Predicting length of stay, functional outcome, and aftercare in the rehabilitation of stroke patients. The dominant role of higher-order cognition

BACKGROUND AND PURPOSE: Research in recent years has revealed factors that are important predictors of physical and functional rehabilitation: demographic variables, visual and perceptual impairments, and psychological and cognitive factors. However, there is a remaining uncertainty about prediction of outcome and a need to clinically apply research findings. This study was designed to identify the relative importance of medical, functional, demographic, and cognitive factors in predicting length of stay in rehabilitation, functional outcome, and recommendations for postdischarge continuation of services. METHODS: The influence of these factors was determined by comparing diagnostic, medical, demographic, functional, and neuropsychological information that was retrospectively obtained by reviewing the records of 86 patients admitted for comprehensive rehabilitation due to stroke (n = 36) or orthopedic injury (n = 50). Multiple linear regression with statistical adjustment to control for overprediction of variance was used to predict outcomes. RESULTS: The study revealed the primary importance of higher-order cognitive impairments (comprehension, judgment, short-term verbal memory, and abstract thinking) in extending length of stay and increasing referrals for outpatient therapies and home services after discharge for the cerebrovascular accident patients in comparison with orthopedic cohorts. CONCLUSIONS: The need is discussed for early, comprehensive assessment of deficits in cognition that affect a stroke survivor's ability to participate in a rehabilitation program and remediation that facilitates functional improvement by building on residuals of impaired abilities or teaching compensatory behaviors.     

Statistical versus clinical prediction: Length of neuropsychiatric hospital stay.

Statistical and clinical prediction methods are compared in a "field" situation, predicting patient stay in a psychiatric hospital. 5 statistical methods from a previous report averaged 71.92% accuracy on the cross-validation sample. 12 clinicians predicting independently in the same hospital over the following 18-mo period achieved an average accuracy of 71.94% on 499 patient predictions. Summaries of the clinicians' reasons for their judgments show some differences between the most and least accurate judges. Neither professional background nor years of professional experience of clinicians was related to predictive accuracy. Actuarial and clinical prediction were not demonstrably different in accuracy. Practical and economic aspects of this prediction problem favor clinical prediction. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Patients in Norwegian hospitals. Length of stay and patterns of use

All 633,987 periods of admission to Norwegian general hospitals in 1991 were analyzed. The length of stay increases considerably with the patient's age. 80-year old patients stay three times as long in hospital as five-year old patients. The typical surgical patient requires 56% more resources than the typical medical patient. For surgical patients, the mean length of stay was 7.2 days, and for medical patients it was 6.8 days. Patients in the age group 70-79 years require almost twice as much resources as the youngest patients. Patients up to the age of 65 who live in a municipality where there is a hospital stay in hospital just as long as corresponding patients from municipalities without a hospital. For older patients there are significant differences in length of stay for these two categories of patients. The discharge rate for men of 70 years and older is significantly higher than the rate for women in the same age group, but the women stay longer in hospital.     

Effects of paint sniffing on neuropsychological test performance.

Examined the effects of paint sniffing on neuropsychological test performance by employing 20 sniffers (mean age 18.5 yrs) and 20 comparable nonsniffers. A wide variety of tests were used as measures (e.g., Finger Tapping Test, Trail Making Test, Stroop Color-Word Test, and Peabody Picture Vocabulary Test). It was found that sniffers were significantly lower than controls in the performance of 11 of the 13 test measures, including tests of motor speed, auditory discrimination, visuomotor functioning, and memory. An important finding was the relation found between duration of paint sniffing and level of test performance. According to the results, the longer a person had been involved in paint sniffing, the lower the performance on the neuropsychological tests. (20 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Length of psychotherapy and outcome: Observations stimulated by Howard, Kopta, Krause, and Orlinsky.

Suggests that the K. I. Howard et al (see record 1986-17818-001) findings on therapy length and outcome are tentative and that it may be premature to assume that such findings can be used in policymaking for setting rational time limits for insurance reimbursement and similar utilization-review decision making. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Alcohol use and its effects on neuropsychological outcome in head injury.

