Impact of early refined nursing program on prognosis of middle-aged and elderly patients with cognitive dysfunction combined with cerebral infarction

Abstract

BACKGROUND

Cerebral infarction is a local or extensive necrosis of brain tissue. Subsequently, the corresponding neurological deficits appear. The incidence of cerebrovascular diseases in China is increasing gradually. After the onset of cerebrovascular disease, the most common sequelae include movement disorders, language disorders, and cognitive dysfunction.

AIM

To investigate the effect of early refined nursing program on the prognosis of middle-aged and elderly patients with cerebral infarction combined with cognitive dysfunction.

METHODS

A retrospective study was conducted to divide 60 patients with cerebral infarction and cognitive impairment into an experimental group (n = 32) and a control group (n = 28). The experimental group received early intensive care every day, and the control group received daily routine care. The scores of the Mini-Mental State Examination (MMSE) and the Trail Making Test (TMT), as well as the latency and amplitude of the event-related potential P300, were used as main indicators to evaluate changes in cognitive function, and changes in BDNF, TGF-β, and GDNF expression were used as secondary indicators.

RESULTS

Both groups experienced notable enhancements in MMSE scores, with the experimental group demonstrating higher scores than the control group (experimental: 28.75 ± 2.31; control: 25.84 ± 2.87). Moreover, reductions in TMT-A and TMT-B scores were observed in both groups (experimental: TMT-A 52.36 ± 6.18, TMT-B 98.47 ± 10.23; control: TMT-A 61.48 ± 7.92, TMT-B 112.63 ± 12.55), with the experimental group displaying lower scores. P300 Latency decreased (experimental: 270.63 ms ± 14.28 ms; control: 285.72 ms ± 16.45 ms), while amplitude increased (experimental: 7.82 μV ± 1.05 μV; control: 6.35 μV ± 0.98 μV) significantly in both groups, with superior outcomes in the experimental cohort. Additionally, the levels of the growth factors BDNF, TGF-β1, and GDNF surged (experimental: BDNF 48.37 ng/mL ± 5.62 ng/mL, TGF-β1 52.14 pg/mL ± 4.28 pg/mL, GDNF 34.76 ng/mL ± 3.89 ng/mL; control: BDNF 42.58 ng/mL ± 4.73 ng/mL, TGF-β1 46.23 pg/mL ± 3.94 pg/mL, GDNF 30.25 ng/mL ± 2.98 ng/mL) in both groups, with higher levels in the experimental group.

CONCLUSION

For middle-aged and elderly patients with cerebral infarction and cognitive dysfunction, early refined nursing can significantly improve their cognitive function and prognosis.

Key Words: Early refined nursing program, Cerebral infraction, Cognitive impairment, Psychiatry, Trajectory test

Core Tip: The incidence of cerebrovascular diseases in China is increasing gradually. After the onset of cerebrovascular disease, the most common sequelae include movement disorders, language disorders, and cognitive dysfunction. Cognitive impairment in patients with cerebral infarction may or may not be accompanied by focal dysfunction, such as apraxia, agnosia, aphasia, memory impairment, and executive dysfunction. For middle-aged and elderly patients with cerebral infarction and cognitive dysfunction, early refined nursing can significantly improve their cognitive function and prognosis.

INTRODUCTION

Cerebral infarction is a local or extensive necrosis of brain tissue. The blood-supplying vessels of the brain exhibit narrowing and occlusion of the lumen. This causes a sudden decrease in blood flow to the brain tissue, or no blood flow through it, resulting in ischemia and hypoxic necrosis of the brain tissue, followed by corresponding neurological deficit symptoms. The incidence of cerebrovascular diseases in China is gradually increasing. According to relevant epidemiological investigations and research, cerebrovascular diseases in China are increasing, with the mortality rate of cerebrovascular diseases ranking first among various causes of death, reaching as high as 22.45%[1]. After the onset of cerebrovascular disease, the most common sequelae include movement disorders, language disorders, and cognitive impairment.

