Four-year trajectories of symptoms and quality of life in individuals hospitalized after mild traumatic brain injury.

OBJECTIVES: 1) To detect distinct trajectories of symptoms and quality of life (QoL) over the first four years after mild traumatic brain injury (mTBI); 2) assess the relationship between symptom trajectory membership and QoL trajectory membership; 3) identify participant characteristics associated with QoL trajectory membership. DESIGN: Prospective longitudinal cohort study. Assessments occurred at 4, 8, 12, 24, 36, and 48 months post-mTBI. SETTING: Recruitment occurred in Level 1 Trauma Centres; follow-up was completed in the community. PARTICIPANTS: Participants were 143 adults (aged 18 to 65) who sustained a mTBI and were hospitalized (at least 24 hours) at a Level 1 Trauma Centre. INTERVENTIONS: Not applicable MAIN OUTCOME MEASURES: Fatigue Severity Scale, Hospital Anxiety and Depression Scale, Insomnia Severity Index, Medical Outcomes Study Cognitive Functioning Scale, Quality of Life after Brain Injury questionnaire, presence/absence of headaches or dizziness RESULTS: Group-based trajectory modeling revealed relatively stable symptom and QoL trajectories over time. Considerable percentages of participants were classified in trajectories of clinically significant symptoms throughout the full follow-up period: 62% for subjective cognitive issues, 54% for fatigue, 44% for anxiety, 43% for insomnia, 27% for depression, 23% for headaches, and 17% for dizziness. Sixty-six percent of participants belonged to trajectories of persistently poor QoL. For all symptoms, trajectories of greater severity were associated with trajectories of poorer QoL. None of the sociodemographic or injury-related variables examined were associated with QoL trajectory membership. CONCLUSIONS: A substantial proportion of individuals hospitalized after mTBI experiences clinically significant persistent symptoms up to four years post-injury, and those with more severe symptoms have poorer QoL. Further research is required to better understand the factors leading to symptom persistence and poor QoL.

Access and adherence to the most recent recommendations regarding resumption of activities after a mild traumatic brain injury.

OBJECTIVES: 1) To examine access and adherence to the Berlin (2016) recommendations for resuming physical and intellectual activities after mild traumatic brain injury (mTBI) (including an exploration of barriers and facilitators). 2) To assess post-mTBI symptoms in relation to recommendation adherence. METHOD: 73 participants who sustained a mTBI completed an online survey with questions about access and adherence to recommendations and validated measures of symptoms. RESULTS: Almost all participants had received recommendations from a health professional after their mTBI. Two thirds of recommendations reported had at least moderate correspondence with the Berlin (2016) recommendations. The vast majority of participants reported weak or partial adherence to these recommendations and only 15.7% reported complete adherence. Overall, adherence to recommendations explained a significant portion of the variance in the severity and number of unresolved post-mTBI symptoms. The most common barriers were: being in a critical period for school or work, pressure to return to work or school, screen use, and presence of symptoms. CONCLUSIONS: Sustained efforts are required to disseminate appropriate recommendations after mTBI. Clinicians should support patients in eliminating barriers to recommendation adherence, as greater adherence may facilitate recovery.

The effect of an Internet-based cognitive behavioral therapy intervention on social support in disaster evacuees.

INTRODUCTION: Both exposure to a natural disaster and psychological symptoms may lead to decreases in social support. Few studies have examined ways to improve social support among victims of natural disasters. AIMS: The objective of the study was to assess emotional and tangible support following a 12-session Internet-based cognitive behavioral therapy (ICBT) targeting posttraumatic stress (PTS), insomnia, and depression symptoms and to examine the association between posttreatment symptoms and emotional and tangible support. MATERIALS AND METHODS: One hundred and seventy-eight wildfire evacuees with significant PTS, depression and/or insomnia symptoms were given access to the ICBT. They completed questionnaires at pre- and posttreatment to measure social support and symptom severity. RESULTS: Results show that completion of the treatment led to an improvement in emotional support. Lower posttreatment PTS and insomnia symptoms were associated with higher posttreatment emotional support. CONCLUSION: ICBT may contribute to enhance emotional support through symptom improvement and probably more so when social support is address directly in treatment.

