History, Nursing and Medical

History, Nursing and Medical

Week 7 Discussion Posts Please include reference Discussion 1: Week 7: Terrorism in the 21st Century Discuss how

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you see the “war on terrorism” as of this date. Do you think the United States should be engaged in such a war? Give reasons for or against this war and whether or not we are giving up our own principles to wage it. Answer: Discussion 2: Week 7: The Cold War and America How did the Cold War affect the social and political climate in the United States during the 1950s? In particular, how do you explain McCarthyism and the Red Scare? Can you think of any modern parallels to these events, when fear and paranoia threatened basic American liberties? Elaborate. Answer: Discussion 3: Week 7: Applying and Sharing Evidence to Practice. This week’s graded discussion topic relates to the following Course Outcomes (COs). • • • • CO1 Examine the sources of evidence that contribute to professional nursing practice. (PO 7) CO2 Apply research principles to the interpretation of the content of published research studies. (POs 4 and 8) CO4 Evaluate published nursing research for credibility and lab significance related to evidence-based practice. (POs 4 and 8) CO5 Recognize the role of research findings in evidence-based practice. (POs 7 and 8) After the data have been analyzed, conclusions are made regarding what the findings mean. Then, this information must be shared with your healthcare team. 1. Choose one of the articles from the Week 5 RRL assignment, and discuss the findings. Would you apply the evidence found to your practice? Explain your answer. (I attached this article). 2. Translating research into practice is the final and most important step in the research process. Review information you found your nursing clinical issue and explain ways in which you would share the research-based evidence with your peers. Answer: [Downloaded free from http://www.ijpm.info on Friday, March 31, 2017, IP: 202.177.173.189] Original Article Quantitative Balance and Gait Measurement in Patients with Frontotemporal Dementia and Alzheimer Diseases: A Pilot Study Selva Ganapathy Velayutham, Sadanandavalli Retnaswami Chandra1, Srikala Bharath2, Ravi Girikamatha Shankar3 ABSTRACT Introduction: Alzhiemers disease and Frontotemporal dementia are common neurodegenerative dementias with a wide prevalence. Falls are a common cause of morbidity in these patients. Identifying subclinical involvement of these parameters might serve as a tool in differential analysis of these distinct parameters involved in these conditions and also help in planning preventive strategies to prevent falls. Patients and Methods: Eight patients in age and gender matched patients in each group were compared with normal controls. Standardizes methods of gait and balance aseesment were done in all persons. Results: Results revealed subclinical involvement of gait and balancesin all groups specially during divided attention. The parameters were significantly more affected in patients. Patients with AD and FTD had involement of over all ambulation index balance more affected in AD patients FTD patients showed step cycle, stride length abnormalities. Discussion: There is balance and gait involvement in normal ageing as well as patients with AD and FTD. The pattern of involvement in AD correlates with WHERE pathway involvement and FTD with frontal subcortical circuits involvement. Conclusion: Identification the differential patterns of involvement in subclinical stage might help to differentiate normal ageing and the different types of cortical dementias. This could serve as an additional biomarker and also assist in initiating appropriate training methods to prevent future falls. Key words: Alzheimer disease, balance impairment, frontotemporal dementia, gait impairment, posturography INTRODUCTION Alzheimer disease (AD) is a neurodegenerative disorder characterized by progressive loss of recent and episodic memory and other cognitive functions, affects 35 million people worldwide. [1] Early diagnosis is important to initiate early treatment strategies to improve disability adjusted life years Website: This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. www.ijpm.info For reprints contact: reprints@medknow.com Access this article online Quick Response Code DOI: 10.4103/0253-7176.203132 How to cite this article: Velayutham SG, Chandra SR, Bharath S, Shankar RG. Quantitative balance and gait measurement in patients with frontotemporal dementia and Alzheimer diseases: A pilot study. Indian J Psychol Med 2017;39:176-82. Departments of Neurological Rehabilitation, 1Neurology and 3Biostatistics, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India, 2South Asian Division, Royal College of Psychiatrists, London, UK Address for correspondence: Dr. Sadanandavalli Retnaswami Chandra Faculty Block, Neurocentre, National Institute of Mental