Identifying biopsychosocial factors that impact decompressive laminectomy outcomes in veterans with lumbar spinal stenosis: a prospective cohort study.

ABSTRACT: One in 3 patients with lumbar spinal stenosis undergoing decompressive laminectomy (DL) to alleviate neurogenic claudication do not experience substantial improvement. This prospective cohort study conducted in 193 Veterans aimed to identify key spinal and extraspinal factors that may contribute to a favorable DL outcome. Biopsychosocial factors evaluated pre-DL and 1 year post-DL were hip osteoarthritis, imaging-rated severity of spinal stenosis, scoliosis/kyphosis, leg length discrepancy, comorbidity, fibromyalgia, depression, anxiety, pain coping, social support, pain self-efficacy, sleep, opioid and nonopioid pain medications, smoking, and other substance use. The Brigham Spinal Stenosis (BSS) questionnaire was the main outcome. Brigham Spinal Stenosis scales (symptom severity, physical function [PF], and satisfaction [SAT]) were dichotomized as SAT < 2.42, symptom severity improvement ≥ 0.46, and PF improvement ≥ 0.42, and analyzed using logistic regression. Sixty-two percent improved in 2 of 3 BSS scales (ie, success). Baseline characteristics associated with an increased odds of success were-worse BSS PF (odds ratio [OR] 1.24 [1.08-1.42]), greater self-efficacy for PF (OR 1.30 [1.08-1.58]), lower self-efficacy for pain management (OR 0.80 [0.68-0.94]), less apparent leg length discrepancy (OR 0.71 [0.56-0.91]), greater self-reported alcohol problems (OR 1.53 [1.07-2.18]), greater treatment credibility (OR 1.31 [1.07-1.59]), and moderate or severe magnetic resonance imaging-identified central canal stenosis (OR 3.52 [1.06-11.6]) moderate, OR 5.76 [1.83-18.1] severe). Using opioids was associated with lower odds of significant functional improvement (OR 0.46 [0.23-0.93]). All P < 0.05. Key modifiable factors associated with DL success-self-efficacy, apparent leg length inequality, and opioids-require further investigation and evaluation of the impact of their treatment on DL outcomes.

A Mind-Body Program for Older Adults With Chronic Low Back Pain: A Randomized Clinical Trial.

IMPORTANCE: Treatment of chronic low back pain (LBP) in older adults is limited by the adverse effects of analgesics. Effective nonpharmacologic treatment options are needed. OBJECTIVE: To determine the effectiveness of a mind-body program at increasing function and reducing pain in older adults with chronic LBP. DESIGN, SETTING, AND PARTICIPANTS: This single-blind, randomized clinical trial compared a mind-body program (n = 140) with a health education program (n = 142). Community-dwelling older adults residing within the Pittsburgh metropolitan area were recruited from February 14, 2011, to June 30, 2014, with 6-month follow-up completed by April 9, 2015. Eligible participants were 65 years or older with functional limitations owing to their chronic LBP (≥11 points on the Roland and Morris Disability Questionnaire) and chronic pain (duration ≥3 months) of moderate intensity. Data were analyzed from March 1 to July 1, 2015. INTERVENTIONS: The intervention and control groups received an 8-week group program followed by 6 monthly sessions. The intervention was modeled on the Mindfulness-Based Stress Reduction program; the control program, on the "10 Keys" to Healthy Aging. MAIN OUTCOMES AND MEASURES: Follow-up occurred at program completion and 6 months later. The score on the Roland and Morris Disability Questionnaire was the primary outcome and measured functional limitations owing to LBP. Pain (current, mean, and most severe in the past week) was measured with the Numeric Pain Rating Scale. Secondary outcomes included quality of life, pain self-efficacy, and mindfulness. Intent-to-treat analyses were conducted. RESULTS: Of 1160 persons who underwent screening, 282 participants enrolled in the trial (95 men [33.7%] and 187 women [66.3%]; mean [SD] age,74.5 [6.6] years). The baseline mean (SD) Roland and Morris Disability Questionnaire scores for the intervention and control groups were 15.6 (3.0) and 15.4 (3.0), respectively. Compared with the control group, intervention participants improved an additional -1.1 (mean, 12.1 vs 13.1) points at 8 weeks and -0.04 (mean, 12.2 vs 12.6) points at 6 months (effect sizes, -0.23 and -0.08, respectively) on the Roland and Morris Disability Questionnaire. By 6 months, the intervention participants improved on the Numeric Pain Rating Scale current and most severe pain measures an additional -1.8 points (95% CI, -3.1 to -0.05 points; effect size, -0.33) and -1.0 points (95% CI, -2.1 to 0.2 points; effect size, -0.19), respectively. The changes in Numeric Pain Rating Scale mean pain measure after the intervention were not significant (-0.1 [95% CI, -1.1 to 1.0] at 8 weeks and -1.1 [95% CI, -2.2 to -0.01] at 6 months; effect size, -0.01 and -0.22, respectively). CONCLUSIONS AND RELEVANCE: A mind-body program for chronic LBP improved short-term function and long-term current and most severe pain. The functional improvement was not sustained, suggesting that future development of the intervention could focus on durability. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01405716.

