10 research outputs found
Abstract Number ‐ 114: Deep Cerebral Venous Thrombosis requiring Venous Thrombectomy and Intra‐arterial Thrombolysis in Young Pregnant Female
Introduction Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and mortality especially in young women and children (1). Even though, first‐line treatment remains anticoagulation, some patients deteriorate and endovascular treatment is needed. Currently there are no randomized controlled trials comparing the efficacy and safety of intracranial thrombolysis and mechanical thrombectomy to standard‐of‐care anticoagulation therapy (2). We present a case of a pregnant lady with CVST with successful clinical outcomes with venous thrombectomy and intraarterial thrombolysis. Methods Case Report Results 30 year old lady with no past medical history, 7 weeks and 4 days pregnant presented with acute progressive encephalopathy associated with nausea, vomiting and headaches. On admission, she was stuporous, had dysarthria, severe hemiparesis, and hemineglect on the right side. She had COVID‐19 infection and her fetus had subchorionic hematoma by ultrasound. Initial CT brain showed extensive cerebral venous sinus thrombosis (CVST). She was intubated and MRI showed venous infarcts. MR venography revealed acute extensive CVST of superior sagittal sinus, vein of galen, right transverse sinus, right sigmoid sinus, and right jugular vein. IV Heparin drip was initiated. Her follow‐up neurological exam deteriorated despite maximal medical therapy. The decision was made for endovascular recanalization. The cerebral angiogram confirmed the occlusion of deep venous system. Thrombectomy of bilateral internal jugular vein and sigmoid sinus was performed with retrieval of thrombi. Post‐thrombectomy runs demonstrated persistent extensive CVST and decision was made for intra‐arterial thrombolysis. A diagnostic catheter was secured in the right internal carotid artery catheter (ICA). Thombolysis was performed with 4 mg/hr recombinant tissue‐plasminogen activator (rt‐PA). Heparin drip IV was continued. Subsequently, the repeat CT brain showed significant improvement in the CVST and interval development of intraparenchymal hemorrhages and subarachnoid hemorrhages. Heparin and rt‐PA were held. The patient was found to have Factor V Leiden mutation and she was started on Enoxaparin 1mg/kg throughout her pregnancy and 6 weeks postpartum. Clinically she demonstrated significant neurologic improvement and was discharged to home from rehabilitation center. Currently, she is thirty‐ four weeks pregnant and neurologically intact without any deficits. Conclusions Pharmacological and mechanical endovascular interventions can have significantly successful clinical outcomes in deep cerebral venous thrombosis. Controlled studies are required to assess the safety and efficacy of these interventions when compared to standard systemic anticoagulation
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THE ASSOCIATION OF MORTALITY WITH DEMENTIA IN VETERANS ENROLLED IN A MEMORY DISORDERS CLINIC: THE EFFECT OF FRAILTY
Dementia is a syndrome of deterioration in cognition and ability to perform everyday activities. Frailty, a state of vulnerability to stressors leading to increased morbidity, mortality and utilization is a determinant of dementia. The aim was to determine if dementia leads to increased mortality in Veterans and whether frailty affects this association. We conducted a retrospective cohort study of 308 Veterans enrolled in VA memory disorders clinic during 2016-2019. Dementia was diagnosed based on complete clinical assessments, brain imaging and neuropsychological testing. A 44–item frailty index (FI) was constructed using demographics, comorbidities, medications, laboratory tests, and activities of daily living. Patients were divided into non-Frail (FI<0.21) and Frail (FI≥0.21). After adjusting for age, race, ethnicity, income, education, substance abuse, BMI, comorbidities, hospitalizations, medication use, the association of dementia with mortality was assessed using Cox proportional hazards regression. Patients were 55.2% White, 74% non-Hispanic, and the mean age was 74.4 ± 8.3 years. 113 patients were diagnosed with dementia out of which 27 died. Over a median follow-up period of 526 days (Interquartile Range: 431.5 days), there were 27 deaths. There was a significant and positive association of dementia with mortality significant even after all adjustments, HR=2.65 (95% CI: 1.02-6.92), p: 0.045. After subgroup analysis, there was no significant association between mortality and dementia according to frailty status. Our study results suggest that dementia is associated with a higher risk for mortality in Veterans at a Memory Disorders clinic. Frailty did not modify the effect
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Cross-sectional association between the area deprivation index (ADI) and cognitive impairment in community-dwelling older veterans
The evidence that lower socio-economic status (SES) may be associated with late-onset dementia is inconsistent. Differences may be related to how SES was assessed. The area deprivation index (ADI) is a validated, composite measure of neighborhood socioeconomic status representing a geographic area level of social deprivation. Previous research has shown an association between ADI and cognitive impairment, but less is known about the Veteran population. The study aim was to determine the cross-sectional association between the area deprivation index (ADI) and cognitive impairment in a Veteran population.
