Patient Effort in Traumatic Brain Injury Inpatient Rehabilitation: Course and Associations With Age, Brain Injury Severity, and Time Postinjury.

OBJECTIVE: To describe patients' level of effort in occupational, physical, and speech therapy sessions during traumatic brain injury (TBI) inpatient rehabilitation and to evaluate how age, injury severity, cognitive impairment, and time are associated with effort. DESIGN: Prospective, multicenter, longitudinal cohort study. SETTING: Acute TBI rehabilitation programs. PARTICIPANTS: Patients (N=1946) receiving 138,555 therapy sessions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Effort in rehabilitation sessions rated on the Rehabilitation Intensity of Therapy Scale, FIM, Comprehensive Severity Index brain injury severity score, posttraumatic amnesia (PTA), and Agitated Behavior Scale (ABS). RESULTS: The Rehabilitation Intensity of Therapy Scale effort ratings in individual therapy sessions closely conformed to a normative distribution for all 3 disciplines. Mean Rehabilitation Intensity of Therapy Scale ratings for patients' therapy sessions were higher in the discharge week than in the admission week (P<.001). For patients who completed 2, 3, or 4 weeks of rehabilitation, differences in effort ratings (P<.001) were observed between 5 subgroups stratified by admission FIM cognitive scores and over time. In linear mixed-effects modeling, age and Comprehensive Severity Index brain injury severity score at admission, days from injury to rehabilitation admission, days from admission, and daily ratings of PTA and ABS score were predictors of level of effort (P<.0001). CONCLUSIONS: Patients' level of effort can be observed and reliably rated in the TBI inpatient rehabilitation setting using the Rehabilitation Intensity of Therapy Scale. Patients who sustain TBI show varying levels of effort in rehabilitation therapy sessions, with effort tending to increase over the stay. PTA and agitated behavior are primary risk factors that substantially reduce patient effort in therapies.

Institutional Variation in Traumatic Brain Injury Acute Rehabilitation Practice.

OBJECTIVE: To describe institutional variation in traumatic brain injury (TBI) inpatient rehabilitation program characteristics and evaluate to what extent patient factors and center effects explain how TBI inpatient rehabilitation services are delivered. DESIGN: Secondary analysis of a prospective, multicenter, cohort database. SETTING: TBI inpatient rehabilitation programs. PARTICIPANTS: Patients with complicated mild, moderate, or severe TBI (N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Mean minutes; number of treatment activities; use of groups in occupational therapy, physical therapy, speech therapy, therapeutic recreation, and psychology inpatient rehabilitation sessions; and weekly hours of treatment. RESULTS: A wide variation was observed between the 10 TBI programs, including census size, referral flow, payer mix, number of dedicated beds, clinician experience, and patient characteristics. At the centers with the longest weekday therapy sessions, the average session durations were 41.5 to 52.2 minutes. At centers with the shortest weekday sessions, the average session durations were approximately 30 minutes. The centers with the highest mean total weekday hours of occupational, physical, and speech therapies delivered twice as much therapy as the lowest center. Ordinary least-squares regression modeling found that center effects explained substantially more variance than patient factors for duration of therapy sessions, number of activities administered per session, use of group therapy, and amount of psychological services provided. CONCLUSIONS: This study provides preliminary evidence that there is significant institutional variation in rehabilitation practice and that center effects play a stronger role than patient factors in determining how TBI inpatient rehabilitation is delivered.

Predictors of Agitated Behavior During Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To identify predictors of the severity of agitated behavior during inpatient traumatic brain injury (TBI) rehabilitation. DESIGN: Prospective, longitudinal observational study. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Consecutive patients enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, who exhibited agitation during their stay (n=555, N=2130). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Daytime Agitated Behavior Scale scores. RESULTS: Infection and lower FIM cognitive scores predicted more severe agitation. The medication classes associated with more severe agitation included sodium channel antagonist anticonvulsants, second-generation antipsychotics, and gamma-aminobutyric acid-A anxiolytics/hypnotics. Medication classes associated with less severe agitation included antiasthmatics, statins, and norepinephrine-dopamine-5 hydroxytryptamine (serotonin) agonist stimulants. CONCLUSIONS: Further support is provided for the importance of careful serial monitoring of both agitation and cognition to provide early indicators of possible beneficial or adverse effects of pharmacologic interventions used for any purpose and for giving careful consideration to the effects of any intervention on underlying cognition when attempting to control agitation. Cognitive functioning was found to predict agitation, medications that have been found in previous studies to enhance cognition were associated with less agitation, and medications that can potentially suppress cognition were associated with more agitation. There could be factors other than the interventions that account for these relations. In addition, the study provides support for treatment of underlying disorders as a possible first step in management of agitation. Although the results of this study cannot be used to draw causal inferences, the associations that were found can be used to generate hypotheses about the most viable interventions that should be tested in future controlled trials.

Neurocognitive Impairment in Post-COVID-19 Condition in Adults: Narrative Review of the Current Literature.

The severe acute respiratory syndrome coronavirus 2 virus has, up to the time of this article, resulted in >770 million cases of COVID-19 illness worldwide, and approximately 7 million deaths, including >1.1 million in the United States. Although defined as a respiratory virus, early in the pandemic, it became apparent that considerable numbers of people recovering from COVID-19 illness experienced persistence or new onset of multi-system health problems, including neurologic and cognitive and behavioral health concerns. Persistent multi-system health problems are defined as Post-COVID-19 Condition (PCC), Post-Acute Sequelae of COVID-19, or Long COVID. A significant number of those with PCC report cognitive problems. This paper reviews the current state of scientific knowledge on persisting cognitive symptoms in adults following COVID-19 illness. A brief history is provided of the emergence of concerns about persisting cognitive problems following COVID-19 illness and the definition of PCC. Methodologic factors that complicate clear understanding of PCC are reviewed. The review then examines research on patterns of cognitive impairment that have been found, factors that may contribute to increased risk, behavioral health variables, and interventions being used to ameliorate persisting symptoms. Finally, recommendations are made about ways neuropsychologists can improve the quality of existing research.

