Identification of research priorities in CHD: empowering patients and families through participation in the development of formal research agendas.

BACKGROUND: Conquering CHD, formerly known as the Pediatric Congenital Heart Association (PCHA), is the leading congenital heart disease (CHD) patient advocacy organisation in the United States of America, and places high priority on patient engagement in the research process. Participatory design is an approach to problem-solving that utilises the knowledge and opinions of groups of people to generate plans and new ideas. Utilising this mode of patient engagement, patients and families engaged with Conquering CHD assisted in developing a list of research priorities which was then distributed to the larger membership with instructions to rank the priorities in order of importance. Upon completion, these items were compared to the current scientific literature to assess correlation with current publications. This cross-sectional study and literature review aimed to assess the priorities of patients and families in CHD research and to determine the reflection of these areas in the current body of scientific literature. METHODS: This cross-sectional study utilised a survey asking participants to rank the importance of research items within categories including "Technology Advances," "Genetic and Cellular Research," "Broad Understanding of CHD," and "Psychosocial Outcomes" which was distributed through social media and email to 43,168 accounts across all platforms. Respondents were asked to place each item in a ranked order in each category, with the value "1" representing the most preferred for each participant. Anyone engaged with Conquering CHD was eligible to complete the study, including patients and families. Subsequently, a literature review of the largest medical databases including PubMed, Scopus, and ScienceDirect was undertaken to determine the number of articles published per each topic which was then assessed to determine if there is a correlation between patient-ranked priorities and the current body of literature. RESULTS: The study generated a total response of 527 participants. Regarding "Technology Advances," valve replacement was the preferred topic (mean rank 2.07, IQR 2). Stem cell research was the favoured topic in "Genetic and Cellular Research" (mean rank 2.53, IQR 2). Access to care was the priority in the "Broadening Understanding of CHD" (mean rank 1.24, IQR 1). Pertaining to "Psychosocial Outcomes", psychological/emotional effects was the highest ranked topic (mean rank 1.46, IQR 1). The literature review returned a total of 135,672 articles in the areas of interest. For "Valve Replacement", 8361 articles resulted reflecting a proportion of 0.097 of total articles. For "Stem Cell Research", 9921 articles resulted reflecting a proportion of 0.115 of total articles. For "Access to Care", 7845 articles resulted reflecting a proportion of 0.091 of total articles. For "Psychological/Emotional Effects", 6422 articles resulted reflecting a proportion of 0.074 of total articles. A Spearman's correlation demonstrated no correlation between the preferred domain of CHD research and the number of articles published for that domain (rs = 0.02, p = 0.94). CONCLUSIONS: This process demonstrates the effectiveness of participatory design, using a patient and family network to determine the research items of concern to those affected by CHD. The cross-sectional survey was effective in assessing patient and family priorities but was limited by access to reliable internet and delivery only in English. Though the study had a large response rate, it was limited to patients already engaged with Conquering CHD. For these reasons, it may not completely reflect the opinions of the total population affected by CHD. However, this offers valuable insight into patient-determined priorities and reveals that the current scientific literature does not correlate with these items. These data serve to inform individual and institutional research agendas to better reflect the needs and desires of this population.

Predicting Duration of Outpatient Physical Therapy Episodes for Individuals with Spinal Cord Injury Based on Locomotor Training Strategy.

