What Predicts Health-Related Quality of Life for Patients With Displaced Femoral Neck Fractures Managed With Arthroplasty? A Secondary Analysis of the HEALTH Trial

BACKGROUND

Total hip arthroplasty (THA) has been argued to improve health-related quality of life (HRQoL) and function in femoral neck fracture patients compared with hemiarthroplasty (HA). The HEALTH trial showed no clinically important functional advantages of THA over HA. The current analysis explores factors associated with HRQoL and function in this population.

METHODS

Using repeated measures regression, we estimated the association between HRQoL and function [Short Form-12 (SF-12) physical component score (PCS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score] and 23 variables.

RESULTS

THA as compared to monopolar HA, but not bipolar HA, was more likely to improve PCS scores (adjusted mean difference [AMD] 1.88 points, P = 0.02), whereas higher American Society of Anesthesiologists score (AMD -2.64, P < 0.01), preoperative use of an aid (AMD -2.66, P < 0.01), and partial weight-bearing status postoperatively (AMD -1.38, P = 0.04) demonstrated less improvement of PCS scores over time. THA improved WOMAC function scores over time compared with monopolar HA (but not bipolar HA) (AMD -2.40, P < 0.01), whereas higher American Society of Anesthesiologists classification (AMD 1.99, P = 0.01) and preoperative use of an aid (AMD 5.39, P < 0.01) were associated with lower WOMAC function scores. Preoperative treatment for depression was associated with lower functional scores (AMD 7.73, P < 0.01).

CONCLUSION

Patients receiving THA are likely to receive small and clinically unimportant improvements in health utility and function compared with those receiving monopolar HA and little improvement compared with those receiving bipolar HA. Patient-specific characteristics seem to play a larger role in predicting functional improvement among femoral neck fracture patients.

LEVEL OF EVIDENCE

Prognostic Level II.

Cortical Neuroplasticity and Cognitive Function in Early-Stage, Mild-Moderate Hearing Loss: Evidence of Neurocognitive Benefit From Hearing Aid Use

Age-related hearing loss (ARHL) is associated with cognitive decline as well as structural and functional brain changes. However, the mechanisms underlying neurocognitive deficits in ARHL are poorly understood and it is unclear whether clinical treatment with hearing aids may modify neurocognitive outcomes. To address these topics, cortical visual evoked potentials (CVEPs), cognitive function, and speech perception abilities were measured in 28 adults with untreated, mild-moderate ARHL and 13 age-matched normal hearing (NH) controls. The group of adults with ARHL were then fit with bilateral hearing aids and re-evaluated after 6 months of amplification use. At baseline, the ARHL group exhibited more extensive recruitment of auditory, frontal, and pre-frontal cortices during a visual motion processing task, providing evidence of cross-modal re-organization and compensatory cortical neuroplasticity. Further, more extensive cross-modal recruitment of the right auditory cortex was associated with greater degree of hearing loss, poorer speech perception in noise, and worse cognitive function. Following clinical treatment with hearing aids, a reversal in cross-modal re-organization of auditory cortex by vision was observed in the ARHL group, coinciding with gains in speech perception and cognitive performance. Thus, beyond the known benefits of hearing aid use on communication, outcomes from this study provide evidence that clinical intervention with well-fit amplification may promote more typical cortical organization and functioning and provide cognitive benefit.

Factor structure and construct validity of the Behavioral Dyscontrol Scale-II

The Behavioral Dyscontrol Scale-II (BDS-II) was developed as an improved scoring method to the original BDS, which was designed to evaluate the capacity for independent regulation of behavior and attention. The purpose of this study was to evaluate the factor structure and construct validity of the BDS-II, which had not been adequately re-examined since the development of the new scoring system. In a sample of 164 Veterans with a mean age of 35 years, exploratory factor analysis was used to evaluate BDS-II latent factor structure. Correlations and regressions were used to explore validity against 22 psychometrically sound neurocognitive measures across seven neurocognitive domains of sensation, motor output, processing speed, attention, visual-spatial reasoning, memory, and executive functions. Factor analysis found a two-factor solution for this sample which explained 41% of the variance in the model. Validity analyses found significant correlations among the BDS-II scores and all other cognitive domains except sensation and language (which was not evaluated). Hierarchical regressions revealed that PASAT performance was strongly associated with all three BDS-II scores; dominant hand Finger Tapping Test was also associated with the Total score and Factor 1, and CPT-II Commissions was also associated with Factor 2. These results suggest the BDS-II is both a general test of cerebral functioning, and a more specific test of working memory, motor output, and impulsivity. The BDS-II may therefore show utility with younger populations for measuring frontal lobe abilities and might be very sensitive to neurological injury.