Neuropsychological outcome was examined in relation to head-injury severity and degree of alcohol problems in a large sample of head-injured Ss to determine whether preinjury alcohol abuse exacerbates the neuropsychological effects of a head injury. The results showed neuropsychological outcome is significantly related to head-injury severity and to alcohol use. However, the mechanisms responsible for the alcohol-related impairments are not as clear as those for head injury. Although it is difficult to untangle the specific contributions of a host of factors to the impairments observed, the results point to a subtype that is characterized by limited education, neuropsychological impairments, and a lifestyle concurrent with heavy drinking, including an increased risk for head injuries. Contrary to expectation, there was no evidence for a greater head-injury effect in those with more severe alcohol problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Hypertension and neuropsychological performance in men: Interactive effects of age.

Potentially interactive effects of hypertension and age on the performance of neuropsychological and information processing tests were examined in 123 untreated hypertensive and 50 normotensive men. After covarying education, average alcohol consumption, trait anxiety, and depression scores, results indicated an interaction of age and hypertension. Young hypertensive men (23–40 years) scored significantly worse than young normotensive men on tests of attention/executive function and working memory; middle-aged hypertensive (41–56 years) and normotensive participants were not distinguished by any measures. Hypertensive men performed significantly more poorly than normotensive men on tests of manual dexterity. Results suggest that neuropsychological sequelae of hypertension are more pronounced in young than in middle-aged hypertensive individuals and are independent of various demographic, psychosocial, and alcohol-related factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The adolescent outcome of hyperactive children diagnosed by research criteria: II. Academic, attentional, and neuropsychological status.

One hundred hyperactive children meeting research diagnostic criteria and 60 community control children were followed prospectively over an 8-year period into adolescence. Younger (12–24 years) and older (15–20 years) groups were tested on measures of academic skills, attention and impulse control, and select frontal lobe functions. At follow-up, hyperactive Ss demonstrated impaired academic achievement, impaired attention and impulse control, and greater off-task, restless, and vocal behavior during an academic task, compared with control Ss. The limited set of frontal lobe measures did not differentiate groups. Age did not interact with group membership. However, several measures did not differentiate groups. Age did not interact with group membership. However, several measures showed age-related declines in both groups. It is concluded that hyperactive children may remain chronically impaired in academic achievement, inattention, and behavioral disinhibition well into their late adolescent years. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Baseline EEG asymmetries and performance on neuropsychological tasks

Thirty-two participants were tested for both resting electroencephalography (EEG) and neuropsychological function. Eight one-minute trials of resting EEG were recorded from 14 channels referenced to linked ears, which was rederived to an average reference. Neuropsychological tasks included Verbal Fluency, the Tower of London, and Corsi's Recurring Blocks. Asymmetries in EEG alpha activity were correlated with performance on these tasks. Similar patterns were obtained for delta and theta bands. Factor analyses of resting EEG asymmetries over particular regions suggested that asymmetries over anterior scalp regions may be partly independent from those over posterior scalp regions. These results support the notions that resting EEG asymmetries are specified by multiple mechanisms along the rostral/caudal plane, and that these asymmetries predict task performance in a manner consistent with lesion and neuroimaging studies.     

Fragile-X: neuropsychological test performance, CGG triplet repeat lengths, and hippocampal volumes

The purpose of this study was to compare a new MR macromolecular contrast medium (MMCM), gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA)-24-cascade-polymer, to a well-studied prototype MMCM, for the potential of distinguishing tissues of varying endothelial permeability. Three tissue models of varying capillary permeability were studied in a total of 46 rats: normal myocardium (normal capillaries), subcutaneously implanted adenocarcinoma (mild capillary leak), and reperfused infarcted myocardium (high capillary leak). TI-weighted MRI was performed before and dynamically after injection of either albumin-(Gd-DTPA)30 or the cascade polymer (each .02 mmol gadolinium [Gd] per kg). Data analysis based on a two-compartment kinetic model yielded estimates of fractional blood volume (BV) (percentage) and fractional leak rate (FLR) (1 per hour). Permeability to the cascade polymer as reflected in FLR was considerable in normal myocardium (8.24 per hour), of similar value in tumors (8.55 per hour), but significantly greater in infarcted myocardium (39.17 per hour, P < .01) versus normal myocardium. The larger albumin-(Gd-DTPA)30 demonstrated minimal extravasation in normal myocardium (FLR .33 per hour); FLR in tumors was 100% higher (.66 per hour, P < .002) and FLR in reperfused capillaries was significantly greater (7.94 per hour, P < .001). Based on capillary permeability measurements, the cascade polymer may have limited utility for detection of mildly increased microvascular permeabilities. For severe tissue injury, the cascade polymer can resolve abnormal microvascular integrity.     

