Use of Actigraphy to Measure Symptoms of Agitation in Dementia.

OBJECTIVE: To evaluate the feasibility and validity of actigraphy as a measurement of agitation in dementia. METHODS: Participants aged 65 and older, diagnosed with dementia, residing in a geriatric psychiatry inpatient unit or long-term care facility were included in a cross-sectional study. Agitation was assessed using the Cohen-Mansfield Agitation Inventory (CMAI) and the Neuropsychiatric Inventory (NPI). Actigraphy was measured over seven days and compared across groups categorized as low or high agitation based on a CMAI cutoff score of 50. RESULTS: Twenty participants were enrolled (mean age = 74.3 years, standard deviation [SD] = 8.69). The 24-hour mean motor activity as measured with actigraphy was significantly different between the low and high agitation groups (180.23, SD = 86.34 versus 81.51, SD = 30.29, Z = 2.29; p = 0.02). Most actigraph variables had significant correlations with CMAI and NPI scores. CONCLUSION: Actigraphy was highly correlated with informant-based methods for measuring agitation in individuals with dementia and actigraphy may be useful tool for measuring agitation.

The effect of aspirin desensitization on novel biomarkers in aspirin-exacerbated respiratory diseases.

BACKGROUND: Patients with aspirin-exacerbated respiratory disease have been shown to benefit clinically from aspirin desensitization followed by chronic high-dose aspirin therapy. However, the mechanism of this phenomenon is still unclear. OBJECTIVE: The aim of this study was to characterize the airway inflammatory response to aspirin desensitization and after treatment with high-dose aspirin for 6 months. METHODS: Twenty-one adult patients with asthma, chronic polypoid sinusitis, and a convincing history of acute respiratory reaction to the ingestion of aspirin or nonsteroidal anti-inflammatory drugs were selected. These patients underwent an oral desensitization to aspirin over a 2-day period, followed by daily ingestion of aspirin 650 mg twice daily. Induced sputum samples and exhaled nitric oxide measurements were taken before the procedure, during the second day of the procedure, and after 6 months of treatment. RESULTS: There was a significant elevation in both the exhaled nitric oxide level (P = .03) and sputum tryptase level (P = .05) during the desensitization process. After 6 months of aspirin treatment, sputum IL-4 (P = .0007) and matrix metalloproteinase 9 (MMP-9; P = .05) decreased significantly compared with baseline. Predesensitization to postdesensitization changes in MMP-9 and tissue inhibitors of metalloproteinases 1 were highly correlated (r = 0.79; P = .0003). Immediately after the desensitization, MMP-9 and tryptase were correlated (r = 0.82; P = .001), whereas IL-4 was inversely related with FMS-like tyrosine kinase 3 ligand (FLT3-L) (r = -0.79; P = .0008). There was a significant decrease in the average symptom score at 6 months. CONCLUSION: Consistent with previous reports, acute aspirin desensitization in patients with aspirin-exacerbated respiratory disease involves mast cell degranulation. In contrast, long-term treatment with aspirin involves suppression of IL-4 as well as downregulation of proinflammatory MMP-9 while T(H)1 marker FLT3-L increases.

Optimizing Prescribing of Antipsychotics in Long-Term Care (OPAL): A Stepped-Wedge Trial.

BACKGROUND: Inappropriate antipsychotic prescribing is a key quality indicator by which clinical outcomes might be monitored and improved in long-term care (LTC), but limited evidence exists on the most effective strategies for reducing inappropriate antipsychotic use. OBJECTIVES: The objective of the study was to evaluate a multicomponent approach to reduce inappropriate prescribing of antipsychotics in LTC. DESIGN: A prospective, stepped-wedge study design was used to evaluate the effect of the intervention. SETTINGS AND PARTICIPANTS: Interdisciplinary staff at 10 Canadian LTC facilities. METHODS: The intervention consisted of an educational in-service, provision of evidence-based tools to assess and monitor neuropsychiatric symptoms (NPS) in dementia, and monthly interprofessional team meetings. The primary outcome was the proportion of residents receiving an antipsychotic without a diagnosis of psychosis using a standardized antipsychotic quality indicator. RESULTS: The weighted mean change in inappropriate antipsychotic prescribing rate from baseline to 12-month follow-up was -4.6% [standard deviation (SD) = 2.8%, P < .0001], representing a 16.1% (SD = 17.0) relative reduction. After adjusting for site, the odds ratio for the inappropriate antipsychotic prescribing quality indicator at 12 months compared to baseline was 0.73 (95% confidence interval = 0.48-0.94; chi-square = 6.59; P = .01). There were no significant changes in related quality indicators, including falls, restraint use, or behavioral symptoms. CONCLUSIONS AND IMPLICATIONS: This multicomponent intervention was effective in reducing inappropriate antipsychotic prescribing in LTC without adversely affecting other domains related to quality of care, and offers a practical means by which to improve the care of older adults with dementia in LTC.

