Neuropsychiatric Symptoms Predict Faster Cognitive Decline in Dementia Collaborative Care Than Antipsychotic Use.

Background: To compare short-term cognitive outcomes among groups with and without neuropsychiatric symptoms (NPSs) or antipsychotic prescription and to determine which disease status or treatment modality is associated with relatively faster cognitive decline. Methods: We retrospectively analyzed a prospective cohort of patients diagnosed with dementia and mild cognitive impairment. All participants were evaluated using the Cognitive Abilities Screening Instrument (CASI) during their initial clinical assessments and at the annual follow-up. The dependent variable was annual delta CASI. Multivariate linear regression analysis was used to assess the degree of association between NPS, antipsychotic use, and cognitive decline after adjusting for confounding factors. Neuropsychiatric symptoms were examined individually to determine their predictive value for cognitive decline. Results: A total of 407 (N = 407) patients were included in the study. NPSs, rather than antipsychotic use, led to faster cognitive decline. A higher baseline NPI total score predicted a significantly faster decline in CASI scores (1-year delta CASI = -0.22, 95% CI = -0.38~ -0.05, p = 0.010). Specific items (delusions, agitation, depression, anxiety, euphoria, and apathy) in the NPS significantly increased cognitive decline. Conclusion: Certain neuropsychiatric symptoms, rather than antipsychotic use, lead to faster cognitive decline in a dementia collaborative care model. Checking for and providing appropriate interventions for NPS in people with dementia and their caregivers are highlighted.

The Effectiveness of the Case Manager-Centered Collaborative Care Model with Computer-Assisted Assessment on Quality Indicators for the Care of Dementia.

INTRODUCTION: This study aimed to investigate the influence of case management and its corresponding computer-assisted assessment system on the quality improvement of dementia care. METHODS: This observational study enrolled 2029 patients and their caregivers at Changhua Christian Hospital in Taiwan. Physicians who made the diagnosis of dementia would introduce the patient and caregiver dyad to the case manager-centered collaborative care team after obtaining agreement. The achievement rates of 11 quality indicators (QIs) comprising timely diagnostic evaluations, regular screens of cognition and neuropsychiatric symptoms, caregiver support, and proper medication prescriptions were counted. Different timeframes (≤4 months, 4 months-1 year, 1-2 years, 2-3 years, or ≥3 years) from diagnosis of dementia to collaborative care intervention were compared. RESULTS: A significantly higher attainment rate was achieved for patients with earlier entry into the collaborative team model, including QIs about timely diagnosis and regular screening, and caregiver support. The QIs regarding dementia medication prescriptions and documentation of the risk of antipsychotics remained similar regardless of the time of entry into the model. The completion rates of QIs also improved after the information system was launched. CONCLUSIONS: Physician-case manager co-management in the setting of a collaborative care model with a computer-assisted assessment system helps improve QI achievement for dementia care.

Reliability of predicting low-burden (≤ 2) positive axillary lymph nodes indicating sentinel lymph node biopsy in primary operable breast cancer - a retrospective comparative study with PET/CT and breast MRI.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in early breast cancer patients with low-burden axillary metastasis (≤ 2 positive nodes). This study aimed to determine the diagnostic performances of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) and breast magnetic resonance imaging in detecting axillary lymph node (ALN) metastases and the reliability to predict ALN burden. METHODS: A total of 275 patients with primary operable breast cancer receiving preoperative PET/CT and upfront surgery from January 2001 to December 2022 in a single institution were enrolled. A total of 244 (88.7%) of them also received breast MRI. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of PET/CT and breast MRI were assessed. The predictive values to determine ALN burden were evaluated using radio-histopathological concordance. RESULTS: PET/CT demonstrated a sensitivity of 53.4%, specificity of 82.1%, PPV of 65.5%, NPV of 73.5%, and accuracy of 70.9% for detecting ALN metastasis, and the corresponding values for MRI were 71.8%, 67.8%, 56%, 80.8%, and 69.2%, respectively. Combining PET/CT and MRI showed a significantly higher PPV than MRI (72.7% vs 56% for MRI alone, p = 0.037) and a significantly higher NPV than PET/CT (84% vs 73.5% for PET/CT alone, p = 0.041). For predicting low-burden axillary metastasis (1-2 positive nodes), the PPVs were 35.9% for PET/CT, 36.7% for MRI, and 55% for combined PET/CT and MRI. Regarding patients with 0-2 positive ALNs in imaging, who were indicated for SLNB, the predictive correctness was 96.1% for combined PET/CT and MRI, 95.7% for MRI alone, and 88.6% for PET/CT alone. CONCLUSIONS: PET/CT and breast MRI exhibit high predictive values for identifying low-burden axillary metastasis in patients with operable breast cancer with ≦ 2 positive ALNs on imaging.