Numerous studies have shown that survivors of acute ischemic stroke are prone to experiencing decreased levels of cognitive function. The probability of incidence within 3 mo after cerebral infarction is approximately 62.6%, and the long-term functional effects will persist[2,3]. In addition, studies have shown that after the onset of ischemic cerebrovascular disease, more than one-third of patients develop vascular cognitive impairment. In China, the incidence of vascular cognitive impairment in people aged over 60 years is 11.95%[4]. Studies have also conducted follow-ups on cerebral infarction patients and found that the incidence of cognitive impairment after one year reached 49.5%[5]. Cognitive impairment in patients with cerebral infarction may or may not be accompanied by focal functional impairments such as apraxia, agnosia, aphasia, memory impairment, and executive function impairment. Several studies have suggested that advanced age, long-term hypertension, diabetes, and hyperlipidemia can contribute to the occurrence and progression of cognitive impairment in patients with cerebral infarction. These factors are considered to be associated with an increased risk of vascular cognitive impairment[6]. Cognitive impairment has a significant impact on the ability to perform daily activities and engage in social life in patients with cerebral infarction, leading to a decrease in quality of life for these patients[7]. Additionally, cognitive impairment is associated with decreased adherence to treatment and medication, resulting in an impact on treatment efficacy. Furthermore, studies have indicated a higher mortality rate in patients with cerebral infarction who also have cognitive impairment[8]. Conventional models of nursing care are generally effective, but they may lack specificity in addressing individual patient needs. Therefore, it is crucial to explore more targeted and personalized interventions to enhance the effectiveness of nursing care.

The emergence of refined nursing interventions represents a paradigm shift in healthcare, offering a nuanced approach that integrates medical science with a humanistic perspective, addressing patients' physical, psychological, and social needs. Unlike traditional models, the refined nursing program is all-encompassing, spanning from admission to treatment completion. It involves meticulous tailoring of each aspect of care, guided by a patient-centered philosophy, promoting individualized and effective interventions. In contrast to conventional nursing practices, the refined approach emphasizes early intervention, with specific considerations for the unique circumstances of each hospital. The nursing plans are meticulously designed based on the patient's disease type, research findings, surgical outcomes, and potential for functional rehabilitation. Notably, the emphasis on "patient-centered" care underscores the individuality of each patient, tailoring interventions to meet their specific needs. To exemplify the impact of refined nursing, a study by Shi W delved into the early implementation of refined nursing programs for middle-aged and elderly patients with cerebral infarction and cognitive impairment, particularly in the context of respiratory critical care[9].

MATERIALS AND METHODS

Population

Sixty patients with cerebral infarction and cognitive impairment were recruited from the Rehabilitation Medicine Department of Ganzhou People's Hospital, Jiangxi Province, China from January 2021 to September 2022. The Ethics Committee of Ganzhou People's Hospital approved the study (No. 200230107). Written consent was obtained from those who were eligible and willing to participate after admission to the Rehabilitation Medicine Department of Ganzhou People's Hospital.

The inclusion criteria for the participants were as follows: (1) First-time cerebral infarction that met the clinical diagnostic criteria[10] and was confirmed by brain computed tomography or magnetic resonance imaging, with stable vital signs; (2) being conscious and able to cooperate with relevant treatment; (3) having a Montreal Cognitive Assessment Scale score ≤ 24 points; (4) having a disease course of more than 1 mo; and (5) being aged 45-70 years old.

The exclusion criteria for patients were as follows: (1) Having cognitive dysfunction before onset; (2) having contraindications to high-frequency repetitive transcranial magnetic stimulation therapy; (3) having heart, liver, kidney, or other important organ insufficiency; (4) having a history of cerebral hemorrhage, epilepsy, or brain trauma; (5) having a history of alcohol or drug dependence before the onset of this illness; and (6) deterioration of the condition and appearance of a new infarction lesion.

Intervention methods

In the control group, routine nursing measures were used, the patients’ vital signs were closely monitored, nursing assessments were implemented, and medication guidance and health education were provided for 12 wk.

The experimental group received a refined nursing program based on conventional nursing. This primarily involved giving attention and care to patients with cerebral infarction, actively communicating with them, alleviating their tension through positive emotions, soft language, and comforting measures, and providing scientific explanations about their illness.

