Cognitive dysfunction and associated neuroimaging biomarkers in antiphospholipid syndrome: a systematic review.

OBJECTIVES: Cognitive dysfunction is common in patients with aPL (including primary APS or APS associated with SLE). Neuroimaging biomarkers may contribute to our understanding of mechanisms of cognitive dysfunction in these cohorts. This review aimed to investigate: (i) the prevalence of cognitive dysfunction in studies including neuroimaging biomarkers; and (ii) associations between cognition and neuroimaging biomarkers in patients with APS/aPL. METHODS: We conducted a systematic search of electronic databases PubMed, Science Direct, Scopus and PsycINFO, and included studies with descriptions of neuroimaging findings, cognitive dysfunction or both, in patients with aPL positivity (LA, IgG and IgM aCL and anti-ß2 glycoprotein-I antibodies). RESULTS: Of 120 search results we included 20 eligible studies (6 APS, 4 SLE with APS/aPL and 10 NPSLE). We identified a medium risk of bias in 6/11 (54%) of cohort studies and 44% of case-control studies, as well as marked heterogeneity in cognitive assessment batteries, APS and aPL definitions, and neuroimaging modalities and protocols. The prevalence of cognitive dysfunction ranged between 11 and 60.5%. Structural MRI was the most common imaging modality, reporting cognitive dysfunction to be associated with white matter hyperintensities, ischaemic lesions and cortical atrophy (four with cerebral atrophy, two with white matter hyperintensities and two with cerebral infarcts). CONCLUSION: Our findings confirm that cognitive impairment is commonly found in patients with aPL (including APS, SLE and NPSLE). The risk of bias, and heterogeneity in the cognitive and neuroimaging biomarkers reported does not allow for definitive conclusions.

Cognitive impairment before and after intracerebral haemorrhage: a systematic review.

INTRODUCTION: There is increasing interest in understanding cognitive dysfunction before and after Intracerebral haemorrhage (ICH), given the higher prevalence of dementia reported (ranging from 5 to 44%) for this stroke type. Much of the evidence to date examining cognitive impairment associated with cerebrovascular disease has tended to focus more on ischaemic stroke. The aim of this review was to identify and quantify studies that focused on cognitive dysfunction pre and post ICH. METHODS: We conducted a systematic search using databases PubMed, Science Direct, Scopus and PsycINFO to identify studies that exclusively assessed cognitive function pre and post ICH. Studies were included in the review if used a measure of global cognition and/or a neuropsychological battery to assess cognitive function. Nineteen studies were deemed relevant for inclusion, where n = 8 studies examined cognitive impairment pre ICH and n = 11 post ICH. RESULTS: Prevalence of cognitive impairment ranged between 9-29% for pre ICH and 14-88% for post ICH. Predictive factors identified for pre and post ICH were previous stroke, ICH volume and location and markers of cerebral amyloid angiopathy (CAA). Most common cognitive domains affected post ICH were information processing speed, executive function, memory, language and visuo-spatial abilities. Most common cognitive assessments tools were the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) for pre-existing cognitive impairment and the Mini-Mental State Examination for global cognition post ICH and the Trail Making Test where neuropsychological tests were used. CONCLUSION: Cognitive impairment and dementia affected almost one-third of patients, whether assessed pre or post ICH.

Factors Associated with Depression and Anxiety Symptoms Among Medical Students in Bahrain.

OBJECTIVES: Medical training can be a stressful experience and may negatively impact mental health for some students. The purpose of this study was to identify the prevalence of depressive and anxiety symptoms among medical students in one international medical university in the Kingdom of Bahrain and to determine associations between these symptoms, the students' characteristics, and their satisfaction with life. METHODS: This is a cross sectional study using a self-administered questionnaire, distributed to 350 enrolled medical students. We used Beck's Depression Inventory (BDI-II) and Beck's Anxiety Inventory (BAI) instruments to assess depressive and anxiety symptoms. The Satisfaction With Life Scale (SWLS) was used to measure global cognitive judgments of one's life satisfaction. Sociodemographic details including social background and academic information were also documented. RESULTS: Forty percent (n = 124) of the participants had depressive symptoms, of which 18.9% (n = 58) met the criteria for mild, 13% (n = 40) for moderate, and 8.5% (n = 26) for severe depressive symptoms. Depressive symptoms were associated with Arab ethnicity (χ 2 = 5.66, p = .017), female gender (χ 2 = 3.97, p = .046), relationship with peers (p < .001), year of study (χ 2 = 13.68, p = .008), and academic performance (p < 0.001). Anxiety symptoms were present in 51% (n = 158) of students. Anxiety symptoms were associated with female gender (χ 2 = 11.35, p < 0.001), year of study (χ 2 = 10.28, p = .036), and academic performance (χ 2 = 14.97, p = .002). CONCLUSION: The prevalence of depressive and anxiety symptoms among medical students was high. Medical universities in the Middle East may need to allocate more resources into monitoring and early detection of medical student distress. Medical education providers are encouraged to provide adequate pastoral and psychological support for medical students, including culturally appropriate self-care programs within the curriculum.

