Does the Etiology, Phenomenology and Motor Subtype of Delirium Differ When It Occurs in Patients With An Underlying Dementia?: A Multi-Site, International Study.

OBJECTIVES: To compare the etiology, phenomenology and motor subtype of delirium in patients with and without an underlying dementia. METHODS: A combined dataset (n = 992) was collated from two databases of older adults (>65 years) from liaison psychiatry and palliative care populations in Ireland and India. Phenomenology and severity of delirium were analysed using the Delirium Symptom Rating Scale Revised (DRS-R98) and contributory etiologies for the delirium groups were ascertained using the Delirium Etiology Checklist (DEC). Delirium motor subtype was documented using the abbreviated version of the Delirium Motor Subtype Scale (DMSS4). RESULTS: Delirium superimposed on dementia (DSD) showed greater impairment in short term memory, long term memory and visuospatial ability than the delirium group but showed significantly less perceptual disturbance, temporal onset and fluctuation. Systemic infection, cerebrovascular and other Central nervous system etiology were associated with DSD while metabolic disturbance, organ insufficiency and intracranial neoplasm were associated with the delirium only group. CONCLUSION: The etiology and phenomenology of delirium differs when it occurs in the patient with an underlying dementia. We discuss the implications in terms of identification and management of this complex condition.

Why are newly qualified motorists at high crash risk? Modelling driving behaviours across the first six months of driving.

OBJECTIVE: Novice driver crash risk diminishes steeply over the first few months of driving. We explore the characteristics of driving over this period to identify behaviours that might underlie this change in risk. METHODS: We conducted a cross-sectional study of 1456 UK drivers aged 17-21 within six months of gaining their licence. We examined how various forms of driving exposure, such as weekly mileage and driving at night, were related to duration of licencing. We explored the factor structure of the Early Driving Development Questionnaire (EDD-Q); a new instrument designed to measure safety relevant attitudes and behaviours in recently qualified drivers. We examined the relationship of the derived factors to licence duration. RESULTS: There was little evidence that greater exposure to risky driving situations was more common in those with shorter licence durations. Exploratory and Confirmatory Factor Analyses identified EDD-Q factors measuring risky style (12 items), skill deficiencies (8 items) and driving confidence (4 items). Licence duration was positively correlated with both risky style and confidence, with these relationships stronger for older novices. Licence duration was also negatively related to skill deficiencies (i.e., positively correlated with perceived driving skill development): this relationship was stronger in younger novices. CONCLUSIONS: The negative correlation between license duration and skill deficiencies is consistent with the observation of decreasing novice crash involvement as experience is gained. The EDD-Q offers a new brief measure of aberrant driving that is specifically tailored for newly qualified drivers.

Building a transdisciplinary expert consensus on the cognitive drivers of performance under pressure: An international multi-panel Delphi study.

Introduction: The ability to perform optimally under pressure is critical across many occupations, including the military, first responders, and competitive sport. Despite recognition that such performance depends on a range of cognitive factors, how common these factors are across performance domains remains unclear. The current study sought to integrate existing knowledge in the performance field in the form of a transdisciplinary expert consensus on the cognitive mechanisms that underlie performance under pressure. Methods: International experts were recruited from four performance domains [(i) Defense; (ii) Competitive Sport; (iii) Civilian High-stakes; and (iv) Performance Neuroscience]. Experts rated constructs from the Research Domain Criteria (RDoC) framework (and several expert-suggested constructs) across successive rounds, until all constructs reached consensus for inclusion or were eliminated. Finally, included constructs were ranked for their relative importance. Results: Sixty-eight experts completed the first Delphi round, with 94% of experts retained by the end of the Delphi process. The following 10 constructs reached consensus across all four panels (in order of overall ranking): (1) Attention; (2) Cognitive Control-Performance Monitoring; (3) Arousal and Regulatory Systems-Arousal; (4) Cognitive Control-Goal Selection, Updating, Representation, and Maintenance; (5) Cognitive Control-Response Selection and Inhibition/Suppression; (6) Working memory-Flexible Updating; (7) Working memory-Active Maintenance; (8) Perception and Understanding of Self-Self-knowledge; (9) Working memory-Interference Control, and (10) Expert-suggested-Shifting. Discussion: Our results identify a set of transdisciplinary neuroscience-informed constructs, validated through expert consensus. This expert consensus is critical to standardizing cognitive assessment and informing mechanism-targeted interventions in the broader field of human performance optimization.