The Behavioral Dyscontrol Scale-II with non-elderly veterans

The Behavioral Dyscontrol Scale-II (BDS-II) is a unique test of frontal lobe function. Although the test was created for use in geriatric populations, it can add useful data to assessments of non-elderly patients. The original scoring system for the BDS was characterized by a low ceiling, limiting its use with higher functioning populations. The BDS-II scoring system was created to address this issue; however, new normative data were not published. This study used a non-elderly Veteran sample to compare the psychometric properties of the BDS and BDS-II scoring systems. The BDS-II showed improved psychometric properties (reductions in skewness and kurtosis) and was significantly more reliable than the BDS. Normative data using both the total sample, as well as the subsample of healthy individuals, are provided for clinical use.

Functional status of men with the fragile X premutation, with and without the tremor/ataxia syndrome (FXTAS)

BACKGROUND

Fragile X-associated tremor/ataxia syndrome (FXTAS), which occurs in some premutation carriers of the fragile X mental retardation 1 (FMR1) gene, is a neurodegenerative disorder characterized by action tremor, gait ataxia, and impaired executive cognitive functioning.

OBJECTIVE

To evaluate the nature and severity of functional limitations among male carriers of the fragile X premutation, both with and without FXTAS.

METHODS

Forty-two subjects with FXTAS and 24 asymptomatic premutation carriers were compared to 32 control subjects on measures of physical functioning, activities of daily living (ADLs; e.g. eating, bathing), and instrumental activities of daily living (IADLs; e.g. shopping, managing medications). Ordinary least squares regression, controlling for age, education, medical comorbidity, and pain, was used to examine group differences in physical and functional performance.

RESULTS

Men with FXTAS performed significantly worse than control subjects on all dependent measures, showing greater limitations in physical functioning, as well as ADL and IADL performance (p < 0.05). Subsequent analyses suggested that physical and functional impairments among men with FXTAS result largely from deficits in motor and executive functioning and that CGG repeat length is associated with functional impairment. Asymptomatic carriers of the fragile X premutation performed similarly to control subjects on all measures.

CONCLUSIONS

This study provides the first comprehensive evaluation of functional status among male premutation carriers. Although carriers without FXTAS performed similarly to control subjects, men with FXTAS showed evidence of significant physical and functional impairment, which appears to result largely from motor and executive deficits characteristic of the syndrome.

Executive function (capacity for behavioral self-regulation) and decline predicted mortality in a longitudinal study in Southern Colorado

OBJECTIVE

To assess the relationship between mortality and impairment and decline in a specific executive cognitive function, the capacity for behavioral self-regulation.

STUDY DESIGN AND SETTING

This study examined the association between mortality and baseline and 22-month decline in the capacity for behavioral self-regulation, as measured by the Behavioral Dyscontrol Scale, among 1,293 participants of the San Luis Valley Health and Aging Study (SLVHAS), a population-based longitudinal study. The Behavioral Dyscontrol Scale and a measure of overall mental status, the Mini-Mental State Examination, were administered at baseline and follow-up interviews. Cox regression was used to examine baseline and decline in capacity for behavioral self-regulation as possible predictors of mortality.

RESULTS

Baseline Behavioral Dyscontrol Scale score was predictive of mortality, independent of demographics and comorbidity count (hazard ratio [HR]=1.07; 95% confidence interval [CI]: 1.04, 1.09). It remained a significant predictor with further adjustment for Mini-Mental State Examination score. Decline in this specific executive cognitive function was associated with mortality after adjustment for covariates and baseline cognitive scores (HR=1.09; 95% CI: 1.04, 1.13).

CONCLUSION

Thus, both baseline capacity for behavioral self-regulation and its decline over time predicted mortality in the SLVHAS cohort. These associations may partly be attributed to maintaining the ability for self-care. Understanding how specific forms of impairment contribute to mortality may help identify patients who could benefit from early intervention.

