultured in vitro, and LiESWT was applied through the cultured dish to the adherent cells. Tissues and cell cultures were harvested at corresponding time points for a reverse transcription-polymerase chain reaction, Western blotting, and immunofluorescence staining. Multiple groups were compared by using one-way analysis of variance followed by the Tukey-Kramer test for post hoc comparisons.

Results:

LiESWT treatment promoted the functional recovery of lower extremities with SNI. More nerve fibers and myelin sheath were found after LiESWT treatment associated with local upregulation of mechanical sensitive yes-associated protein (YAP)/transcriptional co-activator with a PDZ-binding domain (TAZ) signaling pathway. In vitro results showed that SCs were more sensitive to LiESWT than PNFs. LiESWT promoted SCs activation with more expression of p75 (a SCs dedifferentiation marker) and Ki67 (a SCs proliferation marker). The SCs activation process was dependent on the intact YAP/TAZ signaling pathway as knockdown of TAZ by TAZ small interfering RNA significantly attenuated this process.

Conclusion:

The LiESWT mechanical signal perception and YAP/TAZ upregulation in SCs might be one of the underlying mechanisms for SCs activation and injured nerve axon regeneration.

Unconventional Care at a Convention Center: An Overview of Patient Focused Care at a COVID-19 Alternative Care Site in New Orleans

In March 2020, the State of Louisiana opened an alternative care site at the New Orleans Convention Center, known as the Medical Monitoring Station (MMS). The facility was designed, constructed, and staffed to serve a population with basic medical needs as they recovered from COVID-19. As the MMS prepared to open, local hospitals indicated a greater need for assistance with patients requiring a higher acuity of care and populations unable to be discharged due to infection risks. In response to this, the capabilities of the facility were altered to accommodate primarily elderly patients, with significant comorbidities, requiring extensive care. This manuscript presents the demographics of the first 250 patients seen at the MMS, and describes the most critical policies/protocols, interventions, and resources that proved successful in adjusting to effectively serve its population.

Effects of uncomfortable care and histamine H2-antagonists on delirium in acute stroke: A propensity score analysis

BACKGROUND AND PURPOSE

Uncomfortable care and histamine H2 antagonist (H2A) are implicated in precipitating delirium. In acute stroke, however, the need for them depends on stroke severity, an established risk factor for delirium. So, it is unclear whether care or H2A itself is responsible for delirium. We aimed to evaluate their causal effects on delirium in acute stroke patients.

METHODS

This is a prospective cohort study on acute stroke patients admitted to a stroke care unit. Patients without stupor, coma, sedation, or delirium upon admission were enrolled. The treatment was H2A and five care modalities given during the first 24 h: restraint use, prohibited self-transfer, no oral feeding, indwelling catheters, and frequent nighttime care. The outcome was delirium within 5 days defined as Intensive Care Delirium Screening Checklist ≥4 points. We estimated the relative risk (RR) for delirium with regression models weighted by overlap weights using propensity scores estimated through logistic models incorporating known and potential confounders, including stroke severity.

RESULTS

Of the 387 participants, 188 were given at least one care modality and 130 were given H2A. A total of 42 developed delirium. Delirium was significantly associated with prohibited self-transfer (RR 1.7, 95% CI 1.0-3.0), frequent nighttime care (RR 2.1, 95% CI 1.2-3.7), and multiple care modalities (RR 2.4, 95% CI 1.3-4.4), while other care modalities and H2A were not.

CONCLUSIONS

This study showed possible causal effects of uncomfortable care on delirium and suggests that minimizing it could prevent delirium in acute stroke.

[Exercise and physical training as interventions in gerontopsychiatry]

The treatment of mental disorders in older adults is often restricted by limitations in efficacy and tolerability of pharmacologically dominated standard therapeutic strategies. Therefore, nonpharmacological therapeutic alternatives and supplements play a crucial role in these patients. Structured exercise and training are interventions that are associated with a high level of evidence in prevention and treatment of mental and cognitive disorders. This article is based on a selective search of the literature and provides an overview of the current scientific evidence with respect to the mechanisms of action, the effects on frequently occurring clinical disorders and modalities of the exercise interventions.

CCCDTD5: Reducing the risk of later-life dementia. Evidence informing the Fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD-5)

The Fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD-5) was a year-long process to synthesize the best available evidence on several topics. Our group undertook evaluation of risk reduction, in eight domains: nutrition; physical activity; hearing; sleep; cognitive training and stimulation; social engagement and education; frailty; and medications. Here we describe the rationale for the undertaking and summarize the background evidence-this is also tabulated in the Appendix. We further comment specifically on the relationship between age and dementia, and offer some suggestions for how reducing the risk of dementia in the seventh decade and beyond might be considered if we are to improve prospects for prevention in the near term. We draw to attention that a well-specified model of success in dementia prevention need not equate to the elimination of cognitive impairment in late life.