Cognitive functioning following traumatic brain injury in older adults: associations with social participation and health-related quality of life.

OBJECTIVES: To describe objective and subjective cognitive functioning older adults who sustained TBI at age 65 or over, and to determine whether cognitive functioning is associated with health-related quality of life (HRQoL) and social participation. METHOD: The sample consisted of 40 individuals with TBI (mean age = 73 years; 65% mild, 35% moderate/severe TBI). On average 15 months post-injury, they completed measures of objective and subjective cognitive functioning (Telephone Interview for Cognitive Status-Modified, Alphaflex, Medical Outcomes Study Cognitive Functioning Scale), HRQoL (SF-12), and social participation (Participation Assessment with Recombined Tools - Objective). RESULTS: Mean score for objective cognitive functioning was lower than normative values, while mean scores for executive functioning and subjective cognitive functioning were comparable to normative values. There was no relationship between objective and subjective measures. Subjective cognitive functioning and (to a lesser extent) global objective cognitive functioning were significantly associated with mental HRQoL but not with physical HRQoL or social participation. CONCLUSION: These results underscore the importance of considering both subjective perception and objective performance when assessing and intervening on cognition to promote better mental HRQoL in older adults with TBI.

Persistent Postconcussion Symptoms: An Expert Consensus-Based Definition Using the Delphi Method.

OBJECTIVE: To provide an expert consensus definition of persistent postconcussion symptoms following a mild traumatic brain injury (mTBI). PARTICIPANTS: Canadian healthcare professionals caring for patients with mTBI. DESIGN: Online Delphi process. MAIN MEASURES: A first Delphi round documented important dimensions or criteria to consider when defining persistent symptoms. Expert opinions were then resubmitted in 4 subsequent Delphi rounds and their relevance was rated using a 9-point Likert scale. An item with a median rating of 7 or more and a sufficient level of agreement were considered consensual. RESULTS: After 5 rounds, consensus was reached on a set of criteria that can be summarized as follows: presence of any symptom that cannot be attributed to a preexisting condition and that appeared within hours of an mTBI, that is still present every day 3 months after the trauma, and that has an impact on at least one sphere of a person's life. CONCLUSION: This Delphi consensus proposes a set of criteria that support a more uniform definition of persistent symptoms in mild TBI among clinicians and researchers. This definition may help clinicians better identify persistent postconcussion symptoms and improve patient management.

Performance during dual-task walking in a corridor after mild traumatic brain injury: A potential functional marker to assist return-to-function decisions.

Objective: To compare the performance of participants with mTBI and healthy control on locomotor-cognitive dual-tasks in a corridor with limited technology.Design: Prospective study of twenty participants with mTBI (10 women; 22.10 ± 2.97 years; 70.9 ± 22.31 days post-injury), and 20 sex- and age-matched control participants (10 women; 22.55 ± 2.72 years).Methods: Participants performed six different dual-tasks combining locomotor tasks (level-walking, obstacle-crossing, and tandem gait) and cognitive tasks (counting backwards and verbal fluency). Symptoms and neuropsychological performance were also assessed.Results: No differences between groups were found for symptoms and neuropsychological measures. For gait speed, the group effect was not significant, but a significant group X cognitive task interaction was found, revealing a tendency toward slower gait speed in the mTBI group during dual-task conditions. A significantly greater dual-task cost for gait speed was found for the mTBI group. Although no statistically significant differences in cognitive performance were observed during dual-tasks, the mTBI group subjectively reported being significantly less concentrated.Conclusion: The present study revealed that in persons who seem to have well recovered after mTBI, on average 71 days post-injury, alterations in gait are detectable using a simple, "low-tech," corridor-based dual-task walking assessment.

Virtual reality-based assessment of cognitive-locomotor interference in healthy young adults.