Pain and decreased cognitive function negatively impact physical functioning in older adults with knee osteoarthritis.

OBJECTIVE: We hypothesized that among community-dwelling older adults without dementia with advanced chronic knee osteoarthritis (OA) pain: 1) higher levels of self-reported pain would be associated with decreased executive cognitive function and decreased physical function; and 2) decreased cognitive function would be associated with decreased physical function. METHODS: Substudy on 79 older adults who were participants in a Veterans Affairs clinical trial of periosteal stimulation therapy for advanced painful knee OA. Participants were ≥ 60 years, had radiographic evidence of Kellgren-Lawrence 3 or 4 knee OA on a standing anterior-posterior X-ray, had pain of at least moderate intensity and of at least 3 months' duration, and knee pain severity greater than pain severity in other parts of the body. Measures included computerized cognitive tests of executive function, pain, and physical function (gait speed and stair climbing). RESULTS: As pain scores worsened, gait speed and stair climbing worsened (P = 0.007 and P = 0.035, respectively). Lower performance on the executive function tests was also significantly associated with decreased gait speed and stair climbing (P = 0.002 and P = 0.014, respectively). We did not find a significant relationship between pain and cognitive function. We explored the relationship between pain and physical function adjusted for executive functioning and found that pain was no longer associated with gait speed (P = 0.06). CONCLUSION: Worse pain scores and executive function scores were associated with worse physical function in older adults with painful knee OA. This suggests that slower gait speed in patients could be an indication to clinicians to monitor their patient's cognitive function. Executive function in particular affected the relationship between gait speed and pain, suggesting a possible mediating relationship.

Association between Cognitive Decline in Older Adults and Use of Primary Care Physician Services in Pennsylvania.

OBJECTIVE: To assess the relationship between cognitive decline of older patients (≥ 65 y) and use of primary care physician (PCP) services over 24 months. DESIGN: Retrospective analysis of prospectively collected data from a cluster randomized trial that took place from 2006-2010 and investigated the relationship between formal neuropsychological evaluation and patient outcomes in primary care. SETTING: Twenty-four PCPs in 11 practices in southwestern Pennsylvania. Most practices were suburban and included more than 5 PCPs. PARTICIPANTS: A sample of 423 primary care patients 65 years old or older. MEASUREMENTS: The association between the number of PCP visits and a decline in cognitive status, as determined by multivariable analyses that controlled for patient-level, physician-level, and practice-level factors (eg, patient age, comorbidities, and symptoms of depression; practice location and size; PCP age and sex) and used a linear mixed model with a random intercept to adjust for clustering. RESULTS: Over a 2-year follow-up, 199 patients (47.0%) experienced a decline in cognitive status. Patients with a cognitive decline had a mean of 0.69 more PCP visits than did patients without a cognitive decline (P < .05). CONCLUSIONS: Early signs of cognitive decline may be an indicator of greater use of primary care. Given the demographic trends, more PCPs are likely to be needed to meet the increasing needs of the older population.

High medical co-morbidity and family history of dementia is associated with lower cognitive function in older patients.

BACKGROUND: Risk factors for cognitive decline in ageing are multifactorial, including medical co-morbidities and familial genetic risk. OBJECTIVES: To assess the effect of medical co-morbidity and family history of dementia on cognitive performance in older outpatients of family practitioners. METHODS: Analysis of 535 outpatients from 11 practices aged 65 and older, without a diagnosis of dementia. Information on medical co-morbidities, family history of dementia and cognitive test data were obtained. RESULTS: Patients were classified into high or low medical co-morbidities (<7 versus >8) and positive or negative family history of dementia. After controlling for age, education, gender and depression, global cognitive test scores, as well as memory, executive function, spatial ability and attention were significantly lower for persons having a high number of medical co-morbidities. Cognitive test scores were not significantly different for persons with or without a family history of dementia. A significant interaction between medical co-morbidities and family history of dementia was observed for the global cognitive score, executive function and spatial ability. Those persons with a high number of medical co-morbidities and positive family history of dementia had the lowest performance. Separate regression analysis assessing individual disease risk factors (e.g. hypertension and diabetes) did not find any relationship between specific medical variables and cognitive test scores for any of the subgroups. CONCLUSIONS: A high number of medical co-morbidities in addition to a reported family history of dementia are particularly detrimental to cognitive performance in elderly non-demented family practice patients.

