Cognition, emotional state, and quality of life of survivors after cardiac arrest with rhythmic and periodic EEG patterns.

AIM: Rhythmic and periodic patterns (RPPs) on the electroencephalogram (EEG) in comatose patients after cardiac arrest have been associated with high case fatality rates. A good neurological outcome according to the Cerebral Performance Categories (CPC) has been reported in up to 10% of cases. Data on cognitive, emotional, and quality of life outcomes are lacking. We aimed to provide insight into these outcomes at one-year follow-up. METHODS: We assessed outcome of surviving comatose patients after cardiac arrest with RPPs included in the 'treatment of electroencephalographic status epilepticus after cardiopulmonary resuscitation' (TELSTAR) trial at one-year follow-up, including the CPC for functional neurological outcome, a cognitive assessment, the hospital anxiety and depression scale (HADS) for emotional outcomes, and the 36-item short-form health survey (SF-36) for quality of life. Cognitive impairment was defined as a score of more than 1.5 SD below the mean on ≥ 2 (sub)tests within a cognitive domain. RESULTS: Fourteen patients were included (median age 58 years, 21% female), of whom 13 had a cognitive impairment. Eleven of 14 were impaired in memory, 9/14 in executive functioning, and 7/14 in attention. The median scores on the HADS and SF-36 were all worse than expected. Based on the CPC alone, 8/14 had a good outcome (CPC 1-2). CONCLUSION: Nearly all cardiac arrest survivors with RPPs during the comatose state have cognitive impairments at one-year follow-up. The incidence of anxiety and depression symptoms seem relatively high and quality of life relatively poor, despite 'good' outcomes according to the CPC.

The Coping with Attention and Memory Complaints Questionnaire (CAMQ): psychometric evaluation of an instrument in suspected chronic solvent-induced encephalopathy (CSE).

Long-term occupational exposure to organic solvents may induce chronic solvent-induced encephalopathy (CSE), leading to neuropsychological impairments. We developed the Coping with Attention and Memory Complaints Questionnaire (CAMQ), an instrument for the assessment of coping strategies in patients suspected of CSE with neuropsychological complaints. Items for the CAMQ were based on existing coping dimensions and constructed by experts. The psychometric properties of the CAMQ were evaluated in a sample of 307 workers suspected of CSE. Factor analysis revealed four coping subscales: active coping, avoidance, acceptance, and seeking social support, all with good internal consistency (alphas .71-.78) and good test-retest reliability (ICCs .67-.82). The subscales demonstrated moderate correlations with related external constructs such as anxiety and depression, locus of control, meta-memory, mastery and generic coping styles. In conclusion, this study: (1) shows that the newly developed CAMQ is a reliable instrument, and (2) provides evidence for its validity in assessing coping with complaints of memory and attention in CSE-suspected patients. These results may serve for further study on coping with complaints of memory and attention, psychological adjustment and well-being in CSE patients.

Psychosocial and cognitive rehabilitation of patients with solvent-induced chronic toxic encephalopathy: a randomised controlled study.

BACKGROUND: There is little experience with the (neuro) psychological treatment of patients with solvent-induced chronic toxic encephalopathy (CSE). In this randomised controlled trial (RCT), a treatment programme was evaluated based on previous outcome studies of patients with chronic fatigue, whiplash and traumatic brain damage. METHODS: The treatment consisted of 8 group sessions based on cognitive behavioural principles focusing on inadequate illness behaviours, and 8 sessions of cognitive strategy training to compensate memory problems. The research design was an RCT with follow-up, comparing the cumulative effect of the 2 interventions allocated in random order with a waiting-list control group. Outcome measures were treatment satisfaction, self-ratings of psychosocial and cognitive changes, psychosocial and memory questionnaires and neuropsychological tests. Multiple linear regression analyses were performed with baseline scores, treatment versus control condition, effort status, and litigation or financial compensation status as predictors. RESULTS: Ninety-five patients started treatment, 84 patients had complete data. Treatment satisfaction was high. After the treatment, only the treatment group had improved on objective memory tests and on complaints related to CSE, but not on other questionnaires. Treatment effects diminished at follow-up. Insufficient effort and litigation were negatively associated with treatment outcome. CONCLUSIONS: The positive treatment effects on the cognitive tests were only temporary. It might be important to study the effect of booster sessions to update practiced cognitive strategies. Effort was an important predictor of success, more important than involvement in a litigation procedure. This finding should have implications for the selection of patients.

Suboptimal performance on neuropsychological tests in patients with suspected chronic toxic encephalopathy.

Suboptimal performance during neuropsychological testing can seriously complicate assessment in behavioral neurotoxicology. We present data on the prevalence of suboptimal performance in a group of Dutch patients with suspected chronic toxic encephalopathy (CTE) after long-term occupational exposure to solvents. One hundred and forty-five subjects referred to one of two Dutch national assessment centers for CTE were administered the Amsterdam Short-Term Memory Test (ASTM) and the Test of Memory Malingering (TOMM), two tests specifically developed for the detection of suboptimal performance. For both tests, very cautious cut-off scores were chosen with a specificity of 99%. Results indicated that suboptimal performance appears to be a substantial problem in this group of patients with suspected CTE after long-term exposure to organic solvents. Only 54% of our subjects obtained normal scores on both tests of malingering, i.e. at or above cut-off score. The two tests seemed to measure the same concept in that nearly all the subjects with low TOMM scores also had low ASTM scores. However, a higher proportion of subjects scored below the cut-off on the ASTM than on the TOMM.