OBJECTIVE: To characterize individuals with spinal cord injuries (SCI) who use outpatient physical therapy or community wellness services for locomotor training and predict the duration of services, controlling for demographic, injury, quality of life, and service and financial characteristics. We explore how the duration of services is related to locomotor strategy. DESIGN: Observational study of participants at 4 SCI Model Systems centers with survival. Weibull regression model to predict the duration of services. SETTING: Rehabilitation and community wellness facilities at 4 SCI Model Systems centers. PARTICIPANTS: Eligibility criteria were SCI or dysfunction resulting in motor impairment and the use of physical therapy or community wellness programs for locomotor/gait training. We excluded those who did not complete training or who experienced a disruption in training greater than 45 days. Our sample included 62 participants in conventional therapy and 37 participants in robotic exoskeleton training. INTERVENTIONS: Outpatient physical therapy or community wellness services for locomotor/gait training. MAIN OUTCOME MEASURES: SCI characteristics (level and completeness of injury) and the duration of services from medical records. Self-reported perceptions of SCI consequences using the SCI-Functional Index for basic mobility and SCI-Quality of Life measurement system for bowel difficulties, bladder difficulties, and pain interference. RESULTS: After controlling for predictors, the duration of services for the conventional therapy group was an average of 63% longer than for the robotic exoskeleton group, however each visit was 50% shorter in total time. Men had an 11% longer duration of services than women had. Participants with complete injuries had a duration of services that was approximately 1.72 times longer than participants with incomplete injuries. Perceived improvement was larger in the conventional group. CONCLUSIONS: Locomotor/gait training strategies are distinctive for individuals with SCI using a robotic exoskeleton in a community wellness facility as episodes are shorter but individual sessions are longer. Participants' preferences and the ability to pay for ongoing services may be critical factors associated with the duration of outpatient services.

Change in Event Centrality and Posttraumatic Stress Disorder Symptoms During Intensive Treatment.

Event centrality, defined as the extent to which a traumatic event becomes a core component of a person's identity (Berntsen & Rubin, 2006), is both a correlate and predictor of posttraumatic stress disorder (PTSD) symptoms, over and above event severity. These findings suggest that decreasing the perceived centrality of a traumatic event to one's identity might result in decreases in PTSD symptom severity. To date, few studies have examined how centrality is affected by PTSD treatment. The present study tested the hypotheses that change in centrality would be associated with both change in PTSD symptom severity and discharge PTSD symptom severity in an exposure-based PTSD partial hospitalization program (N = 132; 86.0% White; 85.2% female; M age = 36 years). At discharge (i.e., after approximately 6 weeks of treatment), both PTSD symptoms and centrality had significantly decreased, ds = .70 and .98, respectively, with large effect sizes. Decreases in Centrality of Events Scale (CES) scores at posttreatment, baseline CES scores, and baseline PTSD Checklist for DSM-5 (PCL-5) scores were associated with change (i.e., decrease) in PCL-5 scores, p < .001, as well as with posttreatment PCL-5 scores, p < .001. Decreases in CES scores over time, baseline CES scores, and baseline PCL-5 scores explained 31% of the variance in PCL-5 change and 34% of the variance in posttreatment PCL-5 scores. The results indicate the potential importance of decreasing the centrality of a traumatic event in PTSD treatment and recovery.

A Systematic Review and Meta-Analysis of Risk Factors for Postpartum Depression Among Latinas.

OBJECTIVES: The purpose of this article was to describe the findings from a systematic review, quality review, and meta-analysis of risk factors for postpartum depression among adult Latinas in the United States. METHODS: Databases were searched from inception to May 2020 for studies published in English related to Latina/Hispanic mothers and risk factors of postpartum depression. Of 115 abstracts screened, 10 met the inclusion criteria for the review and meta-analysis. Eleven risk factors from these studies were included: acculturation, age, economic stress, education, marital status, number of children, prenatal depression, recent and remote intimate partner violence (IPV), general social support, and partner/father's social support. RESULTS: Partner/father's social support had a large effect size. Prenatal depression and recent IPV had medium effect sizes, while education, economic stress, general social support and remote IPV had small effect sizes. Negligible effect sizes were found for age, marital status, number of children, and acculturation. CONCLUSIONS: Prenatal depression, IPV, social support (general and from partner/father), economic stress and education are risk factors that should be screened for when working with perinatal Latinas. Future directions for clinical practice and research are discussed.