The refined nursing program for patients with cerebral infarction specifically focused on those in the acute stage. It primarily included timely admission to the intensive care unit (ICU) or other appropriate departments, minimizing waiting time in the emergency department, establishing an infusion channel, promptly administering oxygen and other necessary measures, and closely monitoring changes in the patients’ condition according to first-level nursing standards. Additionally, efforts were made to minimize patient movements, including both the number and amplitude of such movements. At the same time, according to the sex and height of the cerebral infarction patient, the head of the bed should be appropriately raised, and the cleaning and care of the mouth, mucous membranes, skin, and vulva of patients with cerebral infarction should be strengthened.

According to the cognitive function of patients, a neuroprotective diet, including the Mediterranean diet, was provided, and the cessation of the diet triggered high blood pressure or increased the consumption of olive oil. Patients in the acute phase need no drinking water, need to use a gastric tube to inject nutritional supplements through nasal feeding, and can be assisted by a nasogastric pump when conditions permit.

Admission and critical care

Routine nursing care (control group): Patients in the control group received standard care, with no specific emphasis on timely admission to specialized units or critical care measures.

Refined nursing program (experimental group): The refined program prioritized timely admission to the ICU or suitable departments, minimized wait times, and ensured prompt administration of oxygen and other necessary measures following first-level nursing standards.

Psychological and emotional support

Routine nursing care (control group): Standard care included general psychological support but lacked a structured approach to alleviate tension through positive emotions, soft language, and comforting measures.

Refined nursing program (experimental group): Actively engaging with patients, the refined program aimed to establish a strong nurse-patient relationship, reduce psychological burdens, and enhance patient confidence through tailored emotional care.

Personalized dietary care

Routine nursing care (control group): Dietary care in the control group was generally standard, without specific consideration for cognitive function or a neuroprotective diet.

Refined nursing program (experimental group): Tailored meal care included providing a neuroprotective diet, such as the Mediterranean diet, and adjusting diets based on cognitive function, avoiding triggers for high blood pressure.

Complication management

Routine nursing care (control group): Standard procedures were followed, without specific adjustments to air conditioning parameters or detailed observations of urine output and color.

Refined nursing program (experimental group): The program included meticulous complication management, with adjustments to air conditioning parameters, maintenance of an optimal environment, and detailed observation and guidance on urine output and water intake.

Encouragement of physical activity

Routine nursing care (control group): Exercise was generally encouraged without specific emphasis on early-stage exercise or the principle of "step by step."

Refined nursing program (experimental group): Actively encouraging early-stage exercise, the refined program followed the principle of "step by step," promoting exercise in the company of family members or nursing workers.

In summary, the refined nursing program demonstrated a comprehensive and tailored approach, addressing not only the physical but also the psychological and environmental needs of patients, particularly those in the acute stage of cerebral infarction. The control group, in contrast, received standard care without the specific refinements outlined in the experimental group's program.

Cognitive outcome parameters

Primary indicators included the scores of the Mini-Mental State Examination (MMSE)[11] and the Trail Making Test (TMT), as well as the latency and amplitude of the event-related potential P300. The P300 Latency and amplitude were measured using an electromyography/evoked potential instrument.

Secondary indicators were changes in growth factors including BDNF, TGF-β1, and GDNF, and they were utilized to assess changes in cognitive function at 0, 6, and 12 wk after the start of the intervention. BDNF, TGF-β1, and GDNF were measured via enzyme-linked immunoassay after venous blood collection.

Statistical analysis

SPSS 24.0 was used for all statistical analyses. After conducting the Kolmogorov-Smirnov test, continuous variables that followed a normal distribution are presented as the mean ± SD. For intergroup analysis, the independent sample t test was used. Moreover, repeated-measures ANOVA was used for intergroup analysis. Discontinuous variables that did not conform to a normal distribution are expressed as percentages, and nonparametric tests were used for intergroup analysis. Statistical significance was set at P < 0.05.

