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Relationship between cognition and functional outcomes after dysvascular lower extremity amputation: a prospective study.

ABSTRACT: OBJECTIVE:The aim of this study was to examine associations between a cognitive screen and four neuropsychologic tests administered at both 6 wks and 4 mos after amputation and five functional outcomes measured 12 mos after lower extremity amputation. DESIGN:This study includes a prospective cohort from four medical centers. Participants were primarily male Veterans experiencing their first lower extremity amputation as a result of complications of diabetes mellitus or peripheral arterial disease. Of those eligible, 87 (64%) enrolled; 75 (86%) were retained at 12 mos. Measures included demographic/health information, four neuropsychologic measures, the Locomotor Capability Index-5, the Gronigen Activity Restriction Scale, prosthetic use, community participation, and social integration. RESULTS:Better performance on the Short Portable Mental Status Questionnaire at 4 mos was associated with greater 12-mo mobility and social integration. Better attention and working memory abilities 6 wks after amputation were associated with increased 12-mo prosthetic wear; and at 4 mos after amputation, with greater 12-mo mobility. Better verbal memory at 6 wks was associated with greater 12-mo social integration and community participation as well as increased prosthetic wear. CONCLUSIONS:These findings highlight the potential value in including a brief, formal cognitive assessment in addition to a general mental status screen. Specific domains of cognitive function are differentially associated with functional outcomes and may inform amputation rehabilitation decisions.

SUBMITTER: Williams RM

PROVIDER: S-EPMC7518634 | biostudies-literature | 2015 Sep

REPOSITORIES: biostudies-literature

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Relationship between cognition and functional outcomes after dysvascular lower extremity amputation: a prospective study.

Williams Rhonda M RM Turner Aaron P AP Green Monica M Norvell Daniel C DC Henderson Alison W AW Hakimi Kevin N KN Blake Donna Jo DJ Czerniecki Joseph M JM

American journal of physical medicine & rehabilitation 20150901 9

<h4>Objective</h4>The aim of this study was to examine associations between a cognitive screen and four neuropsychologic tests administered at both 6 wks and 4 mos after amputation and five functional outcomes measured 12 mos after lower extremity amputation.<h4>Design</h4>This study includes a prospective cohort from four medical centers. Participants were primarily male Veterans experiencing their first lower extremity amputation as a result of complications of diabetes mellitus or peripheral ...[more]

PMID: 25357146

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Project description:ObjectiveThe objective of this study was the development of AMPREDICT-Mobility, a tool to predict the probability of independence in either basic or advanced (iBASIC or iADVANCED) mobility 1 year after dysvascular major lower extremity amputation.MethodsTwo prospective cohort studies during consecutive 4-year periods (2005-2009 and 2010-2014) were conducted at seven medical centers. Multiple demographic and biopsychosocial predictors were collected in the periamputation period among individuals undergoing their first major amputation because of complications of peripheral arterial disease or diabetes. The primary outcomes were iBASIC and iADVANCED mobility, as measured by the Locomotor Capabilities Index. Combined data from both studies were used for model development and internal validation. Backwards stepwise logistic regression was used to develop the final prediction models. The discrimination and calibration of each model were assessed. Internal validity of each model was assessed with bootstrap sampling.ResultsTwelve-month follow-up was reached by 157 of 200 (79%) participants. Among these, 54 (34%) did not achieve iBASIC mobility, 103 (66%) achieved at least iBASIC mobility, and 51 (32%) also achieved iADVANCED mobility. Predictive factors associated with reduced odds of achieving iBASIC mobility were increasing age, chronic obstructive pulmonary disease, dialysis, diabetes, prior history of treatment for depression or anxiety, and very poor to fair self-rated health. Those who were white, were married, and had at least a high-school degree had a higher probability of achieving iBASIC mobility. The odds of achieving iBASIC mobility increased with increasing body mass index up to 30 kg/m2 and decreased with increasing body mass index thereafter. The prediction model of iADVANCED mobility included the same predictors with the exception of diabetes, chronic obstructive pulmonary disease, and education level. Both models showed strong discrimination with C statistics of 0.85 and 0.82, respectively. The mean difference in predicted probabilities for those who did and did not achieve iBASIC and iADVANCED mobility was 33% and 29%, respectively. Tests for calibration and observed vs predicted plots suggested good fit for both models; however, the precision of the estimates of the predicted probabilities was modest. Internal validation through bootstrapping demonstrated some overoptimism of the original model development, with the optimism-adjusted C statistic for iBASIC and iADVANCED mobility being 0.74 and 0.71, respectively, and the discrimination slope 19% and 16%, respectively.ConclusionsAMPREDICT-Mobility is a user-friendly prediction tool that can inform the patient undergoing a dysvascular amputation and the patient's provider about the probability of independence in either basic or advanced mobility at each major lower extremity amputation level.

