Diagnostic Utility of Hippocampal Volumetric Data in a Memory Disorder Clinic Setting.

BACKGROUND: Hippocampal volumetric data are widely used in research but are rarely examined in clinical populations in regard to aiding diagnosis or correlating with objective memory test scores. OBJECTIVE: To replicate and expand on the few prior clinical examinations of the utility of hippocampal volumetric data. We evaluated MRI volumetric data to determine (a) the degree of hippocampal loss across diagnostic groups compared with a cognitively intact group, (b) if total or lateralized hippocampal volumes predict diagnostic group membership, and (c) how total and lateralized volumes correlate with memory tests. METHOD: We retrospectively examined hippocampal volumetric data and memory test scores for 294 individuals referred to a memory clinic. RESULTS: Individuals with mild cognitive impairment or Alzheimer disease had smaller hippocampal volumes compared with cognitively intact individuals. The raw and normalized total and lateralized hippocampal volumes were essentially equal for predicting diagnostic group membership, and notably low hippocampal volumes evidenced greater specificity than sensitivity. All of the volumetric data correlated with the memory test scores, with the total and left hippocampal volumes accounting for the slightly more variance in the diagnostic groups. CONCLUSION: The diagnostic groups exhibited hippocampal volume loss, which can be a potential biomarker for neurodegenerative disease in clinical practice. However, solely using hippocampal volumetric data to predict diagnostic group membership or memory test failure was not supported. While extreme hippocampal volume loss was rare in the cognitively intact group, the sensitivity of these volumetric data suggests a need for supplementation by other tools when making a diagnosis.

Burnout During the COVID-19 Pandemic: Descriptive and Predictive Data from a Survey of Psychologists at a Single Academic Medical Center.

OBJECTIVE: Burnout in academic medicine has been widely studied, but most work has been conducted among physicians. Psychologists in academic medicine have unique burnout factors. Therefore, investigating the prevalence and predictors of burnout among psychologists in academic medicine during the COVID-19 pandemic represents an important addition to the literature. METHODS: Sixty-two psychologists responded to burnout-related items in a larger, 40-item Psychiatry Department climate survey conducted from October to November 2020. Five items from the MINI-Z survey were administered to examine control over workload and sufficiency of documentation time as predictors of both continuous and dichotomously defined burnout. Linear and logistic regression was employed with years as a faculty member entered as a covariate. RESULTS: Slightly less than half (48.4%) of respondents met dichotomous criteria for burnout. Faculty with fewer years of experience scored higher on their level of continuous burnout. Both control over workload and sufficiency of time for documentation were independent predictors of continuous burnout, but only control over workload remained a statistically significant predictor in a simultaneous model. Control over workload was a significant predictor in dichotomous models but did not remain so once sufficiency of documentation time was also added. CONCLUSION: Burnout prevalence among psychologists was comparable to rates among physicians at other institutions, even when examined during the COVID-19 pandemic. Academic medicine administrators and organizational leaders should consider policies and programming to increase control over workload, especially among junior psychologist faculty.

Change in Balance and Neuropsychological Measures Post-Lumbar Drain Trial in Patients with Suspected Normal Pressure Hydrocephalus.

OBJECTIVE: Ventriculoperitoneal (VP) shunting is commonly used to treat normal pressure hydrocephalus (NPH). Assessment of cognition and balance pre- and post-lumbar drain (LD) can be used to provide objective metrics which may help determine the potential benefit of VP shunting. The aim of this investigation was to determine which measures identify clinical change as a result of a LD trial and to develop recommendations for standard NPH clinical assessment procedures. METHODS: The Berg Balance Scale (BBS) and a brief battery of commonly used neuropsychological tests pre- and post-LD (MMSE, trail making test, animal fluency, Hopkins Verbal Learning Test - Revised, and digit span) were administered to 86 patients with a diagnosis of NPH. Subjects were divided into groups based on whether or not clinical change was present, and thus, VP shunting was recommended post-LD, and predictors of group membership were examined. RESULTS: Significant improvements (p < 0.05) were seen on the BBS and Trail Making Part B in the VP shunt-recommended group, with no other significant changes over time in either group. Regression analyses found that VP shunt recommendation was accurately predicted for 80% of the sample using the BBS score alone, with accuracy increasing to 85% when Trails B was added. CONCLUSIONS: Scores from the BBS and Trails B were most likely to change in those chosen to undergo VP shunting post-LD. Given that the typical clinical presentation of NPH includes gait disturbance and cognitive impairment, it is recommended that a standard pre-/post-LD evaluation include the BBS and trail making test.

