Dexmedetomidine Use in Intensive Care Unit Sedation and Postoperative Recovery in Elderly Patients Post-Cardiac Surgery (DIRECT).

OBJECTIVE: This study examined recovery, delirium, and neurocognitive outcome in elderly patients receiving dexmedetomidine or propofol sedation after undergoing cardiac surgery. DESIGN: Open-label randomized trial. SETTING: Single center. PARTICIPANTS: A total of 70 patients older than 75 years without English language limitations and Mini Mental State Examination scores >20. INTERVENTIONS: Patients received either propofol (group P) or dexmedetomidine (group D) postoperatively until normothermic and hemodynamically stable. MEASUREMENTS AND MAIN RESULTS: Quality of recovery (QoR) was measured by the QoR-40 questionnaire on postoperative day (POD) three. Secondary outcomes were incidence and duration of delirium, time to extubation, length of hospital stay, hospital mortality rate, postoperative quality of life (QoL; measured by SF-36 performed at baseline and six months postoperatively), and neurocognitive disorder (measured by Minnesota Cognitive Acuity Screen [MCAS] performed at baseline, POD5, and six months postoperatively). A total of sixty-seven patients completed the trial. There was no significant difference in QoR-40 scores (95% confidence interval [CI], -7.6081-to-10.9781; p = 1.000), incidence of delirium (group P, 42%; group D, 24%; p = 0.191), mean hospital stay (95% CI, -5.4838-to-1.5444; p = 0.297), mean time to extubation (95% CI, -19.2513-to-7.5561; p = 0.866), or mean duration of delirium (95% CI, -4.3065-to-1.067; p = 0.206) between groups. No patients died in the hospital. There were no significant differences in changes in SF-36 or MCAS scores over time between groups. There was a decline in MCAS score from preoperatively to POD5 in group P (95% CI, -8.95725-to- -2.61775; p = 0.0005), which was greater than that observed in group D. CONCLUSIONS: The authors' findings demonstrated that the use of dexmedetomidine compared with propofol in elderly patients undergoing cardiac surgery was unlikely to improve QoR/postoperative QoL. Although the study was underpowered to detect secondary outcomes, the results suggested no reductions in delirium, time to extubation, and hospital stay, but a potential decrease in delayed neurocognitive recovery.

The relationship between theory of mind and cognition in Alzheimer's disease: A systematic review.

Introduction: Theory of Mind (ToM) refers to an individual's ability to attribute mental states to others. It is well established that the behavioral variant of frontotemporal dementia can undermine ToM. However, there is no consensus on how Alzheimer's disease affects ToM. The following report represents a systematic literature review of ToM in Alzheimer's disease over the past ten years.Method: We performed a survey using the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) criteria. The literature search was performed using the electronic databases MEDLINE (Pubmed) and Science Citation Index (ISI). The following descriptors were used in the review process: theory of mind or mentalizing and Alzheimer disease or Alzheimer's disease or Alzheimer type dementia. This systematic review was recorded in the International Prospective Register of Systematic Reviews (PROSPERO) under the number CDR42018115152.Results: We identified 117 articles, 24 of which met our criteria. The most common assessment measure used in the evaluation of the ToM was the first and second order false belief task. Many studies reported that individuals with Alzheimer's disease were impaired on more complex tasks, such as second-order false belief tasks, but had intact performance on simpler tasks, such as first order false beliefs and affective ToM. In contrast, some studies reported that ToM deficits may also appears in simpler and affective tasks.Conclusions: The variability in methodologies, the design and complexity of the tasks applied, the heterogeneity in terms of dementia stage/severity, and the level of cognitive impairment contribute to the variability and inconsistency of the results. Future research should investigate the ToM using more ecological and standardized methods.

Cognitive functioning and late-life depression.

This brief report provides an introduction to the topic of cognitive functioning in late-life depression (LLD). In addition to providing a review of the literature, we present a framework for understanding the heterogeneity of cognitive outcomes in this highly prevalent disorder. In addition, we discuss the relationship between LLD and dementia, and highlight the importance of regularly assessing cognitive functioning in older adults who present with depressive symptoms. If cognitive deficits are discovered during a neuropsychological assessment, we recommend referral to a geriatric psychiatrist or cognitive neurologist, for evaluation and treatment of the patient's symptoms.

Changes in neuropsychological functioning following treatment for late-life generalised anxiety disorder.