Corrigendum: A comparison of caregiver burden for different types of dementia: an 18-month retrospective cohort study.

[This corrects the article DOI: 10.3389/fpsyg.2021.798315.].

Case Management-based Collaborative Care Model Associated with improvement in neuropsychiatric outcomes in community-dwelling people living with dementia.

BACKGROUND: This study aimed to explore the association between adherence of collaborative care model and short-term deterioration of BPSD after controlling patient and caregiver factors. METHODS: This retrospective case-control study enrolled 276 participants who were newly diagnosed with dementia and BPSD. A dementia collaborative care team interviewed patients and caregivers to form a care plan and provided individualized education or social resource referrals. A multivariate logistic regression model with backward selection was used to test factors associated with BPSD deterioration, defined as worse neuropsychiatric inventory (NPI) scores 1 year after joining the care model. RESULTS: Male sex (odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.25-0.84) and higher clinical dementia rating scale sum of boxes scores (CDR-SOB) (OR = 0.90; 95% CI = 0.83-0.98) were protective factors, whereas spouse caregivers and withdrawals from the care model (OR = 3.42; 95% CI = 1.28-9.15) were risk factors for BPSD deterioration. CONCLUSIONS: Our study showed that both patient and caregiver factors were associated with deterioration of BPSD. The case manager-centered dementia collaborative care model is beneficial for the management of BPSD. Healthcare systems may consider implementing a case management model in clinical dementia care practice.

Influence of care modes and social resources on psychotropic medication use in community-dwelling dementia patients.

Background: Optimal use of psychotropic medications for people living with dementia is important. By finding potentially modifiable factors, dementia care teams may find solutions to achieve the appropriate use of psychotropic drugs. Objective: This study aimed to elucidate patient and caregiver factors associated with the use of psychotropic drugs listed in the potentially inappropriate medications (PIMs) in community-dwelling people with dementia. Methods: This cross-sectional study enrolled 808 patients newly diagnosed with dementia, and their caregivers, from a dementia clinic at Changhua Christian Hospital. Patient and caregiver characteristics, care mode, and social resource usage were recorded. Multivariate logistic regression was used to identify factors associated with prescribing psychotropic medications. Results: Of all the participants, 39.1% used at least one of psychotropic medication categorized as PIM. Patients with frontotemporal dementia, with behavior or psychological symptoms, or cared by sole foreign care workers; caregivers with higher depression scores, employed or non-spouse caregivers carried a higher risk of prescription of psychotropic medications listed in PIMs. Conclusion: Psychotropic drug prescriptions are associated with patient and caregiver factors. Therefore, implementing appropriate interventions, especially those targeting potentially modifiable factors, is important to reduce psychotropic medication use.

The Effectiveness of Community Aging Care Centers on Global Function for People Living with Dementia.

BACKGROUND: The global population with dementia is growing rapidly. Dementia patients have been included in the services of the long-term care Act 2.0, supported by Taiwan's government since 2017. Community aging care centers are extensively established, which are places providing social connections and group physical and cognitive training programs for elderly people. OBJECTIVE: To elucidate the efficacy of community aging care centers on cognitive function in people with dementia. METHODS: A total of 1,277 patients with dementia diagnosed at the Changhua Christian Hospital outpatient departments were enrolled. A total of 113 patients who used community aging care centers and 452 subjects matched for age, education, and initial score of clinical dementia rating scale sum of boxes (CDR-SOB) control group were analyzed. The primary outcome was the change in CDR-SOB scores before and after utilization of community aging care centers. RESULTS: The mean annual change of CDR-SOB scores were 1.72±2.97, 1.08±2.36, and 1.04±3.64 in control, Community Service Centers for Dementia, and community elderly stations, respectively, after about 1.5 years follow-up. Patients with dementia using community aging care centers had significantly less progression in CDR-SOB scores than those in the control group (-0.65; 95% CI: -1.27, -0.03; p = 0.041). Using one more day of community aging care centers per week significantly promotes 0.16 points of CDR-SOB decline (-0.16, 95% CI: -0.31; -0.00; p = 0.045). CONCLUSION: Community aging care centers, based on the long-term care Act 2.0 in Taiwan, were effective in delaying the decline in global function in people living with dementia.

