Mortality following Traumatic Brain Injury among Individuals Unable to Follow Commands at the Time of Rehabilitation Admission: A National Institute on Disability and Rehabilitation Research Traumatic Brain Injury Model Systems Study.

Severe traumatic brain injury (TBI) has been associated with increased mortality. This study characterizes long-term mortality, life expectancy, causes of death, and risk factors for death among patients admitted within the National Institute on Disability and Rehabilitation Research (NIDRR) TBI Model Systems Programs (TBIMS) who lack command following at the time of admission for inpatient TBI rehabilitation. Of the 8084 persons enrolled from 1988 and 2009, 387 from 20 centers met study criteria. Individuals with moderate to severe TBI who received inpatient rehabilitation were 2.2 times more likely to die than individuals in the U.S. general population of similar age, gender, and race, with an average life expectancy (LE) reduction of 6.6 years. The subset of individuals who were unable to follow commands on admission to rehabilitation was 6.9 times more likely to die, with an average LE reduction of 12.2 years. Relative to the U.S. general population matched for age, gender, and race/ethnicity, these non-command following individuals were more than four times more likely to die of circulatory conditions, 44 times more likely to die of pneumonia, and 38 times more likely to die of aspiration pneumonia. The subset of individuals with TBI who are unable to follow commands upon admission to inpatient rehabilitation are at a significantly increased risk of death when compared with the U.S. general population and compared with all individuals with moderate to severe TBI receiving inpatient rehabilitation. Respiratory causes of death predominate, compared with the general population.

Descriptive characteristics and rehabilitation outcomes in active duty military personnel and veterans with disorders of consciousness with combat- and noncombat-related brain injury.

OBJECTIVE: To report the injury and demographic characteristics, medical course, and rehabilitation outcome for a consecutive series of veterans and active duty military personnel with combat- and noncombat-related brain injury and disorder of consciousness (DOC) at the time of rehabilitation admission. DESIGN: Retrospective study. SETTING: Rehabilitation center. PARTICIPANTS: From January 2004 to October 2009, persons (N=1654) were admitted to the Polytrauma Rehabilitation System of Care. This study focused on the N=122 persons admitted with a DOC. Participants with a DOC were primarily men (96%), on active duty (82%), ≥12 years of education, and a median age of 25. Brain injury etiologies included mixed blast trauma (24%), penetrating (8%), other trauma (56%), and nontrauma (13%). Median initial Glasgow Coma Scale score was 3, and rehabilitation admission Glasgow Coma Scale score was 8. Individuals were admitted for acute neurorehabilitation approximately 51 days postinjury with a median rehabilitation length of stay of 132 days. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Recovery of consciousness and the FIM instrument. RESULTS: Most participants emerged to regain consciousness during neurorehabilitation (64%). Average gains ± SD on the FIM cognitive and motor subscales were 19 ± 25 and 7 ± 8, respectively. Common medical complications included spasticity (70%), dysautonomia (34%), seizure occurrence (30%), and intracranial infection (22%). Differential outcomes were observed across etiologies, particularly for those with blast-related brain injury etiology. CONCLUSIONS: Despite complex comorbidities, optimistic outcomes were observed. Individuals with severe head injury because of blast-related etiologies have different outcomes and comorbidities observed. Health-services research with a focus on prevention of comorbidities is needed to inform optimal models of care, particularly for combat injured soldiers with blast-related injuries.

Pre- and post- GPi DBS neuropsychological profiles in a case of X-linked dystonia-Parkinsonism.

We present the pre to post bilateral globus pallidus interna (GPi) deep brain stimulation neuropsychological profiles of a 69-year-old patient with a 12-year history of X-linked dystonia-Parkinsonism (XDP). Pre-operative cognitive function was impaired in almost all domains and this impaired performance was not dependent on his medications. Following DBS, changes in neuropsychological functioning were examined using Reliable Change Indices and standardized z-score comparisons. Results showed reductions in processing speed in the context of stable performance in language and visuospatial domains. Post-operative improvements occurred on a cognitive screening measure, verbal memory, and a test of problem-solving skills. This is the first report on an individual with XDP who was cognitively impaired, but had good outcome following GPi bilateral stimulation to treat debilitating motor symptoms. The possible mechanisms for his stable cognitive performance include the target of his DBS, reduced medication dosage, and improvement in dystonia that may in turn have reduced patient's pain.

Third party observation during neuropsychological evaluation: an update on the literature, practical advice for practitioners, and future directions.