Validation of the Behavioral Dyscontrol Scale-Electronic Version: Sensitivity to subtle sequelae of mild traumatic brain injury

PRIMARY OBJECTIVE

To determine whether a new computer-administered battery (Behavioral Dyscontrol Scale-Electronic Version; BDS-EV) can detect subtle executive weaknesses among individuals with a self-reported history of mild head trauma (MHT), and to compare the utility of this battery to the original, non-electronic BDS and other traditional executive measures. Both BDS-EV and BDS are comprised of three factors (motor programming, environmental independence, and fluid intelligence).

METHOD

Participants with (n = 19) and without (n = 24) MHT were compared on their performance on the BDS-EV, the non-electronic BDS, and three traditional measures of executive abilities.

RESULTS

Participants with MHT differed from those without MHT on the BDS-EV motor programming and environmental independence, but not on any other measures.

CONCLUSION

The results show that electronic administration improved the sensitivity of the battery, and support prior findings that traditional executive measures are generally insensitive to subtle executive deficits associated with chronic MHT.

The impact of executive cognitive functioning on rates of smoking cessation in the San Luis Valley Health and Aging Study

Cigarette smoking is one of the leading preventable causes of death. Previous research has shown that many common smoking cessation interventions are effective with older smokers; a few interventions have been tailored to this population. To our knowledge, however, no smoking cessation research or interventions targeted at older adults have addressed the influence of cognition on successful smoking cessation. We hypothesized that impairment of executive cognitive functioning (ECF), which is relatively prevalent among older adults, would negatively influence smoking cessation rates among older smokers. The relationship of ECF to smoking cessation was examined in a population-based sample of 1,338 community-dwelling older persons in Colorado's San Luis Valley, 204 of whom were current smokers. As predicted, current ECF did not predict early smoking behaviour, but was a significant predictor of successful smoking cessation. Older persons suffering from executive dysfunction were less likely to have quit smoking than were their cognitively intact counterparts (OR = 1.10, 95% CI 1.04-1.17, P < 0.01). Among those with normal ECF, 73.7% had quit smoking, compared with 65.1% of participants showing any level of ECF impairment. Limiting the sample to individuals who were active smokers at or after the age of 65, when executive impairment is relatively common, produced similar results. Individuals with better executive functioning were more likely to have quit smoking (OR = 1.12, 95% CI 1.02-1.23, P = 0.02).

BEHAVIORAL DYSCONTROL SCALE-ELECTRONIC VERSION: FIRST EXAMINATION OF RELIABILITY, VALIDITY, AND INCREMENTAL UTILITY

Behavioral Dyscontrol Scale (BDS) is a clinical measure previously shown to be related to frontal lobe integrity, executive abilities, and functional independence. Electronic version of the scale (BDS-EV) was developed and its reliability and validity were examined. The BDS-EV, the original BDS, and a brief battery of traditional clinical tests were administered to 55 community-dwelling adults ages 18 to 68. The results yielded high internal consistency and provided support for convergent, discriminant, and incremental validity. Overall, the results demonstrate the feasibility of converting the BDS into an electronic instrument and support continued research and development of this instrument.

Executive functioning in psychogeriatric patients: scalability and construct validity of the Behavioral Dyscontrol Scale (BDS)

OBJECTIVES

Item response theory was used to test the scalability of the Behavioral Dyscontrol Scale (BDS). The BDS assesses the control of voluntary movement, working memory and self-monitoring. Construct validity of the BDS was examined with confirmatory factor analysis.

METHODS

The BDS was administered to 693 consecutive, community-dwelling visitors of a psychogeriatric day unit (424 women and 269 men between the ages of 50 and 94). Unidimensionality of the BDS was determined using Mokken's scalogram analysis. The BDS total score was correlated with other measures of executive function (Expanded Mental Control Test, category fluency, and alternating graphical sequences) and with episodic memory tests of orientation and delayed picture recognition in order to test a model of distinct latent constructs of executive functioning and episodic memory.

RESULTS

Loevinger's scalability coefficient H was 0.58 for the complete item set of the BDS. Subjects can be ordered on the latent dimension of executive ability. The first eight items of the BDS (deleting the insight rating) satisfy the assumption of non-intersecting item characteristic curves (double monotonicity) which means that they comprise a Guttman-ordered scale (H = 0.60). The BDS and three independent measures of executive control strongly correlated with a latent construct of executive functioning (convergent validity). However, discriminant relations with a nonexecutive construct (recognition memory and orientation) could not be demonstrated.

CONCLUSIONS

The BDS satisfies criteria for scalability according to item response theory. Its construct validity as an executive-specific measure is as yet unclear.