This is a cross-sectional study among community-dwelling Veterans aged ≥50 years enrolled in a VA primary care clinic from July 2019-May 2020. Patients were mailed questionnaires including sociodemographic, the Self-Administered Gerocognitive Examination (SAGE). Clinical information was extracted from the electronic health records (EHR). To assess frailty, we used a 31-item VA Frailty Index (VA-FI) generated from EHR data matched to the study date. We calculated the ADI from 17 socioeconomic indicators available from the US Census. ADIs were generated for census tracts corresponding to veterans' addresses. Higher ADI values are consistent with increased deprivation. After adjusting for age, gender, marital status, race, ethnicity, body mass index and frailty, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using binomial logistic regression models with cognitive impairment (MCI and dementia) as the outcome variable and ADI as the independent variable.
Participants were 1060 Veterans (response rate of 20.14%), mean age of 68.39 (SD=8.52) years, 59.0% Caucasian, 69.2% non-Hispanic, 95.8% male, 12.0% screened positive for MCI and 15.6% for dementia. Among ADI quintile groups, patients in the highest group had a significantly higher proportion of cognitive impairment (40.59%) when compared to lower groups, p<.001. No significant differences were found between quintiles 1 to 4. The highest ADI quintile was the only group associated with cognitive impairment, adjusted OR: 1.916 (95% CI:1.187-3.093), p=.008.
This study shows a cross-sectional association between ADI and dementia in community-dwelling older Veterans. Further investigation of the links between neighborhood social deprivation and cognitive impairment may assist in the development of strategies that lower the incidence of cognitive impairment in these communities
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THE ASSOCIATION OF FRAILTY WITH MCI AND DEMENTIA IN A MEMORY DISORDERS CLINIC FOR OLDER VETERANS
Frailty, a state of increased vulnerability to stressors due to multiple physiological dysfunction is associated with mild cognitive impairment (MCI) as well as dementia and may moderate its progression. Frailty and cognitive decline are highly prevalent in the Veteran population. The aim of our study was to determine whether frailty is associated with MCI and dementia in older Veterans at a Memory Disorders Clinic. We performed a cross-sectional study of 308 Veterans enrolled in VA Memory Disorders Clinic during 2016-2019. MCI and dementia were diagnosed based on complete clinical assessment including cognitive testing, brain imaging and neuropsychological testing. A 44–item frailty index (FI) was constructed using potential variables (demographics, comorbidities, number of medications, laboratory tests, and activities of daily living). Binomial logistic regression was run using MCI and dementia as outcome variable and frailty status (frail and non-frail) as independent variable. Age, race, marital status, ethnicity, median household income, education, comorbidities, BMI, history of substance abuse, smoking, alcohol, hospitalizations, anticholinergic use, and utilization were considered as covariates. The mean age was 74.43± 8.31 years. 43.2% population was frail (FI>0.21) and 56.8% was non-frail (FI≤0.21). The number of Veterans with MCI and dementia was 114 and 113 respectively. Frailty was significantly and positively associated with dementia (OR: 2.29 95%CI:1.25-4.21, p=0.007) but there was no association with MCI (OR: 1.06 95%CI: 0.605-1.886, p=0.820). Our study results suggest that frailty might not be associated with MCI but has significant association with dementia in a group of Veterans at a Memory Disorder Clinic
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ARE SUBSTANCE USE DISORDERS ASSOCIATED WITH FRAILTY IN US OLDER VETERANS WITH COGNITIVE IMPAIRMENT?