How do delirium motor subtypes differ in phenomenology and contributory aetiology? a cross-sectional, multisite study of liaison psychiatry and palliative care patients.

OBJECTIVES: To investigate whether delirium motor subtypes differ in terms of phenomenology and contributory aetiology. DESIGN: Cross-sectional study. SETTING: International study incorporating data from Ireland and India across palliative care, old age liaison psychiatry and general adult liaison psychiatry settings. PARTICIPANTS: 1757 patients diagnosed with delirium using criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM IV). PRIMARY AND SECONDARY OUTCOME MEASURES: Hyperactive, mixed and hypoactive delirium subtypes were identified using the abbreviated version of the Delirium Motor Subtype Scale. Phenomenology was assessed using the Delirium Rating Scale Revised. Contributory aetiologies were assessed using the Delirium Aetiology Checklist (DEC), with a score >2 indicating that the aetiology was likely or definitely contributory. RESULTS: Hypoactive delirium was associated with dementia, cerebrovascular and systemic infection aetiologies (p<0.001) and had a lower overall burden of delirium symptoms than the other motor subtypes. Hyperactive delirium was associated with younger age, drug withdrawal and the DEC category other systemic aetiologies (p<0.001). Mixed delirium showed the greatest symptom burden and was more often associated with drug intoxication and metabolic disturbance (p<0.001). All three delirium motor subtypes had similar levels of impairment in attention and visuospatial functioning but differed significantly when compared with no subtype (p<0.001). CONCLUSIONS: This study indicates a pattern of aetiology and symptomatology of delirium motor subtypes across a large international sample that had previously been lacking. It serves to improve our understanding of this complex condition and has implications in terms of early detection and management of delirium.

The problem in differentiation between psoriatic-related polyenthesitis and fibromyalgia.

The recognition of the primacy of enthesitis in animal models of spondyloarthritis and the prevalence of clinically occult enthesopathy in psoriatic subjects and of persistent joint pain in PsA subjects who have ostensibly good reduction of joint swelling under biological therapy has highlighted the potential impact of polyenthesitis in psoriatic disease. In daily practice, the formal demonstration of enthesitis is challenging for the following reasons: the relatively avascular nature of enthesis, often leading to the absence of overt clinical inflammatory signs; the frequent lack of elevation of inflammatory markers; and finally, the limitations of current imaging techniques to provide supportive evidence for inflammation in these areas. Consequently, enthesitis may present as widespread pain indistinguishable from FM or may emerge as the dominant feature after successful biological therapy for suppression of synovitis. The unmet needs in the differentiation between FM and enthesitis in psoriatic disease patients are highlighted and critically evaluated in this article.

Comparison of sleep structure and psychometric profiles in patients with fibromyalgia, osteoarthritis and healthy controls.

