Polypharmacy and the use of medications in inpatients with acquired brain injury during post-acute rehabilitation: A cross-sectional study.

BACKGROUND: This study assessed the use of medications during inpatient post-acute rehabilitation for acquired brain injury (ABI). MATERIALS AND METHODS: All inpatients with ABI undergoing post-acute rehabilitation in centres identified through the roster of the Italian Society for Rehabilitation Medicine were included. A designated physician in each centre collected information through a structured questionnaire. This study calculated (a) prevalence of medication use, (b) logistic regression Odds Ratio (OR), with 95% confidence interval (95% CI), of polypharmacy (≥ 6 medications). RESULTS: A total of 484 patients (median age = 52 years, 63.4% men, median time from acute event = 18.5 weeks) were included; 33.8% had Rancho Los Amigos Levels of Cognitive Functioning Scale (RLAS) score 1-2, 8.1% had a score of 7-8, of whom 92.0% received medications, 51.8% had a score of 6-10, of whom 83.9% had at least one psychotropic medication and 66.9% had two or more; 51.8% received anti-epileptics, 32.1% anti-depressants, 14.5% anti-psychotics, peaking in RLAS 4 (37.3%) and decreasing in RLAS 7-8. Polypharmacy was directly associated with age (55-64 years, OR = 2.1; 95% CI = 1.1-4.1; ≥ 65 years, OR = 1.7; 95% CI = 0.9-3.3), inversely with RLAS score (1-2 vs 7-8, OR = 4.3; 95% CI = 1.9-9.8). CONCLUSION: Polypharmacy and concurrent use of psychotropic medications was common, raising concern about drug-drug interactions. Safety and effectiveness of medications should be monitored, particularly when used concurrently.

Prescribing practice and off-label use of psychotropic medications in post-acute brain injury rehabilitation centres: a cross-sectional survey.

OBJECTIVE: Guidance on pharmacotherapy of neurobehavioural sequelae post-acquired brain injury (ABI) is limited. Clinicians face the choice of prescribing off-label. This survey assesses prescribing practice and off-label use of psychotropic medications in Italian brain injury rehabilitation centres and factors associated with atypical antipsychotics use. MATERIALS AND METHODS: Centres were identified through the roster of the Italian Society for Rehabilitation Medicine. Information was collected through a structured questionnaire. This study calculated the prevalence of centres reporting to use off-label individual medications and unconditional logistic regression Odds Ratio (OR), with 95% confidence interval (95% CI) of atypical antipsychotics use. RESULTS: Psychotropic medications were commonly used. More than 50% of the 35 centres (participation ratio 87.5%) reported to use off-label selected antipsychotics, mostly for agitation (90.5%) and behavioural disturbances (19.0%), and antidepressants, mostly for insomnia (37.5%) and pain (25.0%). Atypical antipsychotic use was directly associated with age <40 years (OR = 2.68; 95% CI = 1.25-5.76), recent ABI (1.74; 0.74-4.09), not with reported off-label use (0.98; 0.44-2.18). CONCLUSION: In clinical practice, the effectiveness and safety of medications, in particular off-label, should be systematically monitored. Studies are needed to improve the quality of evidence guiding pharmacotherapy and to evaluate effectiveness and safety of off-label prescribing.

The prevalence of vegetative and minimally conscious states: a systematic review and methodological appraisal.

OBJECTIVES: To systematically review prevalence studies of vegetative state (VS) and minimally conscious state (MCS) in geographically defined populations, to appraise study methods and assess sources of heterogeneity. METHODS: MEDLINE, EBM Reviews, and EMBASE databases were searched using key terms. Two reviewers independently identified pertinent articles and screened the references for additional studies. Studies measuring the prevalence of VS and/or MCS in a defined population were included, and information on characteristics, methods, and results was extracted. Heterogeneity was quantified through the statistic I. RESULTS: We identified 5 cross-sectional prevalence surveys of VS and 1 of MCS. Prevalence ranged from 0.2 cases per 100,000 inhabitants to 3.4 for VS and was 1.5 per 100,000 for MCS. Relevant heterogeneity (I = 99.0%) prevented us from calculating a summary estimate. The prevalence of trauma cases varied from 21.9% to 53.8%. Variability pertaining to diagnostic criteria, definition of case, and methods of ascertainment was found. CONCLUSION: In the few prevalence studies of VS and MCS that were identified, the estimates showed high variability and could not be pooled. Future studies should consider using comparable methods for the definition, ascertainment, and confirmation of cases.

The role of the basal ganglia in action imitation: neuropsychological evidence from Parkinson's disease patients.