Substance use disorders are common in US Veterans receiving care at Veteran health care facilities. Substance use disorders are associated with unhealthy lifestyles, mental and physical multimorbidity, increased healthcare utilization and higher mortality. Substance use disorders have also been implicated in the development of cognitive impairment. The pernicious effects of substance use disorders may lead to frailty, a state of increased vulnerability to stressors due to multiple physiological dysfunctions. However, the association of substance use disorders and frailty is unknown. The purpose of the study was to determine whether substance use disorders were associated with frailty in Older Veterans with cognitive impairment enrolled at a VA Memory Disorders Clinic.
Participants and Setting: Cognitively impaired US Veterans enrolled in a VA Memory Disorders Clinic during a period of 2016-2019. Study design: Cross-sectional study. Measures and Outcomes: We constructed a 44-item frailty index using all potential variables such as demographics, comorbidities, number of medications, laboratory tests, and activities of daily living. Patients were categorized into non-frail (FI <0.21) and frail (FI ≥0.21). We extracted data from the VA electronic health record (EHR) to obtain socio-demographic information (age, gender, race, ethnicity), number of medications, functional status, and median household income. Substance use disorders including alcohol, cannabis, opioids, cocaine were ascertained from medical records using ICD-9 and 10 codes. Data Analysis: Odds Ratios (OR) and 95% confidence intervals (CI) were calculated using binomial logistic regression using frailty as the dependent variable and substance use disorders as the independent variable adjusted for covariates (age, race, ethnicity, median household income, education, body mass index (BMI), and number of medications).
Two-hundred twenty-seven, cognitively impaired Veterans enrolled in a VA Memory Disorders Clinic were included in the study. Patients were 54.6% (n=124) white, and 75.3% (n=171) non-Hispanic, 114 (50.0%) had mild cognitive impairment, and 113 (50.7%) had dementia. The mean age was 75.5 (SD=8.4) years. The proportion of frail and non-frail patients was 47.1% (n=107) and 52.9% (n=120) respectively. Veterans with a history of substance use disorders represented 17.6% (n=40) of the sample. Substance use disorders included alcohol (14.1%, n=32), cannabis (1.3%, n=3), opioids (0.4%, n=1) and cocaine (2.6%, n=6). Substance use disorder was associated with an increased risk of frailty, unadjusted OR: 2.44 95%CI: 1.14-5.22, p=0.02). However, after adjusting for covariates, substance use disorder was no longer associated with frailty in cognitively impaired Veterans, OR: 2.17 95%CI: 0.94-5.01, p=0.06).
Conclusion: Substance use disorder was not cross-sectionally associated with frailty in cognitively impaired Veterans after controlling for known covariates.
This research was funded by: No fundin
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Race-Based Differences in MCI And Dementia: A Propensity Score Matching Study
Mild cognitive impairment (MCI) and dementia are characterized by objective deficits in several cognitive domains. These cognitive disorders are prevalent in the fast-growing older population worldwide. There are several modifiable and non-modifiable risk factors for these cognitive disorders. Research has shown that the African American race is predictive of incident dementia. However, the African-American race is confounded by other risk factors which may explain much of the racial disparity in cognitive disorders, most notably education, socio-economic status and lack of access. The aim of this study was to compare the prevalence of MCI and Dementia between African-American and Caucasian community-dwelling older Veterans after matching of baseline characteristics.
We conducted a cross-sectional study using propensity score matching (PSM) among community-dwelling Veterans aged ≥50 years enrolled in VA primary care clinics from July 1, 2019 to May 31, 2020. Participants with baseline dementia diagnosis were excluded. Patients received mailed questionnaires including sociodemographic, information about exercise, education and an assessment of cognitive status using the validated Self-Administered Gerocognitive Examination (SAGE). We complemented the information with data from the electronic health records (EHR). To assess frailty, we used a 31-item VA Frailty Index (VA-FI) generated from claims-based data matched to the study date. The VA-FI categorizes patients into robust (<0.10), pre-frail (0.10-0.20) and frail (≥0.21). Geographical socio-economic conditions were determined by using the US Area Deprivation Index (ADI) datasets. The ADI score distribution was divided by tertiles (Low, Middle, High), with higher scores corresponding to more socio-economic deprivation. African American Veterans were matched with Caucasians using PSM with one-to-one nearest neighbor matching without replacement. Matching covariates used to calculate the propensity score included age, gender, marital status, BMI, ethnicity, years of education, frailty (VA-FI), Obstructive Sleep Apnea (OSA), and ADI with a tolerance level of .01. Using a Chi-Square test, we compared the proportion of patients with MCI and Dementia among Caucasians and African-Americans after matching for baseline characteristics.