Complementary and Alternative Medicine Mind-Body Approaches Used Among Racially and Ethnically Diverse Adolescents.

PURPOSE: The aim of this paper is to examine complementary and alternative medicine (CAM) use among racially and ethnically diverse adolescents. Greater understanding of CAM use among this group is warranted to better inform health care providers in delivering a culturally relevant health promotion approach. DESIGN AND METHODS: A secondary data analysis was conducted using the 2012 Child Complementary and Alternative Medicine Supplement of the National Health Interview Survey (CAM-NHIS) data, which was collected from a national sample of adolescents aged 12-17 years. A logistic regression test was employed to investigate the predictors associated with CAM use among racially and ethnically diverse adolescents. RESULTS: While Black and Hispanic adolescents were the least likely to use CAM compared to their White counterparts, families with higher incomes, higher education attainment, and adolescents who experienced pain were more likely to use CAM. CONCLUSIONS: Findings suggest the need for future research to gain a greater understanding of CAM use among racially and ethnically diverse adolescents, and insights into how health disparities impact CAM use. Greater understanding of how CAM use intersects with health beliefs and outcomes is also warranted. PRACTICE IMPLICATIONS: Based on the CAM-NHIS survey, few racially and ethnically diverse adolescents have reported use of CAM. Development of culturally appropriate instruments and methods to assess CAM use among racially and ethnically diverse adolescents may yield specific data for this population. Informed health care providers can advocate for improved access to CAM for minority adolescents and alter disparate use.

Development and Psychometric Analysis of the Patient Preferences for Engagement Tool.

BACKGROUND: Assessing patients' preferences for engaging in healthcare is needed to inform the planning and delivery of individualized healthcare. Unfortunately, patients are often not engaged in their care to the extent that they would like, leading to patient feelings of disempowerment and frustration. OBJECTIVES: The purpose of this study was to (a) develop and (b) psychometrically test the Patient Preferences for Engagement Tool (PPET), a clinical assessment tool that can be used by nursing staff to identify patient preferences for engagement in healthcare. The usability of the PPET was also examined for both nurses and patients participating in the study. METHODS: The psychometric evaluation design used content and construct validity testing (exploratory and confirmatory factor analysis, known groups comparisons) and reliability estimation using Cronbach's alpha coefficient. The sample consisted of 308 adult patients aged 18-101 years from a Midwestern U.S. Magnet-designated academic medical center. RESULTS: Content validity index was at least 0.8 for all but one item. Using a split sample, a six-factor solution was first identified using exploratory factor analysis and then confirmed using confirmatory factor analysis. Demographic and illness factors were not significant predictors of factor scores. Cronbach's alpha coefficients of all six factors were >0.7. Both patients and nurses gave high ratings to the tool on effectiveness, efficiency, and satisfaction with use. DISCUSSION: The PPET demonstrated acceptable validity and reliability estimates. Assessing patient preferences for engagement gives value to the patient voice and provides an opportunity to have discussions with patients about various ways they can engage in their healthcare. Future research will focus on reducing the number of items on the PPET to construct a clinically useful resource for providers to use to assess patient preferences for healthcare engagement, leading to the development of more personalized care delivery methods.

Systematic review of psychometric properties of instruments measuring patient preferences for engagement in health care.