Using DeepLab v3 + -based semantic segmentation to evaluate platelet activation.

This research used DeepLab v3 + -based semantic segmentation to automatically evaluate the platelet activation process and count the number of platelets from scanning electron microscopy (SEM) images. Current activated platelet recognition and counting methods include (a) using optical microscopy or SEM images to identify and manually count platelets at different stages, or (b) using flow cytometry to automatically recognize and count platelets. However, the former is time- and labor-consuming, while the latter cannot be employed due to the complicated morphology of platelet transformation during activation. Additionally, because of how complicated the transformation of platelets is, current blood-cell image analysis methods, such as logistic regression or convolution neural networks, cannot precisely recognize transformed platelets. Therefore, this study used DeepLab v3 + , a powerful learning model for semantic segmentation of image analysis, to automatically recognize and count platelets at different activation stages from SEM images. Deformable convolution, a pretrained model, and deep supervision were added to obtain additional platelet transformation features and higher accuracy. The number of activated platelets was predicted by dividing the segmentation predicted platelet area by the average platelet area. The results showed that the model counted the activated platelets at different stages from the SEM images, achieving an error rate within 20%. The error rate was approximately 10% for stages 2 and 4. The proposed approach can thus save labor and time for evaluating platelet activation and facilitate related research.

Prediction of Institutionalization for Patients With Dementia in Taiwan According to Condition at Entry to Dementia Collaborative Care.

This study aimed to examine the institutionalization rate in patients with dementia in Taiwan, identify the predictors of institutionalization, and conduct a mediation analysis of caregiver burden between neuropsychiatric symptoms and institutionalization. We analyzed data from a retrospective cohort registered in dementia collaborative care (N = 518). The analyses applied univariate and multivariate Cox proportional hazard regression with Firth's penalized likelihood to assess the relationship between each predictor at entry and institutionalization for survival analysis. Thirty (5.8%) patients were censored due to institutionalization after a median follow-up of one-and-a-half years. Neuropsychiatric symptoms, loss of walking ability, and living alone predicted institutionalization. Caregiver burden may partially mediate the effects of neuropsychiatric symptoms and institutionalization. High caregiver burden due to presence of neuropsychiatric symptoms may partially contribute to institutionalization among people living with dementia in Taiwan. However, proper management of neuropsychiatric symptoms and caregiver empowerment may ameliorate institutionalization risk.

Stridor as a Harbinger of Congenital Cardiovascular Anomaly.

BACKGROUND: There is an intimate spatial relationship between the cardiovascular and airway structures. Central airway compression related to congenital cardiovascular anomalies should be considered in neonates, infants, and young children presenting with stridor. METHODS: From July 31, 1990 to December 31, 2018, 24 pediatric patients, including 18 males and 6 females, aged 1 day to 11.3 years old, presenting with stridor and/or lip cyanosis were enrolled in this study. At presentation, none of the patients had a known history of congenital heart disease. Patients with congenital bronchopulmonary vascular/foregut malformations, congenital pulmonary venolobar syndrome, congenital pulmonary malinosculations, Eisenmenger syndrome, secondary pulmonary hypertension, and idiopathic pulmonary arterial hypertension were excluded from this study. Available profiles of 24 patients were reviewed and the underlying congenital cardiovascular anomalies contributing to the clinical manifestation of stridor were analyzed, including chart recordings, chest radiograms, echocardiograms, computerized tomography, electrocardiograms, esophagograms, cardiac catheterization, magnetic resonance imaging, and bronchography. RESULTS: Stridor was an early sign of congenital cardiovascular anomalies, including double aortic arch, right aortic arch (RAA) with Kommerell diverticulum, mirror-image right aortic arch with aortic diverticulum, anomalous right innominate artery, left pulmonary artery sling, RAA with tetralogy of Fallot and persistent fifth aortic arch, a vertical patent ductus arteriosus from a transverse left aortic arch, and absent pulmonary valve syndrome. Notably, chest radiography provided the first clue of RAA in 18 of the 24 patients. CONCLUSIONS: Stridor can be a harbinger of congenital cardiovascular anomalies causing central airway compression in pediatric patients.