Association of blood lead concentrations with mortality in older women: a prospective cohort study.

BACKGROUND: Blood lead concentrations have been associated with increased risk of cardiovascular, cancer, and all-cause mortality in adults in general population and occupational cohorts. We aimed to determine the association between blood lead, all cause and cause specific mortality in elderly, community residing women. METHODS: Prospective cohort study of 533 women aged 65-87 years enrolled in the Study of Osteoporotic Fractures at 2 US research centers (Baltimore, MD; Monongahela Valley, PA) from 1986-1988. Blood lead concentrations were determined by atomic absorption spectrometry. Using blood lead concentration categorized as < 8 microg/dL (0.384 micromol/L), and > or = 8 microg/dL (0.384 micromol/L), we determined the relative risk of mortality from all cause, and cause-specific mortality, through Cox proportional hazards regression analysis. RESULTS: Mean blood lead concentration was 5.3 +/- 2.3 microg/dL (range 1-21) [0.25 +/- 0.11 micromol/L (range 0.05-1.008)]. After 12.0 +/- 3 years of > 95% complete follow-up, 123 (23%) women who died had slightly higher mean (+/- SD) blood lead 5.56 (+/- 3) microg/dL [0.27(+/- 0.14) micromol/L] than survivors: 5.17(+/- 2.0) [0.25(+/- 0.1) micromol/L] (p = 0.09). Women with blood lead concentrations > or = 8 microg/dL (0.384 micromol/L), had 59% increased risk of multivariate adjusted all cause mortality (Hazard Ratio [HR], 1.59; 95% confidence interval [CI], 1.02-2.49) (p = 0.041) especially coronary heart disease (CHD) mortality (HR = 3.08 [CI], (1.23-7.70)(p = 0.016), compared to women with blood lead concentrations < 8 microg/dL(< 0.384 mumol/L). There was no association of blood lead with stroke, cancer, or non cardiovascular deaths. CONCLUSION: Women with blood lead concentrations of > or = 8 microg/dL (0.384 micromol/L), experienced increased mortality, in particular from CHD as compared to those with lower blood lead concentrations.

Association of cumulative lead and neurocognitive function in an occupational cohort.

Lead is a neurotoxicant that accumulates in bone with a half life of 25-30 years. To evaluate the association of lead biomarkers and cognitive function, a cohort of exposed and nonexposed workers who had been previously assessed in 1982 was retested approximately 22 years later. For the current assessment, both blood lead and tibia bone lead levels were determined. In addition, cognitive function was tested with the Pittsburgh Occupational Exposures Test battery, which had previously been administered in 1982. In exposed workers, bone lead level predicted lower current cognitive performance and cognitive decline over 22 years. In those lead-exposed workers older than age 55, higher levels of bone lead predicted poorer cognitive scores, suggesting vulnerability for older workers with higher past lead exposure. Finally, there was no association with bone lead level and recency of exposure, suggesting that cumulative body burden is most likely responsible for the progressive cognitive decrement evidenced with vulnerability because of aging.

Subjective memory complaints and concurrent memory performance in older patients of primary care providers.

Subjective memory complaints (SMCs) are known to be inconsistently related to current memory impairment in older adults but this association has not been well investigated in primary care provider (PCP) settings. To characterize the complexity of the relationship between SMCs and objective memory in older outpatients of PCPs, we collected neuropsychological, subjective memory, depression and medical chart data from outpatients aged 65 and older, without documented dementia diagnoses, in eleven PCP offices in and around the Pittsburgh metropolitan area. Results indicated that self-estimates of current memory ability were most strongly associated with objective memory performance; in contrast, perception of worsening memory over the past year showed no association; and specific memory-related activities were only weakly associated. Women were more likely than men to show inconsistency between SMCs and objective memory performance. Only two of the 11 most significantly memory-impaired participants endorsed SMCs and only four had PCP chart documentation of memory problems. Eliciting SMCs in non-demented older adults can be of clinical value in a PCP setting, but significant limitations of patient self-report in more memory-impaired patients underscore the need to develop brief, objective indicators of memory impairment for PCP office use when there is suspicion of decline.