Ascertainment bias and neuropsychological performance in HIV-1 disease.

This study investigated the potential source of bias arising from selection site and method of participant recruitment in studies of neuropsychological performance among participants with HIV-1 infection. Neuropsychological test data on participants with asymptomatic and symptomatic HIV-1 infection from 3 sites were compared: participants recruited from a private medical group, a community-dwelling volunteer cohort, and an immunodeficiency clinic at a Veterans Affairs Medical Center. Results revealed that selection site and method of participant recruitment are significant factors related to neuropsychological test performance in both symptomatic and asymptomatic HIV-infected gay or bisexual participants and may serve as potential sources of bias affecting the results of neuropsychological studies of HIV-1 infection. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impact of comorbid depressive symptoms on neuropsychological performance in obsessive-compulsive disorder.

There is indirect evidence from previous research that several executive disturbances in obsessive-compulsive disorder (OCD) are mediated by comorbid depressive symptoms. For the present study, the authors investigated whether OCD patients with elevated Hamilton Rating Scale for Depression (HRSD; M. Hamilton, 1967) scores would exhibit deficits in tasks sensitive to the medial and dorsolateral frontal cortex as well as other executive tasks. The 36 OCD patients were split along the median according to their HRSD scores and compared with matched control subjects. Patients with high HRSD scores performed significantly worse than control subjects and patients with low HRSD scores on the Wisconsin Card Sorting Test (J. Loong, 1990), the Trail-Making Test (TMT, Part B; R. M. Reitan, 1992), and the TMT difference score. Moreover, patients with high HRSD scores exhibited deficits on a (creative) verbal fluency task. It is suggested that comorbid depressive symptoms may have artificially inflated some executive deficit scores in previous studies. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychotherapy length of stay and outcome: A meta-analysis of the effect of therapist sex.

This meta-analysis combined results from 64 published and unpublished studies that sought to determine the effect of therapist sex on the outcome of psychotherapy. The articles were obtained using PsychLit and PsychInfo and spanned the years 1930–2000. Results show that therapist sex was found to be a poor predictor of outcome for both male and female clients. Level of therapist training, theoretical orientation of treatment, quality of study, age of clients, and number of treatment sessions did not moderate the minimal effect of therapist sex on the outcome of psychotherapy. The authors conclude that the sex of the therapist has little overall effect on the outcome of psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The impact of candidemia on length of hospital stay, outcome, and overall cost of illness

Although numerous studies have examined trends in nosocomial fungal infections, few have specifically addressed the cost of care associated with candidemia. This study analyzes the direct medical costs associated with treating candidemia in the United States. The study design was a cost-of-illness analysis estimating the average cost of candidemia for a single episode of care. Data were obtained from three sources: the 1993 Healthcare Cost and Utilization Project of the Agency for Health Care Policy and Research, the relevant literature, and a clinical expert in systemic fungal infections. The estimated cost (1997 U.S.$) of an episode of care for candidemia is $34,123 per Medicare patient and $44,536 per private insurance patient. The major cost associated with candidemia is that of an increased hospital stay. The estimated cost of care for candidemia may change in the future because of the use of more expensive antifungal treatments with improved safety and efficacy profiles.     

Clinical, neuropsychological, and brain structural correlates of smooth-pursuit eye tracking performance in chronic schizophrenia.

Examined the relation of smooth-pursuit eye tracking dysfunction to neuropsychological performance, brain structural anomalies, and clinical state in a sample of 61 patients with chronic schizophrenia. No association was found between impaired pursuit oculomotion and measures of chronicity or clinical state. Likewise, no association emerged between eye tracking integrity and brain structural anomalies. Patients with dysfunctional eye tracking were more likely to have impaired performance on tests that assess frontal lobe functioning. In addition, they had more negative symptoms and a relative absence of positive symptoms. Because negative symptoms are often found among patients wih frontal lobe impairment, their association with abnormal eye tracking provides converging support for the hypothesis that the cortical locus of deviant smooth-pursuit eye tracking is in the frontal lobes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mathematical disabilities: Cognitive, neuropsychological, and genetic components.

