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Del Bene VA, Martin RC, Brinkerhoff SA, Olson JW, Nelson MJ, Marotta D, Gonzalez CL, Mills KA, Kamath V, Cutter G, Hurt CP, Wade M, Robinson FG, Bentley JN, Guthrie BL, Knight RT, Walker HC. Differential Cognitive Effects of Unilateral Subthalamic Nucleus Deep Brain Stimulation for Parkinson's Disease. Ann Neurol 2024. [PMID: 38501317 DOI: 10.1002/ana.26903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 02/21/2024] [Accepted: 02/22/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE The aim of this study was to investigate the cognitive effects of unilateral directional versus ring subthalamic nucleus deep brain stimulation (STN DBS) in patients with advanced Parkinson's disease. METHODS We examined 31 participants who underwent unilateral STN DBS (left n = 17; right n = 14) as part of an National Institutes of Health (NIH)-sponsored randomized, double-blind, crossover study contrasting directional versus ring stimulation. All participants received unilateral DBS implants in the hemisphere more severely affected by motor parkinsonism. Measures of cognition included verbal fluency, auditory-verbal memory, and response inhibition. We used mixed linear models to contrast the effects of directional versus ring stimulation and implant hemisphere on longitudinal cognitive function. RESULTS Crossover analyses showed no evidence for group-level changes in cognitive performance related to directional versus ring stimulation. Implant hemisphere, however, impacted cognition in several ways. Left STN participants had lower baseline verbal fluency than patients with right implants (t [20.66 = -2.50, p = 0.02]). Verbal fluency declined after left (p = 0.013) but increased after right STN DBS (p < 0.001), and response inhibition was faster following right STN DBS (p = 0.031). Regardless of hemisphere, delayed recall declined modestly over time versus baseline (p = 0.001), and immediate recall was unchanged. INTERPRETATION Directional versus ring STN DBS did not differentially affect cognition. Similar to prior bilateral DBS studies, unilateral left stimulation worsened verbal fluency performance. In contrast, unilateral right STN surgery increased performance on verbal fluency and response inhibition tasks. Our findings raise the hypothesis that unilateral right STN DBS in selected patients with predominant right brain motor parkinsonism could mitigate declines in verbal fluency associated with the bilateral intervention. ANN NEUROL 2024.
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Affiliation(s)
- Victor A Del Bene
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
- The Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
- The Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Sarah A Brinkerhoff
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Joseph W Olson
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Matthew J Nelson
- Department of Neurosurgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Dario Marotta
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Christopher L Gonzalez
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Kelly A Mills
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Vidyulata Kamath
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Gary Cutter
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chris P Hurt
- Department of Physical Therapy, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Melissa Wade
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Frank G Robinson
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - J Nicole Bentley
- Department of Neurosurgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Barton L Guthrie
- Department of Neurosurgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Robert T Knight
- Department of Psychology, University of California, Berkeley, California, USA
- Helen Wills Neuroscience Institute, University of California, Berkeley, California, USA
| | - Harrison C Walker
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
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Whittington C, Skains RM, Zhang Y, Osborne JD, O'Leary T, Freeman HB, Martin RC, Vickers JK, Flood KL, Markland AD, Buford TW, Brown CJ, Kennedy RE. Delirium Due to Potentially Avoidable Hospitalizations Among Older Adults. J Gerontol A Biol Sci Med Sci 2024; 79:glad256. [PMID: 37940689 DOI: 10.1093/gerona/glad256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Delirium is a common complication during acute care hospitalizations in older adults. A substantial percentage of admissions are for ambulatory care-sensitive conditions (ACSCs) or potentially avoidable hospitalizations-conditions that might be treated early in the outpatient setting to prevent hospitalization and hospital complications. METHODS This retrospective cross-sectional study examined rates of delirium among older adults hospitalized for ACSCs. Participants were 39 933 older adults ≥65 years of age admitted from January 1, 2015 to December 31, 2019 to general inpatient units and ICUs of a large Southeastern academic medical center. Delirium was defined as a score ≥ 2 on the Nursing Delirium Screening Scale or positive on the Confusion Assessment Method for the Intensive Care Unit during admission, and ACSCs were identified from the primary admission diagnosis using standardized definitions. Generalized linear mixed models were used to examine the association between ACSCs and delirium, compared with admissions for non-ACSC diagnoses, adjusting for covariates and repeated observations for individuals with multiple admissions. RESULTS Delirium occurred in 15.6% of admissions for older adults. Rates were lower for ACSC admissions versus admissions for other conditions (13.9% vs 15.8%, p < .001). Older age and higher comorbidity were significant predictors of the development of delirium. CONCLUSIONS Rates of delirium among older adults hospitalized for ACSCs were lower than rates for non-ACSC hospitalization but still substantial. Optimizing the treatment of ACSCs in the outpatient setting is an important goal not only for reducing hospitalizations but also for reducing risks for hospital-associated complications such as delirium.
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Affiliation(s)
- Caroline Whittington
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Yue Zhang
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John D Osborne
- Division of General Internal Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tobias O'Leary
- Division of General Internal Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Hyun B Freeman
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jasmine K Vickers
- Department of Nursing Research and Scholarship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kellie L Flood
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Alayne D Markland
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama, USA
| | - Thomas W Buford
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham/Atlanta Geriatric Research, Education, and Clinical Center (GRECC), Department of Veterans Affairs, Birmingham, Alabama, USA
| | - Cynthia J Brown
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Richard E Kennedy
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Sharma AA, Mackensie Terry D, Popp JL, Szaflarski JP, Martin RC, Nenert R, Kaur M, Brokamp GA, Bolding M, Allendorfer JB. Neuromorphometric associations with mood, cognition, and self-reported exercise levels in epilepsy and healthy individuals. Epilepsy Behav Rep 2023; 25:100643. [PMID: 38264358 PMCID: PMC10803905 DOI: 10.1016/j.ebr.2023.100643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/25/2024] Open
Abstract
Regular physical activity may promote beneficial neuroplasticity, e.g., increased hippocampus volume. However, it is unclear whether self-reported physical exercise in leisure (PEL) levels are associated with the brain structure features demonstrated by exercise interventions. This pilot study investigated the relationship between PEL, mood, cognition, and neuromorphometry in patients with idiopathic generalized epilepsy (IGEs) compared to healthy controls (HCs). Seventeen IGEs and 19 age- and sex-matched HCs underwent magnetic resonance imaging (MRI) at 3T. The Baecke Questionnaire of Habitual Physical Activity, Profile of Mood States, and Montreal Cognitive Assessment (MoCA) assessed PEL, mood, and cognition, respectively. Structural MRI data were analyzed by voxel- and surface-based morphometry. IGEs had significantly lower PEL (p < 0.001), poorer mood (p = 0.029), and lower MoCA scores (p = 0.027) than HCs. These group differences were associated with reduced volume, decreased gyrification, and altered surface topology (IGEs < HCs) in frontal, temporal and cerebellar regions involved in executive function, memory retrieval, and emotional regulation, respectively. These preliminary results support the notion that increased PEL may promote neuroplasticity in IGEs, thus emphasizing the role of physical activity in promoting brain health in people with epilepsy.
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Affiliation(s)
- Ayushe A. Sharma
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
| | - D. Mackensie Terry
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
| | - Johanna L. Popp
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
| | - Jerzy P. Szaflarski
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
- University of Alabama at Birmingham (UAB), Department of Neurobiology, Birmingham, AL, USA
- University of Alabama at Birmingham (UAB), Department of Neurosurgery, Birmingham, AL, USA
- University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Roy C. Martin
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
- University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Rodolphe Nenert
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
| | - Manmeet Kaur
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
- University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Gabrielle A. Brokamp
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
| | - Mark Bolding
- University of Alabama at Birmingham (UAB), Department of Radiology, Birmingham, AL, USA
| | - Jane B. Allendorfer
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
- University of Alabama at Birmingham (UAB), Department of Neurobiology, Birmingham, AL, USA
- University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
- University of Alabama at Birmingham (UAB), UAB Center for Exercise Medicine, Birmingham, AL, USA
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Loyd C, Blue K, Turner L, Weber A, Guy A, Zhang Y, Martin RC, Kennedy RE, Brown C. National Norms for Hospitalizations Due to Ambulatory Care Sensitive Conditions among Adults in the US. J Gen Intern Med 2023; 38:2953-2959. [PMID: 36941421 PMCID: PMC10027258 DOI: 10.1007/s11606-023-08161-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/10/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Ambulatory care sensitive conditions (ACSCs) are acute or chronic health issues that lead to potentially preventable hospitalizations when not treated in the outpatient primary care setting. OBJECTIVE To describe national hospitalization rates due to ACSCs among adult inpatients in the US. DESIGN A retrospective cross-sectional analysis of the 2018 US National Inpatient Sample (NIS) dataset from the Healthcare Cost and Utilization Project at the Agency of Healthcare Research and Quality was completed in the year 2022. PARTICIPANTS Participants were adult inpatients from community hospitals in 48 states of the US and District of Columbia. MAIN MEASURES ACSC admission rates were calculated using ICD-10 codes and the Purdy ACSC definition. The admission rates were weighted to the US inpatient population and stratified by age, sex, and race. KEY RESULTS ACSC hospitalization rates varied considerably across age and average number of hospitalizations varied across sex and race. ACSC hospitalization rates increased with age, male sex, and Native American and Black race. The most common ACSCs were pneumonia, diabetes, and congestive heart failure. CONCLUSIONS Previous studies have emphasized the importance of preventable hospitalizations, however, the national rates for ACSC hospitalizations across all ages in the US have not been reported. The national rates presented will facilitate comparisons to identify hospitals and health care systems with higher-than-expected rates of ACSC admissions that may suggest a need for improved primary care services.
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Affiliation(s)
- Christine Loyd
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Kylie Blue
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Laci Turner
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashley Weber
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ashley Guy
- Department of Clinical and Diagnostic Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yue Zhang
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Richard E Kennedy
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Cynthia Brown
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
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Gerstenecker A, Kennedy R, Zhang Y, Martin RC, Mackin RS, Weiner MW, Howell T, Petersen RC, Roberson ED, Marson DC. Item Response Analysis of the Financial Capacity Instrument-Short Form. Arch Clin Neuropsychol 2023; 38:739-758. [PMID: 36644855 PMCID: PMC10369359 DOI: 10.1093/arclin/acac112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 06/17/2023] Open
Abstract
OBJECTIVE The Financial Capacity Instrument-Short Form (FCI-SF) is a performance-based measure of everyday financial skills that takes 15 min to administer. Although the FCI-SF has demonstrated excellent psychometric properties, advanced psychometric methods such as item response theory (IRT) can provide important information on the performance of individual test items in measuring financial capacity and in distinguishing between healthy and cognitively impaired individuals. METHOD Participants were 272 older adults diagnosed with mild cognitive impairment (MCI) and 1,344 cognitively healthy controls recruited from the Mayo Clinic Study of Aging at the Mayo Clinic in Rochester, Minnesota and also from the Cognitive Observations in Seniors study at the University of Alabama at Birmingham. Participants in each study were administered the FCI-SF, which evaluates coin/currency calculation, financial conceptual knowledge, use of a checkbook/register, and use of a bank statement. RESULTS A unidimensional two-parameter logistic model best fit the 37 FCI-SF Test items, and most FCI-SF items fit the unidimensional two-parameter model well. The results indicated that all FCI-SF items robustly distinguished cognitively healthy controls from persons with MCI. CONCLUSIONS The study results showed that the FCI-SF performed well under IRT analysis, further highlighted the psychometric properties of the FCI-SF as a valid and reliable measure of financial capacity, and demonstrated the clinical utility of the FCI-SF in distinguishing between cognitively normal and cognitively impaired individuals.