Return on Investment and Value Research in Neuropsychology: A Call to Arms†.

There is substantial empirical evidence to support the clinical value of neuropsychological evaluation and the incremental value of neuropsychological assessment, suggesting such evaluation is beneficial in the prediction and management of clinical outcomes. However, in the cost-conscious and evolving era of healthcare reform, neuropsychologists must also establish the economic value, or return on investment, of their services. There is already a modest body of literature that demonstrates the economic benefits of neuropsychological evaluation, which is reviewed in the current paper. Neuropsychologists will need to be able to communicate, and develop evidence of, economic value of their services; thus, this paper also discusses common concepts, terms, and models used in healthcare valuation studies. Finally, neuropsychologists are urged to incorporate these financial concepts in their clinical practice and research.

Integrative Care Models in Neuropsychology: A National Academy of Neuropsychology Education Paper.

Although collaborative, and more specifically, integrated models of care have existed for years, the 2010 Patient Protection and Affordable Care Act expanded their use, and Medicare has adopted a value-based payment system that further emphasizes service provision within the collaborative health care setting. Neuropsychology as a field is well-situated to work within the integrated health care setting, which presents both opportunities and challenges for clinical neuropsychologists. This education paper details how different neuropsychology clinical practice settings fit into an integrated care framework; discusses challenges to service delivery and fiscal viability in such settings and other health care related settings; and examines future directions for the role of neuropsychology within a dynamic health care system.

Neurocognition and Cerebral Lesion Burden in High-Risk Patients Before Undergoing Transcatheter Aortic Valve Replacement: Insights From the SENTINEL Trial.

OBJECTIVES: The authors sought to determine baseline neurocognition before transcatheter aortic valve replacement (TAVR) and its correlations with pre-TAVR brain imaging. BACKGROUND: TAVR studies have not shown a correlation between diffusion-weighted image changes and neurocognition. The authors wanted to determine the extent to which there was already impairment at baseline that correlated with cerebrovascular disease. METHODS: SENTINEL (Cerebral Protection in Transcatheter Aortic Valve Replacement) trial patients had cognitive assessments of attention, processing speed, executive function, and verbal and visual memory. Z-scores were based on normative means and SDs, combined into a primary composite z-score. Brain magnetic resonance images were obtained pre-TAVR on 3-T scanners with a T2 fluid-attenuated inversion recovery (FLAIR) sequence. Scores ≤-1.5 SD below the normative mean (7th percentile) were considered impairment. Paired t tests compared within-subject scores, and chi-square goodness-of-fit compared the percentage of subjects below -1.5 SD. Correlation and regression analyses assessed the relationship between neurocognitive z-scores and T2 lesion volume. RESULTS: Among 234 patients tested, the mean composite z-score was -0.65 SD below the normative mean. Domain scores ranged from -0.15 SD for attention to -1.32 SD for executive function. On the basis of the ≥1.5 SD normative reference, there were significantly greater percentages of impaired scores in the composite z-score (13.2%; p = 0.019), executive function (41.9%; p < 0.001), verbal memory (p < 0.001), and visual memory (p < 0.001). The regression model between FLAIR lesion volume and baseline cognition showed statistically significant negative correlations. CONCLUSIONS: There was a significant proportion of aortic stenosis patients with impaired cognition before TAVR, with a relationship between baseline cognitive function and lesion burden likely attributable to longstanding cerebrovascular disease. These findings underscore the importance of pre-interventional testing and magnetic resonance imaging in any research investigating post-surgical cognitive outcomes in patients with cardiovascular disease.

Early self-awareness following traumatic brain injury: comparison of brain injury and orthopedic inpatients using the Functional Self-Assessment Scale (FSAS).

OBJECTIVE: To examine the Functional Self-Assessment Scale (FSAS) in hospitalized orthopedic patients with no brain dysfunction, and compare results to prior self-awareness data collected with brain injury patients. DESIGN: Comparison of patient and staff ratings on FSAS using paired sample t tests. PARTICIPANTS: Thirty-one adult volunteers hospitalized on National Rehabilitation Hospital (NRH) orthopedic treatment unit. MEASURES: FSAS was used to compare patient and staff ratings of patient performance on tasks relevant for inpatient rehabilitation. Subjects were screened to rule out brain impairment. RESULTS: Statistically significant but very small differences were found between orthopedic patients and therapist ratings using the FSAS. However, brain injury patients' ratings show a significantly larger discrepancy between self-therapist ratings than do orthopedic patients. CONCLUSION: Impaired self-awareness is related to brain injury rather than nonspecific factors in rehabilitation inpatients.

Miranda comprehension in adults with mental retardation and the effects of feedback style on suggestibility.

Interrogations present several major challenges to persons with mental retardation (MR). Sixty adults with mild MR completed measures of Miranda comprehension and tendency to yield to leading questions. In addition, suggestibility was assessed based on whether participants revised answers to questions in response to unfriendly, friendly, or neutral feedback to original responses. Furthermore, we examined how expressed confidence in answers to repeated questions varied with the type of feedback received. Results revealed that participants demonstrated marked difficulties understanding their Miranda rights and greater likelihood of changing answers to questions for which they received friendly feedback than for questions for which they received unfriendly or neutral feedback. Most participants who received positive reinforcement for their answers on a second trial expressed confidence about improvement from trial 1 to trial 2, although accuracy did not improve. Implications of these results are reviewed.