Behaviours of concern following moderate to severe traumatic brain injury in individuals living in the community.

PRIMARY OBJECTIVE: Behaviours of Concern (BoC) following traumatic brain injury (TBI) have a significant negative impact on the daily functioning and quality of life for the individual and their family. However, there has been limited research examining the nature and severity of BoC beyond the acute recovery period, including the perspective of the individual with TBI as well as close others (COs). METHODS AND PROCEDURE: Eighty-nine individuals with predominantly severe TBI, at a mean of 11.4 years' post-injury, were identified through a no-fault accident compensation system database. Structured interviews were completed with 65 individuals with TBI, and 62 COs. Current BoC were documented using the Overt Behaviour Scale (OBS). MAIN OUTCOMES AND RESULTS: 70.5% of participants exhibited BoC on the OBS, with an average of 3 behaviours. Verbal aggression and socially inappropriate behaviour were the most common BoC. Self-report of behaviour change was endorsed by 81% of the sample. There was generally poor concordance between the perspectives of the individual with the TBI and their CO. CONCLUSION: Severe BoC, across multiple behaviour types, may be evident many years following predominantly severe TBI. There is a need to provide long-term behaviour support for these individuals.

The nature, frequency and course of psychiatric disorders in the first year after traumatic brain injury: a prospective study.

BACKGROUND: Psychiatric disorders are common following traumatic brain injury (TBI). However, few studies have examined the course of disorder development and the influence of pre-injury psychiatric history. The present study aimed to examine the frequency of, and association between, psychiatric disorders occurring pre- and post-injury, and to examine the post-injury course of disorders. METHOD: Participants were 102 adults (75.5% male) with predominantly moderate-severe TBI. Participants were initially assessed for pre-injury and current disorders, and reassessed at 3, 6 and 12 months post-injury using the Structured Clinical Interview for DSM-IV Disorders (SCID). RESULTS: Over half of the participants had a pre-injury psychiatric disorder; predominantly substance use, mood, and anxiety disorders. In the first year post-injury, 60.8% of participants had a psychiatric disorder, commonly anxiety and mood disorders. Post-injury disorders were associated with the presence of a pre-injury history (p<0.01), with 74.5% of participants with a pre-injury psychiatric history experiencing a post-injury disorder, which commonly presented at initial assessment or in the first 6 months. However, 45.8% of participants without a pre-injury history developed a novel post-injury disorder, which was less likely to emerge at the initial assessment and generally developed later in the year. CONCLUSIONS: Despite evidence that most post-injury psychiatric disorders represent the continuation of pre-existing disorders, a significant number of participants developed novel psychiatric disorders. This study demonstrates that the timing of onset may differ according to pre-injury history. There seem to be different trajectories for anxiety and depressive disorders. This research has important implications for identifying the time individuals are most at risk of psychiatric disorders post-injury.

The impact of intrinsic motivation on session attendance and reliable cognitive improvement in cognitive remediation in schizophrenia.

OBJECTIVE: Cognitive remediation (CR) is considered a potentially effective method of improving cognitive function in people with schizophrenia. Few studies, however, have explored the role of intrinsic motivation on treatment utilization or training outcomes in CR in this population. This study explored the impact of task-specific intrinsic motivation on attendance and reliable cognitive improvement in a controlled trial comparing CR with a computer game (CG) playing control. METHODS: Forty-nine participants with schizophrenia or schizoaffective disorder, allocated to 10 weeks of group-based CR (n = 25) or CG control (n = 24), provided complete outcome data at baseline. Forty-three participants completed their assigned intervention. Cognition, psychopathology and intrinsic motivation were measured at baseline and end-treatment. Regression analyses explored the relative contribution of baseline motivation and other clinical factors to session attendance as well as the association of baseline and change in intrinsic motivation with the odds of reliable cognitive improvement (calculated using reliable change indices). RESULTS: Baseline reports of perceived program value were the only significant multivariable predictor of session attendance when including global cognition and psychiatric symptomatology. The odds of reliable cognitive improvement significantly increased with greater improvements in program interest and value from baseline to end-treatment. Motivational changes over time were highly variable between participants. CONCLUSION: Task-specific intrinsic motivation in schizophrenia may represent an important patient-related factor that contributes to session attendance and cognitive improvements in CR. Regular evaluation and enhancement of intrinsic motivation in cognitively enhancing interventions may optimize treatment engagement and the likelihood of meaningful training outcomes.