BACKGROUND: A recent literature review emphasized the importance of assessing dual-task (DT) abilities with tasks that are representative of community ambulation. Assessing DT ability in real-life activities using standardized protocols remains difficult. Virtual reality (VR) may represent an interesting alternative enabling the exposure to different scenarios simulating community walking. To better understand dual-task abilities in everyday life activities, the aims of this study were (1) to assess locomotor and cognitive dual-task cost (DTC) during representative daily living activities, using VR, in healthy adults; and 2) to explore the influence of the nature and complexity of locomotor and cognitive tasks on DTC. METHODS: Fifteen healthy young adults (24.9 ± 2.7 years old, 8 women) were recruited to walk in a virtual 100 m shopping mall corridor, while remembering a 5-item list (DT condition), using an omnidirectional platform and a VR headset. Two levels of difficulty were proposed for the locomotor task (with vs. without virtual agent avoidance) and for the cognitive task (with vs. without items modification). These tasks were also performed in single task (ST) condition. Locomotor and cognitive DTC were measured by comparing performances in ST and DT conditions. Locomotor performance was characterized using walking speed, walking fluidity, and minimal distance between the participant and the virtual agent during avoidance. Cognitive performance was assessed with the number of items correctly recalled. Presence of DTC were determined with one-sample Wilcoxon signed-rank tests. To explore the influence of the tasks' complexity and nature on DTC, a nonparametric two-way repeated measure ANOVA was performed. RESULTS: No locomotor interference was measured for any of the outcomes. A cognitive DTC of 6.67% was measured (p = .017) while participants performed simultaneously both complex locomotor and cognitive tasks. A significant interaction between locomotor task complexity and cognitive task nature (p = .002) was identified on cognitive DTC. CONCLUSIONS: In challenging locomotor and cognitive conditions, healthy young adults present DTC in cognitive accuracy, which was influenced by the locomotor task complexity task and the cognitive task nature. A similar VR-based protocol might be used to investigate DT abilities in older adults and individuals with a stroke.

Efficacy of cognitive-behavioural therapy interventions on reducing burden for caregivers of older adults with a neurocognitive disorder: a systematic review and meta-analysis.

By 2025, 34 million people worldwide will be living with Alzheimer's disease or another form of dementia (i.e., neurocognitive disorders). Symptoms of neurocognitive disorders have functional repercussions on daily activities. People with neurocognitive disorders often rely on a caregiver to alleviate the impact of their symptoms, but this help has consequences for the caregiver. Indeed, caregivers report subjective burden, depressive symptoms, stress, anxiety and a lower quality of life than non-caregivers. Multiple cognitive-behavioral therapy (CBT) trials have been conducted to reduce these symptoms for caregivers. No meta-analysis has been conducted to evaluate the efficacy of this type of intervention on reducing subjective burden. Articles were selected from PsycNet, MEDLINE, AgeLine and ProQuest Dissertation and Theses for the period from 2000 to 2017. Article selection, data extraction and bias analysis for individual studies were completed by two independent authors who used a consensus procedure when discrepancies occurred. A total of 20 articles were included in the systematic review. Ten studies evaluated the efficacy of CBT in reducing subjective burden, and the meta-analysis suggested a significant reduction in subjective burden following CBT. Additionally, 17 studies evaluated the efficacy in reducing depressive symptoms, and the meta-analysis revealed a significant reduction for these caregivers following CBT. CBT for caregivers of individuals with a neurocognitive disorder had no impact on stress, anxiety, or quality of life.

A Portrait of Mental Health Services Utilization and Perceived Barriers to Care in Men and Women Evacuated During the 2016 Fort McMurray Wildfires.

This study examines the influence of gender on mental health services utilization and on perceived barriers to treatment one year after the 2016 Fort McMurray wildfires. Data was collected through a phone survey from May to July 2017 (N = 1510). Participants were English-speaking evacuees aged 18 and older. Mental health services utilization and barriers to mental health care were assessed with the Perceived Need for Care questionnaire. Probable diagnoses of posttraumatic stress disorder, depression and insomnia were assessed with validated self-report questionnaires. Multiple logistic regressions confirmed that gender was a significant predictor of services utilization, after controlling for associated sociodemographic variables and presence of probable diagnoses. Women were respectively 1.50, 1.55 and 1.86 times more likely than men to receive information, medication and psychological help. Self-reliance was the most frequently reported reason for not receiving help, and motivational barriers, such as pessimism and stigma, were reported in a higher proportion than structural barriers, including nonresponse and finance. No significant gender differences were found in the types of perceived barriers to services. Among the Fort McMurray fire evacuees, mental health services utilization was similar to other studies on natural disaster victims, and higher in women than in men. Efforts to increase services utilization in natural disaster victims should focus on motivational barriers and offering treatments fostering people's autonomy, such as online treatments.