Cognitive, neuropsychological, and genetic correlates of mathematical achievement and mathematical disability (MD) are reviewed in an attempt to identify the core deficits underlying MD in children. Three types of distinct cognitive, neuropsychological, or cognitive and neuropsychological deficits associated with MD are identified. The 1st deficit is manifested by difficulties in the representation or retrieval of arithmetic facts from semantic memory. The 2nd type of deficit is manifested by problems in the execution of arithmetical procedures. The 3rd type involves problems in the visuospatial representation of numerical information. Potential cognitive, neuropsychological, and genetic factors contributing to these deficits and the relationship between MD and reading disabilities are discussed. Finally, suggestions for the subtyping of math disorders are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Influences of beliefs and personality disorders on treatment outcome in anxiety patients.

The present study investigated the effects of personality disorders (PDs) and specific PD-related beliefs on the results of (cognitive-)behavioral therapy for anxiety disorders in a sample of 398 outpatients. The authors used a prospective design in which relationships between PD variables before treatment and outcome measures at posttest and follow-up were evaluated with multilevel analyses. People with PDs and PD-related beliefs reported higher symptom levels at outcome. However, these effects were not as strong as might be expected on the basis of prevailing clinical thought in this area. Dropout rates were not influenced by the presence of 1 or more PDs or PD-related beliefs. Results indicate that treatment of anxiety disorders in patients with concomitant one or more PDs is appropriate. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Oral contraceptives and androgenicity: Influences on visuospatial task performance in younger individuals.

The current study investigated whether the androgenic activity of oral contraceptives (OC) mediates performance on sexually dimorphic cognitive tasks in 155 younger individuals. Participants were categorized by hormonal contraceptive use (user vs. nonuser) and the androgenic activity of each OC (OC generation). OC generation was determined based on previous research in which users are grouped based on the type of progestin contained in each OC. Cognitive tasks included the mental rotation task (MRT) and a recognition memory task. In addition, we examined the correlates of both menstrual cycle phase and OC use, such as mood, premenstrual syndrome, depression, blood pressure, and body fat using standardized measures. The main result was that OC androgenicity influenced MRT performance. Second generation OCs are the most androgenic. Thus, MRT performance was best in these OC users as compared to third generation users, Yasmin users and nonusers. On the other hand, Yasmin, a newer generation of OC, contains an "antiandrogenic" progestin, dropirenone. Yasmin users not only performed more poorly on the MRT in comparison to second and third generation pill users, but they performed significantly worse than OC nonusers. Results show that the androgenic activity in OCs influences MRT performance in the presence of static estrogen levels. Overall, the resulting pattern is consistent with a broad range of results demonstrating that visuospatial performance may be enhanced in women who are exposed to androgenic treatments. Furthermore, visuospatial performance is hindered with the introduction of antiandrogenic preparations. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Short-term neuropsychological outcome following uncomplicated mild TBI: Effects of day-of-injury intoxication and pre-injury alcohol abuse.

Research suggests that individuals who are intoxicated at the time of traumatic brain injury (TBI) have worse cognitive outcome compared with those who are sober. Worse outcome in patients with day-of-injury intoxication might (a) be related to the increased magnitude of brain injury resulting from a variety of negative responses not present following TBI in nonintoxicated individuals, or (b) reflect the effect of pre-injury alcohol abuse that is prevalent in individuals intoxicated at the time of injury. Most studies in this area have focused on patients with moderate to severe TBIs, and on medium- to long-term neuropsychological outcome. The purpose of this study was to examine the relative contributions of day-of-injury intoxication versus pre-injury alcohol abuse on short-term cognitive recovery following mild TBI. Participants were 169 patients with uncomplicated mild TBIs who were assessed on 13 cognitive measures within 7 days postinjury. The prevalence of intoxication at the time of injury was 54.4%. The prevalence of possible pre-injury alcohol abuse was 46.2%. Overall, the results suggest that pre-injury alcohol abuse, compared with day-of-injury alcohol intoxication, had the most influence on short-term neuropsychological outcome from uncomplicated mild TBI. However, the influence of pre-injury alcohol abuse was considered small at best. (PsycINFO Database Record (c) 2010 APA, all rights reserved)