Reynolds Intellectual Screening Instrument 1st versus 2nd Edition in a Memory Disorder Sample.

OBJECTIVE: The Reynolds Intellectual Screening Instrument (RIST) and its second edition (RIST-2) are brief intelligence screening instruments that potentially have value in older populations as their norms extend over age 90. This study examined performance on these two instruments in a sample of individuals presenting for evaluation in a memory disorder clinic. METHOD: A sample of 1,145 subjects over the age of 50 was chosen from 1,761 consecutive referrals. Individuals who obtained a consensus diagnosis of Mild Cognitive Impairment (MCI; n = 536), possible dementia of the Alzheimer Type (DAT; n = 400), or those with subjective cognitive complaints (SCC; n = 209) and who completed a neuropsychological battery that included either the RIST (n = 747) or the RIST-2 (n = 398) were included in the sample. No clinically significant demographic or neuropsychological performance differences were found for those taking either version of the RIST. RESULTS: Unlike the original version, RIST-2 Total and subtest scores were well below the mean for the DAT group and over 1 SD mean difference was seen for the DAT group when comparing the RIST and RIST-2 Totals. Diagnostic accuracy calculations suggested that the RIST-2 showed greater discrimination between the three groups although both versions achieved greater sensitivity than specificity. CONCLUSIONS: Performance differences were evident when comparing the RIST and RIST-2, particularly for the DAT group. Although the RIST-2 evidenced greater diagnostic accuracy than its predecessor it should not be utilized in isolation for the clinical determination of DAT or MCI.

Wechsler adult intelligence scale-4th edition digit span performance in subjective cognitive complaints, amnestic mild cognitive impairment, and probable dementia of the Alzheimer type.

Objective: The Digit Span (DS) subtest from the Wechsler Adult Intelligence Scale-4th Edition (WAIS-IV) was updated to better measure working memory which is potentially clinically relevant as prior unreplicated studies showed that sequencing tasks differentiated normal from neurologic groups. This study examines performance on DS for individuals from a memory disorder clinic diagnosed with amnestic mild cognitive impairment (aMCI), probable dementia of the Alzheimer type (DAT), or those with subjective cognitive complaints (SCC). Method: Seven hundred and six individuals were drawn from 1256 consecutive referrals who underwent a standard neuropsychological evaluation and obtained a consensus diagnosis from a neuropsychologist and a neurologist of DAT, aMCI, or having SCC. This resulted in a sample of 290 individuals with DAT, 255 with aMCI, and 161 with SCC. Results: Those with DAT performed significantly worse for DS Forward, Backward, and Total Score versus those with aMCI and SCC, whose performances were similar. Digit Span Sequencing was significantly different in each group (DAT < aMCI < SCC), with a high rate of the DAT group showing cross-task perseveration. Conclusions: The DS sequencing results differed between the three clinical groups, which is consistent with the hypothesis that working memory declines would be evident on this measure. Discontinuation of DSS due to cross-task perseveration was frequently seen in, although not unique to, the DAT group. Both poorer DSS performance and the presence of perseveration can offer useful clinical information on the context of a thorough evaluation of the aMCI/DAT spectrum.

Clinical outcomes of normal pressure hydrocephalus in 116 patients: objective versus subjective assessment.

OBJECTIVE: Objective assessment tests are commonly used to predict the response to ventriculoperitoneal (VP) shunting in patients with normal pressure hydrocephalus (NPH). Whether subjective reports of improvement after a lumbar drain (LD) trial can predict response to VP shunting remains controversial. The goal in this study was to compare clinical characteristics, complication rates, and shunt outcomes of objective and subjective LD responders who underwent VP shunt placement. METHODS: This was a retrospective review of patients with NPH who underwent VP shunt placement after clinical improvement with the LD trial. Patients who responded after the LD trial were subclassified into objective LD responders and subjective LD responders. Clinical characteristics, complication rates, and shunt outcomes between the 2 groups were compared with chi-square test of independence and t-test. RESULTS: A total of 116 patients received a VP shunt; 75 were objective LD responders and 41 were subjective LD responders. There was no statistically significant difference in patient characteristics between the 2 groups, except for a shorter length of stay after LD trial seen with subjective responders. The complication rates after LD trial and VP shunting were not significantly different between the 2 groups. Similarly, there was no significant difference in shunt response between objective and subjective LD responders. The mean duration of follow-up was 1.73 years. CONCLUSIONS: Reports of subjective improvement after LD trial in patients with NPH can be a reliable predictor of shunt response. The currently used objective assessment scales may not be sensitive enough to detect subtle changes in symptomatology after LD trial.