Access to Psychiatrist Services for Older Adults in Long-Term Care: A Population-Based Study.

OBJECTIVES: Although mental health disorders are common among older adults in long-term care (LTC), little is known about access to psychiatric services in LTC. We described the need for psychiatric services in LTC settings and identified variables associated with receipt of psychiatric services. DESIGN: Population-based retrospective cohort study. SETTING AND PARTICIPANTS: All adults aged 66 years and older who resided in LTC homes in Ontario, Canada, between 2015 and 2016. Individuals were included in the study at the time of LTC admission or first annual reassessment. MEASURES: We determined the percentage of LTC residents who received any psychiatric service within 90 days. We then compared the characteristics of individuals who did and did not receive any psychiatric service to determine variables associated with receipt of psychiatric services. Multivariate logistic regression was used to determine independent variables associated with receipt of psychiatric services. RESULTS: A total of 67,165 unique participants were included in the study sample, 27,650 (41.2%) of whom had identified psychiatric need. Overall, 3175 (4.7%) individuals received any psychiatric service within 90 days following cohort entry. After adjustment for potential confounders, receipt of psychiatric services was positively associated with younger age, male gender, history of major mental disorders, previous receipt of psychiatric services, indicators of psychiatric need, residence in larger LTC homes, and health region of residence. CONCLUSIONS/IMPLICATIONS: Receiving psychiatric services in Ontario LTC homes is limited when compared to the high need for services. Several factors other than patient need symptoms are associated with receipt of services, which suggests inequities in access to care. Improving the distribution of psychiatric services may help address these inequities, and additional psychiatric resources are also likely required to meet these needs. Our results directly apply to a Canadian context and have implications for other comparable countries, including the United States.

The diagnosis and management of acute and chronic sinusitis.

Both acute and chronic sinusitis are common diseases associated with significant morbidity and consumption of health care dollars. Acute sinusitis is caused by an infectious process and can often be difficult to distinguish from a viral upper respiratory infection, as signs, symptoms, and even the results of most diagnostic tests overlap. In contrast, chronic sinusitis is an inflammatory disease and, contrary to common practice, long term antibiotics are likely not useful. This article reviews the diagnosis and management of both acute and chronic sinusitis and includes discussion of the prevalence of disease, our current understanding of disease pathogenesis, diagnosis, and contemporary treatment.

Meta-Analysis of the Prevalence of Major Depressive Disorder Among Older Adults With Dementia.

OBJECTIVE: Little is known about the overall prevalence of major depressive disorder (MDD) in persons with dementia (ie, "depression in dementia": DpD). The aim of this systematic review and meta-analysis was to determine the prevalence and factors associated with DpD among older adults (age range 58.7-87.8 years). The protocol was registered in the PROSPERO registry (2015:CRD42015020681). DATA SOURCES: We searched the following electronic databases: MEDLINE (1946-February 2017), Embase (1980-2017 week 5), and PsycINFO (1967-February 2017) using medical subject headings and free-text search terms for studies in the English language. STUDY SELECTION: We screened 9,421 studies, and 55 met the inclusion criteria (ie, used validated criteria for both MDD and dementia). DATA EXTRACTION: Two independent reviewers extracted data from included studies. Meta-analysis was used to determine the pooled estimates and 95% confidence intervals for the prevalence of DpD. Prevalence across dementia subtypes, study setting, diagnostic criteria, and dementia severity was compared in subgroup analyses. RESULTS: The prevalence of MDD in all-cause dementia was 15.9% (95% CI, 12.6%-20.1%). The prevalence of MDD was higher among individuals with vascular dementia (24.7%) compared to Alzheimer's disease (14.8%). Studies using the provisional diagnostic criteria for DpD reported a higher prevalence (35.6%) compared to studies using either the DSM-III-R (13.2%) or DSM-IV (17.3%) criteria. CONCLUSIONS: Depression is common among individuals with dementia, and the type of dementia and diagnostic criteria affect prevalence estimates of DpD. Further studies are required to understand factors that lead to the development of DpD and strategies to prevent and treat DpD.

Functional Magnetic Resonance Imaging of the Human Brainstem and Cervical Spinal Cord during Cognitive Modulation of Pain.