Metacognitive function poststroke: a review of definition and assessment.

Metacognition is the conscious knowledge individuals have about their own cognitive capacities and the regulation of these activities through self-monitoring. The aim of this review was to identify the definitions and assessment tools used to examine metacognition in relation to stroke studies. A computer database search was conducted using MEDLINE, CINAHL, PsycINFO, Cochrane Reviews, Scopus and Web of Science. A total of 1412 publications were retrieved from the initial database search. Following the removal of unrelated articles, 34 articles remained eligible. 5 studies examined metacognition in relation to cognitive and/or emotional functioning, 4 examined the concept in relation to memory, while others investigated its relationship to driving, employment or restrictions in daily living. 12 studies examined metacognitive function exclusively in stroke. Only 1 study examined metacognition in the acute phase of stroke. 7 studies adhered to the standard definition of metacognition in line with the neuropsychological literature. The main assessment tools utilised included the Self-Regulation and Skills Interview (SRSI), the Self-Awareness of Deficits Interview (SADI), the Awareness Questionnaire (AQ) and the Patient Competency Rating Scale (PCRS). Assessment of metacognition has tended to focus on traumatic and other acquired brain injury in comparison to stroke. The majority of the studies that examined metacognition in stroke did not assess patients in the acute phase. The heterogeneity of assessment tools was in keeping with the variation in the definition of metacognition. The emergence of a standard metacognitive assessment tool may have important implications for future rehabilitative programmes.

Association Between Metacognition and Mood Symptoms Poststroke.

INTRODUCTION: The link between metacognition and mood has been well established, particularly in other conditions with psychological comorbidity, however, there is no evidence regarding this association in the area of stroke. AIM: The aim of this study was to examine the association between metacognition, based on the Self-Regulatory Executive Function model, and mood symptoms in the acute phase after stroke. METHODS: One hundred thirty patients were recruited to a prospective stroke study in Bahrain, and n = 64 were assessed for mood and cognition. A neuropsychological battery of cognitive assessments included the following measures: the Mini-Mental State Examination, the Trail Making Test (A+B), and the Metacognition Questionnaire 30 (MCQ-30) for metacognition. The Hospital Anxiety and Depression Scale assessed mood symptoms, and stroke severity was measured using the National Institute of Health Stroke Severity Scale. RESULTS: Total MCQ-30 scores were significantly associated with both anxiety (r = .47, P = .001) and depression (r = .54, P <. 0001). The MCQ-30 subscales' cognitive confidence, cognitive self-consciousness, and uncontrollability/danger were the specific factors to be associated with mood symptoms (P < .01). Global cognition (r =.32, P < .01), but not executive function, was significantly associated with depression only. Metacognition remained a statistically significant correlate with depression (ß = .42, P < .0001) and anxiety (ß = .51, P < .0001) after adjusting for education and global cognition. DISCUSSION: Metacognition is a better determinant of mood symptoms after stroke, especially in regions where illiteracy levels are high in older populations, in comparison to executive function and global cognition.

A survey of nurses' practices and perceptions of family-centered care in Ireland.