RESULTS

Baseline patient information

A total of 60 patients with cerebral infarction and cognitive impairment were enrolled in the study. The average age of the patients was 59.64 ± 4.13 years, and the average body mass index (BMI) was 24.47 ± 3.45 kg/m². Among the participants, 58.33% were male and 41.67% were female. A total of 41.67% of the patients had a history of smoking, and 18.33% had a history of drinking. Moreover, 66.67% of the patients had an education level below junior high school, 21.67% had a high school education background, and 11.66% had an education level above university. Additionally, 61.67% of the patients had left-sided infarctions, while 38.33% had right-sided infarctions. Furthermore, 11.66% of the patients had a history of coronary heart disease, and 11.66% had a history of atrial fibrillation.

There were no significant differences observed between the two groups regarding age, sex, BMI, lesion side, educational background, history of hypertension, history of coronary heart disease, or history of atrial fibrillation (P > 0.05; Table 1).

Table 1 Comparison of demographic data between the two groups, n (%)/mean ± SD.

Item	Experimental group (n = 32)	Control group (n = 28)	t/χ2/Z	P value
Age (yr)	59.45 ± 3.94	59.87 ± 4.40	0.390	0.697
Gender			0.765	0.381
Man	17 (53.13)	18 (64.29)
Woman	15 (46.87)	10 (35.71)
BMI (kg/m²)	24.88 ± 3.62	24.01 ± 3.27	0.971	0.335
Smoking history	13 (40.63)	12 (42.85)	0.030	0.861
Drinking history	5 (15.62)	6 (21.42)	0.335	0.561
Side of lesion			2.116	0.145
Left side	17 (53.13)	20 (71.43)
Right side	15 (46.87)	8 (28.57)
Education background			1.558	0.119
Junior high school and below	24 (75.00)	16 (57.14)
Senior high school	6 (18.75)	7 (25.00)
College and above	2 (6.25)	5 (17.86)
History of hypertension	23 (71.87)	19 (67.85)	0.114	0.734
History of coronary heart disease	4 (12.50)	3 (10.71)	0.035	0.850
History of atrial fibrillation	5 (15.62)	2 (7.14)	0.381	0.536

Changes in MMSE and TMT scores

The differences in the intergroup comparison, time comparison, and intergroup time interactive comparison of MMSE and TMT-A scores between the two groups were statistically significant (P < 0.05). Similarly, for the TMT-B scores, the differences in the intergroup comparison and the time comparison between the two groups were statistically significant (P < 0.05), while the difference in the intergroup time interaction comparison was not statistically significant (P > 0.05). At 6 wk and 12 wk, both groups exhibited higher MMSE scores compared to their respective scores at 0 wk, whereas the scores of TMT-A and TMT-B were lower than those at 0 wk in both groups. These differences were statistically significant (P < 0.05). Furthermore, the MMSE scores in the experimental group were greater than those of the control group, and the TMT-A and TMT-B scores were lower than those of the control group. These differences were also statistically significant (P < 0.05; Table 2).

Table 2 Changes in Mini-Mental State Examination and Trail Making Test scores, mean ± SD.

Item	Time (wk)	Experimental group (n = 32)	Control group (n = 28)	Inter-group comparison (F/P value)	Time comparison (F/P value)	Inter-group time interactive comparison (F/P value)
MMSE score	0	18.45 ± 3.52	18.84 ± 4.74	9.451/0.002	37.030/< 0.001	4.395/0.013
	6	21.69 ± 3.24a,b	19.32 ± 3.05b
	12	25.26 ± 2.38a,b	22.12 ± 2.19b
TMT-A score	0	82.35 ± 12.84	81.66 ± 14.57	9.016/0.003	193.200/< 0.001	3.664/0.027
	6	61.58 ± 10.25a,b	71.34 ± 11.46b
	12	41.59 ± 5.32a,b	46.75 ± 5.87b
TMT-B score	0	162.18 ± 45.25	163.36 ± 42.16	5.332/0.022	57.420/< 0.001	1.151/0.318
	6	123.73 ± 23.11a,b	141.39 ± 22.96b
	12	96.76 ± 16.33a,b	109.42 ± 19.86b

^aP < 0.05 compared with control group.

^bP < 0.05 compared with 0 wk.

MMSE: Mini-Mental State Scale; TMT: Trail Making Test.

