Relationships Among History of Psychosis, Cognition and Functioning in Later-Life Remitted Major Depression.

OBJECTIVE: This study tested the hypotheses that, in older adults with remitted major depression, a history of psychotic features and poorer neuropsychological performance would be independently associated with poorer everyday functioning, but that neuropsychological performance would explain more of the variance in functioning than history of psychotic features. METHODS: This cross-sectional study included 73 patients aged 50 years or older with remitted psychotic major depression or nonpsychotic major depression. The dependent variables were subjective and objective measures of function. The independent variables were history of psychotic features during one or more major depressive episodes in the previous 10 years and neuropsychological performance. Linear regression models examined the association of independent variables with function, controlling for pertinent covariates. Effect sizes were calculated for the magnitude of difference in function between the patient participants and an age- and gender-matched nonpsychiatric group, and distribution of functioning scores were compared between groups. RESULTS: In separate models, history of psychotic features and poorer processing speed, executive function, and verbal learning were independently associated with poorer participant-reported functioning and performance-based functioning. However, the association of psychotic features with functioning was no longer statistically significant when tested in the same models as neuropsychological measures. Effect sizes of the difference in functioning between patients and the nonpsychiatric group were significantly larger for the remitted psychotic than the remitted nonpsychotic depression group; functioning scores were more heterogeneous in the remitted psychotic depression group. CONCLUSION: Patients with remitted psychotic depression exhibit greater, and clinically important, impairment in everyday functioning than those with remitted nonpsychotic depression. Neuropsychological impairment appears to contribute to this relationship.

Relationship of Hair Cortisol with History of Psychosis, Neuropsychological Performance and Functioning in Remitted Later-Life Major Depression.

INTRODUCTION: Major depressive disorder (MDD) is associated with hypothalamic-pituitary-adrenal axis dysfunction that may persist into remission. Preliminary evidence suggests that this dysfunction may be associated with impaired neuropsychological performance in remitted MDD. MDD with psychotic features ("psychotic depression") is associated with greater neuropsychological and functional impairment than nonpsychotic depression, including in remission. Therefore, the aim of this exploratory study was to examine the relationships among hair cortisol concentration (HCC) - a marker of longer term endogenous cortisol exposure - and history of psychotic features, neuropsychological performance, and functioning in remitted MDD. METHODS: This cross-sectional study compared the relationship between HCC and (i) history of psychosis, (ii) neuropsychological performance, and (iii) everyday functioning in a group of 60 participants with remitted later-life MDD using Pearson's correlation coefficients. This study also measured HCC in a group of 36 nonpsychiatric volunteers to examine the clinical significance of HCC in the patient group. RESULTS: There were no statistically significant correlations between HCC and history of psychotic features, neuropsychological performance, or functioning. Furthermore, there was no clinically meaningful difference in HCC between patients and nonpsychiatric volunteers. CONCLUSION: This study is the first to examine HCC in psychotic depression. The results do not support the hypothesis that impaired neuropsychological performance, and everyday function in remitted psychotic depression is due to a sustained elevation of cortisol.

Representation in rehabilitation research of adults with traumatic brain injury and depression: A scoping review.

Objective: To determine how well comorbid depression is described, defined, and measured in the rehabilitation literature that pertains to TBI and depression.Method: Scoping review of the rehabilitation sciences literature. Six databases were searched (to October 17, 2018) using the three core concepts of TBI, depression, and rehabilitation, as was for gray literature. Two independent reviewers reviewed documents for eligibility.Results: 3737 records were reviewed and 137 documents were analyzed. Primary studies (n = 126) were most prevalent and of quantitative descriptive design (n = 102). The number of participants with TBI and comorbid depression could only be determined for 81/126 (64%) of primary studies, in which they are the minority (median of 30% of sample). Depression reporting was heterogeneous and individuals with TBI and depression were not analyzed as a subgroup in most studies (n = 68, 55%). Depression self-report instruments are commonly used (14 instruments used in 111 studies). Few studies (n = 14, 19%) have participant samples with discrete severity levels of TBI and depression.Conclusions: Better participant representation and reporting of TBI and depression variables are needed to enhance comparability across studies and improve rehabilitation outcomes.