Family-centered care (FCC) is a philosophy of care that recognizes the family's central role in the child's life and in the delivery of care. We used a survey design to investigate the practices and perceptions of nurses toward FCC in Ireland. Data were obtained from 250 nurses in seven hospitals using the Family-Centered Care Questionnaire-Revised (FCCQ-R). Findings indicated that nurses' practices were significantly different from their perceptions of FCC. Nurses with dual registration (children and adult) had significantly lower mean scores on the total current (practice) scale than the other registration subgroups. Nurses with a baccalaureate or a higher academic qualification had higher mean scores than nurses who held a certificate-level qualification on the total necessary (perception) scale, which assessed the activities perceived to be necessary for FCC. Findings showed that nurses support FCC but perceive the design of the health care system and parent-professional collaboration as barriers to FCC practice.

A review of qualitative methodologies used to explore patient perceptions of arts and healthcare.

Although the importance of the arts in healthcare is increasingly recognised, further research is needed to investigate the mechanisms by which arts and health programmes achieve their impact. An overview of the qualitative methods used to explore patients' perceptions of these interventions is lacking. We reviewed the literature to gain insights into the qualitative methods used to explore patients' perceptions of the role of arts in healthcare with a view to identifying the most common methodologies used and to guide researchers embarking on research regarding patients' perceptions of arts in healthcare. Our results indicate a paucity of qualitative studies, a variety of methods used and variability of methodological rigour. Grounded theory and phenomenology were the most common approaches adopted, mixed methods approaches were relatively frequent, and versions of 'thematic' or 'content' analysis were commonly cited. Semi-structured interviews were the most popular data collection method. The emphasis of all of the studies was on active or participative arts engagement, with no focus on receptive engagement with the arts and aesthetics. It was concluded that careful consideration of appropriate methodology is important when researching such an exploratory and sensitive area. Individual interviews were most popular and might be appropriate when exploring personal, sensitive experiences. Mixed method studies possibly provide a comprehensive approach which might satisfy both the arts and healthcare settings need for evidence. It seems important to pay attention to rigour in any methodology chosen and a greater focus on receptive engagement with the arts might be encouraged in future research.

Physiological Mechanisms and Associated Pathophysiology of Dysphagia in Older Adults.

Dysphagia can be a common secondary sequela of neurological and neurodegenerative disorders in older adults. Early screening, identification, and management of dysphagia is essential to avoid serious complications, including malnutrition, dehydration, aspiration pneumonia; and promote quality of life. Although individuals of all ages may experience swallowing difficulties, dysphagia and its complications are more common in older adults. This literature review aims to provide an overview of the physiological mechanisms of normal swallowing in healthy individuals and age-related changes to swallowing function, the pathophysiology of dysphagia associated with three common neurological disorders affecting older adults (stroke, Parkinson's disease, and dementia), and implications for interdisciplinary clinical practice. Increased awareness of these issues may contribute to a more timely and efficient identification of older adults with dysphagia and to improve overall dysphagia management.

Dysphagia screening in residential care settings: A scoping review.

BACKGROUND: Older adults with dysphagia are at a higher risk of experiencing serious complications where dysphagia is not identified and adequately managed. Nursing personnel are critical for timely identification and management of dysphagia and prevention of these subsequent serious complications in residential care settings. OBJECTIVES: To identify dysphagia screening tools used in residential care and to establish whether validated and used as per guidelines, their diagnostic accuracy and reliability and to identify the prevalence rate of dysphagia in this setting. DESIGN: A scoping review based on Arksey & O'Malley (2005) methodological framework. DATA SOURCES: An electronic search of databases CINAHL, Pubmed and Scopus was conducted. Reference lists were checked in all identified articles for additional studies. Peer-reviewed publications describing the process of identifying dysphagia and using a screening protocol in residential care settings were considered for inclusion. REVIEW METHODS: All identified studies were screened by reading of titles, keywords and abstracts. Those articles that were deemed eligible for inclusion were read in full. RESULTS: Nineteen quantitative studies and one mixed-methods study out of 1,674 articles were included in the review. Thirteen different instruments for dysphagia screening were identified, with the Modified Water Swallow Test being the most commonly used. Other diagnostic procedures, such as fiberoptic endoscopic evaluation of swallowing, pulse oximetry or cervical auscultation, were implemented along with the administration of a dysphagia screening tool in six studies. The 3-Ounce Water Swallow Test, the Yale Swallow Protocol and the Gugging Swallowing Screen were identified as the instruments with the best clinical accuracy values. The reported prevalence of dysphagia in this setting ranged from 15% to 70%. CONCLUSIONS: Formal dysphagia screening in residential care settings is not common practice. The dysphagia screening tools identified in this review are not validated for use in this setting. The implementation of dysphagia screening protocols specific to this population may facilitate identification of dysphagia and avoid complications.