While research indicates that both the macro- and microstructure of sleep may be altered in fibromyalgia syndrome, few studies have controlled for symptom duration or included pain-control participants (i.e. patients with chronic pain and sleep disturbance not associated with fibromyalgia syndrome). A frequently reported alteration found in the sleep microstructure of patients with fibromyalgia syndrome is the alpha-delta sleep anomaly. Although alpha waves have been observed during N3 sleep in healthy individuals, it has been proposed that there is an increase in alpha wave activity during slow-wave sleep in fibromyalgia syndrome. Originally considered a possible neurological contribution to fibromyalgia syndrome, whether the alpha-delta sleep anomaly is fundamental to the development of fibromyalgia syndrome, or results mainly from the pain experience remains unknown. The present study was designed to compare sleep macro- and microstructure, and psychometric profiles, in three broadly age-matched groups of female participants: patients with fibromyalgia syndrome (n = 19); patients with osteoarthritis with sleep disturbance (n = 17); and healthy adults (n = 10). Patients with fibromyalgia syndrome met the American College of Rheumatology diagnostic criteria and were recruited within 6 months of diagnosis. Subjective sleep quality was significantly lowest, and levels of anxiety and depressive symptoms were significantly highest for patients with fibromyalgia syndrome. However, the groups showed no significant differences in polysomnographic measures of total sleep time, sleep latency and total wake after sleep onset. Levels of alpha-delta sleep were statistically similar in both clinical (fibromyalgia syndrome and osteoarthritis) groups, indicating that it is not a specific abnormality of fibromyalgia syndrome. Overall, subjective measurements of anxiety, depression, fatigue and sleep quality better discriminated between the three groups than did objective measurements of sleep variables.

Development of the four-item Letter and Shape Drawing test (LSD-4): A brief bedside test of visuospatial function.

Conventional bedside tests of visuospatial function such as the Clock Drawing (CDT) and Intersecting Pentagons (IPT) lack consistency in delivery and interpretation. We compared performance on a novel test of visuospatial ability - the LSD - with the IPT, CDT and MMSE in 180 acute elderly medical inpatients [mean age 79.7±7.1 (range 62-96); 91 females (50.6%)]. 124 (69%) scored ≤23 on the MMSE; 60 with mild (score 18-23) and 64 with severe (score ≤17) impairment. 78 (43%) scored ≥6 on the CDT, while for the IPT, 87 (47%) scored ≥4. The CDT and IPT agreed on the classification of 138 patients (77%) with modest-strong agreement with the MMSE categories. Correlation between the LSD and visuospatial tests was high. A four-item version of the LSD incorporating items 1,10,12,15 had high correlation with the LSD-15 and strong association with MMSE categories. The LSD-4 provides a brief and easily interpreted bedside test of visuospatial function that has high coverage of elderly patients with neurocognitive impairment, good agreement with conventional tests of visuospatial ability and favourable ability to identify significant cognitive impairment. [181 words].

Identifying beliefs underlying pre-drivers' intentions to take risks: An application of the Theory of Planned Behaviour.

Novice motorists are at high crash risk during the first few months of driving. Risky behaviours such as speeding and driving while distracted are well-documented contributors to crash risk during this period. To reduce this public health burden, effective road safety interventions need to target the pre-driving period. We use the Theory of Planned Behaviour (TPB) to identify the pre-driver beliefs underlying intentions to drive over the speed limit (N=77), and while over the legal alcohol limit (N=72), talking on a hand-held mobile phone (N=77) and feeling very tired (N=68). The TPB explained between 41% and 69% of the variance in intentions to perform these behaviours. Attitudes were strong predictors of intentions for all behaviours. Subjective norms and perceived behavioural control were significant, though weaker, independent predictors of speeding and mobile phone use. Behavioural beliefs underlying these attitudes could be separated into those reflecting perceived disadvantages (e.g., speeding increases my risk of crash) and advantages (e.g., speeding gives me a thrill). Interventions that can make these beliefs safer in pre-drivers may reduce crash risk once independent driving has begun.

The Letter and Shape Drawing (LSD) test: An efficient and systematised approach to testing of visuospatial function.

The automation and systemisation of the next generation of cognitive assessment approaches have the potential to change how clinicians assess and interact with patients. This may be especially pertinent in the case of delirium, as current methods often rely on the subjective opinion of clinicians and specialists, with potential for the condition to be overlooked or misdiagnosed. Currently, one of the most commonly used tests, is the clock-drawing test, which has relatively wide appeal as a cognitive screening instrument due to its clinical utility and psychometric properties. However, there are a number of inconsistencies associated with its use and interpretation. In this paper, we describe a new assessment methodology that we have developed, facilitated by the advances in tablet technology. In trials, our "Letter and Shape Drawing (LSD)" tool, involving both an automated scoring capability and a simpler user interaction, has demonstrated correlation with other conventional cognitive test methods although some optimisation requirements remain.