Measurement Properties of the Multiple Errands Test: A Systematic Review.

OBJECTIVE: To systematically review, summarize, and evaluate published evidence on measurement properties of real-world versions of the Multiple Errands Test (MET) following Consensus-based Standards for the Selection of Health Measurement Instruments guidelines. DATA SOURCES: Four databases were searched in May 2019 using multiple variants of the name of the MET from 1991 onward following the publication of the original MET. STUDY SELECTION: We included peer-reviewed original research articles in English that provided data on measurement properties (reliability, validity, and responsiveness to change) on real-world versions of the MET in any clinical population. DATA EXTRACTION: Data on the MET characteristics, study population, and evidence for each measurement property were extracted using predefined criteria. The review team critically appraised the methodological quality and rated the results from each study as sufficient (+), insufficient (-), or indeterminate (?). DATA SUMMARY: Data on each measurement property were pooled. Pooled results were rated as sufficient (+), insufficient (-), mixed (±), or indeterminate (?). The overall quality of evidence per measurement property was graded based on risk of bias, sample size, and consistency of results. The overall evidence for each measurement property was determined as high, moderate, low, or very low. RESULTS: We found 33 studies that provided data on measurement properties of real-world versions of the MET. Pooled results revealed high-quality evidence for interrater reliability and moderate-quality evidence for known-group validity. Limited support for other kinds of reliability and validity was found. CONCLUSIONS: This review suggests the MET should be used cautiously. Reasons for the limited psychometric support are discussed, the value of generic forms of the MET that do not require site specific adaptations is noted, and areas for further psychometric work are highlighted.

Associations between self-generated strategy use and MET-Home performance in adults with stroke.

Self-generated strategy use has substantial potential for improving community living outcomes in adults with impaired executive function after stroke. However, little is known about how self-generated strategies support task performance in people with post-stroke executive function impairments living in the community. We explored strategy use among home-dwelling persons with stroke and neurologically-healthy control participants during the Multiple Errands Test-Home Version (MET-Home), a context-specific assessment with evidence of ecological validity designed to examine how post-stroke executive dysfunction manifests during task performance in the home environment. For persons with stroke, significant associations were identified between planning and tasks accurately completed on the MET-Home. Significant associations were also identified among the control participants for self-monitoring, multitasking, and "using the environment" strategies. These associations are related to enhanced MET-Home performance on sub-scores for levels of accuracy, passes, and total time. Rehabilitation interventions that focus on reinforcing self-generated strategy use may support community living outcomes in persons with post-stroke executive function impairments, but this area needs additional investigation.

In-home contextual reality: a qualitative analysis using the Multiple Errands Test Home Version (MET-Home).

Adults with stroke frequently experience executive dysfunction. Despite the range of assessments that examine the effects of executive dysfunction on daily tasks, there remains a paucity of literature that examines the influence of the environment on performance in the community. The MET-Home is an ecologically valid assessment for examining post-stroke executive dysfunction in the home environment. This qualitative study explores the relationship between the environment and MET-Home performance among home-dwelling adults with stroke and matched controls. Using a descriptive qualitative approach, we analysed video, interview, and observation notes from a MET-Home validation study. An overarching theme of interplay between everyday task performance and the home environment produced further themes: naturalistically emerging supports and barriers and environment as strategy. Within naturalistically emerging supports and barriers, five contextual sub-themes were discovered: physical environment, social environment, temporal context, virtual context, and personal context. Within environment as strategy, we identified four sub-themes: reducing distractions, using everyday technologies, planning in context, and seeking social support. These findings extend the conceptualisation of how we evaluate executive dysfunction in the context of the community to also consider the inherent influence of the environment.

Interventions to address burden among family caregivers of persons aging with TBI: A scoping review.