Stroke presentation and hospital management: comparison of neighboring healthcare systems with differing health policies.

BACKGROUND AND PURPOSE: Acute stroke care is shaped by healthcare policies. Differing policies in similar populations allow for assessment of policy impact on health and healthcare outcomes. The purpose of this study was to compare stroke presentation and hospital care in two adjacent healthcare systems with differing healthcare policies. METHODS: Interviews and chart review of consecutive acute stroke admissions in Northern Ireland (n=103) and the Republic of Ireland (n=100). RESULTS: Marked regional contrasts were evident for key aspects of hospital care. Northern Ireland performed significantly better on 15 of 16 quality of care (Sentinel Audit) items. Delivery on standards was significantly better in Northern Ireland for early assessment (Northern Ireland 72%; Republic of Ireland 54%, P<0.01), multidisciplinary review (Northern Ireland 69%; Republic of Ireland 31%, P<0.001), medications review (Northern Ireland 54%; Republic of Ireland 19%, P<0.001), and for discharge-rehabilitation planning (Northern Ireland 83%; Republic of Ireland 8%, P<0.001). Preadmission prescription of advised cardiovascular medications was similar between regions for antihypertensives and anticoagulants but significantly higher in Northern Ireland for antiplatelets (Northern Ireland 65%; Republic of Ireland 38%, P=0.001) and lipid-regulating medication (Northern Ireland 44%; Republic of Ireland 26%; P=0.006). Prescribing levels increased in both regions and all medication categories by discharge but with significantly lower levels in Northern Ireland for antihypertensives (Northern Ireland 60%; Republic of Ireland 75%, P=0.025). Northern Ireland patients were more functionally dependent (mean Barthel Index 10.5 versus 12.7 [Republic of Ireland], P=0.013) and less aphasic (mean Frenchay Aphasia Screening Test 17.8 versus 16.8 [Republic of Ireland], P=0.022). CONCLUSIONS: In similar neighboring acute stroke populations, differing healthcare policies were associated with significant differences in processes of patient care. Policy reform is an important tool in ensuring optimal stroke care delivery.

Stroke awareness in the general population: knowledge of stroke risk factors and warning signs in older adults.

BACKGROUND: Stroke is a leading cause of death and functional impairment. While older people are particularly vulnerable to stroke, research suggests that they have the poorest awareness of stroke warning signs and risk factors. This study examined knowledge of stroke warning signs and risk factors among community-dwelling older adults. METHODS: Randomly selected community-dwelling older people (aged 65+) in Ireland (n = 2,033; 68% response rate). Participants completed home interviews. Questions assessed knowledge of stroke warning signs and risk factors, and personal risk factors for stroke. RESULTS: Of the overall sample, 6% had previously experienced a stroke or transient ischaemic attack. When asked to identify stroke risk factors from a provided list, less than half of the overall sample identified established risk factors (e.g., smoking, hypercholesterolaemia), hypertension being the only exception (identified by 74%). Similarly, less than half identified established warning signs (e.g., weakness, headache), with slurred speech (54%) as the exception. Overall, there were considerable gaps in awareness with poorest levels evident in those with primary level education only and in those living in Northern Ireland (compared with Republic of Ireland). CONCLUSION: Knowledge deficits in this study suggest that most of the common early symptoms or signs of stroke were recognized as such by less than half of the older adults surveyed. As such, many older adults may not recognise early symptoms of stroke in themselves or others. Thus, they may lose vital time in presenting for medical attention. Lack of public awareness about stroke warning signs and risk factors must be addressed as one important contribution to reducing mortality and morbidity from stroke.

Executive dysfunction and balance function post-stroke: A cross-sectional study.