We obtained a response rate of 19.75% (n =1073) out of 5,432 mailed surveys. After propensity score matching of those Veterans who responded, 202 Caucasians and 202 African-Americans were selected and compared. Participants had a mean age of 68.57(SD=7.9) years, 50.2% were married, 90.6% non-Hispanic and 96% male. Almost all patients had achieved at least 10 years of education (91.8%), 39.9% were obese and 34.9% had OSA. The mean ADI score was 98.29 (SD=20.16) and 37.9% were found to be in the high ADI tertile. Regarding frailty status, 23.5%, 36.1%, and 40.3% were robust, pre-frail and frail respectively. After matching, all the baseline clinical characteristics were comparable between the two groups. Using a Chi-Square test after PSM, we found that the proportions of MCI (43.8%) and Dementia (40.3%) in Caucasian patients were not significantly different from that of African-Americans (MCI=56.3%, Dementia=59.7%), p=.087.
This study results suggest that race alone is not independently associated with MCI or Dementia. Even though some studies have shown that African-Americans are more likely to develop cognitive impairment, this association may be due to other socio-demographic factors that are more prevalent in the African-American population.
Bruce W. Carter VA Medical Center - Geriatric Research, Education and Clinical Center (GRECC
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The association of health literacy, numeracy and graph literacy with frailty
Background
Frailty is a state of vulnerability to stressors which may result in high mortality, morbidity, and health-care utilization in older adults. Whether health literacy, graph literacy and numeracy are associated with frailty is unknown.
Aim
To assess the association of health literacy, numeracy and graph literacy with frailty in male veterans.
Methods
This is a retrospective study of 470 cognitively intact, non-depressed veterans who completed evaluations of health literacy, numeracy and graph literacy at Miami VA facility in 2012. A 43-item frailty index was created as a proportion of all potential variables (demographics, comorbidities, number of medications, laboratory tests, and activities of daily life). Odds ratios and 95% confidence intervals were calculated by multinomial logistic regression models with frailty status (robust, prefrail and frail) as the outcome variable, and with health literacy, numeracy, and graph literacy scores as independent variables. Age, race, ethnicity, education, socio-economic status, and comorbidities were considered as covariates.
Results
Patients were 100% male, 40% White, 82% non-Hispanic, mean age was 56.8 years. The proportion of robust, pre-frail and frail was 10.0%, 61.3% and 28.7%, respectively. Neither health literacy nor objective nor subjective numeracy was associated with frailty after adjustment for covariates. In contrast, higher graph literacy scores were associated with a lower risk for frailty (
p
= .015) even after adjusting known risk factors for frailty.
Discussion and conclusion
Neither health literacy nor numeracy is associated with frailty. Higher graph literacy score is associated with a lower risk for frailty even after adjusting for known risk factors for frailty
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The Association of Health Literacy Domains With Hospitalization and Mortality
OBJECTIVES: To determine whether health Literacy, numeracy, and graph literacy are associated with all-cause hospitalizations or mortality in community-dwelling veterans.
STUDY DESIGN: Retrospective cohort study.
METHODS: A total of 470 community-dwelling veteran underwent evaluations of health literacy, numeracy, an graph literacy with validated instruments in 2012 and were followed until 2018. At the end of follow-up, the associations with all-cause hospitalizations and mortality were determined with the Andersen-Gill model and Cox regression multivariate analysis, respectively.
RESULTS: There were no associations of health literacy, numeracy, or graph literacy with all-cause hospitalization or mortality after multivariate adjustment. In subgroup analysis, subjective numeracy was associated with hospitalizations in African Americans. Higher objective and subjective numeracy were associated with future hospitalizations only for those with a history of hospitalization. Higher graph Literacy was associated with lower mortality in those with a history of hospitalization.
CONCLUSIONS: This study did not show associations of health literacy, numeracy, or graph literacy scores with Lower risk of all-cause hospitalization or mortality. Further research is needed with random sampling in a broader spectrum of healthcare settings to better understand what roles health literacy, numeracy, and graph literacy might play in healthcare utilization and clinical outcomes