Development of clinical recommendations for progressive return to activity after military mild traumatic brain injury: guidance for rehabilitation providers.

OBJECTIVE: Previously published mild traumatic brain injury (mTBI) management guidelines provide very general recommendations to return individuals with mTBI to activity. This lack of specific guidance creates variation in military rehabilitation. The Office of the Army Surgeon General in collaboration with the Defense and Veterans Brain Injury Center, a component center of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, convened an expert working group to review the existing literature and propose clinical recommendations that standardize rehabilitation activity progression following mTBI. PARTICIPANTS: A Progressive Activity Working Group consisted of 11 Department of Defense representatives across all service branches, 7 Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury representatives, and 8 academic/research/civilian experts with experience assessing and treating individuals with mTBI for return to activity. An expert working group meeting included the Progressive Activity Working Group and 15 additional subject matter experts. METHODS: In February 2012, the Progressive Activity Working Group was established to determine the need and purpose of the rehabilitation recommendations. Following literature review, a table was created on the basis of the progression from the Zurich consensus statement on concussion in sport. Issues were identified for discussion with a meeting of the larger expert group during a July 2012 conference. Following development of rehabilitation guidance, the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury coordinated a similar process for military primary care providers. RESULTS: End products for rehabilitation and primary care providers include specific recommendations for return to activity after concussion. A 6-stage progression specifies activities in physical, cognitive, and balance/vestibular domains and allows for resumption of activity for those with low-level or preinjury symptom complaints. CONCLUSIONS: The clinical recommendations for progressive return to activity represent an important effort to standardize activity progression across functional domains and offer providers duty-specific activities to incorporate into intervention. Recommendations were released in January 2014.

A Randomized Controlled Trial Investigating the Feasibility of a Low-Intensity Psychological Intervention for Fear of Memory Loss and Quality of Life in Older Adults: Protocol for the Reducing Fear and Avoidance of Memory Loss (REFRAME) Study.

BACKGROUND: Dementia is the most feared disease associated with aging. Prolonged fears about memory loss and dementia can have harmful consequences even in the absence of cognitive decline. Fear of dementia is associated with poorer health outcomes and psychological well-being and increased memory failures in older adults. OBJECTIVE: We will conduct a randomized controlled trial to determine the feasibility of a tailored, web-based mindfulness program to reduce fear of memory loss and increase quality of life in older adults experiencing heightened fear. METHODS: Eighty participants will be recruited and divided into 2 groups (40 in each group). One group will receive psychoeducation plus mindfulness training. A second group will receive psychoeducation, mindfulness training, and additional modules targeting maladaptive behavioral avoidance (ie, social and cognitive withdrawal). RESULTS: Our recent etiological model posits that maladaptive behavioral avoidance strategies critically underlie psychosocial dysfunction associated with fear of memory loss. Thus, we predict better outcomes in the second group, including reduced fear of memory loss (primary outcome), Alzheimer disease, anxiety, and subjective memory failures, and increased quality of life (secondary outcomes). Outcome measures will be applied at 5 time points (before, baseline, interim, and after the intervention, and at 3-month follow-up). Data will be analyzed using mixed models and correlations. CONCLUSIONS: Results from this study will contribute to the current literature on dementia-related fear and improve our understanding of how to effectively address and reduce these fears. TRIAL REGISTRATION: ClinicalTrials.gov NCT04821960; https://clinicaltrials.gov/ct2/show/NCT04821960. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/30514.

Elders with epilepsy.

Why is it important to learn about epilepsy in the elderly? The answers are many. As this article has highlighted, compared with younger individuals epilepsy is more common and the causes are more structural and symptomatic than in younger patients (particularly stroke). The clinical presentation is different in the elderly. The diagnosis is more difficult and often delayed. The most common seizures are simple partial and complex partial seizures, which are more often extratemporal in location. Confusion and memory problems are common presenting symptoms and postictal deficits often are prolonged. The prognosis for epilepsy in the elderly generally is favorable for seizure control, but if untreated, depression and quality of life suffer and seizures frequently recur. Seizures respond well at lower serum concentrations of antiepileptic drugs but these patients are also more sensitive (less tolerant) to side effects at lower doses than younger adults.

Development and assessment of a neuropsychological battery to aid in predicting driving performance.

PURPOSE: This study was conducted to select a neuropsychological battery that correlated with driving simulator skills, thus enabling practitioners to provide information to older patients and their families about driving risks. METHODS: The study was conducted in two phases. In Phase 1, a survey inquiring as to the kinds of neuropsychological tests currently used to screen patients for driving was sent to 292 licensed neuropsychologists. Of these 292 surveys, 125 (43%) were returned. We used the responses to develop a battery of nine tests, including eight neuropsychological tests and one other cognitive measure: (1) the Seashore Rhythm Test, (2) Logical Memory (Immediate [I] and Delayed [II]) of the Wechsler Memory Scale-Revised (WMS-R), (3) WMS-R Visual Reproduction (Immediate [I] and Delayed [II]), (4) Trails A and B, (5) Digit Span, (6) Digit Symbol, (7) Block Design, (8) Visual Form Discrimination, and (9) a Zoo Map Test. The complete battery included 12 measures. In Phase 2, 22 licensed drivers were recruited ranging in age from 67 to 91 years (14 males and 8 females). The Mini-Mental Status Exam (MMSE) was administered to all subjects. Scores on this test served as a criterion cutoff for placement into a group of subjects with suspected dementia (Group 1, MMSE score below 25) or a group of control subjects (Group 2, with a MMSE score of 25 or above). None of the patients had any gross motor difficulties. Following screening, subjects were administered the neuropsychological battery, a driving simulator test, and a Driving Habits Interview. RESULTS: Data revealed a significant difference between the performance of Groups 1 and 2 on the driving simulator test in two distinct areas, staying within one's lane boundaries and speed. The suspected dementia subjects had significantly more lane boundary crossings than the control subjects and drove at significantly slower speeds. Ten neuropsychological measures correlated with driving simulator performance. The number of lane boundary crossings correlated with the greatest number of neuropsychological tests, with more lane boundary crossings correlated with poorer performance on the neuropsychological tests. In particular, Trails A, Trails B, and Logical Memory (Immediate) correlated with the largest number of driving measures. CONCLUSION: Preliminary findings show that commonly used neuropsychological tests correlated with driving simulator skills as measured with a driving simulator. Because the driving simulator has been shown to be correlated with actual on-road driving, one may hypothesize that these neuropsychological tests may be predictive of on-road driving. This research is important in defining an appropriate battery to screen for driving skills in patients with known or suspected dementia.