Ventriculoperitoneal Shunt Outcomes of Normal Pressure Hydrocephalus: A Case Series of 116 Patients.

Background Permanent cerebrospinal fluid (CSF) diversion with a ventriculoperitoneal shunt (VPS) is a treatment option for patients with normal pressure hydrocephalus (NPH). Objectives Herein, we examine the outcomes, complication rates, and associations between predictors and outcomes after VPS in patients with NPH. Methods This was a retrospective review of 116 patients (68 males, 48 females) with NPH who underwent VPS placement from March 2008 to September 2017 after demonstrating objective and/or subjective improvement after a lumbar drain trial. The Chi-square test of independence was used to examine associations between predictors and clinical improvement after shunting. Complications associated with the VPS procedure were recorded. Results The mean age was 77 years (range 52-93). The mean duration of disturbance in gait, cognition, and continence were 29, 32, and 28 months, respectively. Of the 116 patients, 111 followed up at two weeks; of these, improvement in gait, incontinence, and cognition were reported in 72, 20, and 23 patients, respectively. Gait improved more than incontinence or cognition. A shorter duration of gait disturbance predicted an improvement in gait after shunting (p<0.01). Being on a cognition-enhancing medication predicted an improvement in cognition and/or incontinence after shunting (p<0.05). Complications included misplaced proximal catheters (n=6), asymptomatic catheter tract hemorrhages (n=3), bilateral hygromas (n=7), subdural hematomas (SDH) (n=5), and CSF leak (n=1). Conclusion VPS placement in patients with NPH is well-tolerated and associated with improved outcomes at least in the short-term follow-up (<6 months). A shorter duration of gait disturbance and being on a cognition-enhancing medication are associated with greater improvement after VPS.

Lumbar drain trial outcomes of normal pressure hydrocephalus: a single-center experience of 254 patients.

OBJECTIVE: A short-term lumbar drain (LD) trial is commonly used to assess the response of normal pressure hydrocephalus (NPH) patients to CSF diversion. However, it remains unknown whether the predictors of passing an LD trial match the predictors of improvement after ventriculoperitoneal shunting. The aim of this study was to examine outcomes, complication rates, and associations between predictors and outcomes after an LD trial in patients with NPH. METHODS: The authors retrospectively reviewed the records of 254 patients with probable NPH who underwent an LD trial between March 2008 and September 2017. Multivariate regression models were constructed to examine predictors of passing the LD trial. Complications associated with the LD trial procedure were recorded. RESULTS: The mean patient age was 77 years and 56.7% were male. The mean durations of gait disturbance, cognitive decline, and urinary incontinence were 29 months, 32 months, and 28 months, respectively. Of the 254 patients, 30% and 16% reported objective and subjective improvement after the LD trial, respectively. Complications included a sheared LD catheter, meningitis, lumbar epidural abscess, CSF leak at insertion site, transient lower extremity numbness, slurred speech, refractory headaches, and hyponatremia. Multivariate analyses using MAX-R revealed that a prior history of stroke predicted worse outcomes, while disproportionate subarachnoid spaces (uneven enlargement of supratentorial spaces) predicted better outcomes after the LD trial (r2 = 0.12, p < 0.05). CONCLUSIONS: The LD trial is generally safe and well tolerated. The best predictors of passing the LD trial include a negative history of stroke and having disproportionate subarachnoid spaces.

Neuropsychology in a Memory Disorder Clinic.

The rationale for and factors related to embedding a neuropsychologist in the midst of a neurology-based memory disorder clinic are discussed. Common conditions encountered are briefly reviewed, along with an evaluation aimed at assisting with differential diagnosis. Advice for neuropsychologists is offered in terms of creating and refining a working model in a neurology clinic and strategies to improve communication and effectiveness are presented.

Patient-physician communication: why and how.

Patient-physician communication is an integral part of clinical practice. When done well, such communication produces a therapeutic effect for the patient, as has been validated in controlled studies. Formal training programs have been created to enhance and measure specific communication skills. Many of these efforts, however, focus on medical schools and early postgraduate years and, therefore, remain isolated in academic settings. Thus, the communication skills of the busy physician often remain poorly developed, and the need for established physicians to become better communicators continues. In this article, the authors briefly review the why and how of effective patient-physician communication. They begin by reviewing current data on the benefits of effective communication in the clinical context of physicians caring for patients. The authors then offer specific guidance on how to achieve effective communication in the patient-physician relationship.

Motor perseveration in geriatric medical patients.