PURPOSE: To capture the scope of literature exploring interventions for caregivers of aging persons with TBI. METHODS: A scoping review of peer reviewed literature was conducted in two phases. Phase I: Searching seven databases, two independent raters screened articles using a set of predetermined criteria. Included articles were reviewed, and categorized according to common themes. Phase II: Five stakeholders were engaged in a consultation. A content analysis was performed by extracting statements from each interview using an inductive strategy, and organizing each into themes. FINDINGS: A total of 11 articles were included in the final analysis. Inter-rater reliability was assessed at both the title and abstract search [98.8% agreement; k = 0.3425 (95% CI, .246 to .439), p < .05]; and the full-text review [83% agreement; k = 0.542 (95% CI, 0.340 to 0.745), p < .05] phases. Seven articles identified potential interventions, and four identified and evaluated an intervention. Interventions targeted subjective burden (n = 4) and objective burden (n = 4), with caregiver knowledge and skill development (n = 3) classified as a sub-category of objective burden. Stakeholders overwhelmingly emphasized the need for interventions to reduce objective burden. IMPLICATIONS: Included articles were primarily composed of levels six and seven evidence, suggesting that this literature is in an early stage of development. Future research should emphasize the development and evaluation of interventions to reduce objective burden.

Optimising activity and participation outcomes for people with self-awareness impairments related to acquired brain injury: an interventions systematic review.

Impaired self-awareness related to acquired brain injury (ABI-ISA) can result in limitations in daily living activities and community participation. We hypothesise that with the appropriate interventions, outcomes for adults with ABI-ISA can be enhanced. The objectives of the study were to describe and examine critically the non-pharmacological intervention literature and to identify intervention elements that optimise everyday living outcomes in adults with ABI-ISA. Two reviewers selected articles and extracted data using five databases, a review protocol, and systematic review standards (i.e., Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Assessing the Quality and Applicability of Systematic Reviews (AQASR)). Included studies reported quantitative activity and participation intervention outcomes for people with stated or measured ABI-ISA, and the methodological quality of randomised controlled trials (RCT) was rated using the Physiotherapy Evidence Database scale (PEDro). Seventeen articles discussing 15 unique intervention studies were found, including two RCTs of good methodological quality. All studies reported improvements on measures of everyday living, utilised interventions with multiple therapeutic elements, and used various forms of external feedback. Evidence supports the use of intervention protocols including elements of experiential practice, external feedback, Socratic guided discussion, and metacognitive strategy training.

Development, Reliability, and Validity of the Multiple Errands Test Home Version (MET-Home) in Adults With Stroke.

OBJECTIVE: Our objective was to perform initial psychometric analysis of the Multiple Errands Test Home Version (MET-Home), which was designed to assess the influence of poststroke executive dysfunction on in-home task performance. METHOD: We examined the reliability and validity of the MET-Home in adults with stroke (n = 23) and individually matched control participants (n = 23). All participants completed a series of assessments during a single in-home visit. RESULTS: Notable differences in MET-Home subscores were discovered between participants with stroke and control participants. Participants with stroke omitted more tasks, broke more rules, passed by tasks more often, and were less efficient than matched control participants. The MET-Home demonstrated evidence of adequate internal consistency, excellent interrater reliability, and significant moderate associations with several tests. CONCLUSION: This preliminary study suggests that the MET-Home differentiates between adults with stroke and matched control participants. The MET-Home provides evidence of initial reliability and validity among adults with stroke.

A Systematic Review of the Measurement of Function in Late-Life Depression.