Decision rules for assessment of chronic solvent-induced encephalopathy: Results in 2370 patients.

For the diagnosis of patients suspected of chronic solvent-induced encephalopathy (CSE), it would be helpful if the applied cognitive tests show a characteristic profile of impairment in this disease. We investigated the existence of such a profile. In 1997-2006 two expert teams in The Netherlands systematically examined 2370 patients referred for evaluation of suspected CSE. The procedure included two selection steps: (1) intake interview, using criteria of exposure, development of symptoms and absence of non-solvent causes, and (2) seven tests of the computerized Neurobehavioural Evaluation System (NES). Patients showing negligible impairments were considered free from CSE and were not further examined. The third step comprised a neuropsychological, neurological and exposure evaluation. Explicit decision rules for the diagnosis of CSE were developed, including a minimum score for cognitive impairment summarizing 25 cognitive tests. These rules were retroactively applied to 563 patients, comprising 513 patients who had regularly completed all diagnostic steps and a sample of 50 out of the approximately 450 patients with negligible impairments on the NES, who were fully examined. The data from this sample were extrapolated to the original number of 450. In the combined population of 963 patients, a calculated 301 patients were given the diagnosis 'Solely CSE', 242 'CSE and other disease', 158 'Other Disease' and 262 'No (known) disease'. In the Solely CSE patients, the most impaired tests regarded Verbal Fluency & -Similarities, Motor Speed and Simple Attention. A profile of test results that might support the identification of patients with CSE amongst the other referred patients, was not found. The diverging results of related cognitive tests indicate that the use of a core test battery is needed to improve comparability. We consider the decision rules as a step towards a more objective assessment of CSE.

Prevalence of psychiatric disorders in patients with chronic solvent induced encephalopathy (CSE).

INTRODUCTION: Long term occupational exposure to organic solvents may induce chronic solvent-induced encephalopathy (CSE), characterized by mild to severe cognitive impairment, generally seen as the key diagnostic feature. Psychiatric disorders are often diagnosed in subjects with CSE, but were never studied in more detail. This study was designed to establish the prevalence rates of DSM IV mood, anxiety, and alcohol and substance related disorders in patients with CSE. MATERIALS AND METHODS: In CSE, n=203 (consecutively recruited between 2002 and 2005), defined according to the criteria of the World Health Organisation (WHO), one month prevalence rates of DSM IV mood, anxiety, and life time alcohol/substance related disorders were assessed using the Structured Clinical Interview for DSM IV disorders (SCID). These prevalences were compared with those from an age and gender matched community sample (n=3212) while controlling for insufficient neuropsychological test effort. RESULTS: In CSE, prevalence rates for major depressive disorder (n=36, relative risk (RR)=7.4), dysthymia (n=15, RR=6.0), panic disorders (n=18, RR=7.1), agoraphobia (n=7, RR=5.5) and generalized anxiety disorder (n=19, RR=15.8) were increased. Reduced prevalence rates were found for alcohol related disorders (n=21, RR=0.3). Insufficient neuropsychological test effort was not associated with increased prevalence rates of DSM IV disorders in subjects suspected of CSE. DISCUSSION AND CONCLUSIONS: In conclusion, in this first large scale study in patients with CSE, prevalence rates of DSM IV mood and anxiety disorders were elevated as compared with those in the general community, while the prevalence rates of alcohol related disorders were reduced. Further study must determine whether CSE, and mood and anxiety disorders, share a same, solvent induced, neurobiological pathway, supporting the use of a more inclusive diagnostic approach. Additionally, randomised controlled trials are needed for the urgent issue of how to treat mood and anxiety disorders in CSE patients effectively.

Psychological treatment of patients with chronic toxic encephalopathy: lessons from studies of chronic fatigue and whiplash.

BACKGROUND: Chronic toxic encephalopathy (CTE), which can result from long-term exposure to organic solvents, is characterized by problems of attention and memory, fatigue and affective symptoms. There is little experience with (neuro)psychological treatment in this patient group. We reviewed treatment outcome studies of CTE and comparable syndromes, namely, chronic whiplash-associated disorder (WAD) and chronic fatigue syndrome (CFS), with a view to providing recommendations for the psychological treatment of patients with CTE. METHODS: PubMed and PsychLIT were systematically searched and reference lists of retrieved articles were studied. The articles were classified according to study design and level of evidence. RESULTS: The studies of CFS provided high-level evidence for the effectiveness of cognitive-behavior therapy (CBT) in challenging dysfunctional cognitions regarding the effectiveness of rest and in stimulating graded activity. The studies of WAD were methodologically weaker, and most evaluated a combination of CBT and graded activity training. There was some evidence that changing fatigue- or pain-related behaviors may result in cognitive improvement. Two uncontrolled studies of CTE evaluated cognitive rehabilitation techniques but yielded inconsistent findings. CONCLUSIONS: CBT techniques focusing on changing illness attributions and on stimulating graded activity might be useful for patients with CTE, diminishing fatigue-related problems of concentration and memory. Future studies should evaluate whether cognitive deficits of CTE patients as a result of neurotoxic effects of exposure should be treated by cognitive rehabilitation.