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Affiliation(s)
- Adam Gerstenecker
- Department of Neurology, University of Alabama at Birmingham, San Francisco, CA, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, San Francisco, CA, USA
- Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, San Francisco, CA, USA
| | - Richard Kennedy
- Alzheimer’s Disease Center, University of Alabama at Birmingham, San Francisco, CA, USA
- Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, San Francisco, CA, USA
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, San Francisco, CA, USA
- Interdisciplinary Center for Aging Research, University of Alabama at Birmingham, San Francisco, CA, USA
| | - Yue Zhang
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, San Francisco, CA, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, San Francisco, CA, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, San Francisco, CA, USA
- Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, San Francisco, CA, USA
| | - R Scott Mackin
- Department of Psychiatry, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
- San Francisco Veteran's Administration Medical Center, San Francisco, CA, USA
| | - Michael W Weiner
- San Francisco Veteran's Administration Medical Center, San Francisco, CA, USA
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, CA, USA
| | - Taylor Howell
- Department of Psychiatry, Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA, USA
| | | | - Erik D Roberson
- Department of Neurology, University of Alabama at Birmingham, San Francisco, CA, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, San Francisco, CA, USA
- Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, San Francisco, CA, USA
- Interdisciplinary Center for Aging Research, University of Alabama at Birmingham, San Francisco, CA, USA
| | - Daniel C Marson
- Department of Neurology, University of Alabama at Birmingham, San Francisco, CA, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, San Francisco, CA, USA
- Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, San Francisco, CA, USA
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Freeman H, Martin RC, Whittington C, Zhang Y, Osborne JD, O'Leary T, Vickers JK, Flood KL, Skains RM, Markland AD, Buford TW, Brown CJ, Kennedy RE. Delirium Mediates Incidence of Hospital-Associated Disability Among Older Adults. J Am Med Dir Assoc 2023; 24:533-540.e9. [PMID: 36931323 PMCID: PMC10370492 DOI: 10.1016/j.jamda.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 02/05/2023] [Accepted: 02/07/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To examine whether delirium predicts occurrence of hospital-associated disability (HAD), or functional decline after admission, among hospitalized older adults. DESIGN Retrospective cross-sectional study. SETTING AND PARTICIPANTS General inpatient (non-ICU) units of a large regional Southeastern US academic medical center, involving 33,111 older adults ≥65 years of age admitted from January 1, 2015, to December 31, 2019. METHODS Delirium was defined as a score ≥2 on the Nursing Delirium Screening Scale (NuDESC) during hospital admission. HAD was defined as a decline on the Katz Activities of Daily Living (ADL) scale from hospital admission to discharge. Generalized linear mixed models were used to examine the association between delirium and HAD, adjusting for covariates and repeated observations with multiple admissions. We performed multivariate and mediation analyses to examine strength and direction of association between delirium and HAD. RESULTS One-fifth (21.6%) of older adults developed HAD during hospitalization and experienced higher delirium rates compared to those not developing HAD (24.3% vs 14.3%, P < .001). Age, presence of delirium, Elixhauser Comorbidity Score, admission cognitive status, admission ADL function, and length of stay were associated (all P < .001) with incident HAD. Mediational analyses found 46.7% of the effect of dementia and 16.7% of the effect of comorbidity was due to delirium (P < .001). CONCLUSIONS AND IMPLICATIONS Delirium significantly increased the likelihood of HAD within a multivariate predictor model that included comorbidity, demographics, and length of stay. For dementia and comorbidity, mediation analysis showed a significant portion of their effect attributable to delirium. Overall, these findings suggest that reducing delirium rates may diminish HAD rates.
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Affiliation(s)
- Hyun Freeman
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Caroline Whittington
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yue Zhang
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - John D Osborne
- Division of General Internal Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tobias O'Leary
- Division of General Internal Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jasmine K Vickers
- Department of Health Behavior, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kellie L Flood
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alayne D Markland
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham/Atlanta VA Geriatric Research, Education, and Clinical Center (GRECC), Birmingham, AL, USA
| | - Thomas W Buford
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Cynthia J Brown
- Department of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Richard E Kennedy
- Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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Del Bene VA, Martin RC, Brinkerhoff SA, Olson JW, Nelson MJ, Marotta D, Gonzalez CL, Mills KA, Kamath V, Bentley JN, Guthrie BL, Knight RT, Walker HC. Differential cognitive effects of unilateral left and right subthalamic nucleus deep brain stimulation for Parkinson disease. medRxiv 2023:2023.02.27.23286478. [PMID: 36909562 PMCID: PMC10002774 DOI: 10.1101/2023.02.27.23286478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Objective To investigate hemispheric effects of directional versus ring subthalamic nucleus (STN) deep brain stimulation (DBS) surgery on cognitive function in patients with advanced Parkinson's disease (PD). Methods We examined 31 PD patients (Left STN n = 17; Right STN n = 14) who underwent unilateral subthalamic nucleus (STN) DBS as part of a NIH-sponsored randomized, cross-over, double-blind (ring vs directional) clinical trial. Outcome measures were tests of verbal fluency, auditory-verbal memory, and response inhibition. First, all participants were pooled together to study the effects of directional versus ring stimulation. Then, we stratified the groups by surgery hemisphere and studied the longitudinal changes in cognition post-unilateral STN DBS. Results Relative to pre-DBS cognitive baseline performances, there were no group changes in cognition following unilateral DBS for either directional or ring stimulation. However, assessment of unilateral DBS by hemisphere revealed a different pattern. The left STN DBS group had lower verbal fluency than the right STN group (t(20.66 = -2.50, p = 0.02). Over a period of eight months post-DBS, verbal fluency declined in the left STN DBS group (p = 0.013) and improved in the right STN DBS group over time (p < .001). Similarly, response inhibition improved following right STN DBS (p = 0.031). Immediate recall did not significantly differ over time, nor was it affected by implant hemisphere, but delayed recall equivalently declined over time for both left and right STN DBS groups (left STN DBS p = 0.001, right STN DBS differ from left STN DBS p = 0.794). Conclusions Directional and ring DBS did not differentially or adversely affect cognition over time. Regarding hemisphere effects, verbal fluency decline was observed in those who received left STN DBS, along with the left and right STN DBS declines in delayed memory. The left STN DBS verbal fluency decrement is consistent with prior bilateral DBS research, likely reflecting disruption of the basal-ganglia-thalamocortical network connecting STN and inferior frontal gyrus. Interestingly, we found an improvement in verbal fluency and response inhibition following right STN DBS. It is possible that unilateral STN DBS, particularly in the right hemisphere, may mitigate cognitive decline.
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Affiliation(s)
- Victor A Del Bene
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
- The Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Roy C. Martin
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
- The Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Sarah A. Brinkerhoff
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Joseph W. Olson
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Matthew J. Nelson
- Department of Neurosurgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Dario Marotta
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Christopher L. Gonzalez
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Kelly A. Mills
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Vidyulata Kamath
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - J. Nicole Bentley
- Department of Neurosurgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Barton L. Guthrie
- Department of Neurosurgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Robert T. Knight
- Department of Psychology, University of California, Berkeley, CA, USA
- Helen Wills Neuroscience Institute, University of California, Berkeley, CA, USA
| | - Harrison C. Walker
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
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Pilonieta G, Pisu M, Martin RC, Shan L, Kennedy RE, Oates G, Kim YI, Geldmacher DS. Specialist Availability and Drug Adherence in Older Adults with Dementia Across Regions of the United States. J Alzheimers Dis 2023; 93:927-937. [PMID: 37125546 PMCID: PMC10634245 DOI: 10.3233/jad-220620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND Access to specialists facilitates appropriate Alzheimer's disease and related dementia (ADRD) medication use and adherence. However, there is little information on the impact of specialists' availability on ADRD medication adherence, especially in regions of the United States (US) where specialists are scarce, e.g., the Deep South (DS). OBJECTIVE To ascertain whether the availability of specialty physicians in the DS and other US regions predicts ADRD medication adherence among community-dwelling older adultsMethods:We conducted secondary analyses of claims data for 54,194 Medicare beneficiaries with ADRD in 2013-2015. Medication adherence was measured using the proportion of days covered (PDC). Multivariable-adjusted Modified Poisson regression was used to examine associations of adherence with physicians' availability by region. RESULTS The race/ethnicity distribution was 81.44% white, 9.17% black, 6.24% Hispanic, 2.25% Asian, and 1% other; 71.81% were female, and 42.36% were older than 85 years. Beneficiaries across regions differed in all individual and contextual characteristics except sex and comorbidities. Neurologists and psychiatrists' availability was not significantly associated with adherence (DS = 1.00, 0.97-1.03 & non-DS = 1.01, 1.00-1.01). Race and having ≥1 specialist visits were associated with a lower risk of adherence in both regions (p < 0.0001). Advanced age, dual Medicare/Medicaid eligibility, and living in non-large metropolitan areas, were associated with adherence in the non-DS region. CONCLUSION Among older Americans with ADRD, a context defined by specialist availability does not affect adherence, but other context characteristics related to socioeconomic status may. Research should further examine the influence of individual and contextual factors on ADRD treatment among older adults.
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Affiliation(s)
- Giovanna Pilonieta
- Department of Neurology, University of Alabama at Birmingham, Sparks Center, Suite 350, 1720 7th Avenue South, Birmingham, AL 35233, USA
- Department of Health Services Administration, University of Alabama at Birmingham, USA
| | - Maria Pisu
- Division of Preventive Medicine, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL 35294-4410, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C. Martin
- Department of Neurology, University of Alabama at Birmingham, Sparks Center, Suite 350, 1720 7th Avenue South, Birmingham, AL 35233, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Liang Shan
- School of Nursing, University of Alabama at Birmingham, USA
| | - Richard E. Kennedy
- Alzheimer’s Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Gerontology, Geriatrics and Palliative Care, 933 19th Street South, CH19 201, Birmingham, AL 35294, USA
| | - Gabriela Oates
- Department of Pediatrics, University of Alabama at Birmingham, 1600 7 Avenue South, Birmingham, AL 35233, USA
| | - Young-Il Kim
- Division of Preventive Medicine, University of Alabama at Birmingham, 1720 2nd Ave South, Birmingham, AL 35294-4410, USA
| | - David S. Geldmacher
- Department of Neurology, University of Alabama at Birmingham, Sparks Center, Suite 350, 1720 7th Avenue South, Birmingham, AL 35233, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
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Gerstenecker A, Martin RC, Hebert K, Triebel K, Marson DC. Cognitive Correlates of Impaired Testamentary Capacity in Alzheimer's Dementia. Arch Clin Neuropsychol 2022; 37:1148-1157. [PMID: 35731016 DOI: 10.1093/arclin/acac034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Testamentary capacity (TC) is a legal construct about the ability to make or change a will. Although studies of financial and medical capacities have noted a strong association between capacity and cognition, no study has examined the cognitive correlates of TC in Alzheimer's disease (ad). METHODS Study participants were 22 cognitively healthy controls and 20 persons with mild to moderate ad who were administered a neuropsychological battery and the Testamentary Capacity Instrument (TCI), a new performance-based measure of TC. Both TCI Element and TCI Total scores were calculated. TCI Total scores were calculated for the purposes of expanding correlational analyses (i.e., Pearson's product-moment) and are not intended for forensic TC evaluations. Final predictors were identified using linear and logistic regression modeling. RESULTS All ad participants but one obtained TCI Totals that fell >2.5 standard deviations below the control group mean. Initial cognitive correlates of TCI performance were measures of general cognition, language, verbal memory, executive function, and processing speed. The four cognitive variables showing the highest t values and correlating with TCI Total score > 0.7 were entered into logistic and linear regression models. Final predictor models consisted of measures of verbal memory, executive function, and semantic knowledge and demonstrated shared variance of 0.71 (linear) and 0.82 (logistic). CONCLUSIONS A diagnosis of ad dementia is associated with clinical impairment in TC and associated cognitive abilities and indicates that a legal assessment of TC is warranted. Second, the results offer insight into the cognitive basis of TC in persons with Alzheimer's dementia.
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Affiliation(s)
- Adam Gerstenecker
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL, USA.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL, USA.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Katina Hebert
- Tuscaloosa Veteran's Administration, Tuscaloosa, AL, USA
| | - Kristen Triebel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL, USA.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Daniel C Marson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL, USA.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
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10
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Martin RC, Gerstenecker A, Hebert K, Triebel K, Marson D. Assessment of Testamentary Capacity in Older Adults: Description and Initial Validation of a Standardized Interview Instrument. Arch Clin Neuropsychol 2022; 37:1133-1147. [PMID: 35596954 DOI: 10.1093/arclin/acac028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Testamentary capacity (TC) is a legal construct, which concerns a person's mental capacity to make or amend a will. Although expert clinicians are frequently asked to assess TC in forensic settings, there are few instruments and little empirical research to inform and guide their assessments. The present study describes the development and psychometric properties of a standardized assessment measure of TC (Testamentary Capacity Instrument-TCI), and investigates its reliability and validity. METHODS The TCI is an interview-based, psychometric measure, which assesses a testator's knowledge of four conceptual elements, which together comprise the legal basis for TC in the Anglo-American legal system: (1) what a will is, (2) nature and extent of assets/property, (3) possible heirs/claimants to property, and (4) plan to distribute assets to heirs after death. Cronbach's alpha and percentage exact agreement were used to examine TCI element reliabilities. Using independent samples t-tests, MANOVA and MANCOVA, we investigated validity by comparing TCI element performance of cognitively intact older adults (n = 22) and older adults with ad dementia (n = 20). RESULTS The TCI elements showed good internal consistency and good inter-rater reliability. The ad group performed significantly below the control group on all four TCI elements, with effect sizes exceeding 1.2, suggesting that the TCI has content and construct validity. CONCLUSIONS Relative to cognitively intact older adults, older adults with ad dementia showed significant impairment on all four TCI conceptual elements. The TCI has promise as a standardized quantitative measure of TC to support clinical assessment of TC in forensic settings.