Pain is a complex sensory experience, and cognitive factors such as attention can influence its perception. Modulation of pain involves a network of subcortical structures; however, the role and relationship of these regions in cognitive modulation of pain are not well understood. The aims of this research were to evaluate the behavioral effect of cognitive modulation of pain and investigate the neural correlates of this mechanism in the brainstem and cervical spinal cord (SC), using functional magnetic resonance imaging (fMRI) and structural equation modeling (SEM). We applied noxious thermal stimulation on the C6 dermatome to 12 healthy female participants while they performed the n-Back task. Our findings demonstrate a significant attenuation in pain perception across the group as a result of the task, along with high intersubject variability in the degree of modulation. Using fMRI, our studies characterize neural responses in subcortical regions that are involved in the modulation of pain. SEM analysis reveals connectivity between the brainstem and SC at the group and individual levels, depending on cognitive load and degree of pain modulation, respectively. All together, our research demonstrates the behavioral effect of cognitive modulation on pain and provides insight into the subcortical neural response to the process.

Neural Correlates of Cognitive Modulation of Pain Perception in the Human Brainstem and Cervical Spinal Cord using Functional Magnetic Resonance Imaging: A Review.

Pain is a multifaceted and malleable sensory experience that is processed at all levels of the central nervous system (CNS). The experience of pain can vary widely across a healthy population and even within an individual and can be influenced by cognitive factors such as attention, expectation, suggestion, and attitudes. The neurophysiological role of attention in cognitive modulation of pain is the focus for the work presented in this review. Behavioral studies show that pain perception was reduced under cognitive loads that placed a continuous demand on executive functions such as working memory. Neuroimaging, pharmacological studies, and electrophysiological studies provide evidence that the underpinnings of cognitive modulation of pain involve a network of descending modulation of pain among cortical and brainstem structures. However, the role and relationship of subcortical regions in the brainstem and spinal cord during cognitive modulation of pain are not well understood. This review examines the neurophysiology of pain, processing in the CNS, and how cognitive factors such as attention can modulate nociceptive signaling and alter the perception of pain, especially at the subcortical level.

Changes in Pain Processing in the Spinal Cord and Brainstem after Spinal Cord Injury Characterized by Functional Magnetic Resonance Imaging.

Traumatic spinal cord injury (SCI) has a number of devastating consequences, including high prevalence of chronic pain and altered pain sensitivity. The causes of altered pain states vary depending on the injury and are difficult to diagnose and treat. A better understanding of pain mechanisms after SCI is expected to lead to better diagnostic capabilities and improved treatments. We therefore applied functional magnetic resonance imaging (fMRI) of the brainstem and spinal cord in a group of participants with previous traumatic SCI to characterize changes in pain processing as a result of their injuries. The same thermal stimulus was applied to the medial palm (C8 dermatome) as a series of repeated brief noxious thermal pulses in a group of 16 participants with a cervical (n = 14) and upper thoracic (n = 2) injuries. Functional MRI of the brainstem and spinal cord was used to determine the neuronal activity evoked by the noxious stimulation, and connectivity between regions was characterized with structural equation modeling (SEM). The results show that pain ratings, the location and magnitude of blood oxygenation-level dependent fMRI results, and connectivity assessed with SEM varied widely across participants. However, the results varied in relation to the perceived pain and the level/severity of injuries, particularly in terms of hypothalamus connectivity with other regions, and descending modulation via the periaqueductal gray matter-rostral ventromedial medulla-cord pathway. The results, therefore, appear to provide sensitive indicators of each individual's pain response, and information about the mechanisms of altered pain sensitivity. The ability to characterize changes in pain processing in individuals with SCI represents a significant technological advance.

Continuous Descending Modulation of the Spinal Cord Revealed by Functional MRI.

Spontaneous variations in spinal cord activity may arise from regulation of any of a number of functions including sensory, motor, and autonomic control. Here, we use functional MRI (fMRI) of healthy participants to identify properties of blood oxygenation-level dependent (BOLD) variations in the spinal cord in response to knowledge that either a noxious stimulus is impending, or that no stimulus is to be expected. Expectation of a noxious stimulus, or no stimulus, is shown to have a significant effect on wide-spread BOLD signal variations in the spinal cord over the entire time period of the fMRI acquisition. Coordination of BOLD responses between/within spinal cord and brainstem regions are also influenced by this knowledge. We provide evidence that such signal variations are the result of continuous descending modulation of spinal cord function. BOLD signal variations in response to noxious stimulation of the hand are also shown, as in previous studies. The observation of both continuous and reactive BOLD responses to emotional/cognitive factors and noxious peripheral stimulation may have important implications, not only for our understanding of endogenous pain modulation, but also in showing that spinal cord activity is under continuous regulatory control.