The effect of traumatic brain injury on the timing of sleep.

While there have been single case reports of the development of circadian rhythm sleep disorders, most commonly delayed sleep phase syndrome following traumatic brain injury (TBI), to our knowledge there have been no group investigations of changes to sleep timing in this population. The aim of the present study was to investigate sleep timing following TBI using the dim light melatonin onset (DLMO) as a marker of circadian phase and the Morningness-Eveningness Questionnaire (MEQ) as a measure of sleep-wake behavior. A sleep-wake diary was also completed. It was hypothesized that the timing of DLMO would be delayed and that there would be a greater tendency toward eveningness on the MEQ in a post-acute TBI group (n=10) compared to a gender and age matched control group. Participants were recruited at routine outpatient review appointments (TBI) and from the general population (control) as part of a larger study. They attended the sleep laboratory where questionnaires were completed, some retrospectively, and saliva melatonin samples were collected half-hourly according to a standard protocol. The results show that the TBI and control groups reported similar habitual sleep times and this was reflected on the MEQ. There was, however, significant variability in the TBI group's change from the pre-injury to the current MEQ score. The timing of melatonin onset was not different between the groups. While subtle changes (advances or delays) in this small sample may have cancelled each other out,. the present study does not provide conclusive objective evidence of shift in circadian timing of sleep following TBI. Furthermore, although participants did report sleep timing changes, it is concluded that the MEQ may not be suitable for use with this cognitively impaired clinical group.

Cerebral control of saccades and neuropsychological test results after head injury.

Abnormalities in the control of saccades have been described in patients with cerebral pathology.(1, 2) We assessed control of visually guided, reflexive and volitional saccades in 16 patients suffering severe traumatic brain injury and 12 controls and related the results to deficits on neuropsychological tests of speed of information processing and goal directed behaviour. All saccadic latencies were prolonged. Suppression of inappropriate saccades was impaired on volitional saccade tests which proved to be more sensitive in identifying impairment of goal directed behaviour than the neuropsychological test results. Patients' self-paced saccade rate was lower than controls' and correlated with performance on several visually mediated neuropsychological test results. Patients' visually guided, reflexive saccades were hypometric; this hypometria correlated with both visual and non-visual neuropsychological test results and with post-traumatic amnesia duration. Hypometria in reflexive saccades may reflect diffuse brain injury. Re-examination after 12 months revealed that the control of volitional saccades improved but there was no improvement in the visually guided reflexive saccade measures. The volitional saccade tests may be useful in documenting both impairment and subsequent recovery.

Sleep disturbance and melatonin levels following traumatic brain injury.

OBJECTIVES: Sleep disturbances commonly follow traumatic brain injury (TBI) and contribute to ongoing disability. However, there are no conclusive findings regarding specific changes to sleep quality and sleep architecture measured using polysomnography. Possible causes of the sleep disturbances include disruption of circadian regulation of sleep-wakefulness, psychological distress, and a neuronal response to injury. We investigated sleep-wake disturbances and their underlying mechanisms in a TBI patient sample. METHODS: This was an observational study comparing 23 patients with TBI (429.7 +/- 287.6 days post injury) and 23 age- and gender-matched healthy volunteers on polysomnographic sleep measures, salivary dim light melatonin onset (DLMO) time, and self-reported sleep quality, anxiety, and depression. RESULTS: Patients with TBI reported higher anxiety and depressive symptoms and sleep disturbance than controls. Patients with TBI showed decreased sleep efficiency (SE) and increased wake after sleep onset (WASO). Although no significant group differences were found in sleep architecture, when anxiety and depression scores were controlled, patients with TBI showed higher amount of slow wave sleep. No differences in self-reported sleep timing or salivary DLMO time were found. However, patients with TBI showed significantly lower levels of evening melatonin production. Melatonin level was significantly correlated with REM sleep but not SE or WASO. CONCLUSIONS: Reduced evening melatonin production may indicate disruption to circadian regulation of melatonin synthesis. The results suggest that there are at least 2 factors contributing to sleep disturbances in patients with traumatic brain injury. We propose that elevated depression is associated with reduced sleep quality, and increased slow wave sleep is attributed to the effects of mechanical brain damage.