AIM: To identify, critically appraise, and summarize instruments that measure patients' preferences for engagement in health care. DESIGN: Psychometric systematic literature review. DATA SOURCES: PubMed, Embase, CINAHL, and PsycINFO were searched from inception to March 2019. REVIEW METHODS: Three reviewers independently evaluated the 'methodological quality' and the 'measurement properties' of the included instruments using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist and Terwee's quality criteria. Each instrument was given a Grading of Recommendations Assessment, Development and Evaluation (GRADE) score. The review was registered at PROSPERO (registry number CRD42018109253). RESULTS: A total of 16 studies evaluating 8 instruments measuring patients' preferences for engagement in health care were included. All instruments were downgraded for their 'methodological quality' or 'measurement properties', or a combination of both. Common concerns were lack of theoretical basis, absence of patient input during development, incorrect usage and reporting of validity measures and absence of a priori hypotheses to test validity. CONCLUSIONS: There were no identified instruments that demonstrated adequate evidence for all measurement properties. The Patient Preferences for Patient Participation Scale (4Ps) and 10-item Decisional Engagement Scale (DES-10) had the highest overall GRADE scores; however, each had some underlying developmental or methodological issues. IMPACT: Assessing how patients prefer to engage in their care is a critical first step to truly individualize engagement interventions to meet patient expectations. Systematic reviews of measures of patient experience with engagement in health care have been undertaken but none are available on measures of patient preferences for engagement. The results highlight the need to further develop and test instruments that measure patients' preferences for engagement in health care within a framework for consumerism. Involving the consumer in the instrument development process will ensure that engagement strategies used by healthcare providers are relevant and individualized to consumer preferences.

Testing Measurement Invariance with Ordinal Missing Data: A Comparison of Estimators and Missing Data Techniques.

Ordinal missing data are common in measurement equivalence/invariance (ME/I) testing studies. However, there is a lack of guidance on the appropriate method to deal with ordinal missing data in ME/I testing. Five methods may be used to deal with ordinal missing data in ME/I testing, including the continuous full information maximum likelihood estimation method (FIML), continuous robust FIML (rFIML), FIML with probit links (pFIML), FIML with logit links (lFIML), and mean and variance adjusted weight least squared estimation method combined with pairwise deletion (WLSMV_PD). The current study evaluates the relative performance of these methods in producing valid chi-square difference tests ([Formula: see text]) and accurate parameter estimates. The result suggests that all methods except for WLSMV_PD can reasonably control the type I error rates of [Formula: see text] tests and maintain sufficient power to detect noninvariance in most conditions. Only pFIML and lFIML yield accurate factor loading estimates and standard errors across all the conditions. Recommendations are provided to researchers based on the results.

Engaging Parents in Education for Discharge (ePED): Evaluating the Reach, Adoption & Implementation of an Innovative Discharge Teaching Method.

PURPOSE: This paper describes the evaluation of the implementation of an innovative teaching method, the "Engaging Parents in Education for Discharge" (ePED) iPad application (app), at a pediatric hospital. DESIGN AND METHODS: The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to guide the evaluation. Three of the five RE-AIM elements are addressed in this study: Reach, Adoption, and Implementation. RESULTS: The Reach of the ePED was 245 of 1015 (24.2%) patient discharges. The Adoption rate was 211 of 245 (86%) patients discharged in the five months' study period. High levels of fidelity (89.3%) to Implementation of the ePED were attained: the Signs and Symptoms domain had the highest (93%) and Thinking Forward about Family Adjustment screen had the lowest fidelity (83.3%). Nurse themes explained implementation fidelity: "It takes longer", and "Forgot to do it." CONCLUSIONS: The ePED app operationalized how to have an engaging structured discharge conversation with parents. While the Reach of the ePED app was low under the study conditions, the adoption rate was positive. Nurses were able to integrate a theory-driven practice change into their daily routine when using the ePED app. IMPLICATIONS FOR PRACTICE: The rates of adoption and implementation fidelity support the feasibility of future hospital wide implementation to improve patient and family healthcare experience. Attention to training of new content and the interactive conversation approach will be needed to fully leverage the value of the ePED app. Future studies are needed to evaluate the maintenance of the ePED app.

Using the Engaging Parents in Education for Discharge (ePED) iPad Application to Improve Parent Discharge Experience.