Perseveration has long been considered as a pathognomonic sign of neurological disease, yet, surprisingly, little research exists regarding the accuracy of this assumption. This study matched 56 geriatric medical inpatients with 56 inpatients with recent cerebrovascular accidents. Participants were given one of two measures of general cognition and four Lurian tasks of motor coordination. The results suggest that both motor incoordination and across-tasks perseveration were associated with decreased cognitive status. After controlling for cognitive status, individuals with a neurological history evidenced greater dyscoordination and increased perseveration when compared to age-equivalent general medical patients. Perseveration in participants with recent strokes appeared more related to the amount of neural system disruption as opposed to specific lesion sites. Overall, the results suggest that motor incoordination and "stuck-in-set" perseveration are more indicative of global than localizable brain dysfunction. Possible nonneurologic factors associated with this behavior are also proposed as benchmarks for future research.

The effects of aging on the attentional demands of walking toward and stepping up onto a curb.

Community ambulation requires the capacity to alter gait in response to obstacles within the path of travel that appear at a known location. Acquiring information from the environment to safely negotiate a curb may increase the cognitive demands of walking. The purpose of this study was to examine the attentional demands of walking toward and stepping up onto a curb in young, middle-age and older adults. Single and dual-task voice reaction time (VRT) was measured in community-dwelling young (n = 24), middle-age (n = 24), and older adults (n = 24) across 5 conditions: sitting in a chair, standing, level walking, and walking toward and while stepping up onto a curb. A 3 (group) by 5 (task condition) ANOVA was used to examine VRT. The interaction of group with task revealed statistically significant within group increases in VRT when comparing either sitting and/or standing to walking on a level surface and walking toward the curb and stepping up onto the curb. When compared to the other groups, older adults had significantly longer VRT for all walking tasks. Stepping onto the curb significantly increased the attentional requirements of walking for all of the groups when compared to level walking. The pattern of statistically significant between group and within group differences during the walking tasks indicate the effects of a curb located at a predictable place in the environment on attentional allocation.

Clinical prediction of falls in the elderly.

OBJECTIVE: To assess the ability of physical and occupational therapists engaged in rehabilitation of the elderly to predict posttreatment falls. DESIGN: Prospective cohort study of 15 mo in duration at an urban academic medical center rehabilitation unit. A total of 165 consecutively admitted geriatric individuals were rated for fall risk by 14 physical and seven occupational therapists. Measurements included the Mini-Mental State Examination, Geriatric Depression Scale, FIM, and therapists' ratings of fall likelihood. RESULTS: Both disciplines evidenced an ability to predict who would fall in the 3 mo after discharge. Clinical judgment regarding fall risk, however, added little value over two major predictors of future falls, fall history and the presence of a neurologic condition. CONCLUSION: Trying to predict an infrequent future event such as falls is inherently difficult. Education regarding known fall-risk factors and inclusion of standardized measurements of physical status are recommended to potentially improve rates of detection, along with adoption of a realistic attitude regarding our abilities to forecast infrequent events.

Rehabilitation therapists' recognition of cognitive and mood disorders in geriatric patients.

OBJECTIVE: To determine if physical and occupational therapists can recognize 2 known predictors of rehabilitation outcome, cognition and mood, in their geriatric patients. DESIGN: Survey. SETTING: Urban academic medical center rehabilitation unit. PARTICIPANTS: One hundred two consecutive geriatric admissions rated by 20 physical and 8 occupational therapists for the presence of cognitive or affective disorders. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mini-Mental State Examination, Geriatric Depression Scale, and therapists' ratings. RESULTS: Both disciplines had low rates of accurate detection of both cognitive abnormalities and symptoms of depression. Patients scoring in the intact range of either domain were more likely to be correctly identified by the therapists than were patients whose results were possibly or probably impaired. CONCLUSION: Rehabilitation therapists had difficulty recognizing patients with cognitive and affective disorders. I recommend including a mental health professional on the treatment team, staff inservicing, and/or the use of standardized measures of mood and mental status to increase recognition of these syndromes in geriatric rehabilitation patients.

Limitations of the Oral Trail Making Test in a mixed sample of older individuals.

The utility of the Oral Trail Making Test (OTMT), a motor and visual-free alternative to the traditional Trail Making Test, was examined in 86 older (> or =60 years old) medical inpatients and 30 healthy controls. The OTMT-Part B evidenced a moderate correlation with the MMSE, and individuals with medical conditions that affect cognition displayed a high failure rate (more than five errors or 300+s). Moderate education effects were present for the OTMT-Part B. Thus, the current study suggests caution when employing this test and the above noted cutoffs with older medical patients or those with lower levels of education.