OBJECTIVES: This study investigated the: (1) prevalence of executive dysfunction (ED); (2) demographic and clinical differences between participants with ED and without ED and; (3) independent association between executive function (EF) and balance post-stroke. DESIGN: Prospective observational cross-sectional study. SETTING: Four large acute hospitals. PARTICIPANTS: Convenience sample of people with first stroke. MAIN OUTCOME: Balance function. SECONDARY OUTCOMES: EF, stroke severity, depression and global cognition. METHODS: Descriptive statistics were used to report the prevalence of ED post-stroke. Comparisons of demographic and clinical characteristics were made between participants with ED and participants without ED using independent t-tests. Hierarchical multiple linear regression analysis determined the association between EF and balance post-stroke. RESULTS: Participant (n=100) age ranged from 31 to 98 years, time since stroke ranged from 4 to 180 days and the participants reported formal education ranging from 7 to 21 years. Participants with ED had more severe strokes (BADS) [median (IQR) vs. median (IQR), p-value] [(44 (16) vs. (51 (7), p<0.01], poorer global cognition [24 (6) vs. 29 (2), p<0.01] and poorer balance [29 (40) vs. 46.5 (17), p<0.01] in comparison with participants without ED. Age (ß=-0.24, p<0.05), years in education, (ß=-0.21, p<0.05), stroke severity (ß=0.71, p<0.01), time since stroke, (ß=-0.17, p<0.01) and EF (ß=0.19, p<0.05) were independently associated with balance post-stroke. The total variance in balance explained by the model was 72%. CONCLUSIONS: ED is independently associated with balance post-stroke. Physiotherapists should consider this when developing rehabilitation strategies to improve balance post-stroke.

Predictors of Vascular Cognitive Impairment Poststroke in a Middle Eastern (Bahrain) Cohort: A Proposed Case-Control Comparison.

BACKGROUND: Poststroke dementia and cognitive impairment are associated with poor long-term outcomes after stroke. The contribution of genetic factors such as the presence of apolipoprotein (ApoE) ɛ4 allele and its association with cognitive impairment poststroke remains inconclusive, particularly in Middle Eastern regions. OBJECTIVE: The aim of this study is to examine all correlates and potential predictors of cognitive impairment including self-awareness and regulation deficits in stroke patients and compare these functions with healthy older adults from a Middle Eastern population. METHODS: A prospective stroke sample of 200 patients (case group) and 100 healthy aging individuals (control group) will be recruited from the largest medical complex in Bahrain. A neuropsychological battery of cognitive assessments (global, executive, and metacognition) will be conducted on all participants. Participants will be categorized into 4 subgroups (nonvascular cognitive impairment, vascular cognitive impairment with no dementia, vascular dementia, and mixed dementia) using standardized cognitive assessment scores and the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, dementia criteria. Biomarkers will include ApoE genotype, soluble form of receptor for advanced glycation end products, neprilysin, beta-secretase 1, biochemistry, and hematology measurements. RESULTS: The primary study outcome is to determine early risk factors for cognitive impairment after stroke in a Bahraini cohort. The study has received full ethical approval from the Bahrain Ministry of Health and from the affiliated university. CONCLUSIONS: With increasing stroke incidence rates in the Middle East, this research study will provide useful biological and epidemiological data for future development and planning of health policies and guidelines for stroke care within the Gulf region.

Executive dysfunction post-stroke: an insight into the perspectives of physiotherapists.

PURPOSE: To gain an understanding of physiotherapy practice in relation to executive dysfunction (ED) post-stroke. METHOD: Three focus groups were conducted using semi-structured interview schedules to highlight how ED post-stroke was understood by 12 physiotherapists with greater than 1 year of experience working in the area of stroke care. The focus group data were analysed using qualitative data analysis. RESULTS: The themes extracted from the data on physiotherapists' self-reported knowledge of ED post-stroke were: physiotherapists' lack of knowledge of ED post-stroke; current physiotherapy practice regarding ED post-stroke; the negative impact of ED on physiotherapy rehabilitation post-stroke and the future learning needs of physiotherapists regarding ED post-stroke. CONCLUSIONS: Current results demonstrate that ED has negative implications for physiotherapy rehabilitation post-stroke. Although further interdisciplinary research is warranted, the present results suggest that physiotherapists should be aware of the presence of ED in people post-stroke and develop strategies to minimise the impact of ED on physiotherapy rehabilitation. Implications for Rehabilitation Physiotherapists report a lack of knowledge of ED post-stroke and a requirement for future learning and training regarding the optimal management of people with ED undergoing physiotherapy rehabilitation post-stroke. ED has negative implications for physiotherapy rehabilitation post-stroke and physiotherapists should be aware of the presence of ED in people post-stroke and develop strategies to minimise the impact of ED on physiotherapy rehabilitation.