Health and Neurosciences, Bengaluru – 560 029, Karnataka, India. E-mail: drchandrasasi@yahoo.com 176 © 2017 Indian Psychiatric Society | Published by Wolters Kluwer – Medknow [Downloaded free from http://www.ijpm.info on Friday, March 31, 2017, IP: 202.177.173.189] Velayutham, et al.: Gait and balance in cortical dementia and reduce caregiver burden. The other type of cortical dementia is frontotemporal dementia (FTD) which manifests little more early and manifests often with neuropsychiatric manifestations. These two conditions are often misdiagnosed as each other or as purely psychiatric illness which delays the diagnosis. Morbidity and mortality are often due to secondary factors than the disease itself. Cortical structures are wired to subcortex by various functional circuits and therefore there is a possibility that subcortical signs which are easier to measure may be involved subclinically and if any differential pattern is observed it might help as an additional biomarker in early specific diagnosis as AD or FTD and also initiate appropriate treatments to delay progression to serious disability. Gait and balance are the product of successful integration of various posture control mechanisms and locomotion. Neurological disorders at any level can compromise the biomechanics of the same as it involves several complex mechanisms. Posture control needs maintaining the center of mass over the BOS all through the gait cycle. Dynamic balance needs cerebellum, vestibular system, and unconscious reactive reflexes such as long loop reflexes. Standing balance needs sensory information with reference to environment generated by vision, proprioception, and vestibular system. Because of the frontal-subcortical circuits breaking down in FTD and WHERE dorsal pathway dysfunction in Ad, both these disorders are likely to have gait and balance-related problems. Older persons with cognitive dysfunction are especially vulnerable for gait and balance problems resulting in repeated falls because of the associated multiaxial “dysfunction involving not only cognition but also, joints, ligaments, tendons, vision, and hearing.” [2] Patients with attention and cognitive disorders are at risk of disequilibrium in this automatic, unconscious act of walking due to inability to concentrate in dual tasking.[3-14] There is evidence for abnormal equilibrium in Ad and motor dysfunction in FTD.[15-17] This can increase morbidity significantly in these patients.[18-22] The changes are expected to be subclinical in the early phase, and hence quantitative measurements will be of great help in understanding the pattern which apart from probably serving as a easily accessible biomarker, might also serve in initiating rehabilitatory tools early in the course of disease. PATIENTS AND METHODS Twenty-four male subjects with 50–70 years of age, 8 in each group of probable bvFTD diagnosed by revised consensus criteria,[23] probable AD, diagnosed by ADs association criteria,[24] and healthy volunteers as controls. The FTD and AD groups were recruited from Outpatient Department of Neurology and Geriatric Clinic, controls from the community. Informed consent was obtained from all and ethical clearance received from the Institute Ethical Committee. Subjects with orthopedic, visual deficit, other neurological conditions, and cardiovascular ailments were excluded. All demographic factors including age, gender, and height, weight are recorded. The balance was measured by Biodex Balance Master Incorp., USA, using dynamic posturography, in single and dual tasks and gait with Biodex Gait Trainer. T h e e q u i p m e n t h a s a p o s t u ro g r a p h y – b a s e d force platform which provides objective balance measurements in two situations, i.e., (1) dynamic balance and (2) limits of stability (LOS). It has a circular platform and a display monitor kept in front of the subject to see and get the feedback about their status of standing. The platform becomes unstable and the subject’s experience wobbling. The change in the center of pressure due to this will be displayed in the monitor as a biofeedback as the cursor moves from the epicenter of the grid. Each subjects “base of support” requirement for the perturbed stand is tested, and subjects are asked to adjust their BOS making the tilted platform to the neutral and stable position. They can utilize the feedback about their stand position from the display monitor and instructed to target at the innermost circle or epicenter of the grid. At the end, BOS is recorded including measurement of the angle of foot deviations and during the process. Dynamic balance – Single task Three trials each of 20 s duration are done. The amount of deviation from original BOS and direction of deviation were recorded without using handrail support. The test results contain overall balance index (OBI), anteroposterior index (API), i.e., amount of front to back sway, mediolateral index (MLI), i.e., side to side sway. Higher