Project description:BACKGROUND:Prosthesis rehabilitation after dysvascular transtibial amputation (TTA) is focused on optimizing functional capacity with limited emphasis on promoting health self-efficacy. Self-efficacy interventions decrease disability for people living with chronic disease, but the influence of self-efficacy on disability is unknown for people with dysvascular TTA. OBJECTIVES:To identify if self-efficacy mediates the relationship between self-reported functional capacity and disability after dysvascular TTA. DESIGN:Cross-sectional, secondary data analysis. SETTING:Outpatient rehabilitation facilities. PARTICIPANTS:Thirty-eight men (63.6 ± 9.1 years old) with dysvascular TTA. METHODS:Participants had been living with an amputation for less than 6 months and using walking as their primary form of locomotion using a prosthesis. The independent variable, functional capacity, was measured using the Prosthesis Evaluation Questionnaire-Mobility Scale (PEQ-MS). The proposed mediator, self-efficacy, was measured with the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD). MAIN OUTCOME MEASURE:Disability was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire. RESULTS:The relationship between self-reported functional capacity and disability is partially mediated by self-efficacy. Relationships between WHODAS 2.0 and PEQ-MS (r = -0.61), WHODAS 2.0 and SEMCD (r = -0.51), and PEQ-MS and SEMCD (r = 0.44) were significant (P < .01). Controlling for SEMCD (P = .04), the relationship between PEQ-MS and WHODAS 2.0 remained significant (P < .01). Statistically significant mediation was determined by a bootstrap method for the product of coefficients (95% confidence interval: -2.23, -7.39). CONCLUSIONS:This study provides initial evidence that the relationship between self-reported functional capacity and disability is partially mediated by self-efficacy after dysvascular TTA. The longitudinal effect of self-efficacy should be further examined to identify causal pathways of disability after dysvascular amputation. Furthermore, additional factors contributing to the relationship between self-reported functional capacity and disability need to be identified. LEVEL OF EVIDENCE:III.

Project description:Lower extremity amputation is often performed in patients where both lower extremities are at risk due to peripheral arterial disease or diabetes, yet the proportion of patients who progress to amputation of their contralateral limb is not well defined. We sought to determine the rate of subsequent amputation on both the ipsilateral and contralateral lower extremities following initial amputation.We conducted a retrospective review of all patients undergoing lower extremity amputation (exclusive of trauma or tumor) at our institution from 1998 to 2010. We used International Classification of Diseases-Ninth Revision codes to identify patients and procedures as well as comorbidities. Outcomes included the proportion of patients at 1 and 5 years undergoing contralateral and ipsilateral major and minor amputation stratified by initial major vs minor amputation. Cox proportional hazards regression analysis was performed to determine predictors of major contralateral amputation.We identified 1715 patients. Mean age was 67.2 years, 63% were male, 77% were diabetic, and 34% underwent an initial major amputation. After major amputation, 5.7% and 11.5% have a contralateral major amputation at 1 and 5 years, respectively. After minor amputation, 3.2% and 8.4% have a contralateral major amputation at 1 and 5 years while 10.5% and 14.2% have an ipsilateral major amputation at 1 and 5 years, respectively. Cox proportional hazards regression analysis revealed end-stage renal disease (hazard ratio [HR], 3.9; 95% confidence interval [CI], 2.3-6.5), chronic renal insufficiency (HR, 2.2; 95% CI, 1.5-3.3), atherosclerosis without diabetic neuropathy (HR, 2.9; 95% CI, 1.5-5.7), atherosclerosis with diabetic neuropathy (HR, 9.1; 95% CI, 3.7-22.5), and initial major amputation (HR, 1.8; 95% CI, 1.3-2.6) were independently predictive of subsequent contralateral major amputation.Rates of contralateral limb amputation are high and predicted by renal disease, atherosclerosis, and atherosclerosis with diabetic neuropathy. Physicians and patients should be alert to the high risk of subsequent amputation in the contralateral leg. All patients, but particularly those at increased risk, should undergo close surveillance and counseling to help prevent subsequent amputations in their contralateral lower extremity.