Recovery of everyday premorbid function is a primary goal in the treatment of depression. Measurement of function is an important part of achieving this goal. A multitude of scales have been used to measure function in depression, reflecting the complex, multifaceted nature of functioning. Currently, however, there are no evidence-based guidelines to assist the researcher or clinician in deciding which instruments are best suited to measure function in late-life depression (LLD). Thus, the aims of this study are to 1) systematically review and identify the instrumental activities of daily living and social functioning assessment instruments used in the LLD literature; 2) identify and appraise the measurement properties of these instruments; and 3) suggest factors for LLD researchers and clinicians to consider when selecting functional assessment instruments and make pertinent recommendations. We performed a systematic review of MEDLINE and CINAHL to identify studies that i) incorporated subjects aged 60 years and older with a depressive disorder, and ii) measured instrumental activities of daily living and/or social functioning. Our search yielded 21 functional assessment instruments. Only two of these instruments, the 36-Item Short Form Survey and the Performance Assessment of Self-Care Skills, have formal validation data in LLD. Four additional instruments, although not formally validated, have relevant data regarding their measurement properties. The primary finding of this study is that very few functional assessment instruments have been validated in LLD, and the available measurement property data are mixed; there is a need for further instrument validation in late-life depression. With this caveat in mind, we provide evidence-based suggestions for researchers and clinicians assessing functioning in LLD patients.

Research Priorities for Optimizing Long-term Community Integration after Brain Injury.

OBJECTIVE: This paper reports on a funded summit, which convened a multidisciplinary group of experts to provide consensus on the research priorities necessary for improving long-term community integration of individuals with traumatic brain injury (TBI) and their caregivers. METHODS: The 2-day summit was directed using the World Café Methodology, to engage stakeholders and collaboratively arrive at a consensus on the problems to be targeted in research. Participants (n=54), drawn from two Canadian provinces, included an interdisciplinary group of researchers, clinicians, representatives from brain injury associations, individuals with TBI, and caregivers. In small groups, participants discussed challenges to long-term community integration and potential initiatives that would address these barriers. Field notes from the discussions were analyzed using qualitative content analysis. RESULTS: The consensus on prioritized research directions included developing interventions to optimize the functioning and participation of individuals with TBI, reducing caregiver burden, and evaluating how emerging technology can facilitate delivery of care. CONCLUSIONS: The World Café Methodology was an effective method for developing research priorities. The breadth of expertise of participants and the collegial environment allowed for the identification of a broad perspective on important future research directions with potential to enhance the long-term community integration of individuals with brain injury.

Systematic Review of Measurement Property Evidence for 8 Financial Management Instruments in Populations With Acquired Cognitive Impairment.

OBJECTIVES: To critically appraise the measurement property evidence (ie, psychometric) for 8 observation-based financial management assessment instruments. DATA SOURCES: Seven databases were searched in May 2015. STUDY SELECTION: Two reviewers used an independent decision-agreement process to select studies of measurement property evidence relevant to populations with adulthood acquired cognitive impairment, appraise the quality of the evidence, and extract data. Twenty-one articles were selected. DATA EXTRACTION: This review used the COnsensus-based Standards for the selection of health Measurement Instruments review guidelines and 4-point tool to appraise evidence. After appraising the methodologic quality, the adequacy of results and volume of evidence per instrument were synthesized. Measurement property evidence with high risk of bias was excluded from the synthesis. DATA SYNTHESIS: The volume of measurement property evidence per instrument is low; most instruments had 1 to 3 included studies. Many included studies had poor methodologic quality per measurement property evidence area examined. Six of the 8 instruments reviewed had supporting construct validity/hypothesis-testing evidence of fair methodologic quality. There is a dearth of acceptable quality content validity, reliability, and responsiveness evidence for all 8 instruments. CONCLUSIONS: Rehabilitation practitioners assess financial management functions in adults with acquired cognitive impairments. However, there is limited published evidence to support using any of the reviewed instruments. Practitioners should exercise caution when interpreting the results of these instruments. This review highlights the importance of appraising the quality of measurement property evidence before examining the adequacy of the results and synthesizing the evidence.

Changes in working memory performance in youth following concussion.