Though previous studies have suggested that the basal ganglia are necessarily involved in action imitation, their precise role is unclear. An important source of evidence concerns patients with Parkinson's disease (PD) who suffer basal ganglia impairments. Some studies report poor execution of observed meaningful (MF) transitive (tool-related) actions but normal performance with intransitive (non-tool-related) MF and meaningless (ML) actions (Leiguarda et al. in Brain 120:75-90, 1997; Leiguarda 2001 in Neuroimage 14:137-141). In other cases, though, patients with lesions involving the basal ganglia appear impaired in imitating ML as compared to meaningful MF transitive pantomimes. Here, we tested a group of PD patients in a full 2 × 2 design with MF transitive and intransitive pantomimes and matched ML movements. PD patients generated higher scores when imitating MF transitive actions than ML-matched actions. On the other hand, ML than MF intransitive actions did not differ significantly. The performance of the patients on imitating ML transitive actions also correlated with their performance on the Corsi block test of visuospatial memory and their scores at the test of verbal fluency for phonemic categories (FAS) while MF intransitive actions correlated with FAS and the neurological evaluation (UPDRS) The results are discussed in terms of the factors that load on visual memory for action reproduction, as well as the possible role of the basal ganglia in communicative actions (for MF intransitive actions).

The tracheotomy tube weaning in patients with severe acquired brain injury: comparison of two operative procedures in a postacute rehabilitation hospital.

BACKGROUND: Despite the high frequency of tracheotomy in severe acquired brain injury (sABI) patients, available literature about the weaning procedure is mainly represented by expert opinions with no standardized and evidence-based criteria. AIM: The Institute of Physical and Rehabilitation Medicine "Gervasutta" adopted a new decannulation procedure, recommended by the Italian Society of Physical Medicine and Rehabilitation (SIMFER). This study evaluates whether the new procedure helps to improve the decannulation process of sABI patients. DESIGN: A prospective observational with historical control was performed by dividing sABI patients into two groups depending on whether they were treated with or without the new procedure. SETTING: The Department of Neurorehabilitation of the Institute of Physical and Rehabilitation Medicine "Gervasutta" in Udine, Italy. POPULATION: sABI patients with tracheal cannula admitted to the Institute of Physical and Rehabilitation Medicine "Gervasutta" from January 2015 to March 2019. METHODS: Clinical data were collected as both process and outcome indicators before and after the adoption of the new procedure. Data have been processed with Simple Interactive Statistical Analysis (SISA; Irving, TX, USA) software. RESULTS: A sample of 141 patients was analysed. Among the 141 patients, 57 (40.4%) were treated with the new procedure. No differences were found between the two groups in terms of complications, functional independence measure (FIM), or level of cognitive functioning (LCF) at the admission. When the new procedure was applied, the decannulation rate was significantly higher (OR=1.8; 95% CI=1.2-9.8; P=0.01) and the time (days) between admission and oral feeding resumption was significantly lower (P<0.001; 95% CI=-10, -34 days). CONCLUSIONS: The introduction of the new protocol allowed the safe achievement of both oral feeding resumption and decannulation, which are two of the main early rehabilitation goals. CLINICAL REHABILITATION IMPACT: The standardization of the decannulation process has determined the achievement of a significantly faster oral feeding resumption and an increase in the decannulation rate during the rehabilitation of sABI patients.

Supervisory and routine processes in noun and verb generation in nondemented patients with Parkinson's disease.

Despite the increased comprehension of the role of the basal ganglia in cognitive functions such as learning, attention, and executive functions, the exact implication of these structures in language remains unclear. A specific role of basal ganglia in language has been proposed. Nonetheless, a recent hypothesis gives the basal ganglia a non-language specific role in the inhibition of competing alternatives during later controlled processes of language production. In this study we assessed the production of both nouns and verbs in a population of 20 nondemented patients with Parkinson's disease (NDPD). Aspects of selection demands and stimulus-response association strength were investigated in both tasks. Performance of NDPD patients was compared with that of 20 matched elderly subjects. An impairment in verb production was found in PD patients. A selection effect on verb production was found in PD patients along with a greater effect of stimulus-response association strength. PD patients had the greatest difficulty in situations of weak stimulus-response association strength. A "Task-Relevant-Response" analysis carried out on stimuli (nouns) in condition of free association suggested that verb production happens in the context of strongly activated nouns. This means that, in order to produce a verb a switch has to be done from a task irrelevant to a task relevant response. Our results are in line with the proposed non-language specific involvement of the basal ganglia in the supervisory rather than the routine semantic processes required during lexical retrieval.

The validity of the hospital anxiety and depression scale and the geriatric depression scale in Parkinson's disease.

We assessed the concurrent validity of the Hospital Anxiety and Depression Scale (HADS) and the Geriatric Depression Scale (GDS) against the Hamilton Rating Scale for Depression (Ham-D) in patients with Parkinson's disease (PD). Forty-six non-demented PD patients were assessed by a neurologist on the Ham-D. Patients also completed four mood rating scales: the HADS, the GDS, the VAS and the Face Scale. For the HADS and the GDS, Receiver Operating Characteristics (ROC) curves were obtained and the positive and negative predictive values (PPV, NPV) were calculated for different cut-off scores. Maximum discrimination between depressed and non-depressed PD patients was reached at a cut-off score of 10/11 for both the HADS and the GDS. At the same cut-off score of 10/11 for both the HADS and the GDS, the high sensitivity and NPV make these scales appropriate screening instruments for depression in PD. A high specificity and PPV, which is necessary for a diagnostic test, was reached at a cut-off score of 12/13 for the GDS and at a cut-off score of 11/12 for the HADS. The results indicate the validity of using the HADS and the GDS to screen for depressive symptoms and to diagnose depressive illness in PD.