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Affiliation(s)
- Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL 35294, USA.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Adam Gerstenecker
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL 35294, USA.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Katina Hebert
- Birmingham Veterans Administration Medical Center, Birmingham, AL 35233, USA
| | - Kristen Triebel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL 35294, USA.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Daniel Marson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.,Evelyn F. McKnight Brain Institute, University of Alabama at Birmingham, Birmingham, AL 35294, USA.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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11
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Aita SL, Del Bene VA, Marotta DA, Pizer JH, Hawley NA, Niccolai L, Walker HC, Gerstenecker A, Martin RC, Clay OJ, Crowe M, Triebel KL, Hill BD. Neuropsychological Functioning in Primary Dystonia: Updated and Expanded Multidomain Meta-Analysis. Mov Disord 2022; 37:1483-1494. [PMID: 35385165 DOI: 10.1002/mds.29022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Primary dystonia is conventionally considered as a motor disorder, though an emerging literature reports associated cognitive dysfunction. OBJECTIVES Here, we conducted meta-analyses on studies comparing clinical measures of cognition in persons with primary dystonia and healthy controls (HCs). METHODS We searched PubMed, Embase, Cochrane Library, Scopus, and PsycINFO (January 2000-October 2020). Analyses were modeled under random effects. We used Hedge's g as a bias-corrected estimate of effect size, where negative values indicate lower performance in dystonia versus controls. Between-study heterogeneity and bias were primarily assessed with Cochran's Q, I2 , and Egger's regression. RESULTS From 866 initial results, 20 studies met criteria for analysis (dystonia n = 739, controls n = 643; 254 effect sizes extracted). Meta-analysis showed a significant combined effect size of primary dystonia across all studies (g = -0.56, P < 0.001), with low heterogeneity (Q = 25.26, P = 0.15, I2 = 24.78). Within-domain effects of primary dystonia were motor speed = -0.84, nonmotor speed = -0.83, global cognition = -0.65, language = -0.54, executive functioning = -0.53, learning/memory = -0.46, visuospatial/construction = -0.44, and simple/complex attention = -0.37 (P-values <0.01). High heterogeneity was observed in the motor/nonmotor speed and learning/memory domains. There was no evidence of publication bias. Moderator analyses were mostly negative but possibly underpowered. Blepharospasm samples showed worse performance than other focal/cervical dystonias. Those with inherited (ie, genetic) disease etiology demonstrated worse performance than acquired. CONCLUSIONS Dystonia patients consistently demonstrated lower performances on neuropsychological tests versus HCs. Effect sizes were generally moderate in strength, clustering around -0.50 SD units. Within the speed domain, results suggested cognitive slowing beyond effects from motor symptoms. Overall, findings indicate dystonia patients experience multidomain cognitive difficulties, as detected by neuropsychological tests. © 2022 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Stephen L Aita
- Department of Psychiatry, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA.,Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Victor A Del Bene
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Dario A Marotta
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA.,Alabama College of Osteopathic Medicine, Dothan, Alabama, USA
| | - Jasmin H Pizer
- Department of Psychology, University of South Alabama, Mobile, Alabama, USA
| | - Nanako A Hawley
- Department of Psychology, University of South Alabama, Mobile, Alabama, USA
| | - Lindsay Niccolai
- Supportive Care Medicine, Moffitt Cancer Center, Tampa, Florida, USA
| | - Harrison C Walker
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Adam Gerstenecker
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Olivio J Clay
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Michael Crowe
- Department of Psychology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kristen L Triebel
- Department of Neurology, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Benjamin D Hill
- Department of Psychology, University of South Alabama, Mobile, Alabama, USA
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12
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Vassilaki M, Aakre JA, Kremers WK, Mielke MM, Geda YE, Machulda MM, Knopman DS, Vemuri P, Lowe VJ, Jack CR, Roberson ED, Gerstenecker A, Martin RC, Kennedy RE, Marson DC, Petersen RC. Association of Performance on the Financial Capacity Instrument–Short Form With Brain Amyloid Load and Cortical Thickness in Older Adults. Neurol Clin Pract 2022; 12:113-124. [PMID: 35747890 PMCID: PMC9208409 DOI: 10.1212/cpj.0000000000001157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractObjective:To investigate the association of the Financial Capacity Instrument–Short Form (FCI-SF) performance and timing total scores with brain β-amyloid and cortical thickness in cognitively unimpaired (CU) at baseline older adults.Methods:309 participants (≥70 years old) of the Mayo Clinic Study of Aging underwent 11C Pittsburgh compound B PET amyloid imaging, MR imaging, and completed the FCI-SF. Abnormal amyloid PET was defined as standardized uptake value ratio ≥1.48 in an Alzheimer's disease (AD)-related region of interest and reduced AD signature cortical thickness as ≤2.68mm (neurodegeneration). A cohort of 218 (of the 309) participants had follow-up visits (every 15 months) with FCI-SF data for longitudinal analysis (number of visits including baseline, median (range): 2 (2-4)). In analysis, we used linear regression and mixed-effects models adjusted for age, sex, education, apolipoprotein ε4 allele status, global cognitive z-score, and prior FCI-SF testing.Results:Participants’ mean age (SD) was 80.2 (±4.8) years (56.3% males). In cross-sectional analysis, abnormal amyloid PET (vs. normal) was associated with a lower FCI-SF Total score and slower Total Composite Time. In longitudinal analysis, FCI-SF Total Score declined faster (difference in annualized rate of change, beta coefficient (β) (95%CI) = -1.123 (-2.086, -0.161)) and FCI-SF Total Composite Time increased faster (difference in annualized rate of change, β (95%CI) = 16.274 (5.951, 26.597) for participants with neurodegeneration at baseline (vs. those without). Participants who had both abnormal amyloid PET and neurodegeneration at baseline had a greater increase in Total Composite Time compared to the group without abnormal amyloid and without neurodegeneration (difference in annualized rate of change, β (95%CI) = 16.750 (3.193, 30.307)).Conclusions:Performance and processing speed on the FCI-SF were associated with imaging biomarkers of AD pathophysiology in CU at baseline older adults. Higher burdens of imaging biomarkers were associated with longitudinal worsening on FCI-SF performance. Additional research is needed to delineate further these associations and their predictive utility at the individual person level.
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Affiliation(s)
- Maria Vassilaki
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Jeremiah A Aakre
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Walter K Kremers
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Michelle M Mielke
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Yonas E Geda
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Mary M Machulda
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - David S Knopman
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Prashanthi Vemuri
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Val J Lowe
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Clifford R Jack
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Erik D Roberson
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Adam Gerstenecker
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Roy C Martin
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Richard E Kennedy
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Daniel C Marson
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
| | - Ronald C Petersen
- Department of Quantitative Health Sciences (MV, JAA, WKK, M.M. Mielke, RCP), and Department of Neurology (M.M. Mielke, DSK, RCP), Mayo Clinic, Rochester, MN; Department of Neurology (YEG), Barrow Neurological Institute, Phoenix, AZ; Department of Psychiatry and Psychology (M.M. Machulda), and Department of Radiology (PV, VJL, CRJ), Mayo Clinic, Rochester, MN; Department of Neurology (EDR, AG, RCM, DCM), Department of Medicine (REK), and Alzheimer's Disease Center (DCM), University of Alabama at Birmingham
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13
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Pilonieta G, Pisu M, Martin RC, Shan L, Kennedy RE, Oates G, Kim Y, Geldmacher DS. Factors influencing medication adherence among U.S. Medicare beneficiaries with Alzheimer’s disease and related dementia (ADRD). Alzheimers Dement 2021. [DOI: 10.1002/alz.054567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Maria Pisu
- University of Alabama at Birmingham Birmingham AL USA
- Alzheimer's Disease Center Birmingham AL USA
| | - Roy C Martin
- University of Alabama at Birmingham Birmingham AL USA
- Alzheimer's Disease Center Birmingham AL USA
| | - Liang Shan
- University of Alabama at Birmingham Birmingham AL USA
| | - Richard E Kennedy
- University of Alabama at Birmingham Birmingham AL USA
- Alzheimer's Disease Center Birmingham AL USA
| | | | - Young‐Il Kim
- University of Alabama at Birmingham Birmingham AL USA
| | - David S Geldmacher
- University of Alabama at Birmingham Birmingham AL USA
- Alzheimer's Disease Center Birmingham AL USA
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14
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Pisu M, Martin RC, Shan L, Pilonieta G, Kennedy RE, Oates G, Kim Y, Geldmacher DS. Dementia care in diverse older adults in the Deep South and the rest of the United States. Alzheimers Dement 2021. [DOI: 10.1002/alz.054038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Maria Pisu
- University of Alabama at Birmingham Birmingham AL USA
- Alzheimer's Disease Center Birmingham AL USA
| | - Roy C Martin
- University of Alabama at Birmingham Birmingham AL USA
- Alzheimer's Disease Center Birmingham AL USA
| | - Liang Shan
- University of Alabama at Birmingham Birmingham AL USA
| | | | - Richard E Kennedy
- University of Alabama at Birmingham Birmingham AL USA
- Alzheimer's Disease Center Birmingham AL USA
| | | | - Young‐Il Kim
- University of Alabama at Birmingham Birmingham AL USA
| | - David S Geldmacher
- University of Alabama at Birmingham Birmingham AL USA
- Alzheimer's Disease Center Birmingham AL USA
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Abstract
Anecdotal reports of the benefits of cannabis and its components in the treatment of epilepsy have been reported for millennia. However, only recently randomized controlled trial data in support of cannabidiol (CBD) became available resulting in its FDA approval for the treatment of seizures and epilepsy. One of the most common and debilitating comorbidities of epilepsy is cognitive impairment. This impairment has a multifactorial etiology including network dysfunction due to seizures, negative cognitive side effects from anti-seizure medications (ASMs), and mood disturbances. Knowing the effects of a particular ASM (either positive or negative) is vital for providers to counsel patients on expected side effects, and may result in choosing a particular regimen over the other if the patient already suffers from significant cognitive deficits. Unlike most other ASMs and other well-studied cannabinoids such as Δ9-tetrahydrocannabinol, CBD has been shown to have additional mechanisms of action (MOA) that result in neuroprotective, anti-inflammatory, anti-oxidant, and neurogenesis effects. These additional MOAs suggest that the use of CBD could lead to other actions including positive effects on cognition that may be independent of seizure control. This targeted review discusses the currently available data on CBD's effects on cognition in epilepsy. First, we review the proposed mechanisms by which CBD could exert effects on cognition. Then, we present the pre-clinical/animal data investigating cognitive effects of CBD in seizure/epilepsy models. Finally, we discuss the available human data, including the studies in people with epilepsy that included cognitive evaluations pre- and on-CBD, and studies investigating if CBD has any effects on brain structure or function in areas pertinent to memory and cognitive functions.
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Affiliation(s)
- Tyler E Gaston
- Department of Neurology and the UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA; Veteran's Administration Medical Center, Birmingham, AL, USA.
| | - Roy C Martin
- Department of Neurology and the UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jerzy P Szaflarski
- Department of Neurology and the UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA; Departments of Neurobiology and Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Pisu M, Martin RC, Shan L, Pilonieta G, Kennedy RE, Oates G, Kim YI, Geldmacher DS. Dementia Care in Diverse Older Adults in the U.S. Deep South and the Rest of the United States. J Alzheimers Dis 2021; 83:1753-1765. [PMID: 34459392 DOI: 10.3233/jad-210240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Use of specialists and recommended drugs has beneficial effects for older adults living with Alzheimer's disease and related dementia (ADRD). Gaps in care may exist for minorities, e.g., Blacks, and especially in the United States (U.S.) Deep South (DS), a poor U.S. region with rising ADRD cases and minority overrepresentation. Currently, we have little understanding of ADRD care utilization in diverse populations in this region and elsewhere in the U.S. (non-DS), and the factors that adversely impact it. OBJECTIVE To examine utilization of specialists and ADRD drugs (outcomes) in racial/ethnic groups of older adults with ADRD and the personal or context-level factors affecting these outcomes in DS and non-DS. METHODS We obtained outcomes and personal-level covariates from claims for 127,512 Medicare beneficiaries with ADRD in 2013-2015, and combined county-level data in exploratory factor analysis to define context-level covariates. Adjusted analyses tested significant association of outcomes with Black/White race and other factors in DS and non-DS. RESULTS Across racial/ethnic groups, 33%-43% in DS and 43%-50% in non-DS used specialists; 47%-55% in DS and 41%-48% in non-DS used ADRD drugs. In adjusted analyses, differences between Blacks and Whites were not significant. Vascular dementia, comorbidities, poverty, and context-level factor "Availability of Medical Resources" were associated with specialist use; Alzheimer's disease and senile dementia, comorbidities, and specialist use were associated with drug use. In non-DS only, other individual, context-level covariates were associated with the outcomes. CONCLUSION We did not observe significant gaps in ADRD care in DS and non-DS; however, research should further examine determinants of low specialist and drug use in these regions.