OBJECTIVE: The purpose of this study was to compare the working memory (WM) performance pre- and post-concussion, and investigate the relationships between performance changes and characteristics such as self-reported symptom scores, number of days post-injury and age at injury in 10-14-year-old youth. METHODS: Twenty-one youth (17 males) aged 10-14 years recruited from the community completed verbal and non-verbal WM tasks pre- and post-concussion. Performance was measured using accuracy and performance errors (false alarms and misses). Pre- and post-tests were compared using a Wilcoxon signed rank test, and effect size was determined using matched-pairs rank biserial correlation. RESULTS: Comparisons showed lower verbal WM accuracy at post-test, greater verbal and non-verbal WM false alarm errors at post-test, and greater verbal WM miss errors at post-test (all r ≥ 0.30). Correlations between performance and characteristics revealed associations between younger youth and lower non-verbal WM accuracy and more false alarms at post-test, as well as an association among non-verbal WM miss errors, higher PCS scores and fewer days since injury at post-test. CONCLUSIONS: The current study found lower WM performance in youth following concussion. Furthermore, the findings suggest that false alarm errors may be a useful screening measure acutely post-concussion when assessing WM performance in youth.

Cognitive Contributors to Multiple Errands Test (MET) Performance.

OBJECTIVE: The Multiple Errands Test (MET) was designed to measure the effect of executive dysfunction on everyday life activities, but little is known about the cognitive requirements for successful performance. This study's objective was to investigate cognitive functions associated with successful MET performance, specifically, the Baycrest-MET. METHOD: Correlation analysis examined relationships between Baycrest-MET performance and neuropsychological functioning in participants with acquired brain injury (ABI; N = 27). RESULTS: The association of tasks omitted with executive function (EF) accounted for 15.2%-42.3% of the variance; the association of tasks omitted with attention and processing speed, for 16.8%-24.0%; and the association of tasks omitted and total rule breaks with visuospatial memory, for 18.5%-31.4%. CONCLUSION: Poor performance on the Baycrest-MET in people with ABI is associated with impairments of EF, attention, memory, and processing speed. Different patterns of performance may arise from different constellations of impairments.

Clinicians' perceptions of the clinical utility of the Multiple Errands Test for adults with neurological conditions.

This study examined the clinical utility of the Multiple Errands Test (MET) from the perspective of clinicians. Employing a qualitative descriptive design, in-depth semi-structured interviews were conducted with eight occupational therapists. Participants had an average of 12 years clinical experience and their experience using the MET varied. Interviews were transcribed and analysed using framework analysis. Three dominant themes emerged from the data. Theme 1 was that clinicians value the MET because it reflects real-life functioning. Clinicians perceived the MET to be a unique assessment collecting data on functional performance, and sensitive to higher level cognitive deficits. Theme 2 was that the MET could be used flexibly depending on one's rehabilitation goals. Clinicians employed the MET as an assessment to inform the direction of treatment and as a component of their intervention. Theme 3 was that the MET is a challenging assessment requiring buy in and commitment from therapists. This study is the first to report clinicians' perspectives of the clinical utility of the MET. It reinforces the importance of ecologically valid tests, and augments existing research evaluating psychometric properties of the MET by describing how the MET has been employed in rehabilitation settings to improve health outcomes for adults with neurological conditions.

Reliability and construct validity of a revised Baycrest Multiple Errands Test.

Surprisingly few ecologically-valid assessments of executive function exist, but the Baycrest Multiple Errands Test (BMET) shows promise in identifying executive impairment. The goal of the present study was to develop both a revised version of the assessment (BMET-R), to improve the test's ability to discriminate between patients and healthy participants, and an alternate form of the BMET-R to permit repeat testing. Sixteen individuals with acquired brain injury (ABI) due to stroke or trauma and 16 healthy participants completed a series of neuropsychological assessments, questionnaires, the BMET-R and its alternate form (in counterbalanced order). The results of the study indicated that participants with ABI omitted more tasks, broke more rules, and were less efficient than healthy participants on both the revised BMET-R and its alternate form. Moreover, significant correlations were found between the two versions of the BMET-R for task completions, omissions, errors, rule breaks and inefficiencies but few significant correlations were observed between the BMET-R versions and measures of executive dysfunction in everyday life. These results indicate that the two versions of the BMET-R are able to dissociate the performance of participants with ABI from that of healthy participants. However, despite overlaps in performance and correlations between the two versions of the BMET-R, they did not identically assess executive deficits. This suggests that caution should be used when constructing and validating alternate versions of performance-based assessments.