the score indicates poorer the balance. Limits of stability – Single task In the second part of balance test, the subjects ability to come back to the original BOS after a self-initiated sway in eight different direction, namely, (1) forward (F), (2) backward, (3) right, (4) left, (5) forward right, (6) forward left, (7) backward right, and (8) backward left was tested. The maximum overall score, individual direction score was 100 with the maximum time of 300 s. Higher the score and shorter the time taken indicates better the balance. Indian Journal of Psychological Medicine | Volume 39 | Issue 2 | March-April 2017 177 [Downloaded free from http://www.ijpm.info on Friday, March 31, 2017, IP: 202.177.173.189] Velayutham, et al.: Gait and balance in cortical dementia Procedure The platform becomes unstable, and the subject sees a square box in the display monitor, the subjects has to shift the body weight toward the direction of the box so that the cursor moves and get inside the box and hold for 2 s. Then move to the direction where the next box appears. The display of the boxes appears in such a way that the subject needs to come back to the first box after completing the individual box in a different direction. The maximum time to complete the task is 300 s. The result generated consists of overall balance, forward, backward, forward right, forward left, backward right, backward left, and time take to complete the test. Dual task In dual task, the subject performs dynamic balance, LOS task along with cognitive task and repeated after a rest period for 2 min from the single task. The cognitive task includes digital subtraction of 3, 2, from 100 in dynamic balance, LOS tasks, respectively.[25,26] The patients are expected to utilize the visual feedback to obtain balance. A safety harness protects the subject from falling. Gait assessment The subjects gait was measured by Biodex Gait Trainer USA Incorp. The persons recruited had to walk for 2 min in a sensor-based treadmill at a comfortable speed. A safety harness was provided to protect the person from falling. Kinematic data includes gait speed, stride and step length, coefficient variation of the steps (CV) were gathered. After a rest period of about 2 min, the test was administered for the second time for a dual task where the subject counted backward from 100 as a cognitive task[27] while walking on a treadmill. The result contains total walking distance, average walking speed, average step cycle, average step length, CV of the right and left leg. Higher the score in gait parameter indicates better gait stability, however, increased coefficient variation of steps indicate poor gait stability. RESULTS The Shapiro–Wilkins test was conducted to test the normality of the parameters. Descriptive analysis was done for age, body mass index, education in years. Within group analysis of single versus dual task was analyzed with paired t-test. One-way ANOVA was conducted to reveal the difference between groups, followed by post hoc test with Bonferroni correction. The mean age of FTD group = 58.37 ± 8.38; AD group = 66.7 ± 5.5; Control group = 59.5 ± 7.03, all the subjects were male (8 in each group), the Hindi Mental Status Examination score of FTD and AD group were significantly lower than the controls [Table 1]. Within group comparison of single versus dual Dynamic balance The OBI and API of the dynamic balance of FTD group and control group significantly differed between single versus dual task. However, AD group had significant difference in mediolateral (MLI) stability index only [Table 2 and MLI score in Figure 1]. Limits of stability All the three group had significant difference in overall LOS score between single vs. dual task however the sub-component of LOS revealed FTD patients had problem balancing on forward lateral direction and control group had problem in forward, left direction whereas the AD group had significant difficulty in backward direction [Table 2 and overall LOS score in Figure 2]. Gait analysis FTD, AD group, performed poorly in dual task gait analysis while the control group showed no significant worsening of gait. Ambulation index (AI) is a cumulative score of overall gait performance which is found to be low on dual task for both dementias [Figure 3]. In addition, FTD group had significant reduction of step cycle, step length especially on the right side [Table 3]. Between group comparisons Dynamic balance – Single task FTD group had a significant worsening of balance in comparison with control group in all subcomponent of dynamic balance, i.e., OBI, API, and MLI. The Table 1: Age, body mass index, HMSE score, education of patients with FTD and AD FTD (n=8) AD (n=8) Control (n=8) P (ANOVA) Age (mean±SD) BMI Education in years HMSE 58.37±8.38 23.26±2.86 9.50±5.21 16.25±7.3 66.7±5.57 20.8±1.63 11.63±5.20 16.88±5.91 59.5±7.03 23.75±3.83 11±3.46 30.8±0.34 NS NS NS 0.000 (
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