Changes in P300

The differences in the intergroup comparison and the time comparison of the P300 Latency and amplitude between the two groups were statistically significant (P < 0.05). However, the difference in the intergroup time interaction coefficient was not statistically significant (P > 0.05). At 6 and 12 wk, the P300 Latency in both groups was shorter than that at 0 wk within the same group. Additionally, the amplitude of the P300 was greater than that at 0 wk within the same group. These differences were statistically significant (P < 0.05). Moreover, the latency of P300 in the experimental group was lower than that of the control group, and the amplitude was greater than that of the control group. These differences were also statistically significant (P < 0.05; Table 3).

Table 3 Changes in the latency and amplitude of P300, mean ± SD.

Group	Latency (ms)			Amplitude (μv)
	0 wk	6 wk	12 wk	0 wk	6 wk	12 wk
Experimental group (n = 32)	452.38 ± 40.52	402.31 ± 21.14a,b	365 ± 15.13a,b	4.53 ± 2.14	6.18 ± 1.74a,b	6.89 ± 1.45a,b
Control group (n = 28)	467.84 ± 43.99	437.79 ± 22.57b	384.23 ± 16.46b	4.41 ± 2.08	5.22 ± 1.93b	6.02 ± 1.66b
Inter-group comparison (F/P value)	30.340/< 0.001			5.556/0.019
Time comparison (F/P value)	136.700/< 0.001			17.600/< 0.001
Inter-group time interactive comparison (F/P value)	2.179/0.116			0.932/0.395

^aP < 0.05 compared with control group.

^bP < 0.05 compared with 0 wk.

Changes in growth factors

The differences in the intergroup comparison, time comparison, and intergroup time interactive comparison of BDNF, TGF-β1, and GDNF levels between the two groups were statistically significant (P < 0.05). At 6 wk and 12 wk, the levels of BDNF, TGF-β1, and GDNF in both groups were greater than those at 0 wk within the same group. Furthermore, the experimental group exhibited higher levels of BDNF, TGF-β1, and GDNF than did the control group. These differences were statistically significant (P < 0.05; Table 4).

Table 4 Changes in growth factors, mean ± SD.

Item	Time (wk)	Experimental group (n = 32)	Control group (n = 28)	Inter-group comparison (F/P value)	Time comparison (F/P value)	Inter-group time interactive comparison (F/P value)
BNDF (ng/mL)	0	4.85 ± 0.79	4.92 ± 0.83	19.330/< 0.001	146.100/< 0.001	9.113/< 0.001
	6	6.63 ± 1.05a,b	6.07 ± 0.86b
	12	8.77 ± 1.25a,b	7.28 ± 1.14b
TGF-β1 (ng/L)	0	15.42 ± 2.54	15.68 ± 2.99	19.080/< 0.001	92.220/< 0.001	8.759/< 0.001
	6	20.44 ± 3.12a,b	18.56 ± 3.08b
	12	25.71 ± 3.52a,b	21.13 ± 3.66b
GDNF (pg/mL)	0	288.61 ± 25.26	282.74 ± 24.18	40.080/< 0.001	157.200/< 0.001	6.016/0.003
	6	346.59 ± 25.84a,b	312.72 ± 26.38b
	12	392.27 ± 29.96a,b	355.06 ± 30.47b

^aP < 0.05 compared with control group.

^bP < 0.05 compared with 0 wk.

DISCUSSION

In this study, after 6 and 12 wk of intervention, the experimental group exhibited higher scores on the MMSE, P300 amplitude, BDNF, TGF-β1, and GDNF than the control group. Moreover, the experimental group showed lower scores on the Trail Making Test parts A and B (TMT-A and TMT-B) and P300 Latency than the control group. These differences were statistically significant (P < 0.05). These results suggest that the refined nursing model has a more pronounced impact on cognitive function than the conventional nursing model.

