Curriculum Research: Disseminating Neuropalliative Care Education Through an Adaptable Curriculum: A Multisite Feasibility Trial.

Introduction and Problem Statement: Neurologic disease is a leading cause of disability and death worldwide. As the global population ages, the burden of these diseases is expected to increase. Despite this increased clinical need, neurology trainees are seldom taught skills and concepts in palliative care. Education in Palliative and End-of-Life Care for Neurology (EPEC-N) is a publicly available neuropalliative care curriculum designed to be taught by both palliative care specialists and nonspecialists alike. Objectives: (1) To create a feasible curriculum in neuropalliative care using EPEC-N, (2) to improve learners' satisfaction with neuropalliative care training, and (3) to improve learners' confidence with neuropalliative care topics. Methods and Curriculum Description: Three academic centers implemented a neuropalliative care curriculum for neurology residents using EPEC-N modules. Each site selected 4 of the 26 topics. Instructor backgrounds varied by site and included neurology senior residents, fellows, and faculty; none had completed palliative care fellowship at the time of teaching. Teaching methods included lecture, case discussion, and role-play. To assess feasibility and acceptability of this curriculum, learners, instructors, and site leads completed postsession surveys. Results and Assessment Data: A total of 87 residents attended at least 1 didactic session, and 23 residents completed the evaluation survey. All 3 sites were able to successfully implement an evidence-based and subspecialist-approved neuropalliative care curriculum without relying on subspecialty instruction, despite variations in instructor background, curriculum format, and module selection. Learners overall expressed a positive experience with this curriculum, with most of the respondents indicating that each session was effective in improving their knowledge base, relevant to current practice, and provided in an effective teaching format. Site leads and instructors found the curriculum easy to use, in minimal need of modification, and helpful for delivering neuropalliative care education. Discussion and Lessons Learned: The EPEC-N curriculum was successfully implemented at 3 US sites, demonstrating feasibility, acceptability, and adaptability across institutions. Further research is needed to evaluate the effectiveness of this curriculum in improving neuropalliative care skills for neurologists and raising the standard of primary neuropalliative care.

Oral Health and Brain Health: Cause, Consequence, or Confounding?

Epidemiologic studies of the association between periodontal disease and cardiovascular disease, including stroke, had mixed findings.1 Some studies have found that serum antibodies to major periodontal pathogens are associated with coronary heart disease (CHD), suggesting that periodontal infection or the host response to periodontal infection may play a causal role in CHD.1 More recently, longitudinal studies have supported an association of periodontal disease between cognitive decline and dementia.2 The motivation for these studies has been two-fold. First, periodontal disease is known to be associated with systemic inflammation,3 which, in turn, is known to be causally associated with atherosclerotic disease.4 Second, periodontal disease is potentially modifiable in the population. The limitation of all observational epidemiologic studies is the problem of confounding by incompletely measured or unmeasured variables, such as diet, health behaviors including oral hygiene, and the host response to infection. In addition, studies oral health and either cognitive decline or dementia may suffer from reverse causality; cognitive changes may lead to lessened oral hygiene and periodontal disease.

Sleep Health as a Determinant of Disparities in Stroke Risk and Health Outcome.

Sleep is essential to human survival and overall vascular health. Sleep health encompasses the objective and subjective qualities associated with one's daily pattern of sleep and wakefulness and has become a growing clinical and public health concern. Impaired sleep duration and quality can increase stroke risk and mediate the relationship between the physical aspects of an individual's environment and disparities in stroke incidence. Here, we review observational studies evaluating the association between sleep health and cerebrovascular disease. We assess the influence on sleep of the physical environment, including the ambient environment with noise levels and the built environment. We also describe the influences on sleep health and stroke risk of social determinants of health, including the chronic stressor of racial discrimination. Finally, we discuss how changes in historical neighborhood characteristics or societal policies can influence the social factors affecting sleep health and stroke risk among socioeconomically disadvantaged groups or ethnic and racial minorities. Given the regional and racial or ethnic differences in stroke risk across the United States, an understanding of novel vascular risk factors, such as the multifaceted role of sleep health, will be critical to develop effective public policies to improve population health.

An Update on Palliative Care in Neurocritical Care: Providing Goal­Concordant Care in the Face of Prognostic Uncertainty.

Purpose of review: We investigate the complexities and interplay between the concepts of prognostic uncertainty and patient preferences as they relate to the delivery of goal-concordant care to patients with severe acute brain injuries (SABI) in the Neurological Intensive Care Unit (Neuro-ICU). Recent findings: Patients with SABI in the Neuro-ICU have unique palliative care needs due to sudden, often unexpected changes in personhood and quality of life. A substantial amount of uncertainty is inherent and poses a challenge to both the patient's prognosis and treatment preferences. The delivery of goal-concordant care can be difficult to achieve.

Inpatients with neurologic disease referred for palliative care consultation.

OBJECTIVES: To compare characteristics and needs of inpatients with neurologic disease to those with cancer referred for palliative care (PC) consultation. METHODS: This prospective cohort study used data collected by the Palliative Care Quality Network from January 2013 until December 2016. We compared demographics, reasons for consultation, discharge disposition, Palliative Performance Scale (PPS) score, and outcomes of care among patients with a primary diagnosis of neurologic disease vs cancer. RESULTS: The most common reason for PC consultation in all patients was assistance with goals of care and advanced care planning. PC consultation was less often requested for pain and symptom management in patients with neurologic disease compared to patients with cancer (13.7% vs 43%, odds ratio 0.3) and more often for assistance with transition to comfort measures only and withdrawal of life-sustaining treatment (19.1% vs 7.1%, odds ratio 1.3). Patients with cancer had higher PPS scores (42.1% vs 23.4%) and were more likely to be discharged home from the hospital, while patients with neurologic disease were more likely to die in hospital. CONCLUSIONS: Patients with neurologic disease as a reason for PC consultation are more in need of end-of-life care planning and more likely to die in the hospital than those with cancer, suggesting that targeted approaches may best address the needs of each patient population. Our results can direct further research and education in neuropalliative care.