Semantic memory in schizophrenia: association with cell membrane essential fatty acids.

INTRODUCTION: Semantic memory and language deficits are associated with schizophrenia. Understanding how these systems operate in this disorder will likely require a multi-factorial model that explains their linkages with cognition and modulation by dopamine. A biological factor that may provide causal convergence for these connections is cell membrane composition and dynamics. METHODS: N400 is an electrophysiological measure of semantic memory and language that is sensitive to deficits in schizophrenia. Relationships among N400, cognition, dopamine, and cell membrane polyunsaturated fatty acids (PUFAs) were examined for patients tested under medicated (haloperidol only) and unmedicated (placebo) conditions. Relationships between these factors and clinical symptoms were also evaluated. The sample included 37 male schizophrenia inpatients and 34 male normal controls. The N400 priming effect was measured from visual event-related potentials recorded during a semantic priming-lexical decision task, in which semantic association (related versus unrelated words) and presentation rate (Stimulus Onset Asynchrony/SOAs: 350 and 950 ms) were varied. RESULTS: N400 was associated with cognition (speed, visuoperception, attention) in patients and controls. These relationships were influenced by SOA in both groups, and by pharmacological condition in patients. Levels of total PUFAs and arachidonic acid were associated with N400 in unmedicated patients. Clinical symptoms (paranoia, thought disturbance) were associated with N400, but not with cognition or PUFAs. CONCLUSIONS: Results suggest cell membrane fatty acids are associated with semantic memory and language in schizophrenia. Findings also suggest a series of linkages that are modulated by dopamine: cell membrane fatty acids are associated with N400 semantic priming; N400 semantic priming is associated with clinical symptoms.

Cognitive status and physical function in older african americans.

OBJECTIVES: To investigate the relationship between global cognition, three specific domains of cognition, and lower extremity function in community-dwelling elderly African Americans (AAs) from two community settings. DESIGN: Cross-sectional study. SETTING: Community. PARTICIPANTS: Ninety-six AA men and women aged 60 and older from two community settings, enrolled in the Boosting Minority Involvement (BMI) study, a community-based cohort study designed to increase research participation of older low-income AAs. MEASUREMENTS: Physical performance was assessed using Short Physical Performance Battery score, which is composed of three timed tests: a 4-m walking task, static balance assessment, and a chair stand test. The Bushke Memory Impairment Screen (MIS) and Mini-Mental State Examination were used to assess global memory and global cognition, respectively. For domain-specific performance, three z-score composite scores (attention, verbal memory, and executive function) were developed using the Computer-based Assessment of Mild Cognitive Impairment. RESULTS: All domains of cognition were significant predictors of lower extremity function except for verbal memory. Executive function and MIS were the best predictors of lower extremity function in adjusted models. Participants with poor executive function were more than four times as likely to have poorer lower extremity function (odds ratio=4.96, 95% confidence interval=1.07-23.0). CONCLUSION: Global memory and executive function were the best predictors of lower extremity function in a sample of community-dwelling AA adults. Deficits in lower extremity function may depend on multifaceted higher executive function control processes.

Corpus callosum volume in railroad workers with chronic exposure to solvents.

OBJECTIVE: Changes to cognition and behavior have been reported after long-term exposure to solvents. Solvents are hypothesized to affect brain white matter. To test this, we examined the volume of the corpus callosum in workers with a history of exposure to solvents. METHODS: We manually traced (blind to group membership) the volume of the corpus callosum in 31 railroad workers and 31 matched controls. RESULTS: There was a decrease in the genu of the corpus callosum in the solvent-exposed workers compared with controls. A smaller volume of the genu of the corpus callosum was associated with greater exposure and worse performance on cognitive tasks. CONCLUSIONS: This study supports the hypothesis that occupational exposure to solvents affects the anterior white matter of the brain and is related to extent of exposure and degree of cognitive change.

Neuropsychological function and employment status in a welfare-to-work sample.