Characteristics Predicting a High Caregiver Burden in Patients with Vascular Cognitive Impairment: Using the Apriori Algorithm to Delineate the Caring Scenario.

PURPOSE: The aim of this study was to elucidate the factors and caring scenarios associated with a moderate to severe care burden in the caregivers of patients with vascular cognitive impairment (VCI). PATIENTS AND METHODS: This cross-sectional study included 158 patients with VCI and their caregivers who were managed by the dementia collaborative care team at Changhua Christian Hospital, Taiwan. Gender, age, clinical dementia rating, walking ability, behavioral symptoms, and psychological symptoms were the variables from the patients with VCI. Age, marital status, relation to the VCI patient, education, employment status, help of key activities, type of primary care, frequency of care, ZBI (Zarit burden interview) caregiving burden, and caregiver's mood were the evaluated variables for the caregivers. The Apriori algorithm was used to identify the attributes that resulted in different caregiving burdens from a comprehensive viewpoint of both VCI patients and their caregivers. RESULTS: A total of 1193 rules were identified with 1134 rules belonging to caregivers with a mild to moderate burden and 59 rules belonging to caregivers with a moderate to severe burden. Seven general rules were created based on a summary of these 59 rules. The results showed that an employed female caregiver who was taking care of her husband alone for ≥6 days per week, and who was helping with all key activities was likely to experience a moderate to severe burden when the patient had VCI. Moreover, if the caregiver had a relatively low education level and expressed an abnormal mood during the assessment, this increased the likelihood of the caregiver having a moderate to severe burden. CONCLUSION: The caregiver's gender, relation to the care recipient, education level, mood status, employment status, and care loading were associated with a higher burden of care for caregivers of patients with VCI. Therefore, a dementia care team should provide personalized training for caregivers about the disease, care skills for specific behaviors and psychological symptoms of dementia (BPSD), and strategies to cope with their own feelings. Caregivers should also be referred to appropriate social resources, such as support groups or respite care.

A Comparison of Caregiver Burden for Different Types of Dementia: An 18-Month Retrospective Cohort Study.

BACKGROUND: This study aimed to elucidate the influence of dementia etiologies on the degree of caregiver burden and determine which factors predict a high caregiving burden. METHODS: This 18-month retrospective cohort study enrolled 630 patients and their caregivers from the Dementia Center of Changhua Christian Hospital. The care team performed face-to-face interviews every 6 months, for 18 months from when a diagnosis of dementia was made. The primary outcome was the change in Zarit Burden Interview (ZBI) scores. Generalized estimating equations were used for the longitudinal data analysis. RESULTS: Participants with Lewy body disease (LBD) had a significantly higher caregiving burden compared with those with Alzheimer's disease (AD) (ß = 3.83 ± 1.47, Wald = 6.79, p = 0.009) after adjusting for patient and caregiver features. Caregivers of mixed-type dementia and frontotemporal dementia (FTD) experienced a greater burden than caregivers of AD, at 6- and 18-month follow-up. Patients with more severe dementia, neuropsychiatric symptoms, being cared for by more than two caregivers, or utilizing social resources were associated with higher ZBI scores; the depressive mood of caregiver also predicted higher ZBI scores. CONCLUSION: This longitudinal study demonstrated that caregiver burden was influenced by the underlying dementia etiology of patients. The dementia care team should provide personalized education and transfer patients and caregivers to appropriate resources, especially for high-risk populations.

Care Needs of Community-Residing Male Patients with Vascular Cognitive Impairment.