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Affiliation(s)
- Maria Pisu
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C Martin
- Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Liang Shan
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Giovanna Pilonieta
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Richard E Kennedy
- Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Gerontology, Geriatrics and Palliative Care, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gabriela Oates
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Young-Il Kim
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David S Geldmacher
- Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
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Aita S, Del Bene VA, Pizer JH, Hawley NA, Niccolai L, Marotta DA, Walker HC, Gerstenecker A, Martin RC, Clay OJ, Crowe M, Triebel KL, Hill BD. A-72 Neuropsychological Functioning in Primary Dystonia: A Multi-Domain Meta-Analysis. Arch Clin Neuropsychol 2021. [DOI: 10.1093/arclin/acab062.90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Objective
Primary dystonia is conventionally seen as a motor disorder, though growing literature indicates cognitive dysfunction among persons with primary dystonia (PWD). Here, we completed a meta-analysis comparing cognition on clinical measures between PWD and normal controls.
Method
We searched PubMed, Embase, Cochrane Library, Scopus, and PsycINFO using a uniform search-strategy to locate original research comparing cognition between PWD and control samples. All analyses were modeled under random-effects. We used Hedge’s g as a bias-corrected estimate of effect size. Between-study heterogeneity was assessed using Cochran’s Q and I2.
Results
The initial search strategy yielded 866 results. Twenty studies were analyzed (PWD n = 739, control n = 865; 254 effect sizes extracted). Meta-analysis showed a significant combined effect size of primary dystonia across all studies (g = −0.55, p < 0.001), with low heterogeneity (Q = 23.60, p = 0.21, I2 = 19.49). Trim-and-fill procedure estimated 6 studies missing due to publication bias (adjusted g = −0.47, Q = 44.58). Within-domain effects of primary dystonia were: Motor/Non-Motor Speed = −0.76, Global Cognition/Orientation = −0.65, Language = −0.62, Executive Functioning = −0.50, Learning/Memory = −0.46, Visuospatial/Construction = −0.44, and Simple/Complex Attention = −0.36. Heterogeneity was generally low within domains. Effects were comparable between Speed tasks with (g = −0.85) and without (g = −0.80) a motor component. Meta-regressions indicated age, education, gender, and disease duration were not related to effect sizes.
Conclusions
PWD consistently demonstrated lower performances on neuropsychological tests compared to controls. Effect sizes were generally moderate in strength, with smallest effects in Simple/Complex Attention, and largest in Motor/Non-Motor Speed. Within the Speed domain, results suggested cognitive slowing beyond effects from motor symptoms. This quantitative summary indicates that PWD experience difficulties in multiple aspects of cognition, as detected by neuropsychological tests.
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Popp JL, Szaflarski JP, Kaur M, Martin RC, Brokamp GA, Terry DM, Diggs MD, Allendorfer JB. Relationships between cognitive function, seizure control, and self-reported leisure-time exercise in epilepsy. Epilepsy Behav 2021; 118:107900. [PMID: 33770613 DOI: 10.1016/j.yebeh.2021.107900] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 01/16/2023]
Abstract
Exercise may be a strategy for improvement of cognitive deficits commonly present in people with idiopathic generalized epilepsies (IGE). We investigated the relationship between cognition and level of physical exercise in leisure (PEL) in people with IGE who have been seizurefree for at least 6 months (IGE-) as compared to those who have not been seizurefree (IGE+) and healthy controls (HCs). We hypothesized that higher level of physical exercise is associated with better cognitive functioning in patients with IGE and HCs, and that seizure control affects both PEL levels and cognitive functioning in patients with IGE. We recruited 75 participants aged 18-65: 31 people with IGE (17 IGE-, 14 IGE+) and 44 HCs. Participants completed assessments of quality of life (SF-36), physical activity levels (Baecke questionnaire and International Physical Activity Questionnaire (IPAQ)) and cognition (Montreal Cognitive Assessment (MoCA), Hopkins Verbal Learning Test - Revised (HVLT), and flanker task). Group differences (HCs vs. IGE; HCs vs. IGE+ vs. IGE-) were assessed. Pearson correlations examined linear relationships between PEL and cognitive performance. Groups were similar in age and sex. Compared to HCs, patients with IGE had higher body mass index, fewer years of education, and consistently scored worse on all measures except flanker task accuracy on incongruent trials. When examining IGE- and IGE+ subgroups, compared to HCs, both had higher body mass index, and fewer years of education. Healthy controls scored significantly better than one or both of the IGE groups on SF-36 scores, PEL levels, IPAQ activity level, MoCA scores, HVLT learning and long-delay free-recall scores, and flanker task accuracy on congruent trials. Among patients with IGE, there were no significant differences between age of epilepsy onset, duration of epilepsy, number of anti-seizure drugs (ASDs) currently being used, or the group distribution of type of IGE. In the combined sample (IGE+, IGE- and HCs), PEL positively correlated with MoCA scores (Pearson's r = 0.238; p = 0.0397) and with flanker task accuracy on congruent trials (Pearson's r = 0.295; p = 0.0132). Overall, patients with IGE performed worse than HCs on cognitive and physical activity measures, but the cognitive impairments were more pronounced for IGE+, while physical exercise levels were less for patients with IGE regardless of seizure control. While positive relationships between leisure-time PEL and cognitive performance are promising, further investigations into how exercise levels interact with cognitive functioning in epilepsy are needed.
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Affiliation(s)
- Johanna L Popp
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA; University of Alabama at Birmingham (UAB), Department of Neurobiology, Birmingham, AL, USA; University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Manmeet Kaur
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
| | - Roy C Martin
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA; University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA
| | - Gabrielle A Brokamp
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
| | - D Mackensie Terry
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
| | - M David Diggs
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA
| | - Jane B Allendorfer
- University of Alabama at Birmingham (UAB), Department of Neurology, Birmingham, AL, USA; University of Alabama at Birmingham (UAB), UAB Epilepsy Center, Birmingham, AL, USA.
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19
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Thompson MD, Martin RC, Grayson LP, Ampah SB, Cutter G, Szaflarski JP, Bebin EM. Cognitive function and adaptive skills after a one-year trial of cannabidiol (CBD) in a pediatric sample with treatment-resistant epilepsy. Epilepsy Behav 2020; 111:107299. [PMID: 32759071 DOI: 10.1016/j.yebeh.2020.107299] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/26/2020] [Accepted: 06/28/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Cannabidiol (CBD) is a nonpsychoactive derivative of cannabis. Studies indicate that it is safe and effective in treating certain types of epilepsy. The present study examined the presence of adverse or beneficial cognitive or functional adaptive effects associated with CBD in the treatment of children, adolescents, and teenagers with treatment-resistant epilepsy (TRE) as part of an ongoing prospective, open-label safety study. METHODS Participants (N = 38) between the age of 3 and 19 years with TRE were enrolled in an open-label study of a pharmaceutical formulation of CBD (Epidiolex®; GW Research Ltd.) as an add-on treatment. In addition to baseline physical, neurological, and laboratory testing, cognitive assessment was completed prior to initiating CBD and after one year, both using the NIH Toolbox Cognition Battery (NIHTB-CB). Many participants were unable to complete the NIHTB-CB because of the magnitude of their cognitive impairment (n = 24), and in these cases, the participant's caregiver was asked to complete the Adaptive Behavior Assessment System - Second Edition (ABAS-II) as a measure of functional adaptive skills. RESULTS There were no statistically significant changes in cognitive function, as measured by the NIHTB-CB, in those participants who were able to complete such testing, but there was a nonsignificant trend toward improvement in some cognitive domains. For participants who were unable to complete formal standardized cognitive testing because of the magnitude of their cognitive impairment, their functional adaptive skills, as measured by the ABAS-II, were unchanged after a one-year trial of CBD. SIGNIFICANCE Our findings suggest that CBD, as an add-on drug for TRE in a pediatric sample, does not appear to cause adverse effects (AEs) involving cognition or adaptive function over one year of treatment.
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Affiliation(s)
- Matthew D Thompson
- Children's of Alabama, 1600 7th Avenue South, Birmingham, AL 35233, USA.
| | - Roy C Martin
- University of Alabama at Birmingham, Department of Neurology, 1720 7th Avenue South, Birmingham, AL 35233, USA
| | - Leslie P Grayson
- University of Alabama at Birmingham, Department of Neurology, 1720 7th Avenue South, Birmingham, AL 35233, USA
| | - Steve B Ampah
- University of Alabama at Birmingham, Department of Biostatistics, 1665 University Boulevard #327, Birmingham, AL 35233, USA
| | - Gary Cutter
- University of Alabama at Birmingham, Department of Biostatistics, 1665 University Boulevard #327, Birmingham, AL 35233, USA
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham, Department of Neurology, 1720 7th Avenue South, Birmingham, AL 35233, USA
| | - E Martina Bebin
- University of Alabama at Birmingham, Department of Neurology, 1720 7th Avenue South, Birmingham, AL 35233, USA
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20
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Affiliation(s)
- Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham
| | | | - Mackenzie E Fowler
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | - Yue Zhang
- Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Richard E Kennedy
- Department of Medicine, University of Alabama at Birmingham, Birmingham
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21
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Martin RC. AEDs and Cognition: One Small Fish in a Very Large Pond? Epilepsy Curr 2020; 20:196-198. [PMID: 34025227 PMCID: PMC7427167 DOI: 10.1177/1535759720925763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
[Box: see text]
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22
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Gaston TE, Nair S, Allendorfer JB, Martin RC, Beattie JF, Szaflarski JP. Memory response and neuroimaging correlates of a novel cognitive rehabilitation program for memory problems in epilepsy: A pilot study. Restor Neurol Neurosci 2020; 37:457-468. [PMID: 31282442 DOI: 10.3233/rnn-190919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Memory deficits are very common in epilepsy, but no standard of care exists to effectively manage them. OBJECTIVE We assessed effectiveness of cognitive rehabilitation (CR) on memory and neural plasticity in people with epilepsy (PWE) reporting memory impairments. METHODS Nine PWE completed 6 weekly sessions adapted from 2 generic CR programs enriched with information regarding epilepsy. Participants completed neuropsychological, mood, and quality of life (QOLIE-31) measures prior and after completion of CR; 5/9 participants also completed pre- and post-CR fMRI while performing a verbal paired associates learning task. FMRI data were analyzed using group spatial independent components analysis methods; paired t-tests compared spatial activations for pre-/post-CR. RESULTS Improvements were seen in immediate recall in Rey Auditory Verbal Learning Task, QOLIE-31, and read word recognition in paired associates task (all p's≤0.05). FMRI changes comparing pre-to-post CR were noted through increased activation in the left inferior frontal gyrus (IFG) and anterior cingulate and decreased activation in the left superior temporal gyrus; also noted were decreased activations in the default mode network (DMN), right cingulate, right middle temporal gyrus, right supramarginal gyrus, and increased DMN activation in the left cuneus. CONCLUSIONS This study demonstrates feasibility of conducting CR program in PWE with fMRI as a mechanistic biomarker. Improvements in cognition and cortical plasticity await confirmation in larger samples.