BACKGROUND: Generalised anxiety disorder (GAD) in older adults is associated with neuropsychological impairment. Aims We examined neuropsychological functioning in older adults with GAD in comparison with psychiatrically healthy older adults at baseline, and we examined changes following a 12-week placebo-controlled trial of escitalopram. METHOD: A total of 160 participants without dementia aged ≥60 with current GAD and 37 individuals in a comparison group without psychiatric history underwent neuropsychological assessment. Of these, 129 participants with GAD were reassessed post-treatment (trial registration: NCT00105586). RESULTS: The participants with GAD performed worse than the comparison group in information processing speed, working memory, inhibition, problem-solving (including concept formation and mental flexibility) and immediate and delayed memory. Neuropsychological functioning was correlated with everyday functioning. After treatment, those with low cognitive scores experienced working memory, delayed memory and visuospatial ability improvement and those who reported clinical improvement in anxiety exhibited improvement in the ability to engage inhibition and episodic recall. These improvements were modest and of similar magnitude in both treatment conditions. CONCLUSIONS: Generalised anxiety disorder in older adults is associated with neuropsychological impairments, which are associated with functional impairment. Those with GAD who either have a low cognitive performance or report clinical improvement in anxiety post-treatment, show improvement in multiple cognitive domains. These findings underscore the importance of treatments that aid cognition as well as anxiety symptoms.

Patterns of mild cognitive impairment after treatment of depression in the elderly.

OBJECTIVES: Late-life depression (LLD) is associated with persistent cognitive impairment in a subset of individuals. The purpose of this study was to 1) examine the frequency and characteristics of cognitive diagnoses (Mild Cognitive Impairment [MCI], dementia) among remitted elderly depressed subjects and 2) to compare the prevalence rate and correlates of cognitive diagnoses with those of comparison subjects. DESIGN: Crosssectional. SETTING: Outpatient geriatric mental health clinic. PARTICIPANTS: The authors examined cognitive diagnoses among 109 subjects age 65 and older, after depression treatment response and 65 never-depressed, age- and education-equated comparison subjects. MEASUREMENTS: Cognitive diagnoses were independently established by the University of Pittsburgh's Alzheimer's Disease Research Center. Bivariate and multivariate analyses were conducted to examine the role of specific risk factors for cognitive diagnosis among depressed subjects. RESULTS: Relative to comparison subjects, nearly twice as many depressed subjects were diagnosed with MCI or dementia (48% versus 28%). Of the 109 depressed subjects, 38% were diagnosed with MCI (63% amnestic, 37% nonamnestic). The majority of amnestic MCI subjects (85%) had the multiple domain subtype. Age, but not age of onset or lifetime depression duration, predicted cognitive diagnosis. CONCLUSIONS: Despite adequate depression treatment response, 48% of remitted depressed subjects had a cognitive diagnosis. Of the 38% diagnosed with MCI, there was high representation among both the amnestic and the nonamnestic subtypes, suggesting heterogeneity in cognitive course and outcomes in LLD.

Cognitive functioning and instrumental activities of daily living in late-life bipolar disorder.

OBJECTIVE: The authors report on the relationship between cognitive functioning and instrumental activities of daily living (IADLs) in elderly, clinically euthymic adults with bipolar disorder. METHODS: Twenty patients with bipolar disorder (age range: 61-86 years) were administered comprehensive neuropsychologic testing. Structured in-home performance-based assessments of IADLs were performed in 19 of these patients. RESULTS: Relative to age-equated comparators, bipolar subjects performed worse in information-processing speed and executive functioning. IADL performance was strongly correlated with these cognitive domains. CONCLUSIONS: In euthymic elderly patients with bipolar disorder, decrements in information processing speed and executive functioning characterize cognitive function and are associated with poorer IADL performance.

Anxiety of Alzheimer's disease patients before and after a standardized on-road driving test.

BACKGROUND: A large number of licensed elderly drivers are demented or are likely to become demented. On-road driving tests, a method often used to assess driver competency, are likely anxiety-provoking for elderly individuals. This article examines the relationship between anxiety and driving performance in a mildly demented and elderly control (EC) sample. METHODS: Anxiety ratings of fear and tension, as assessed by visual analog scales, of 84 patients clinically diagnosed with mild Alzheimer's disease (AD) (68 safe/marginal and 16 unsafe drivers) were compared with those of 44 age- and education-equated safe/marginal EC participants, both before and after a standardized on-road driving test. RESULTS: Analyses revealed significant positive correlations between AD patients' pre-road test and post-road test tension and post-road test fear ratings and total road test score. Subsequent analyses of variance showed no significant pre-road test differences in fear ratings between the three groups but significantly higher levels of tension among the unsafe AD participants. After adjusting for baseline group differences, unsafe AD drivers experienced stable or higher anxiety levels after road test, whereas both the EC and safe/marginal AD drivers endorsed a significant reduction in anxiety. DISCUSSION: Unlike their safe EC and safe AD driver counterparts, unsafe AD patients reported continued elevated levels of fear and tension after the road test. Given these findings, we suggest that the most appropriate time for driving instructors to counsel patients regarding their driving skills might be directly after the road test.