Our findings are consistent with those of previous studies. P300, BDNF, TGF-β1, and GDNF are closely associated with cognitive function[10-14]. P300, which is not influenced by the characteristics of physical stimulation, is closely associated with cognitive function. The P300 Latency reflects the speed at which the brain recognizes and processes information, thereby providing an indication of the overall level of cognitive function to some extent[10,12]. BDNF is predominantly expressed by neurons in the central and peripheral nervous systems, particularly in the hippocampus. It plays a vital role in the growth and development of the nervous system, supporting neuron survival and promoting neurogenesis[11]. TGF-β1 is selectively expressed in specific brain regions, such as the hippocampus, cortex, meninges, and choroid plexus. It protects neurons from various forms of damage, including excitotoxicity, hypoxia, ischemia, and trophic factor deprivation[13]. GDNF is a significant growth factor for the development, survival, and maintenance of dopaminergic neurons in the midbrain. It also plays a crucial role in the proliferation, migration, and differentiation of nerve cells[14].

Various factors affecting the normal function and structure of the cerebral cortex can contribute to the development of cognitive impairment[15-18]. The incorporation of rich environmental stimuli in the refined nursing model can facilitate the enhancement of cognitive function by influencing the plasticity of the nervous system, including modifications in the thickness, severity, and volume of the hippocampus. These changes can also influence the levels of neurotransmitters such as dopamine, serotonin, and glutamate and promote the increased production of BDNF and VEGF, which are essential substances involved in shaping neuroplasticity[19]. Animal studies have consistently demonstrated that environmental enrichment can enhance cognitive abilities and improve behavior. For instance, rats exposed to enriched environments exhibit enhanced spatial and nonspatial memory compared to those raised in impoverished environments[20]. Additionally, research has indicated that environmental enrichment positively impacts the information processing ability of the hippocampus and has a beneficial effect on age-related cognitive impairment[21].

The efficacy of cognitive rehabilitation programs in improving cognitive function among stroke survivors has been well-documented[22]. Additionally, interventions aimed at promoting neuroplasticity, such as constraint-induced movement therapy, have shown promising results in stroke rehabilitation[23]. Furthermore, studies have highlighted the neuroprotective effects of growth factors, including BDNF, TGF-β1, and GDNF, in the context of stroke recovery[24]. Extending the findings of this study to broader clinical practice aligns with the principles of patient-centered care and evidence-based medicine. By integrating personalized interventions targeting cognitive function, neuroplasticity, and neuroprotection into routine clinical practice, healthcare providers can optimize treatment outcomes for cerebral infarction patients across diverse healthcare settings[25]. Moreover, collaborative efforts involving interdisciplinary healthcare teams, including neurologists, rehabilitation specialists, and nursing professionals, are essential for implementing and optimizing fine nursing care plans in clinical practice[26].

The results of this study provide potential value for implementing sophisticated care planning in clinical practice, particularly in other healthcare settings and patient populations. The observed improvements, such as increases in cognitive function, neuroplasticity, and growth factor levels, provide strong support for comprehensive treatment options for patients with cerebral infarction. This intensive care plan can include personalized cognitive rehabilitation programs, neuroplasticity promotion measures, and growth factor treatments. By promoting this comprehensive treatment program to other medical institutions and patient groups, it is expected to improve the treatment effect for patients with cerebral infarction and reduce the impact of cognitive dysfunction and neurological damage on patients' quality of life. Therefore, this study provides valuable implications for broader clinical practice and treatment options in the future.

Nevertheless, there are a few limitations in this study. The inclusion of a limited number of participants and the use of a single-center study design may have introduced bias into the results. Additionally, the study participants were exclusively patients with cerebral infarction, which limits the generalizability of the findings to patients with cognitive impairment from other medical conditions. It is important to address these limitations by expanding the sample size, enhancing the study design, and conducting further analysis and discussion of the research results.

CONCLUSION

The early implementation of refined nursing programs holds significant promise for improving the cognitive function of middle-aged and elderly patients with cerebral infarction and cognitive impairment. These refined nursing programs encompass a multifaceted approach that integrates personalized cognitive rehabilitation strategies, neuroplasticity-promoting interventions, and targeted administration of growth factors. By initiating such interventions promptly following the onset of cerebral infarction, healthcare providers can capitalize on the brain's inherent capacity for adaptation and recovery, thereby maximizing treatment efficacy.