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Affiliation(s)
- Tyler E Gaston
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA.,Birmingham Veterans Administration Medical Center, Birmingham, AL, USA
| | - Sangeeta Nair
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jane B Allendorfer
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Julia Fleming Beattie
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.,Department of UAB Epilepsy Center, University of Alabama at Birmingham, Birmingham, AL, USA
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23
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Niccolai L, Aita SL, Walker HC, Martin RC, Clay OJ, Crowe M, Triebel KL. An examination of the neurocognitive profile and base rate of performance impairment in primary dystonia. J Clin Neurosci 2020; 74:1-5. [PMID: 31932183 DOI: 10.1016/j.jocn.2019.12.050] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 12/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary dystonia has been traditionally viewed as a motor disorder. However, non-motor symptoms are frequently present and significantly quality of life. Neuropsychiatric and cognitive symptoms have been identified, but prior studies have been limited in sample size and lack of control groups. This study examined the neurocognitive profile of a sample of persons with primary dystonia (PWD) as compared to demographically matched healthy control group. METHODS A cognitive test battery was administered to 25 PWD who presented for pre-surgical candidacy evaluation for deep brain stimulation surgery. The test battery domains included global cognitive function, attention, expressive language, visuospatial skills, memory, and executive functioning. Twenty-five age, gender, education-matched healthy control participants were compared to the PWD. RESULTS Compared to demographically matched healthy controls, PWD performed worse on measures of global cognitive function, attention, memory, and conceptualization. Based on normative comparison, a large portion of PWD were impaired on tasks of executive functioning and expressive language. Over 80% of the PWD showed impairment on at least one neurocognitive measure and over 60% showed impairment on 3 or more tests. CONCLUSIONS Neurocognitive deficits were prevalent among our PWD sample. These impairments were present across a broad range of cognitive domains. Given the degree of cognitive impairment found in this study, our results have implications for health care providers with providing interventions to PWD.
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Affiliation(s)
- Lindsay Niccolai
- Department of Neuro-Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stephen L Aita
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA; Department of Psychology, University of South Alabama, Mobile, AL, USA
| | - Harrison C Walker
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Olivio J Clay
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael Crowe
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristen L Triebel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA.
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Gerstenecker A, Martin RC, Triebel KL, Marson DC. Anosognosia of financial ability in mild cognitive impairment. Int J Geriatr Psychiatry 2019; 34:1200-1207. [PMID: 30968462 DOI: 10.1002/gps.5118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 04/08/2019] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Although financial ability has been well-studied in mild cognitive impairment (MCI) and Alzheimer's disease (AD) using performance-based financial capacity assessment instruments, research is limited investigating everyday financial problems and declines in persons with AD and MCI and the insight of people with MCI to recognize that financial capacity declines are occurring. To address this gap in the research, we investigated everyday financial activities and skills in a sample of older adults representing the dementia spectrum. METHODS Participants were 186 older adults in three diagnostic classifications: cognitively healthy, MCI likely due to AD, and mild AD dementia. Everyday financial ability was assessed using the Current Financial Activities Report (CFAR). The CFAR is a standardized report-based measure which elicits participant and study partner ratings about a participant's everyday financial abilities. RESULTS Results showed that both CFAR self- and study partner-report distinguished diagnostic groups on key financial capacity variables in a pattern consistent with level of clinical pathology. Study partner-report indicated higher levels of financial skill difficulties in study participants than did the self-report of the same study participants. Study partner-ratings were more highly correlated with participant scores on a performance-based measure of financial capacity than were participant self-ratings. Results also showed that loss of awareness of financial decline is emerging at the MCI stage of AD. CONCLUSIONS People with MCI represent a group of older adults at particular risk for financial missteps and-similar to people with AD-are in need of supervision of their financial skills and activities.
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Affiliation(s)
- Adam Gerstenecker
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL
| | - Kristen L Triebel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL
| | - Daniel C Marson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL.,Alzheimer's Disease Center, University of Alabama at Birmingham, Birmingham, AL
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25
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Martin RC, Gaston TE, Thompson M, Ampah SB, Cutter G, Bebin EM, Szaflarski JP. Cognitive functioning following long-term cannabidiol use in adults with treatment-resistant epilepsy. Epilepsy Behav 2019; 97:105-110. [PMID: 31220785 DOI: 10.1016/j.yebeh.2019.04.044] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 04/22/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
Abstract
Cognitive dysfunction is a common comorbidity in adults with treatment-resistant epilepsy (TRE). Recently, cannabidiol (CBD) has demonstrated efficacy in epilepsy treatment. However, our understanding of CBD's cognitive effects in epilepsy is limited. We examined long-term cognitive effects of CBD in adults with TRE as part of an ongoing prospective, open-label safety study. Twenty-sevenadults with TRE (mean age: 34[SD +14], female 52%) enrolled in the UAB CBD program completed standardized cognitive testing (NIH Toolbox Cognition Battery (NIHTB-CB)) at pre-CBD administration baseline and at one-yearfollow-up. Participants were receiving stable CBD dose at the time of one-year testing (mean=36.5mg/kg/day). The NIHTB-CB consisted of two global composite scales (Fluid and Crystallized) and seven individual tests measuring aspects of working memory, episodic memory, executive function, processing speed, and language. All participants had recorded Chalfont Seizure Severity Scale (CSSS) scores at each visit. Statistical analyses consisted of t-test, Pearson correlation coefficient, and linear regression. At baseline, cognitive test performance was below average for both global composite scales (Fluid: 71 [±18] range: 46-117) and Crystallized (76 [±15] range: 59-112)]. Longitudinal analysis revealed no significant group change across the two global composite scales. Of the seven individual cognitive tests, none changed significantly over time. No correlation was found between the cognitive change scores and CBD dose (all P's≥0.21). Change in cognitive test performance was not associated change in seizure severity rating. These findings are encouraging and indicate that long-term administration of pharmaceutical grade CBD is overall cognitively well-tolerated in adults with TRE.
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Affiliation(s)
- Roy C Martin
- University of Alabama at Birmingham, Department of Neurology, Birmingham, AL, USA.
| | - Tyler E Gaston
- University of Alabama at Birmingham, Department of Neurology, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA
| | | | - Steve B Ampah
- University of Alabama at Birmingham, Department of Biostatistics, Birmingham, AL, USA
| | - Gary Cutter
- University of Alabama at Birmingham, Department of Biostatistics, Birmingham, AL, USA
| | - E Martina Bebin
- University of Alabama at Birmingham, Department of Neurology, Birmingham, AL, USA
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham, Department of Neurology, Birmingham, AL, USA
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26
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Pisu M, Richman J, Szaflarski JP, Funkhouser E, Dai C, Juarez L, Faught E, Martin RC. High health care costs in minority groups of older US Medicare beneficiaries with epilepsy. Epilepsia 2019; 60:1462-1471. [PMID: 31169918 DOI: 10.1111/epi.16051] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To examine health care costs in diverse older Medicare beneficiaries with epilepsy. METHODS Using 2008-2010 claims data, we conducted a longitudinal cohort study of a random sample of Medicare beneficiaries augmented for minority representation. Epilepsy cases (n = 36 912) had ≥1 International Classification of Diseases, Ninth Edition (ICD-9) 345.x or ≥2 ICD-9 780.3x claims, and ≥1 antiepileptic drug (AED) in 2009; new cases (n = 3706) had no seizure/epilepsy claims nor AEDs in the previous 365 days. Costs were measured by reimbursements for all care received. High cost was defined as follow-up 1-year cost ≥ 75th percentile. Logistic regressions examined association of high cost with race/ethnicity, adjusting for demographic, clinical, economic, and treatment quality factors. In cases with continuous 2-year data, we obtained costs in two 6-month periods before and two after the index event. RESULTS Cohort was ~62% African Americans (AAs), 11% Hispanics, 5% Asians, and 2% American Indian/Alaska Natives. Mean costs in the follow-up were ~$30 000 (median = $11 547; new cases, mean = $44 642; median = $25 008). About 19% white compared to 27% AA cases had high cost. AA had higher odds of high cost in adjusted analyses (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.11-1.29), although this was only marginally significant when adjusting for AED adherence (OR = 1.09, 95% CI = 1.01-1.18, P = 0.03). Factors associated with high cost included ≥1 comorbidity, neurological care, and low AED adherence. Costs were highest at ~$17 000 in the 6 months immediately before and after the index event (>$29 000 for new cases). SIGNIFICANCE The financial sequelae of epilepsy among older Americans disproportionally affect minorities. Studies should examine contributors to high costs.
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Affiliation(s)
- Maria Pisu
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Ellen Funkhouser
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chen Dai
- Center for Health Service Research, University of Kentucky, Lexington, Kentucky
| | - Lucia Juarez
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Edward Faught
- Department of Neurology, Emory University, Atlanta, Georgia
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama
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Abstract
This review highlights the literature on the function and adjustment process of family members of persons with adult-onset vision loss. The majority of the literature has focused on the unique role that the family plays in providing both instrumental and emotional support to adults with low vision. In contrast, the impact of low vision on the psychosocial adjustment of the family has been largely understudied. The review concludes with a discussion of the implications for clinical practice, along with directions for future research on the family within the context of low vision rehabilitation.
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Affiliation(s)
- Jennifer K. Bambara
- Department of Psychology, University of Alabama at Birmingham, Campbell Hall, Suite 415, 1300 University Boulevard, Birmingham, AL 35294-1170
| | - Virginia Wadley
- Department of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham, Community Health Services Building, 1530 Third Avenue South, Birmingham, AL 35294-2100
| | - Cynthia Owsley
- Department of Ophthalmology, University of Alabama at Birmingham, Callahan Eye Foundation Hospital, 1720 University Boulevard, Birmingham, AL 35294
| | - Roy C. Martin
- Department of Neurology, University of Alabama at Birmingham, CIRC 312, 1719 Sixth Avenue South, Birmingham, AL 35294
| | - Chebon Porter
- VA Medical Center, Birmingham, 700 South 19th Street, Birmingham, AL 35233
| | - Laura E. Dreer
- Department of Ophthalmology, University of Alabama at Birmingham, Clinical Research Unit, Suite 609, Callahan Eye Foundation Hospital, 1720 University Boulevard, Birmingham, AL 35294
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Martin RC, Martin RR, Putnam ML. First Report of Cocksfoot Mottle Virus Infecting Dactylis glomerata in Forage Production Fields in California. Plant Dis 2018; 102:PDIS02180277PDN. [PMID: 30095321 DOI: 10.1094/pdis-02-18-0277-pdn] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
| | | | - M L Putnam
- Department of Botany and Plant Pathology, Oregon State University, Corvallis 97331
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Martin RC, Gerstenecker A, Triebel KL, Falola M, McPherson T, Cutter G, Marson DC. Declining Financial Capacity in Mild Cognitive Impairment: A Six-Year Longitudinal Study. Arch Clin Neuropsychol 2018; 34:152-161. [DOI: 10.1093/arclin/acy030] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 03/14/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Adam Gerstenecker
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristen L Triebel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael Falola
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tarrant McPherson
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gary Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Daniel C Marson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
- Alzheimer’s Disease Center, University of Alabama at Birmingham, Birmingham, AL, USA
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Faught E, Szaflarski JP, Richman J, Funkhouser E, Martin RC, Piper K, Dai C, Juarez L, Pisu M. Risk of pharmacokinetic interactions between antiepileptic and other drugs in older persons and factors associated with risk. Epilepsia 2018; 59:715-723. [PMID: 29411348 DOI: 10.1111/epi.14010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To determine the frequency of older Americans with epilepsy receiving concomitant prescriptions for antiepileptic drugs (AEDs) and non-epilepsy drugs (NEDs) which could result in significant pharmacokinetic (PK) interaction, and to assess the contributions of racial/ethnic, socioeconomic, and demographic factors. METHODS Retrospective analyses of 2008-2010 Medicare claims for a 5% random sample of beneficiaries ≥67 years old in 2009 augmented for minority representation. Prevalent cases had ≥1 ICD-9 345.x or ≥2 ICD-9 780.3x, and ≥1 AED. Among them, incident cases had no seizure/epilepsy claim codes nor AEDs in preceding 365 days. Drug claims for AEDs, and for the 50 most common NEDs within +/- 60 days of the index epilepsy date were tabulated. Interacting pairs of AEDs/NEDs were identified by literature review. Logistic regression models were used to examine factors affecting the likelihood of interaction risk. RESULTS Interacting drug pairs affecting NED efficacy were found in 24.5% of incident, 39% of prevalent cases. Combinations affecting AED efficacy were found in 20.4% of incident, 29.3% of prevalent cases. Factors predicting higher interaction risk included having ≥ 1 comorbidity, being eligible for Part D low Income Subsidy, and not living in the northeastern US. Protective factors were Asian race/ethnicity, and treatment by a neurologist. SIGNIFICANCE A substantial portion of older epilepsy patients received NED-AED combinations that could cause important PK interactions. The lower frequency among incident vs. prevalent cases may reflect changes in prescribing practices. Avoidance of interacting AEDs is feasible for most persons because of the availability of newer drugs.