Novice drivers' individual trajectories of driver behavior over the first three years of driving.

Identifying the changes in driving behavior that underlie the decrease in crash risk over the first few months of driving is key to efforts to reduce injury and fatality risk in novice drivers. This study represented a secondary data analysis of 1148 drivers who participated in the UK Cohort II study. The Driver Behavior Questionnaire was completed at 6 months and 1, 2 and 3 years after licensure. Linear latent growth models indicated significant increases across development in all four dimensions of aberrant driving behavior under scrutiny: aggressive violations, ordinary violations, errors and slips. Unconditional and conditional latent growth class analyses showed that the observed heterogeneity in individual trajectories was explained by the presence of multiple homogeneous groups of drivers, each exhibiting specific trajectories of aberrant driver behavior. Initial levels of aberrant driver behavior were important in identifying sub-groups of drivers. All classes showed positive slopes; there was no evidence of a group of drivers whose aberrant behavior decreased over time that might explain the decrease in crash involvement observed over this period. Male gender and younger age predicted membership of trajectories with higher levels of aberrant behavior. These findings highlight the importance of early intervention for improving road safety. We discuss the implications of our findings for understanding the behavioral underpinnings of the decrease in crash involvement observed in the early months of driving.

Measuring errors and violations on the road: a bifactor modeling approach to the Driver Behavior Questionnaire.

The Driver Behavior Questionnaire (DBQ) is a self-report measure of driving behavior that has been widely used over more than 20 years. Despite this wealth of evidence a number of questions remain, including understanding the correlation between its violations and errors sub-components, identifying how these components are related to crash involvement, and testing whether a DBQ based on a reduced number of items can be effective. We address these issues using a bifactor modeling approach to data drawn from the UK Cohort II longitudinal study of novice drivers. This dataset provides observations on 12,012 drivers with DBQ data collected at .5, 1, 2 and 3 years after passing their test. A bifactor model, including a general factor onto which all items loaded, and specific factors for ordinary violations, aggressive violations, slips and errors fitted the data better than correlated factors and second-order factor structures. A model based on only 12 items replicated this structure and produced factor scores that were highly correlated with the full model. The ordinary violations and general factor were significant independent predictors of crash involvement at 6 months after starting independent driving. The discussion considers the role of the general and specific factors in crash involvement.

Certolizumab pegol plus MTX administered every 4 weeks is effective in patients with RA who are partial responders to MTX.

OBJECTIVE: Certolizumab pegol (CZP) is known to be effective as monotherapy at a dosage of 400 mg every 4 weeks in patients with active RA who have failed DMARDs. The aim of this study was to investigate every 4-week CZP in addition to continued MTX therapy in patients with an inadequate response to MTX alone. METHODS: Patients with active RA with inadequate response to MTX, on background MTX, were randomized to double-blind treatment with CZP 400 mg or placebo every 4 weeks for 24 weeks (NCT00544154). The primary efficacy end-point was the ACR 20% improvement criteria (ACR20) response rate at Week 24. Other end-points included ACR50 and ACR70 response rates, ACR core components, 28-joint DAS (ESR) with three variables (DAS28-3) and health-related quality-of-life outcomes in addition to safety. RESULTS: Of 247 randomized patients, 126 received CZP and 121 received placebo, in addition to MTX. ACR20 response rates were 45.9 vs 22.9%, respectively [P < 0.001 analysed by the Cochran-Mantel-Haenszel (CMH) method], with improvements being apparent from Week 1. Statistically significant improvements over placebo were seen with CZP for ACR50, ACR core components, DAS28-3 and physical functioning. Rates of treatment-related adverse events were similar between groups (25.0 vs 27.7%), and there were no deaths or serious opportunistic infections. CONCLUSION: CZP 400 mg every 4 weeks plus MTX demonstrated a favourable risk-benefit profile with rapid onset of action in RA patients with an inadequate response to an earlier MTX therapy.