Since 1996, individuals who participate in welfare programs are mandated to find employment. Welfare recipients may have difficulty transitioning to the workforce due to impairments in psychosocial functioning. Examples include mental health and substance use disorders, medical problems, academic and learning difficulties, and lack of resources such as childcare and transportation. An area unexplored as a potential barrier is cognitive functioning as influencing recipient's ability to transition into the workforce. This is important because many Welfare to Work (WtW) recipients have personal risk factors related to impaired cognitive ability. We evaluated the relationship between demographics, cognitive functioning, and substance abuse severity in a group of 180 WtW recipients in order to assess predictors of employment impairment. No relationship was found between employment functioning and alcohol use, drug use, or psychiatric impairment. However neuropsychological test results demonstrate that WtW study participants with lower scores on tests of general intelligence are more impaired in their employment functioning. General intelligence emerged as the best predictor of employment functioning. The results have implications for identifying individuals at risk for unsuccessful transition into the workforce and for the development of effective vocational rehabilitation strategies.

Efficacy of percutaneous electrical nerve stimulation for the treatment of chronic low back pain in older adults.

OBJECTIVES: To determine the efficacy of a complementary analgesic modality, percutaneous electrical nerve stimulation (PENS), for the treatment of chronic low back pain (CLBP) in community-dwelling older adults. DESIGN: Randomized, controlled clinical trial. SETTING: University of Pittsburgh Pain Evaluation and Treatment Institute. PARTICIPANTS: Thirty-four English speaking, community-dwelling adults aged 65 and older with CLBP of at least moderate intensity experienced every day or almost every day. INTERVENTION: Subjects were randomized to receive twice-weekly PENS and physical therapy (PT) or sham PENS and physical therapy for 6 weeks. MEASUREMENTS: At baseline, immediately after the 6-week intervention period, and 3 months later, the primary outcome measures pain intensity and pain-related disability were assessed. The secondary outcome measures physical performance (timed chair rise, functional reach, gait speed, static and isoinertial lifting), psychosocial factors (mood, sleep, and life control), and cognitive function (measures of attention, concentration, and mental flexibility) were also collected. RESULTS: Subjects randomized to PENS plus PT displayed significant reductions in pain intensity measures from pre- to posttreatment (P <.001), but the sham PENS plus PT group did not (P =.94). These pain reduction effects were maintained at 3-month follow-up. Similarly, significant reductions in pain-related disability were observed at posttreatment (P =.002) for the PENS plus PT group and were maintained at follow-up, but the sham PENS plus PT group did not show reductions in pain-related disability (P =.81). Of the secondary outcome measures, psychosocial function, timed chair rise, and isoinertial lifting endurance also improved significantly at posttreatment for the PENS plus PT group, and their improvement was sustained at 3-month follow-up, but the sham PENS plus PT did not display significant changes on these measures after treatment. CONCLUSION: This preliminary study suggests that PENS may be a promising treatment modality for community-dwelling older adults with CLBP, as demonstrated by reduction in pain intensity and self-reported disability, and improvement in mood, life control, and physical performance. Larger studies with longer duration of follow-up are needed to validate these findings and support the use of PENS in clinical practice.

Normative data for a working memory test: the four word short-term memory test.

A number of tests of short-term memory based on the Brown-Peterson paradigm (recall of either trigrams or short words after varying distractor intervals) have been utilized by neuropsychologists in both clinical practice and in research protocols. The present study provides normative data for a large group of subjects (N=350) aged 18-65 on the Four Word Short-Term Memory Test, a measure of working memory based on the Brown-Peterson paradigm. The Four Word Short-Term Memory Test presents subjects with four words at the rate of one word per second and subjects are then asked to recall the words following a distractor interval of counting backwards by threes for 5, 15 or 30 s. Normative data is stratified by age and education and presented in overlapping midpoint intervals. Percentile rankings based on age and education are also provided.

Comparison of neuropsychological test scores between men and women with prior exposure to organic solvents.

The purpose of this study was to determine whether men and women with a history of similar exposure to organic solvents demonstrate differences in neuropsychological performance. An equal number of men and women were compared on a battery of neuropsychological tests. Men and women were matched on age, education, and past history of exposure (i.e., length of exposure, recency of exposure, and history of peak exposure). With the exception of 1 test, there were no differences between men and women on any of the cognitive tests. There were also no differences in self-reported psychological symptoms. There was, however, a different pattern of correlations between test scores and exposure for the men and women: In women, exposure was associated with tests of attention and processing speed, whereas in men, exposure was associated with verbal memory. After controlling for age and education, the findings were diminished for men but remained significant for women. Overall, the results show no differences in neuropsychological test scores between men and women when matched on exposure variables but raise the possibility of differences in the pattern of cognitive deficits associated with solvent exposure between men and women.