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Affiliation(s)
- Edward Faught
- Department of Neurology, Emory University, Atlanta, GA, USA
| | - Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ellen Funkhouser
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kendra Piper
- Department of Gynecology and Obstetrics, Emory University, Atlanta, GA, USA
| | - Chen Dai
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lucia Juarez
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Maria Pisu
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
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Gerstenecker A, Lowry K, Myers T, Bashir K, Triebel KL, Martin RC, Marson DC. Medical decision-making capacity and its cognitive predictors in progressive MS: Preliminary evidence. J Neurol Sci 2017; 380:38-43. [PMID: 28870585 DOI: 10.1016/j.jns.2017.06.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/01/2017] [Accepted: 06/28/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Medical decision-making capacity (MDC) refers to the ability to make informed decisions about treatment and declines in cognition are associated with declines in MDC across multiple disease entities. However, although it is well known that cognitive impairment is prevalent in multiple sclerosis (MS), little is known about MDC in the disease. METHODS Data from 22 persons with progressive MS and 18 healthy controls were analyzed. All diagnoses were made by a board-certified neurologist with experience in MS. All study participants were administered a vignette-based measure of MDC and also a neuropsychological battery. RESULTS Performance on three MDC consent standards (i.e., Appreciation, Reasoning, Understanding) was significantly lower for people with progressive MS as compared to healthy controls. In the progressive MS group, verbal fluency was the primary cognitive predictor for both Reasoning and Understanding consent standards. Verbal learning and memory was the primary cognitive predictor for Appreciation. MS severity was not significantly correlated with any MDC variable. CONCLUSION MDC is a complex and cognitively mediated functional ability that is impaired in many people with progressive MS. Verbal measures of fluency and memory are strongly associated with MDC performances in the current sample of people with MS and could potentially be utilized to quickly screen for MDC impairment in MS.
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Affiliation(s)
- Adam Gerstenecker
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kathleen Lowry
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Terina Myers
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Khurram Bashir
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristen L Triebel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Daniel C Marson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States.
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Gerstenecker A, Myers T, Lowry K, Martin RC, Triebel KL, Bashir K, Marson DC. Financial Capacity and its Cognitive Predictors in Progressive Multiple Sclerosis. Arch Clin Neuropsychol 2017; 32:943-950. [DOI: 10.1093/arclin/acx039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 04/03/2017] [Indexed: 11/12/2022] Open
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Szaflarski JP, Martin RC, Faught E, Funkhouser E, Richman J, Piper K, Juarez L, Dai C, Pisu M. Quality Indicator for Epilepsy Treatment 15 (QUIET-15): Intervening after recurrent seizures in the elderly. Epilepsy Behav 2017; 70:253-258. [PMID: 28412154 PMCID: PMC5438892 DOI: 10.1016/j.yebeh.2017.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/03/2017] [Accepted: 03/04/2017] [Indexed: 11/24/2022]
Abstract
In this study, we examined the provision of care to older adults with epilepsy and compliance with the "Quality Indicator for Epilepsy Treatment 15" (QUIET-15) measure. We analyzed 2008-2010, 5% random sample of Medicare beneficiaries augmented with data from all beneficiaries who identified as a minority with claims related to seizures (780.3x) or epilepsy (345.xx). Of 36,912 identified epilepsy cases, 12.6% had ≥1 emergency room (ER) visit for seizure(s). For those who presented to ER, among those taking anti-epileptic drugs (AEDs), AED was changed in 15.4%, dose adjusted in 19.7%, and stopped in 14.9%; among those not taking AED, therapy was initiated in 68.5%. In adjusted logistic regressions, African-Americans were more likely to have recurrent seizures than Whites (OR 1.41, 95%CI 1.27-1.56), while Asians were less likely to have recurrent seizures (OR 0.71, 95%CI 0.57-0.89). There were no significant racial/ethnic differences in the likelihood of a post-seizure intervention. The chance of seizure recurrence leading to ER visit decreased with age and increased with the number of comorbidities. Patients with seizure recurrence were more likely to be taking an enzyme-inducing AED (OR 1.69, 95%CI 1.57-1.82) and receiving Part D Low Income Subsidy (OR 1.36, 95%CI 1.22-1.51). The probability of AED change after a seizure was higher for patients with ≥4 comorbidities (OR 1.69, 95%CI 1.25-2.27), patients who saw a neurologist (OR 1.49, 95%CI 1.30-1.70), and patients who were taking an enzyme-inducing AED (OR 1.47, 95%CI 1.27-1.71). Overall, a minority of Medicare beneficiaries experienced seizure recurrence that resulted in an ER visit. However, only half of them received treatment concordant with QUIET-15. Though racial differences were observed in occurrence of seizures, none were noted in the provision of care.
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Affiliation(s)
| | - Roy C. Martin
- Department of Neurology, University of Alabama at Birmingham
| | | | - Ellen Funkhouser
- Division of Preventive Medicine, University of Alabama at Birmingham
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham
| | - Kendra Piper
- Department of Gynecology and Obstetrics, Emory University
| | - Lucia Juarez
- Department of Surgery, University of Alabama at Birmingham
| | - Chen Dai
- Department of Surgery, University of Alabama at Birmingham
| | - Maria Pisu
- Department of Surgery, University of Alabama at Birmingham
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Fleming Beattie J, Martin RC, Kana RK, Deshpande H, Lee S, Curé J, Ver Hoef L. Hippocampal dentation: Structural variation and its association with episodic memory in healthy adults. Neuropsychologia 2017; 101:65-75. [PMID: 28472628 DOI: 10.1016/j.neuropsychologia.2017.04.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 04/26/2017] [Accepted: 04/29/2017] [Indexed: 11/29/2022]
Abstract
While the hippocampus has long been identified as a structure integral to memory, the relationship between morphology and function has yet to be fully explained. We present an analysis of hippocampal dentation, a morphological feature previously unexplored in regard to its relationship with episodic memory. "Hippocampal dentation" in this case refers to surface convolutions, primarily present in the CA1/subiculum on the inferior aspect of the hippocampus. Hippocampal dentation was visualized using ultra-high resolution structural MRI and evaluated using a novel visual rating scale. The degree of hippocampal dentation was found to vary considerably across individuals, and was positively associated with verbal memory recall and visual memory recognition in a sample of 22 healthy adults. This study is the first to characterize the variation in hippocampal dentation in a healthy cohort and to demonstrate its association with aspects of episodic memory.
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Affiliation(s)
| | - Roy C Martin
- University of Alabama at Birmingham, Department of Neurology, USA
| | - Rajesh K Kana
- University of Alabama at Birmingham, Department of Psychology, USA
| | | | - Seongtaek Lee
- University of Alabama at Birmingham, Department of Biomedical Engineering, USA
| | - Joel Curé
- University of Alabama at Birmingham, Department of Radiology, USA
| | - Lawrence Ver Hoef
- University of Alabama at Birmingham, Department of Neurology, USA; Birmingham VA Medical Center, Department of Neurology, USA.
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Martin RC, Faught E, Szaflarski JP, Richman J, Funkhouser E, Piper K, Juarez L, Dai C, Pisu M. What does the U.S. Medicare administrative claims database tell us about initial antiepileptic drug treatment for older adults with new-onset epilepsy? Epilepsia 2017; 58:548-557. [PMID: 28176298 DOI: 10.1111/epi.13675] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Disparities in epilepsy treatment are not uncommon; therefore, we examined population-based estimates of initial antiepileptic drugs (AEDs) in new-onset epilepsy among racial/ethnic minority groups of older US Medicare beneficiaries. METHODS We conducted retrospective analyses of 2008-2010 Medicare administrative claims for a 5% random sample of beneficiaries augmented for minority representation. New-onset epilepsy cases in 2009 had ≥1 International Classification of Diseases, Ninth Revision (ICD-9) 345.x or ≥2 ICD-9 780.3x, and ≥1 AED, AND no seizure/epilepsy claim codes or AEDs in preceding 365 days. We examined AED use and concordance with Quality Indicators of Epilepsy Treatment (QUIET) 6 (monotherapy as initial treatment = ≥30 day first prescription with no other concomitant AEDs), and prompt AED treatment (first AED within 30 days of diagnosis). Logistic regression examined likelihood of prompt treatment by demographic (race/ethnicity, gender, age), clinical (number of comorbid conditions, neurology care, index event occurring in the emergency room (ER)), and economic (Part D coverage phase, eligibility for Part D Low Income Subsidy [LIS], and ZIP code level poverty) factors. RESULTS Over 1 year of follow-up, 79.6% of 3,706 new epilepsy cases had one AED only (77.89% of whites vs. 89% of American Indian/Alaska Native [AI/AN]). Levetiracetam was the most commonly prescribed AED (45.5%: from 24.6% AI/AN to 55.0% whites). The second most common was phenytoin (30.6%: from 18.8% Asians to 43.1% AI/AN). QUIET 6 concordance was 94.7% (93.9% for whites to 97.3% of AI/AN). Only 50% received prompt AED therapy (49.6% whites to 53.9% AI/AN). Race/ethnicity was not significantly associated with AED patterns, monotherapy use, or prompt treatment. SIGNIFICANCE Monotherapy is common across all racial/ethnic groups of older adults with new-onset epilepsy, older AEDs are commonly prescribed, and treatment is frequently delayed. Further studies on reasons for treatment delays are warranted. Interventions should be developed and tested to develop paradigms that lead to better care.
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Affiliation(s)
- Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Edward Faught
- Department of Neurology, Emory University, Atlanta, Georgia, U.S.A
| | - Jerzy P Szaflarski
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Ellen Funkhouser
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Kendra Piper
- Department of Gynecology and Obstetrics, Emory University, Atlanta, Georgia, U.S.A
| | - Lucia Juarez
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Chen Dai
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Maria Pisu
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
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Niccolai LM, Triebel KL, Gerstenecker A, McPherson TO, Cutter GR, Martin RC, Marson DC. Neurocognitive Predictors of Declining Financial Capacity in Persons with Mild Cognitive Impairment. Clin Gerontol 2017; 40:14-23. [PMID: 28452629 PMCID: PMC5412082 DOI: 10.1080/07317115.2016.1228022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To identify cognitive predictors of declining financial capacity (FC) in persons with mild cognitive impairment (MCI). METHODS Participants were 66 cognitively normal older adults and 49 persons with MCI who completed neuropsychological testing and a performance measure of financial capacity (Financial Capacity Instrument; FCI) at baseline and two-year follow-up. We calculated two-year change scores for neuropsychological tests and FCI total score. We examined bivariate correlations between demographic/clinical variables and FCI change score, and between neuropsychological and FCI change scores. The five strongest bivariate correlates were entered into a linear regression analysis to identify longitudinal predictors of financial decline within group. RESULTS Persons with MCI showed significant decline on the FCI and most cognitive variables, while controls demonstrated relatively stable performance. For persons with MCI, education correlated with FCI change score. The top four cognitive variable-FCI change score correlations were written arithmetic, confrontation naming, immediate visual memory, and visual attention. In the regression model, written arithmetic was the primary predictor and visual memory and visual attention were secondary predictors of two-year FCI change scores. CONCLUSION Semantic arithmetic knowledge, and to a lesser extent visual memory and attention, are key longitudinal cognitive predictors of financial skill decline in individuals with MCI. CLINICAL IMPLICATIONS Clinicians should consider neurocognitive abilities of written arithmetic, visual memory, and processing speed in their assessments of financial capacity in person with MCI.