Mental time line distortion in right-brain-damaged patients: Evidence from a dynamic spatiotemporal task.

OBJECTIVE: Time is an elusive phenomenon that is difficult to grasp with our senses. Recent work has shown how spatial representations often lie beneath temporal ones, as shown by a family of spatiotemporal congruency effects. For instance, individuals who have been exposed to left-to-right orthographic systems are better at judging short durations with their left effector and long durations with their right effector than vice versa, a phenomenon known as the spatial-temporal association of response codes (STEARC) effect. In the present neuropsychological study, we aimed to provide evidence that spatial attention mechanisms play a crucial role in generating this spatially organized mental time line. METHOD: A group of 13 patients suffering from right hemisphere lesions with different degrees of spatial neglect signs and a control group of 15 age- and education-matched neurologically healthy participants were administered a unimanual version of a spatiotemporal compatibility task (STEARC task). RESULTS: The main results showed that the more a patient suffered from spatial neglect signs, the smaller the accuracy difference was between the left and right side responses for short durations. CONCLUSIONS: These findings corroborate the hypothesis that the presence of disorders in spatial attention affects the left-to-right mental time line representation, especially in its leftward segment, proportionally with the amount of deficit. This study therefore suggests the critical role of spatial attention for the emergence of a spatial representation of time durations.

Preserved and impaired task-switching abilities in non-demented patients with Parkinson's disease.

Existing studies on task switching in Parkinson's disease (PD) patients have led to somewhat different results. In particular, it is unclear whether PD patients have a deficit in attentional control. In this study, we assessed task-switching abilities in samples of non-demented PD patients and elderly controls. We used a paradigm in which there was a random task sequence and the task was cued in every trial. This allowed the investigation of both task-set reconfiguration and task-set dissipation. In terms of the proportion of errors made, the patients showed increased switch cost and congruency effects. For reaction times, PD patients showed enlarged congruency effects on switch trials, specifically in the condition in which we used a short constant response-cue interval (RCI). Nevertheless, in a similar fashion to older controls, the patients showed reductions in reaction time switch cost from a short to a long cue-target interval (CTI) and from a short to a long RCI. While these latter findings, respectively, suggest unimpaired task preparation and task dissipation on correct trials in the PD patients, the overall results show that they have a deficit in biasing and selecting currently relevant task sets and more generally argue in favour of a failure of attentional control in PD.

Interference from retrieval cues in Parkinson's disease.

OBJECTIVE: Existing studies on memory interference in Parkinson's disease (PD) patients have provided mixed results and it is unknown whether PD patients have problems in overcoming interference from retrieval cues. We investigated this issue by using a part-list cuing paradigm. In this paradigm, after the study of a list of items, the presentation of some of these items as retrieval cues hinders the recall of the remaining ones. METHOD: We tested PD patients' (n = 19) and control participants' (n = 16) episodic memory in the presence and absence of part-list cues, using initial-letter probes, and following either weak or strong serial associative encoding of list items. RESULTS: Both PD patients and control participants showed a comparable and significant part-list cuing effect after weak associative encoding (13% vs. 12% decrease in retrieval in part-list cuing vs. no part-list cuing -control- conditions in PD patients and control participants, respectively), denoting a similar effect of cue-driven interference in the two populations when a serial retrieval strategy is hard to develop. However, only PD patients showed a significant part-list cuing effect after strong associative encoding (20% vs. 5% decrease in retrieval in patients and controls, respectively). CONCLUSIONS: When encoding promotes the development of an effective serial retrieval strategy, the presentation of part-list cues has a specifically disruptive effect in PD patients. This indicates problems in strategic retrieval, probably related to PD patients' increased tendency to rely on external cues. Findings in control conditions suggest that less effective encoding may have contributed to PD patients' memory performance.

Vesicourethral dysfunction in multiple sclerosis. Initial assessment based on lower urinary tract symptoms and their pathophysiology.

The most common lower urinary tract symptoms (LUTS) in multiple sclerosis (MS) are irritative, obstructive or mixed (association of irritative and obstructive LUTS). Generally irritative LUTS are typical in patients with cortical, brainstem or mild spinal cord lesions; obstructive symptoms are frequent in patients with spinal cord lesions (below the pontine micturition centre) or at the level of the sacral micturition centre. Irritative LUTS are often associated with detrusor overactivity, whereas obstructive LUTS are associated with detrusor sphincter dyssynergia or detrusor areflexia/hypocontractility. Proper management of these LUTS often could be planned without specialised assessment, in accordance with the algorithms proposed by International Consultation on Incontinence.