Persistence of neuropsychologic deficits in the remitted state of late-life depression.

OBJECTIVE: Cognitive impairment in late-life depression (LLD) is prevalent, disabling, and persists despite the remission of depressive symptoms. This article characterizes neuropsychologic functioning during remission in LLD. METHODS: The authors examined longitudinal performance on a comprehensive neuropsychologic battery in 56 nondemented subjects age 60 or older who initially presented with an episode of nonpsychotic unipolar major depression and 40 nondemented, age- and education-equated comparison subjects with no history of depression. Subjects were assessed at baseline (in a depressed state) and one year later (when remitted). RESULTS: After one year, 45% of the LLD subjects were cognitively impaired despite remission of depression. Visuospatial ability, information-processing speed, and delayed memory were most frequently impaired; 94% of the patients who were impaired at baseline remained impaired one year later. Twenty-three percent of the patients who were cognitively normal while depressed developed impairment one year later. CONCLUSIONS: Most older individuals who are cognitively impaired during a depressive episode remain impaired when their depression remits. In addition, a substantial proportion of older depressed individuals who are cognitively intact when depressed are likely to be impaired one year later, although their depression has remitted.

Does education moderate neuropsychological impairment in late-life depression?

OBJECTIVE: The increased resistance of better-educated individuals to the cognitive effects of neuropathology has been conceptualized as reflecting brain reserve. This study examined whether educational level influences the degree of neuropsychological impairment associated with late-life depression. METHODS: The neuropsychological performances of 115 older depressed patients and of 44 comparison subjects of similar age and education were compared as a function of educational level. RESULTS: While depressed patients performed worse than comparison subjects on all the measures, the severity of this impairment (with respect to comparison subjects) did not differ with the educational level of the patients. CONCLUSIONS: Brain reserve, as indexed by the patients' level of education, does not mitigate the cognitive decrements associated with late-life depression.

Executive functioning, illness course, and relapse/recurrence in continuation and maintenance treatment of late-life depression: is there a relationship?

OBJECTIVE: The authors tested the hypothesis that impaired executive functioning leads to high rates of relapse and recurrence in late-life depression. METHODS: They analyzed data from subjects participating in two independent intervention trials. Study I included 53 elderly depressed patients who participated in an open trial comparing the efficacy of paroxetine and nortriptyline and recurrence prevention over 18 months. Study II focused on 146 elderly depressed patients who received open treatment with paroxetine in a relapse-prevention study over 4 months of continuation treatment. They examined the effect of cognitive functioning, in general, and executive functioning, in particular, on time-to-relapse/recurrence, using baseline and post-treatment measures of neuropsychological functioning. RESULTS: The associations between cognitive measures and both probability of, and time-to-relapse/recurrence were small and statistically nonsignificant. CONCLUSION: Data failed to support the hypothesis that cognitive impairment, in general, or executive dysfunction, in particular, predicts relapse or recurrence of major depression in late life. Authors recommend future testing of the hypothesis with detailed, comprehensive measures over longer periods of observation during maintenance trials.

A preliminary analysis of EMG variance as an index of change in EMG biofeedback treatment of tension-type headache.

The effectiveness of EMG biofeedback training for tension headache has been well established. Previous studies evaluating changes in an average EMG activity score from pre- to posttreatment have not consistently found a relationship between a reduction in average EMG activity and headache improvement at posttreatment. The current study is a preliminary analysis of the utility of EMG variance as another possible mechanism of change. Frontalis EMG average activity and variances from 6 chronic tension-type headache sufferers who demonstrated significant improvement in headache activity at posttreatment (at least 70%) and 6 chronic tension-type headache sufferes who did not demonstrate improvement (less than 30%) were examined across 6 sessions of biofeedback treatment. The improved group demonstrated larger time-specific EMG variance in relation to mean EMG amplitudes during all treatment sessions. A dramatic decline in time-specific variance was observed during the later treatment sessions for improved participants; this pattern was not observed in the group who demonstrated little or no improvement. Results from the current study suggest that the inclusion of both average EMG activity and EMG variance may provide a more comprehensive measure to evaluate possible physiological changes responsible for improvement in headache activity following EMG biofeedback training.