PURPOSE: The aim of this study was to identify the care needs of male patients with vascular cognitive impairment (VCI) and their caregivers. PATIENTS AND METHODS: This cross-sectional study enrolled 389 male patients with VCI and their caregivers who were cared for by the dementia collaborative care team at Changhua Christian Hospital, Taiwan. Fifteen care needs consisting of most of quality measures for people living with dementia and their caregivers were developed by the care team. Through face-to-face evaluations, individualized care needs were collected. The Apriori algorithm was used to identify care bundles for the patients and their caregivers. RESULTS: Six basic care needs for patients and their caregivers were identified, including appropriate schedule of activities, regular outpatient follow-up treatment, introduction and referral of social resources, referral to family support groups and care skills training, care for the mood of the caregiver, and health education for dementia and behavioral and psychological symptoms of dementia. Compared to subjects with all dementia subtypes from the previous studies, care for the mood of the caregiver was an important and frequent care need for the male patients with VCI and their caregivers. A comparison among the study and similar studies was made to highlight the strength of this study concentrating on the precise selection of care needs. CONCLUSION: Collaborative dementia care teams should monitor for caregivers' depression and include this care need into the care bundle when assessing male subjects with VCI.

Using The Apriori Algorithm To Classify The Care Needs Of Patients With Different Types Of Dementia.

PURPOSE: To elucidate specific combinations of care needs for people living with dementia (PLWD) and their caregivers according to specific subtypes of dementia. PATIENTS AND METHODS: A cross-sectional study at memory clinics in Changhua Christian Hospital, Taiwan, was conducted. Five hundred and eight people living with dementia and their caregivers joined the dementia collaborative care model. The care team established 15 care needs containing most of quality measures for PLWD and their caregivers. Individualized care plans including different combinations of care needs were addressed through face-to-face assessments. Apriori algorithm was used to find specific combinations of care needs for particular groups of PLWD and their caregivers. RESULTS: This study identified the basic care needs of PLWD and caregivers including appropriate scheduling of activities, regular outpatient follow-up treatment, introduction and referral of social resources, referral to family support groups and care skills training, and health education for dementia and behavioral and psychological symptoms of dementia. Patients with Alzheimer's dementia required more care to prevent traffic accidents and getting lost, while patients with vascular dementia required more care to prevent falls. The older (≥75 years old) PLWD were associated with more needs of fall prevention and care for the mood of the caregiver, especially in the female patients with mild Alzheimer's dementia (CDR = 1). CONCLUSION: Bundling the needed care needs might be a more effective means to care for a wide variety of patients with dementia.

Vertebral artery dissection stroke in evolution presented with postural headache as initial manifestation.

In young adult, the most common etiology of acute ischemic brain infarction are arterial dissections and cardiogenic embolic stroke. Vertebral artery dissection without preceding trauma history is quite rare in young ischemic stroke patients. Postural headache is even more atypical presentation for vertebral artery dissection. It is often misdiagnosed as spontaneous intracranial hypotension. We described a 37-year-old male suffering from acute onset postural headache with stroke in evolution during hospitalization. The initial brain magnetic resonance imaging (MRI) mislead to diagnosis of ischemic lesion. Nevertheless, with the aid of single photon emission computed tomography, we are confident the patient was afflicted with ischemic/hemorrhagic lesion, instead of neoplasm or demyelinating diseases. Lateral medullary syndrome was confirmed on the repeated brain MRI. His general condition improved with steady gait and clear articulation without easychoking after adequate hydration and rehabilitation training with aspirin as secondary prevention. Cranial artery dissections is a crucial differential diagnosis while thunderclap headache happens even related to postural change without obvious neurological deficit in the beginning presentations.

Revascularization of Concurrent Renal and Cerebral Artery Stenosis in a 14-Year-Old Girl with Takayasu Arteritis and Moyamoya Syndrome.

Concurrent involvement of bilateral renal and cerebral arteries, usually incurred as stenosis, is rare in childhood-onset Takayasu arteritis (c-TA). We report the case of a 14-year-old girl, with c-TA, presenting with transient ischemic attack after endovascular revascularization for renal artery stenosis and cerebrovascular stroke after surgical revascularization for cerebral artery stenosis associated with childhood-onset moyamoya syndrome. We deem that decrease of blood pressure by endovascular revascularization and improvement of cerebral perfusion by surgical revascularization may have jeopardized the cerebral deep watershed zone to cerebral ischemia followed by cerebral hyperperfusion syndrome and caused transient ischemic attack and cerebrovascular stroke in our patient. Revascularization could be a double-edge sword for c-TA patients presenting with concomitant renal artery stenosis and cerebral artery stenosis, and should be performed with caution. Quantitative analysis of cerebral blood flow by brain magnetic resonance imaging and angiography should be performed within 48 hours after surgical revascularization in c-TA.