Project description:BackgroundPatients who undergo lower extremity amputation secondary to the complications of diabetes or peripheral artery disease have poor long-term survival. Providing patients and surgeons with individual-patient, rather than population, survival estimates provides them with important information to make individualized treatment decisions.MethodsPatients with peripheral artery disease and/or diabetes undergoing their first unilateral transmetatarsal, transtibial or transfemoral amputation were identified in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Stepdown logistic regression was used to develop a 1-year mortality risk prediction model from a list of 33 candidate predictors using data from three of five Department of Veterans Affairs national geographical regions. External geographical validation was performed using data from the remaining two regions. Calibration and discrimination were assessed in the development and validation samples.ResultsThe development sample included 5028 patients and the validation sample 2140. The final mortality prediction model (AMPREDICT-Mortality) included amputation level, age, BMI, race, functional status, congestive heart failure, dialysis, blood urea nitrogen level, and white blood cell and platelet counts. The model fit in the validation sample was good. The area under the receiver operating characteristic (ROC) curve for the validation sample was 0·76 and Cox calibration regression indicated excellent calibration (slope 0·96, 95 per cent c.i. 0·85 to 1·06; intercept 0·02, 95 per cent c.i. -0·12 to 0·17). Given the external validation characteristics, the development and validation samples were combined, giving a total sample of 7168.ConclusionThe AMPREDICT-Mortality prediction model is a validated parsimonious model that can be used to inform the 1-year mortality risk following non-traumatic lower extremity amputation of patients with peripheral artery disease or diabetes.

Project description:BackgroundPeople with dysvascular lower limb amputation (LLA) achieve one-third of the recommended steps per day and experience severe disability. Although physical function improves with rehabilitation after dysvascular LLA, physical activity remains largely unchanged, and factors contributing to limited daily step count are unknown.ObjectivesTo identify factors that contribute to daily step count after dysvascular LLA.DesignCross-sectional, secondary data analysis.SettingOutpatient rehabilitation facilities.ParticipantsFifty-eight patients with dysvascular major LLA (age: 64 ± 9 years, body mass index: 30 ± 8 kg/m2 , male: 95%, transtibial LLA: 95%).MethodsData were collected by a blinded assessor after dysvascular LLA. Candidate explanatory variables included (1) demographics, (2) LLA characteristics, (3) comorbidities and health behaviors, and (4) physical function. Variables with univariate associations with log steps/day (transformed due to non-normality) were included in a multiple linear regression model using backward elimination to identify factors that explained significant variability in log steps/day.Primary outcome measureThe primary outcome, daily step count, was measured with accelerometer-based activity monitors worn by participants for 10 days.ResultsParticipants took an average (± SD) of 1450 ± 1309 steps/day. After backward elimination, the final model included four variables explaining 62% of the overall daily step count (P < .0001): 2-minute walk distance (32%), assistive device use (11%), cardiovascular disease (10%), and pre-amputation walking time (11%).ConclusionsAverage daily step count of 1450 steps/day reflects the lowest category of sedentary behavior. Physical function, cardiovascular disease, and pre-amputation walking time explain 62% of daily step count after dysvascular LLA. Although physical rehabilitation commonly focuses on improving physical function, interventions to increase daily step count after dysvascular LLA should also consider chronic disease and health behaviors that predate LLA.Level of evidenceIII.

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Relationship between cognition and functional outcomes after dysvascular lower extremity amputation: a prospective study.

Publications

Relationship between cognition and functional outcomes after dysvascular lower extremity amputation: a prospective study.

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