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Affiliation(s)
| | | | | | | | - Gary R Cutter
- a University of Alabama at Birmingham , Birmingham , Alabama , USA
| | - Roy C Martin
- a University of Alabama at Birmingham , Birmingham , Alabama , USA
| | - Daniel C Marson
- a University of Alabama at Birmingham , Birmingham , Alabama , USA
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Philips P, Scoggins CR, Rostas JK, McMasters KM, Martin RC. Safety and advantages of combined resection and microwave ablation in patients with bilobar hepatic malignancies. Int J Hyperthermia 2016; 33:43-50. [PMID: 27405728 DOI: 10.1080/02656736.2016.1211751] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The multimodality approach has significantly improved outcomes for hepatic malignancies. Microwave ablation is often used in isolation or succession, and seldom in combination with resection. Potential benefits and pitfalls from combined resection and ablation therapy in patients with complex and extensive bilobar hepatic disease have not been well defined. METHODS A review of the University of Louisville prospective Hepato-Pancreatico-Biliary Patients database was performed with multi-focal bilobar disease that underwent microwave ablation with resection or microwave only included. RESULTS One hundred and eight were treated with microwave only (MWA, n = 108) or combined resection and ablation (CRA, n = 84) and were compared with similar disease-burden patients undergoing resection only (n = 84). The groups were comparable except that the MWA group was older (p = .02) and with higher co-morbidities (diabetes, hepatitis). The resection group had larger tumours (4 vs. 3.2 and 3 cm) but the CRA group had more numerous lesions (4 vs. 3 and 2, p = .002). Short-term outcomes including morbidity (47.6% vs. 43%, p = .0715) were similar between the CRA and resection only groups. Longer operative time (164 vs. 126 min, p = .003) and need for blood transfusion (p = .001) were independent predictors of complications. Survival analyses for colorectal metastasis patients (n = 158) demonstrated better overall survival (OS) (43.9 vs. 37.6 and 30.5 months, p = .035), disease-free survival (DFS) (38 vs. 26.6 and 16.9 months, p = .028) and local recurrence-free survival (LRFS) (55.4 vs. 17 and 22.9 months, p < .001) with resection only. CONCLUSION The use of microwave ablation in addition to surgical resection did not significantly increase the morbidities or short-term outcomes. In combination with systemic and other local forms of therapy, combined resection and ablation is a safe and effective procedure.
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Affiliation(s)
- Prejesh Philips
- a Department of Surgical Oncology , University of Louisville , Louisville , KY , USA
| | - C R Scoggins
- a Department of Surgical Oncology , University of Louisville , Louisville , KY , USA
| | - J K Rostas
- a Department of Surgical Oncology , University of Louisville , Louisville , KY , USA
| | - K M McMasters
- a Department of Surgical Oncology , University of Louisville , Louisville , KY , USA
| | - R C Martin
- a Department of Surgical Oncology , University of Louisville , Louisville , KY , USA
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Triebel KL, Gerstenecker A, Meneses K, Fiveash JB, Meyers CA, Cutter G, Marson DC, Martin RC, Eakin A, Watts O, Nabors LB. Capacity of patients with brain metastases to make treatment decisions. Psychooncology 2015; 24:1448-55. [PMID: 25613039 PMCID: PMC4512930 DOI: 10.1002/pon.3753] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/21/2014] [Accepted: 12/18/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to investigate medical decision-making capacity (MDC) in patients with brain metastases. METHODS Participants were 41 adults with brain metastases with Karnofsky Performance Status scores of ≥70 who were recruited from an academic medical center and 41 demographically matched controls recruited from the community. We evaluated MDC using the Capacity to Consent to Treatment Instrument and its four clinically relevant consent standards (expressing a treatment choice, appreciation, reasoning, and understanding). Capacity impairment ratings (no impairment, mild/moderate impairment, and severe impairment) on the consent standards were also assigned to each participant with brain metastasis using cutoff scores derived statistically from the performance of the control group. RESULTS The brain metastasis patient group performed significantly below controls on consent standards of understanding and reasoning. Capacity compromise was defined as performance ≤1.5 standard deviations below the control group mean. Using this definition, approximately 60% of the participants with brain metastases demonstrated capacity compromise on at least one MDC standard. CONCLUSION When defining capacity compromise as performance ≤1.5 standard deviation below the control group mean, over half of patients with brain metastases have reduced capacity to make treatment decisions. This impairment is demonstrated shortly after initial diagnosis of brain metastases and highlights the importance of routine clinical assessment of MDC following diagnosis of brain metastasis. These results also indicate a need for the development and investigation of interventions to support or improve MDC in this patient population.
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Affiliation(s)
- Kristen L. Triebel
- Department of Neurology, UAB, Birmingham, AL
- Comprehensive Cancer Center, UAB, Birmingham, AL
| | | | - Karen Meneses
- Comprehensive Cancer Center, UAB, Birmingham, AL
- School of Nursing, UAB, Birmingham, AL
| | - John B. Fiveash
- Comprehensive Cancer Center, UAB, Birmingham, AL
- Department of Radiation Oncology, UAB, Birmingham, AL
| | - Christina A. Meyers
- Department of Neuro-Oncology, M.D. Anderson Cancer Center, Houston, TX (retired)
| | - Gary Cutter
- Department of Biostatistics, School of Public Health, UAB, Birmingham, AL
| | | | | | | | - Olivia Watts
- Department of Psychology, Boston University, Boston, MA
| | - Louis B. Nabors
- Department of Neurology, UAB, Birmingham, AL
- Comprehensive Cancer Center, UAB, Birmingham, AL
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Martin RC, Gerstenecker A, Nabors LB, Marson DC, Triebel KL. Impairment of medical decisional capacity in relation to Karnofsky Performance Status in adults with malignant brain tumor. Neurooncol Pract 2015; 2:13-19. [PMID: 26034637 DOI: 10.1093/nop/npu030] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We aimed to investigate the relationship between medical decisional capacity (MDC) and Karnofsky Performance Status (KPS) in adults with malignant brain tumors. METHODS Participants were 71 adults with primary (n = 26) or metastatic (n = 45) brain tumors. Testing to determine KPS scores and MDC was performed as close together as possible for each patient. Participants were administered a standardized measure of medical decision-making capacity (Capacity to Consent to Treatment Instrument [CCTI]) to assess 3 treatment consent abilities (ie, appreciation, reasoning, and understanding). Capacity classifications (ie, capable, marginally capable, and incapable) were established using cut scores previously derived from healthy control CCTI performance. RESULTS The majority of participants had KPS scores of 90-100 (n = 39), with the remainder divided between KPS scores of 70-80 (n = 26) and 50-60 (n = 6). Comparisons between persons with KPS scores of 90-100 or 70-80 revealed significant differences on the CCTI consent standards of understanding and appreciation. Participants with KPS ratings of 90-100 achieved 46% capable classifications across all CCTI standards, in contrast with 23% of participants with KPS ratings of 70-80, and 0% of participants with KPS ratings of 50-60. CONCLUSIONS A substantial portion of brain-tumor patients with KPS scores reflecting only minimal disability nonetheless demonstrated impairments on standardized measures of MDC. Clinicians working with this adult population should carefully screen for capacity to make clinical treatment decisions regardless of functional/performance status.
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Affiliation(s)
- Roy C Martin
- Department of Neurology , Division of Neuropsychology, University of Alabama at Birmingham , Birmingham, Alabama (R.C.M., A.G., D.C.M., K.L.T.); Comprehensive Cancer Center, University of Alabama at Birmingham , Birmingham, Alabama (L.B.N.); Department of Neurology , Division of Neuro-Oncology, University of Alabama at Birmingham , Birmingham, Alabama (L.B.N.)
| | - Adam Gerstenecker
- Department of Neurology , Division of Neuropsychology, University of Alabama at Birmingham , Birmingham, Alabama (R.C.M., A.G., D.C.M., K.L.T.); Comprehensive Cancer Center, University of Alabama at Birmingham , Birmingham, Alabama (L.B.N.); Department of Neurology , Division of Neuro-Oncology, University of Alabama at Birmingham , Birmingham, Alabama (L.B.N.)
| | - Louis B Nabors
- Department of Neurology , Division of Neuropsychology, University of Alabama at Birmingham , Birmingham, Alabama (R.C.M., A.G., D.C.M., K.L.T.); Comprehensive Cancer Center, University of Alabama at Birmingham , Birmingham, Alabama (L.B.N.); Department of Neurology , Division of Neuro-Oncology, University of Alabama at Birmingham , Birmingham, Alabama (L.B.N.)
| | - Daniel C Marson
- Department of Neurology , Division of Neuropsychology, University of Alabama at Birmingham , Birmingham, Alabama (R.C.M., A.G., D.C.M., K.L.T.); Comprehensive Cancer Center, University of Alabama at Birmingham , Birmingham, Alabama (L.B.N.); Department of Neurology , Division of Neuro-Oncology, University of Alabama at Birmingham , Birmingham, Alabama (L.B.N.)
| | - Kristen L Triebel
- Department of Neurology , Division of Neuropsychology, University of Alabama at Birmingham , Birmingham, Alabama (R.C.M., A.G., D.C.M., K.L.T.); Comprehensive Cancer Center, University of Alabama at Birmingham , Birmingham, Alabama (L.B.N.); Department of Neurology , Division of Neuro-Oncology, University of Alabama at Birmingham , Birmingham, Alabama (L.B.N.)
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Martin RC, Faught E, Richman J, Funkhouser E, Pisu M. In response: Research using archival health care data: Let the buyer beware. Epilepsia 2015; 56:322-3. [PMID: 25708478 DOI: 10.1111/epi.12889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
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Gerstenecker A, Nabors LB, Meneses K, Fiveash JB, Marson DC, Cutter G, Martin RC, Meyers CA, Triebel KL. Cognition in patients with newly diagnosed brain metastasis: profiles and implications. J Neurooncol 2014; 120:179-85. [PMID: 25035099 PMCID: PMC4295820 DOI: 10.1007/s11060-014-1543-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 07/06/2014] [Indexed: 10/25/2022]
Abstract
Cognitive impairment is a common symptom in patients with brain metastasis, and significant cognitive dysfunction is prevalent in a majority of patients who are still able to engage in basic self-care activities. In the current study, the neurocognitive performance of 32 patients with brain metastasis and 32 demographically-matched controls was examined using a battery of standardized neuropsychological tests, with the goal of comprehensively examining the cognitive functioning of newly diagnosed brain metastasis patients. The cognition of all patients was assessed within 1 week of beginning treatment for brain metastasis. Results indicated impairments in verbal memory, attention, executive functioning, and language in relation to healthy controls. Performance in relation to appropriate normative groups was also examined. Overall, cognitive deficits were prevalent and memory was the most common impairment. Given that cognitive dysfunction was present in this cohort of patients with largely minimal functional impairment, these results have implications for patients, caregivers and health care providers treating patients with brain metastasis.
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Triebel KL, Martin RC, Novack TA, Dreer LE, Turner C, Kennedy R, Marson DC. Recovery over 6 months of medical decision-making capacity after traumatic brain injury. Arch Phys Med Rehabil 2014; 95:2296-303. [PMID: 25152169 DOI: 10.1016/j.apmr.2014.07.413] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 07/14/2014] [Accepted: 07/23/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate recovery of medical decision-making capacity (MDC) over 6 months in persons with traumatic brain injury (TBI) stratified by injury severity. DESIGN Longitudinal study comparing controls and patients with TBI 1 month after injury (t1) and 6 months after injury (t2). SETTING Inpatient TBI rehabilitation unit and outpatient neurology department. PARTICIPANTS Participants (N=151) consisted of control subjects (n=60) and patients with TBI (n=91) stratified by injury severity: mild TBI (mTBI; n=27), complicated mild TBI (cmTBI; n=20), and moderate/severe TBI (msevTBI; n=44). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We used the Capacity to Consent to Treatment Instrument to evaluate MDC performance on 5 consent standards (expressing choice, reasonable choice, appreciation, reasoning, and understanding). We also assigned capacity impairment ratings on the consent standards to each participant with TBI using cut scores referenced to control performance. RESULTS Control performance was stable across time on the consent standards. Patients with mTBI and cmTBI performed below controls on the understanding standard at t1 but not t2. Patients with msevTBI performed below controls on appreciation, reasoning, and understanding at t1, and on appreciation and understanding at t2, but showed substantial improvement over time. CONCLUSIONS Regardless of injury severity, all groups with TBI demonstrated baseline impairment of MDC with subsequent partial or full recovery of MDC over a 6-month period. However, a sizeable proportion of individual patients with TBI in each group continued to demonstrate capacity compromise at 6 months postinjury. Clinically, this finding suggests that individuals with TBI, regardless of injury severity, need continued monitoring regarding MDC for at least 6 months after injury.
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Affiliation(s)
- Kristen L Triebel
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Roy C Martin
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Thomas A Novack
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL
| | - Laura E Dreer
- Department of Ophthalmology, University of Alabama at Birmingham, Birmingham, AL
| | - Crystal Turner
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Richard Kennedy
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Daniel C Marson
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL.