A clash between neuropsychology and the law may exist when a demand is made for third party observation during forensic neuropsychological evaluation. Third party observation includes any person or observational process present during a neuropsychological evaluation aside from the psychologist and the examinee, including electronic devices (e.g., video and audio recordings). The goal of this paper includes succinctly providing to practitioners the scientific, ethical, and pragmatic (i.e., test security and coaching) reasons to not allow third party observation. Practitioners at the individual level need to be aware of the reasoning and be willing and able to advocate protecting the boundaries of neuropsychological practice and test security. We present practitioners with options when confronted with a request, provide a list of resources to educate the legal system and submit with motions, provide responses for some of the more common myths/reasoning used to support a request for a TPO, and encourage more global solutions such as state-by-state legislation.

Advocacy 101: a step beyond complaining. How the individual practitioner can become involved and make a difference.

There are critical issues facing the neuropsychological community, such as inadequate reimbursement for services, a lack of familiarity among public policy makers regarding the science and practice of neuropsychology, and a lack of public policy awareness among professional neuropsychologists. Advocacy for the field is the most effective way to undertake positive change. Currently, a minority of psychological professionals actively engages in an advocacy process, while the majority is not involved, or is involved periodically or passively. With weak advocacy our field risks slower development in key areas, and without strong and constant advocacy we risk losing ground previously gained. The purpose of this article, and those that follow in this special issue of The Clinical Neuropsychologist, is to: (1) convey the importance of advocacy, (2) address and dispel unfounded mental obstacles that inhibit involvement in advocating for the specialty, and (3) aid neuropsychologists in preparing to join the advocacy process. To accomplish this, we acquaint readers with the advocacy process, delineate to practitioners how they can become involved, and encourage participation in advocacy.

Giving context to post-deployment post-concussive-like symptoms: blast-related potential mild traumatic brain injury and comorbidities.

In the military and Veterans Administration systems, individuals with potential MTBI are presenting with symptoms in excess of what would be expected based on initial injury characteristics and/or at unexpected time periods based on current research findings. This article investigates factors that might account for the discrepancy between current research expectations and some occurrences in clinical practice. The physics of blast waves, as well as animal and human research, relevant to explosions are reviewed. Additional factors that occur within the military blast exposure milieu are also explored because the context in which an injury occurs can potentially impact symptom severity and course of recovery. Differential diagnoses, iatrogenic illness, diagnosis threat, and symptom embellishment are also considered.

Neuropsychological profile of a Filipino gentleman with X-linked dystonia-parkinsonism: a case report of Lubag disease.

X-Linked Dystonia-Parkinsonism (XDP or "Lubag") is a progressive neurodegenerative disorder unique to the Island of Panay in the Philippines. Imaging and autopsy studies have suggested involvement of the caudate and putamen in late stages. Because the clinical presentation of patients with XDP resembles that of patients with Parkinson disease or dystonia, it is reasonable to predict the neuropsychological profile might be similar; however, the neuropsychological profile of a XDP patient has not previously been published. We present the neuropsychological findings of a 67-year-old gentleman with a 10-year history of XDP who presented with parkinsonian and dystonic symptoms. He was evaluated for suitability for deep brain stimulation surgery. Neuropsychological findings demonstrated diffuse impairment involving memory, visuospatial, language, and executive functioning.

Classification accuracy and predictive ability of the medical symptom validity test's dementia profile and general memory impairment profile.

When assessing symptom validity in patients with dementia, traditional approaches may be inappropriate because neurological factors may cause altered performance. The Medical Symptom Validity Test has a Dementia Profile that explicitly recognizes this fact. We prospectively evaluated classification accuracy of the Dementia Profile for 52 referrals to a memory disorders clinic. The Dementia Profile correctly classified 36/52 patients. Sensitivity was 54.8%, specificity was 90.5%, positive predictive value was 89.5%, negative predictive value was 60.0%, and the likelihood ratio was 5.77. Of 31 patients with dementia, 11 did not fail symptom validity indices. When only considering patients who failed symptom validity indices, sensitivity of the Dementia Profile was 85%. Classification accuracy statistics are also provided for the Genuine Memory Impairment Profile.

Characterization of the Medical Symptom Validity Test in evaluation of clinically referred memory disorders clinic patients.

We prospectively evaluated performance of 63 referrals to a memory disorders clinic who received the Medical Symptom Validity Test (MSVT) as part of their standard neuropsychological evaluation. The patients were grouped based on independent medical diagnoses and presence or absence of a potential financial incentive to under-perform. Twenty-seven patients (42.9%) scored below cutoffs on the MSVT symptom validity indices. Two individuals in the potential financial incentive group showed clear signs of invalid responding (18.2%). Twenty-two of the remaining 25 patients who failed the symptom validity indices corresponded to the dementia profile. Three individuals did not correspond to the dementia profile but are thought to have performed validly representing a 4.8% false positive rate. When considering all MSVT indices, the base rate of invalid responding in the potential financial incentive to under-perform group increased to 27.3%. Combining all groups our base rate of invalid responding was 4.8%. Specific performances are presented.