Hospitalization and aesthetic health in older adults.

OBJECTIVES: To assess the impact of hospitalization on arts engagement among older people; and to assess perceptions of whether hospitals are aesthetically deprived environments. METHODS: A Survey of Aesthetic and Cultural Health was developed to explore the role of aesthetics before, during and after hospital. Study participants were n = 150 hospital in-patients aged >65. Descriptive and inferential statistics were used to analyze the data. MAIN FINDINGS: Attendance at arts events was an important part of life for this sample and a large drop off was noted in continuation of these activities in the year post-hospital stay. Physical health issues were the main causes but also loss of confidence and transport issues. Film, dance, and music were the most popular arts for this sample prior to hospital stay. Noise pollution caused by other patients, lack of control over TV/radio, and access to receptive arts in hospital (reading and listening to music) were important issues for patients in hospital. CONCLUSIONS: This study identifies a trend for decreasing exposure to arts beginning with a hospital stay and concludes that older people may need encouragement to resume engagement in arts following a hospital stay. There is relatively limited evidence regarding the nature of, and potential benefit from, aesthetics in healthcare and limited studies with rigorous methodology, and further research is needed to understand the aesthetic preferences of older people in hospital.

Implementing clinical guidelines in stroke: a qualitative study of perceived facilitators and barriers.

BACKGROUND: Clinical guidelines are frequently used as a mechanism for implementing evidence-based practice. However research indicates that health professionals vary in the extent to which they adhere to these guidelines. This study aimed to study the perceptions of stakeholders and health professionals on the facilitators and barriers to implementing national stroke guidelines in Ireland. METHODS: Qualitative interviews using focus groups were conducted with stakeholders (n=3) and multidisciplinary team members from hospitals involved in stroke care (n=7). All focus group interviews were semi-structured, using open-ended questions. Data was managed and analysed using NVivo 9 software. RESULTS: The main themes to emerge from the focus groups with stakeholders and hospital multidisciplinary teams were very similar in terms of topics discussed. These were resources, national stroke guidelines as a tool for change, characteristics of national stroke guidelines, advocacy at local level and community stroke care challenges. Facilitators perceived by stakeholders and health professionals included having dedicated resources, user-friendly guidelines relevant at local level and having supportive advocates on the ground. Barriers were inadequate resources, poor guideline characteristics and insufficient training and education. CONCLUSIONS: This study highlights health professionals' perspectives regarding many key concepts which may affect the implementation of stroke care guidelines. The introduction of stroke clinical guidelines at a national level is not sufficient to improve health care quality as they should be incorporated in a quality assurance cycle with education programmes and feedback from surveys of clinical practice.

Associations between executive function and physical function poststroke: a pilot study.

OBJECTIVES: Associations between executive function and physical function poststroke have not been extensively studied. More complex physiotherapy interventions poststroke require a greater degree of cognitive ability, especially executive function. This pilot study aimed to inform the methodology of a larger study by examining the associations between executive function and the performance of basic and complex gait tasks in people poststroke. DESIGN: A cross-sectional pilot study was conducted in a convenience sample of 20 participants recruited from a community-based voluntary stroke organisation and from the outpatient services of two urban hospitals. MAIN OUTCOME MEASURES: A battery of tests was used to measure executive function (Trail Making Test, Stroop Word-Colour Test, Zoo Map test, Frontal Assessment Battery and Digit Span backward test). Basic and complex 10metre gait tests were used to mimic aspects of physiotherapy intervention poststroke. Other measures included the Mini-Mental State Examination (MMSE) and the Motor Assessment Scale (MAS). RESULTS: Observational comparisons between participant executive function scores and age- and/or education-matched normative data demonstrated that executive dysfunction ranged between 55% and 100%. Poorer performance in measures of executive function was more frequently associated with poorer performance in complex gait tests compared with basic gait tests. The MAS was not significantly associated with any measure of executive function. CONCLUSIONS: Executive dysfunction is a common sequel poststroke which may negatively affect physical performance. Physiotherapists should consider executive dysfunction when developing rehabilitation strategies to improve physical function poststroke.