PURPOSE: The purpose of this study was to evaluate the use of the Engaging Parents in Education for Discharge (ePED) iPad application on parent experiences of hospital discharge teaching and care coordination. Hypotheses were: parents exposed to discharge teaching using ePED will have 1) higher quality of discharge teaching and 2) better care coordination than parents exposed to usual discharge teaching. The secondary purpose examined group differences in the discharge teaching, care coordination, and 30-day readmissions for parents of children with and without a chronic condition. DESIGN/METHODS: Using a quasi-experimental design, ePED was implemented on one inpatient unit (n = 211) and comparison group (n = 184) from a separate unit at a pediatric academic medical center. Patient experience outcome measures collected on day of discharge included Quality of Discharge Teaching Scale-Delivery (QDTS-D) and care coordination measured by Care Transition Measure (CTM). Thirty-day readmission was abstracted from records. RESULTS: Parents taught using ePED reported higher QDTS-D scores than parents without ePED (p = .002). No differences in CTM were found between groups. Correlations between QDTS-D and CTM were small for ePED (r = 0.14, p 0.03) and non-ePED (r = 0.29, p < .001) parent groups. CTM was weakly associated with 30-day readmissions in the ePED group. CONCLUSION: The use of ePED by the discharging nurse enhances parent-reported quality of discharge teaching. PRACTICE IMPLICATIONS: The ePED app is a theory-based structured conversation guide to engage parents in discharge preparation. Nursing implementation of ePED contributes to optimizing the patient/family healthcare experience.

The impact of maternal BMI, gestational weight gain, and breastfeeding on early childhood weight: Analysis of a statewide WIC dataset.

Early childhood obesity is a persistent health concern with more frequent and significant impact on low-income families. Maternal weight factors impact offspring weight status, but evidence on whether breastfeeding protects against this impact is mixed. This analysis examined a model to predict early childhood obesity risk, simultaneously accounting for maternal pre-pregnancy body mass index (BMI), gestational weight gain, and breastfeeding. The team analyzed 27,016 unique maternal-child dyadic records collected via the Supplemental Nutrition Program for Wisconsin Women, Infants, and Children (WIC) between 2009 and 2011. Generalized Linear Modeling, specifically logistic regression, was used to predict a child's risk of obesity given the mother's pre-pregnancy BMI, gestational weight gain, and duration of breastfeeding. For each 1 kg/m2 increase in pre-pregnancy BMI, there was a 4.5% increase in risk of obesity compared to children with mothers of normal BMI. Children whose mothers had excessive gestational weight gain were 50% more likely to have obesity compared to those whose mothers had ideal weight gain. For each week of additional breastfeeding, there was a 1.9% increased risk of obesity. The risk models did not differ by race. In this model, accounting for pre-pregnancy weight, gestational weight gain, and breastfeeding among a diverse, low-income sample, women with pre-pregnancy overweight and obesity or who had excessive gestational weight gain had the highest risk of early childhood obesity. While breastfeeding is healthy for many reasons, providers should focus on maternal weight-related behaviors when counseling mothers about how to avoid risk of early childhood obesity.

Testing allostatic load factor structures among adolescents: A structural equation modeling approach.

OBJECTIVES: Allostatic load (AL) represents cumulative biological "wear and tear" that results from chronic stress exposure over time, ultimately increasing risk for chronic disease. A consensus is lacking regarding the best operationalization of AL, particularly for younger, less studied populations. The purpose of this study was to test multiple hypothesized factor structures for AL to determine the best measurement approach for adolescents. METHODS: We analyzed biologic data for 1900 adolescents aged 12-18 from four waves (2003-2010) of the National Health and Nutrition Examination Survey. AL indicator variables included cardiovascular (systolic BP, creatinine), metabolic (HDL, LDL, triglycerides, insulin, fasting glucose, HA1C, body mass index [BMI], waist circumference), and immune (albumin, CRP, WBC, EBV) biomarkers. Structural equation modeling was used to test the fit of five hypothesized AL factor structures. RESULTS: The data best supported a unidimensional factor structure, where the AL construct directly influenced each of the indicator variables. All but two of the indicators (HDL and albumin) had positive factor loadings, thus, as AL increases the values for those indicators also increase. The best indicators for AL were those measuring metabolic dysregulation, with BMI and waist circumference having the highest factor loadings (0.95 and 0.982, respectively). CONCLUSIONS: BMI and waist circumference may be some of the earliest clinical signs of elevated AL that manifest among adolescents. Future research should aim to include neuroendocrine biomarkers in their AL measures to have a more robust estimation of AL in younger populations.