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Martin RC, Faught E, Richman J, Funkhouser E, Kim Y, Clements K, Pisu M. Psychiatric and neurologic risk factors for incident cases of new-onset epilepsy in older adults: Data from U.S. Medicare beneficiaries. Epilepsia 2014; 55:1120-7. [DOI: 10.1111/epi.12649] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Roy C. Martin
- Department of Neurology; University of Alabama at Birmingham; Birmingham Alabama U.S.A
| | - Edward Faught
- Department of Neurology; Emory University; Atlanta Georgia U.S.A
| | - Joshua Richman
- Department of Surgery; University of Alabama at Birmingham; Birmingham Alabama U.S.A
| | - Ellen Funkhouser
- Division of Preventive Medicine; University of Alabama at Birmingham; Birmingham Alabama U.S.A
| | - Yongin Kim
- Division of Preventive Medicine; University of Alabama at Birmingham; Birmingham Alabama U.S.A
| | - Kay Clements
- Department of Health Services Administration; University of Alabama at Birmingham; Birmingham Alabama U.S.A
| | - Maria Pisu
- Division of Preventive Medicine; University of Alabama at Birmingham; Birmingham Alabama U.S.A
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Stoeckel LE, Stewart CC, Griffith HR, Triebel K, C. Okonkwo O, den Hollander JA, Martin RC, Belue K, Copeland JN, Harrell LE, Brockington JC, Clark DG, Marson DC. MRI volume of the medial frontal cortex predicts financial capacity in patients with mild Alzheimer's disease. Brain Imaging Behav 2013; 7:282-92. [PMID: 23504597 PMCID: PMC3716854 DOI: 10.1007/s11682-013-9226-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Persons with mild Alzheimer's disease (AD) have significant deficits in financial abilities. This study examined the relationship between brain structure volumes, cognition, and financial capacity in patients with mild AD. Sixteen mild AD patients and 16 older adult comparisons completed the Financial Capacity Instrument (FCI), a psychometric measure of financial abilities, and also underwent magnetic resonance imaging (MRI) to obtain volumes of the bilateral hippocampi, angular gyri, precunei, and medial and dorsolateral frontal cortices. Mild AD patients performed significantly below comparisons on the FCI and had significantly smaller hippocampi. Among mild AD patients, FCI performance was moderately correlated with frontal (medial and dorsolateral frontal cortex) and posterior (angular gyri and precunei) cortical volumes. Stepwise regression demonstrated that medial frontal cortex volume predicted FCI score. The relationship between medial frontal cortex volume and overall FCI score was partially mediated by two measures of simple attention (DRS Attention, DRS Construction). The findings suggest that medial frontal cortex atrophy and associated declines in simple attention play an increasingly important role in declining financial skills in patients with mild AD.
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Affiliation(s)
- Luke E. Stoeckel
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | | | - Kristen Triebel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
- Department of Alzheimer’s Disease Research Center, University of Alabama at Birmingham, Birmingham, AL
| | - Ozioma C. Okonkwo
- Department of Medicine & Alzheimer's Disease Research Center, University of Wisconsin-Madison, Madison, WI
| | | | - Roy C. Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
- Department of Alzheimer’s Disease Research Center, University of Alabama at Birmingham, Birmingham, AL
| | - Katherine Belue
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
- Department of Alzheimer’s Disease Research Center, University of Alabama at Birmingham, Birmingham, AL
| | | | - Lindy E. Harrell
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
- Department of Alzheimer’s Disease Research Center, University of Alabama at Birmingham, Birmingham, AL
- Birmingham Regional Veterans Affairs Medical Center, Birmingham, AL
| | - John C. Brockington
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
- Department of Alzheimer’s Disease Research Center, University of Alabama at Birmingham, Birmingham, AL
| | - David G. Clark
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
- Department of Alzheimer’s Disease Research Center, University of Alabama at Birmingham, Birmingham, AL
- Birmingham Regional Veterans Affairs Medical Center, Birmingham, AL
| | - Daniel C. Marson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
- Department of Alzheimer’s Disease Research Center, University of Alabama at Birmingham, Birmingham, AL
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Martin RC, Triebel KL, Kennedy RE, Nicholas AP, Watts RL, Stover NP, Brandon M, Marson DC. Impaired financial abilities in Parkinson's disease patients with mild cognitive impairment and dementia. Parkinsonism Relat Disord 2013; 19:986-90. [PMID: 23899743 DOI: 10.1016/j.parkreldis.2013.06.017] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 06/18/2013] [Accepted: 06/25/2013] [Indexed: 01/30/2023]
Abstract
PURPOSE Financial capacity (FC) is an instrumental activity of daily living (IADL) critical to independent functioning and sensitive to cognitive impairment in dementia. Little is known about FC in cognitively impaired patients with Parkinson's disease (PD). The present study investigated FC in PD patients with prodromal and clinical dementia. METHODS Participants were 20 older controls and 35 PD patients who met consensus criteria for either mild cognitive impairment (PD-MCI, n = 18) or PD dementia (PDD, n = 17). FC was assessed using a standardized performance based measure consisting of 9 domain and two global scores (Financial Capacity Instrument; FCI) (1). FCI domain and global performance scores were compared across groups. Capacity impairment ratings (no impairment, mild/moderate impairment, severe impairment) were calculated for each PD patient's domain and global scores. RESULTS Relative to controls, PD-MCI patients were impaired on both FCI global scores and domains of basic monetary skills, financial concepts, and investment decision-making. Relative to both controls and PD-MCI patients, PDD patients were impaired on virtually all FCI variables. With respect to impairment ratings, greater than 50% of PD-MCI patients and greater than 90% of PDD patients were classified as either mild/moderate or severely impaired on the two FCI global scores. CONCLUSIONS Impairment of financial capacity is already present in PD-MCI and is advanced in PDD. Complex cognitively-mediated IADLs such as financial capacity appear to be impaired early in the course of PD dementia.
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Affiliation(s)
- Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA; Alzheimer's Disease Research Center, University of Alabama at Birmingham, Birmingham, AL, USA
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Kleinman NL, Sadosky A, Seid J, Martin RC, Labiner DM. Costs, work absence, and adherence in patients with partial onset seizures prescribed gabapentin or pregabalin. Epilepsy Res 2012; 102:13-22. [DOI: 10.1016/j.eplepsyres.2012.04.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 03/19/2012] [Accepted: 04/21/2012] [Indexed: 11/29/2022]
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Pisu M, Kratt P, Faught E, Martin RC, Kim Y, Clements K, Knowlton R, Funkhouser E, Richman JS. Geographic variation of epilepsy for older Americans: how close to the geographic variation of stroke? Epilepsia 2012; 53:2186-93. [PMID: 22958112 DOI: 10.1111/j.1528-1167.2012.03640.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE Given the strong association of stroke and epilepsy in older persons, and the existence of a Stroke Belt in the United States, we hypothesized that geographic variation in epilepsy prevalence would follow geographic patterns similar to stroke. METHODS We used a 2005 5% random sample of Medicare beneficiaries 65 and older in 48 U.S. contiguous states. Epilepsy was identified from claims for physician visits, hospitalizations, and outpatient procedures. Prevalence was obtained by state and county. Logistic regressions determined the independent association of the likelihood of epilepsy (prevalent or new case) and residence in Stroke Belt states, controlling for residence in highest epilepsy prevalence states, demographics (race, age, gender), comorbid conditions, cerebrovascular disease, dementia, and county characteristics. KEY FINDINGS Of 1,212,015 beneficiaries, 11.9 per 1,000 had prevalent and 2.9 new cases of epilepsy. Nine of 11 Stroke Belt states were among the 20 states with the highest epilepsy prevalence. Counties in the 10 highest epilepsy prevalence states were more likely to be large urban counties with a higher number of neurologists or neurosurgeons per capita. The higher likelihood of prevalent epilepsy cases associated with Stroke Belt residence was explained by beneficiaries' race; that associated with residence in high epilepsy prevalence states was not. The likelihood of new epilepsy cases was negatively associated with Stroke Belt residence when controlling for covariates. SIGNIFICANCE The geographic variation in epilepsy prevalence is not explained by variations in known risk factors. Further research should investigate why eastern U.S. states have higher frequency of epilepsy.
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Affiliation(s)
- Maria Pisu
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294-4410, USA.
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Crowe M, Clay OJ, Martin RC, Howard VJ, Wadley VG, Sawyer P, Allman RM. Indicators of childhood quality of education in relation to cognitive function in older adulthood. J Gerontol A Biol Sci Med Sci 2012; 68:198-204. [PMID: 22546959 DOI: 10.1093/gerona/gls122] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The association between years of education and cognitive function in older adults has been studied extensively, but the role of quality of education is unknown. We examined indicators of childhood educational quality as predictors of cognitive performance and decline in later life. METHODS Participants included 433 older adults (52% African American) who reported living in Alabama during childhood and completed in-home assessments of cognitive function at baseline and 4 years later. Reports of residence during school years were matched to county-level data from the 1935 Alabama Department of Education report for school funding (per student), student-teacher ratio, and school year length. A composite measure of global cognitive function was utilized in analyses. Multilevel mixed effects models accounted for clustering of educational data within counties in examining the association between cognitive function and the educational quality indices. RESULTS Higher student-teacher ratio was associated with worse cognitive function and greater school year length was associated with better cognitive function. These associations remained statistically significant in models adjusted for education level, age, race, gender, income, reading ability, vascular risk factors, and health behaviors. The observed associations were stronger in those with lower levels of education (≤12 years), but none of the education quality measures were related to 4-year change in cognitive function. CONCLUSIONS Educational factors other than years of schooling may influence cognitive performance in later life. Understanding the role of education in cognitive aging has substantial implications for prevention efforts as well as accurate identification of older adults with cognitive impairment.
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Affiliation(s)
- Michael Crowe
- Department of Psychology, University of Alabama at Birmingham, 1530 3rd Avenue S., HMB 111, Birmingham, AL 35294-2100, USA.
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Triebel KL, Martin RC, Novack TA, Dreer L, Turner C, Pritchard PR, Raman R, Marson DC. Treatment consent capacity in patients with traumatic brain injury across a range of injury severity. Neurology 2012; 78:1472-8. [PMID: 22496195 DOI: 10.1212/wnl.0b013e3182553c38] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate medical decision-making capacity (MDC) in patients with acute traumatic brain injury (TBI) across a range of injury severity. METHODS We evaluated MDC cross-sectionally 1 month after injury in 40 healthy controls and 86 patients with TBI stratified by injury severity (28 mild [mTBI], 15 complicated mild [cmTBI], 43 moderate/severe [msevTBI]). We compared group performance on the Capacity to Consent to Treatment Instrument and its 5 consent standards (expressing choice, reasonable choice, appreciation, reasoning, understanding). Capacity impairment ratings (no impairment, mild/moderate impairment, severe impairment) on the consent standards were also assigned to each participant with TBI using cut scores referenced to control performance. RESULTS One month after injury, the mTBI group performed equivalently to controls on all consent standards. In contrast, the cmTBI group was impaired relative to controls on the understanding standard. No differences emerged between the mTBI and cmTBI groups. The msevTBI group was impaired on almost all standards relative to both control and mTBI groups, and on the understanding standard relative to the cmTBI group. Capacity compromise (mild/moderate or severe impairment ratings) on the 3 clinically complex standards (understanding, reasoning, appreciation) occurred in 10%-30% of patients with mTBI, 50% of patients with cmTBI, and 50%-80% of patients with msevTBI. CONCLUSIONS One month following injury, MDC is largely intact in patients with mTBI, but is impaired in patients with cmTBI and msevTBI. Impaired MDC is prevalent in acute TBI and is strongly related to injury severity.
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Affiliation(s)
- K L Triebel
- Department of Neurology, Division of Neuropsychology, University of Alabama at Birmingham, Birmingham, USA
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Roberson ED, Hope OA, Martin RC, Schmidt D. Geriatric epilepsy: research and clinical directions for the future. Epilepsy Behav 2011; 22:103-11. [PMID: 21596624 DOI: 10.1016/j.yebeh.2011.04.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2011] [Accepted: 04/01/2011] [Indexed: 01/01/2023]
Abstract
There is a growing awareness of the need for improved treatment and care of older adults with epilepsy. The present review article highlights key clinical and research issues in the emerging field of geriatric epilepsy. Drs. Martin and Schmidt explore the scope of the problems in the field, outline topic areas including cognitive health/dementia, and diagnostic challenges, and also present important research questions that should be considered for the future. As part of this presentation, we will highlight the work of two promising young investigators whose work holds great promise for the field of geriatric epilepsy. Dr. Roberson will discuss his work focusing on the relationship of epilepsy and cognitive impairment, particularly as it relates to Alzheimer's disease pathology including tau and its role in epileptiform activity. Dr. Hope will outline key issues, as well as her work, relating to defining and measuring quality care in geriatric epilepsy.
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Affiliation(s)
- Erik D Roberson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
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