Sentinel Events During the Transition From Hospital to Home: A Longitudinal Study of Women With Traumatic Brain Injury.

OBJECTIVE: To describe the occurrence of sentinel events and their influence on community integration of women with traumatic brain injury (TBI) transitioning from hospital to home. DESIGN: A longitudinal study was completed with data collected before and at 1, 3, and 6 months after hospital discharge. SETTING: Brain injury rehabilitation unit and acute neuroscience ward. PARTICIPANTS: Women (N=25) with severe TBI (aged between 17 and 50 years; duration of posttraumatic amnesia ranged from 1 to 123d). Sixteen family caregivers also participated. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Community integration was measured using the Mayo-Portland Adaptability Inventory. Depression, anxiety, and stress were measured using the Depression Anxiety Stress Scale. The Sentinel Events Questionnaire was used to record life events that potentially influence the transition process. RESULTS: Most women (>16 at each time point) experienced mild to moderate impairments in psychosocial integration. A third of the sample reported symptoms of depression (n=8), anxiety (n=9), and stress (n=7) that exceeded clinical cutoff levels on at least 1 occasion. At 6 months, 3 women reported clinically significant depression and anxiety (12%) and 2 reported significant stress levels (8%). Positive sentinel events such as return to meaningful occupation were common (n=14). Negative sentinel events were also quite common. For example, reduced access to therapy, reported by 10 women, was associated with poorer participation levels. CONCLUSIONS: These findings suggest that the presence of sentinel events influences the transition experiences of women with TBI in this sample. Rehabilitation should consider the occurrence and impact of sentinel events because this may facilitate successful transitions.

Therapy Online: A Web-Based Video Support Group for Family Caregivers of Survivors With Traumatic Brain Injury.

OBJECTIVE: This innovative descriptive study explores the benefits of a traumatic brain injury (TBI) caregiver support group intervention provided using videoconferencing within a password protected Web-based platform. METHODS: Ten caregivers of family members with TBI were registered to a password-protected Web site (Caring for Others) that provided information about caring for a person with TBI and access to a videoconferencing support group intervention program. Where needed, caregivers were provided with computer equipment, Internet access, and training to negotiate the Web site links. Two groups of 5 caregivers of survivors of TBI participated (average age of survivor-20 years, average time since injury-4.6 years) and met online with a trained clinician weekly for 10 sessions. Using directed content analysis, transcripts of each session were coded with NVivo software. RESULTS: The content analysis reported group process themes, therapeutic interventions used, caregiver outcomes, and the challenges for clinicians delivering a therapeutic intervention online. CONCLUSIONS: Traumatic brain injury caregivers shared similar concerns and problem-solving strategies for managing caregiving tasks. Overall, participants found the sessions helpful for managing the emotional impact of caring for a family member with TBI.

Loss of Financial Management Independence After Brain Injury: Survivors' Experiences.

OBJECTIVE: This pilot study explored the experiences of brain injury survivors after a change in financial management (FM) independence. METHOD: Using a qualitative descriptive design, 6 participants with acquired brain injury were recruited from a community brain injury organization and participated in semistructured interviews. Data were analyzed using thematic analysis. RESULTS: Three themes emerged from the interviews: (1) trajectory of FM change, involving family members as key change agents; (2) current FM situation, involving FM strategies such as automatic deposits and restricted budgets; and (3) the struggle for control, in which survivors desired control while also accepting supports for FM. CONCLUSION: This study identifies some of the challenges brain injury survivors face in managing their finances and the adjustment associated with a loss of FM independence. Occupational therapists should be aware of clients' experiences when supporting them through a change in independence.