Innovation in Clinical Course Delivery and Impact on Students' Clinical Decision-Making and Competence.

The purpose of this study was to explore the differences in clinical decision-making and clinical competence between two different cohorts of graduating baccalaureate nursing students from a traditional prelicensure program in the United States. A quasi-experimental design was used to compare students who had substituted their traditional medical-surgical clinical experiences with simulation (Cohort 1, n = 35) with students who had supplementary simulation in addition to their traditional clinical experiences (Cohort 2, n = 36). The findings demonstrated that when simulation was used as a supplement to traditional clinical experiences, participants performed better patient assessments.

Does an intervention designed to improve self-management, social support and awareness of palliative-care address needs of persons with heart failure, family caregivers and clinicians?

AIMS AND OBJECTIVES: To conduct a formative evaluation of the iPad-Enhanced Shared Care Intervention for Partners (iSCIP) among persons with heart failure (HF), family caregivers and clinicians. Together, persons with HF and family caregivers are referred to as partners. BACKGROUND: There is growing awareness of the caregiver's contributions to HF self-management, social support and reciprocal benefits of interventions that involve both partners. The iSCIP engages both partners in a six-session psychosocial intervention to address three preventable causes of poor outcomes in a HF population: poor self-management skills, inadequate social support and underutilisation of palliative care. An iPad app is used to organise the intervention. The goals of the iSCIP are to engage partners in HF self-management, communication about the HF patient's care values and preferences, and future planning. DESIGN: A qualitative focus group design was used. METHODS: Seven clinicians and eight partners participated in focus groups to explore their experiences, needs and reaction to the iSCIP content and technologies employed. Open-ended questions and closed-ended surveys were used to collect data. Deductive content analysis was used to analyse the qualitative data. NVivo software was used for qualitative data analysis. Bayesian statistical models were used to analyse numeric data. RESULTS: The iSCIP met partners' and clinicians' needs to improve self-management, communicate about care values and preferences and plan for the future. Quantitative analysis of numeric data supported our qualitative findings, in that both groups rated the intervention components useful to very useful. IMPLICATIONS FOR PRACTICE: These findings add to the growing evidence of the feasibility and acceptability of programs that address care values and preferences, and care planning. The iSCIP can be used as a guide for developing interventions and software applications, which involve both partners in care and palliative-care discussions.

Effectiveness of CenteringPregnancy on Breastfeeding Initiation Among African Americans: A Systematic Review and Meta-analysis.

While breastfeeding initiation rates for African American mothers are low, an innovative model of group prenatal care, CenteringPregnancy, holds promise to increase breastfeeding rates. The aim of this systematic review and meta-analysis was to examine the effects of CenteringPregnancy versus individual prenatal care on breastfeeding initiation among African American mothers. Using a systematic approach and PRISMA guidelines, 4 electronic databases were used to search the literature. English-language studies, comparing CenteringPregnancy and individual prenatal care, including African American participants, and specifying breastfeeding initiation as an outcome were screened for inclusion. Study strength and quality were assessed and 7 studies were systematically reviewed and meta-analyzed. Participation in CenteringPregnancy increased the probability of breastfeeding initiation by 53% (95% confidence interval = 29%-81%) (n = 8047). A subgroup analysis of breastfeeding initiation among only African American participants was performed on 4 studies where data were available. Participation in CenteringPregnancy increased the probability of breastfeeding initiation by 71% (95% confidence interval = 27%-131%) (n = 1458) for African American participants. CenteringPregnancy is an effective intervention to increase breastfeeding initiation for participants, especially for African Americans. To close the racial gap in breastfeeding initiation, high-quality research providing specific outcomes for African American participants in CenteringPregnancy are needed.