Evaluation of a remedial programme for attentional deficits following closed-head injury.

Although the frequency and implications of disorders of attention in head-injured subjects have been recognised in recent years, there have been few carefully controlled attempts to evaluate remedial interventions. The present study employed a multiple baseline across subjects design to evaluate a computer-mediated programme for the remediation of deficits in speed of information processing in 10 severely head-injured subjects, aged 17-38 years. Following a baseline period, the effectiveness of computer training alone was compared with that combined with therapist feedback and reinforcement in separate training phases, each lasting 3 weeks. The final phase involved a return to baseline conditions. Dependent measures of attention, taken across all phases, included psychometric measures of processing speed, a rating scale completed by the patient's Occupational Therapist, and a video of the patient working in therapy. Results suggested that, once spontaneous recovery and practice effect were controlled, the patients showed little response to the interventions in terms of the dependent measures used.

Transient global amnesia--a hippocampal phenomenon?

A case of transient global amnesia of clear vascular aetiology is described. Results of neuropsychological testing carried out during the attack clarify the nature of the memory disorder and suggest that the critical region of ischaemia is the medial temporal area around the hippocampus. Follow-up testing suggests that no lasting memory impairment resulted.

Outcome following traumatic brain injury: a comparison between 2 and 5 years after injury.

This study examined long-term outcome in traumatically brain-injured individuals following discharge from a comprehensive rehabilitation programme. Of 254 traumatic brain injury (TBI) patients reviewed at 2 years, 103 have been followed up at 5 years using a structured interview format detailing neurological symptoms, mobility, independence in ADL, productivity status, relationship issues, communication and the presence of cognitive, behavioural and emotional changes. Visual difficulties, headache and fatigue were persistent in a significant number of patients. Between 2 and 5 years there was increased independence in personal, domestic and community ADL and the use of transport. Ten more patients had returned to driving. On the other hand there was a slightly higher incidence of cognitive, behavioural and emotional changes reported at 5 years. Thirty-two per cent of those working at 2 years were not employed at 5 years. Many students had also become unemployed. These findings suggest the need for intermittent lifelong intervention following TBI. Systems of rehabilitation need to be adapted to provide this.

Coping strategies and emotional outcome following traumatic brain injury: a comparison with orthopedic patients.

OBJECTIVES: To investigate coping strategies in relation to emotional adjustment in individuals with traumatic brain injury (TBI) 1-5 years postinjury and to compare these with a group of 40 participants who sustained serious orthopedic injuries. DESIGN: Participants completed measures of handicap and coping strategies, and rated their levels of depression, anxiety, and self-esteem on standardized questionnaires. SETTING: Participants had received inpatient rehabilitation at Bethesda Hospital 1-5 years prior to completing questionnaires. They were recruited from a list of consecutive admissions. PARTICIPANTS: 88 TBI individuals were compared with 40 participants who had sustained serious orthopedic injuries without damage to the central nervous system. They had all been involved in motor vehicle or work-related accidents. OUTCOME MEASURES: Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI). RESULTS: Consistent with previous studies; a significant proportion of the current sample displayed high levels of emotional distress. Results showed few differences between the TBI and orthopedic groups. Coping strategies characterized by worry, wishful thinking, and self-blame were associated with higher levels of depression and anxiety in both groups. Strategies focusing on problem solving and having a positive outlook were related to lower anxiety levels, but to a lesser degree. CONCLUSIONS: This study has provided further evidence that coping strategies are associated with emotional outcome in TBI individuals. There is now a growing empirical basis on which preliminary interventions can be based.