Parental Co-Construction of 5- to 13-Year-Olds' Global Self-Esteem Through Reminiscing About Past Events.

The current study explored parental processes associated with children's global self-esteem development. Eighty 5- to 13-year-olds and one of their parents provided qualitative and quantitative data through questionnaires, open-ended questions, and a laboratory-based reminiscing task. Parents who included more explanations of emotions when writing about the lowest points in their lives were more likely to discuss explanations of emotions experienced in negative past events with their child, which was associated with child attachment security. Attachment was associated with concurrent self-esteem, which predicted relative increases in self-esteem 16 months later, on average. Finally, parent support also predicted residual increases in self-esteem. Findings extend prior research by including younger ages and uncovering a process by which two theoretically relevant parenting behaviors impact self-esteem development.

The Positive Thinking Skills Scale: A screening measure for early identification of depressive thoughts.

BACKGROUND: Depression is currently considered the second leading cause of disability worldwide. Positive thinking is a cognitive process that helps individuals to deal with problems more effectively, and has been suggested as a useful strategy for coping with adversity, including depression. The Positive Thinking Skills Scale (PTSS) is a reliable and valid measure that captures the frequency of use of positive thinking skills that can help in the early identification of the possibility of developing depressive thoughts. However, no meaningful cutoff score has been established for the PTSS. AIM: To establish a cutoff score for the PTSS for early identification of risk for depression. METHODS: This study used a receiver operating characteristic (ROC) curve to establish a PTSS cutoff score for risk for depression, using the Center for Epidemiological Studies-Depression Scale (CES-D) as the gold standard measure. RESULTS: In a sample of 109 caregivers, the ROC showed that the cutoff score of PTSS that best classify the participants is 13.5. With this PTSS score, 77.8% of the subjects with low CES-D are classify correctly, and 69.6% of the subjects with high CES-D are classify correctly. Since the PTSS score should be integer numbers, functionally the cutoff would be 13. CONCLUSION: The study showed that a cut off score of 13 is a point at which referral, intervention, or treatment would be recommended. Consequently, this can help in the early identification of depressive symptoms that might develop because of the stress of caregiving.

Onset of Mild Cognitive Impairment in Parkinson Disease.

OBJECTIVE: Characterize the onset and timing of cognitive decline in Parkinson disease (PD) from the first recognizable stage of cognitively symptomatic PD-mild cognitive impairment (PD-MCI) to PD dementia (PDD). Thirty-nine participants progressed from PD to PDD and 25 remained cognitively normal. METHODS: Bayesian-estimated disease-state models described the onset of an individual's cognitive decline across 12 subtests with a change point. RESULTS: Subtests measuring working memory, visuospatial processing ability, and crystalized memory changed significantly 3 to 5 years before their first nonzero Clinical Dementia Rating and progressively worsened from PD to PD-MCI to PDD. Crystalized memory deficits were the hallmark feature of imminent conversion of cognitive status. Episodic memory tasks were not sensitive to onset of PD-MCI. For cognitively intact PD, all 12 subtests showed modest linear decline without evidence of a change point. CONCLUSIONS: Longitudinal disease-state models support a prodromal dementia stage (PD-MCI) marked by early declines in working memory and visuospatial processing beginning 5 years before clinical diagnosis of PDD. Cognitive declines in PD affect motor ability (bradykinesia), working memory, and processing speed (bradyphrenia) resulting in PD-MCI where visuospatial imagery and memory retrieval deficits manifest before eventual development of overt dementia. Tests of episodic memory may not be sufficient to detect and quantify cognitive decline in PD.