A profile of outcome: 2 years after traumatic brain injury.

A group of 175 traumatic brain injury (TBI) patients who had undergone intensive rehabilitation at Bethesda Hospital attended a follow-up interview 2 years after injury. The majority of patients had suffered severe TBI. Outcome was documented in ten areas: medical/physical, mobility, activities of daily living (ADLs) accommodation, marital status, leisure and recreation, employment/study, communication, cognition and behaviour. Whilst most patients were physically independent and competent in personal and domestic activities of daily living, a third of the group were still reliant on assistance with community skills and transport, and more than half of those who previously had a job, were not working at 2 years post-injury. Around two-thirds of the sample reported cognitive, behavioural and emotional changes. There is clearly a need for ongoing community-based support and assistance in dealing with practical difficulties and psychological problems as they are experienced after return to the community.

Prediction of employment status 2 years after traumatic brain injury.

The present study used a multivariate approach to investigate which of a range of variables relating to demographic factors, injury severity and degree of disability on admission to rehabilitation were the best predictors of employment status 2 years after traumatic brain injury (TBI). Subjects were 74 TBI patients who had been working prior to injury, had undergone rehabilitation at Bethesda Hospital and attended a review clinic 2 years after injury. A cross-validation sample consisted of a further 50 such subjects. Following preliminary analysis four input variables were selected: age under or over 40 at time of injury, Glasgow Coma Scale score on acute hospital admission, duration of post-traumatic amnesia and total score on the Disability Rating Scale (DRS) on admission to rehabilitation. Stepwise discriminant function analysis resulted in a discriminant function consisting of three variables--total score on the Disability Rating Scale, Glasgow Coma Scale Score and age--which correctly classified 74% of grouped cases. A second analysis using the original discriminant function correctly classified 68% of the cross-validation sample. Chi-square analysis showed no significant difference between these results, thus confirming these variables, in combination, as predictors of employment status 2 years after TBI.

Development and psychometric testing of a quality of recovery score after general anesthesia and surgery in adults.

UNLABELLED: A variety of methods have been used to quantify aspects of recovery after anesthesia. Most are narrowly focused, are not patient-rated, and have not been validated. We therefore set out to develop a patient-rated quality of recovery score. We constructed a 61-item questionnaire that asked individuals (patients and relatives, medical and nursing staff; total n = 136) to rate various postoperative items describing features a patient may experience postoperatively. The most highly ranked items were included in a final nine-point index score, which we called the "QoR Score." We then studied two cohorts of surgical patients (n = 449). There was good convergent validity between the QoR Score and the visual analog scale score (rho = 0.55, P < 0.0001). Discriminant construct validity was supported by comparing resultant QoR Scores in patients undergoing day-stay, minor, and major surgery (P = 0.008), as well as a negative correlation with duration of hospital stay (rho = -0.20, P < 0.0001), and, using multivariate regression, demonstrating a significant negative relationship between QoR Score and female gender (P = 0.048) and older age (P = 0.041). There was also good interrater agreement (rho = 0.55, P < 0.0001), test-retest reliability (median rho = 0.61, P < 0.0001), and internal consistency (alpha = 0.57 and 0.90, P < 0.0001). There was a significant difference between the groups of patients recovering from major and minor surgery (P < 0.001). This study demonstrates that the QoR Score has good validity, reliability, and clinical acceptability in patients undergoing many types of surgery. IMPLICATIONS: We set out to develop a patient-rated quality of recovery score (QoR) that could be used both as a measure of outcome in perioperative trials and for clinical audit. We first surveyed patients and staff to identify important aspects of recovery, then developed a nine-point QoR Score. This was then compared with other measures of postoperative outcome. We found that the QoR Score is a useful measure of recovery after anesthesia and surgery.