A Systematic Review and Meta-analysis on PTSD Following TBI Among Military/Veteran and Civilian Populations.

OBJECTIVES: To determine whether persons with traumatic brain injury (TBI) are at greater risk of developing posttraumatic stress disorder (PTSD) than other trauma-exposed populations without TBI, and whether this risk is even greater in military/veteran settings than in civilian settings. DESIGN: A systematic review and meta-analysis was conducted in 7 databases. Reference lists from the 33 identified studies and other relevant reviews were also searched. RESULTS: The pooled PTSD proportion reached 27% (95% confidence interval = 21.8-33.1) in groups with TBI, which was 2.68 times greater than the observed 11% (95% confidence interval = 8.0-15.0) in groups without TBI. PTSD after TBI was more frequently observed in military samples than in civilians (37% vs 16%). Military and civilian samples were respectively 4.18 and 1.26 times more inclined to have a diagnosis of PTSD after TBI than when there was no TBI. The proportion of PTSD after TBI was concurrently attributable to the methods of the included studies (objectives focused on PTSD diagnosis, type of comparison group) and to characteristics specific to the military setting (country, sex, blast injuries). CONCLUSIONS: TBI diagnosis and military setting represent greater risks for PTSD. The dual diagnosis of TBI and PTSD requires interdisciplinary collaboration, as physical and psychological traumas are closely intertwined.

Caregivers' emotional distress due to neuropsychiatric symptoms of persons with amnestic mild cognitive impairment or Alzheimer's disease.

Compared to the literature on Alzheimer's disease (AD), less is known about the emotional distress of caregivers of persons with amnestic Mild Cognitive Impairment (aMCI). This study describes and compares emotional distress due to neuropsychiatric symptoms (NPS) among children and spousal caregivers of aMCI or mild AD care recipients. It also examined the association between the frequency and severity of NPS and caregivers' emotional distress. In total, 108 spouses or children of persons with aMCI or mild AD were administered the Neuropsychiatric Inventory, measuring the frequency/severity of NPS in the patient as well as the associated caregiver's emotional distress. Emotional distress due to each NPS was compared between children and spouses and the relationship between NPS and emotional distress was assessed. There was no significant difference in emotional distress between aMCI and mild AD spousal caregivers for all symptoms, but for children caregivers, emotional distress was significantly higher in the mild AD group than in the aMCI group. Regardless of the caregiver's relationship to the patient or the condition (aMCI vs mild AD) of the latter, there was a positive relationship between the frequency/severity of NPS and caregiver emotional distress. Caregivers of persons with aMCI experienced emotional distress due to the presence of NPS in their significant others at a level that is generally similar to that experienced by caregivers of persons with mild AD. This study highlights the need for interventions to reduce emotional burden by helping caregivers manage NPS in care recipients.

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.

Alcohol and Drug Use Before and During the First Year After Traumatic Brain Injury.

OBJECTIVES: To compare individuals with mild and moderate/severe traumatic brain injury (TBI) on alcohol and drug use and substance use disorders before and in the first year post-TBI; to explore sociodemographic and injury-related variables associated with substance use disorders. PARTICIPANTS: A total of 225 adults hospitalized in a level I trauma center after TBI. DESIGN: Observational cohort study with retrospective (pre-TBI) and prospective (4, 8, and 12 months post-TBI) assessments. MAIN MEASURES: Mini International Neuropsychiatric Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). RESULTS: The percentage of participants using alcohol or drug declined shortly after the injury (4 months) but increased closer to preinjury levels by the end of the first year. Post-TBI alcohol use was higher after mild than moderate/severe TBI, but drug use was similar. About 11% of participants met criteria for a substance use disorder in the first year after TBI. Younger age, not being in a relationship, and suspected substance intoxication at the time of TBI were associated with the presence of a post-TBI substance use disorder. CONCLUSION: Individuals with milder injuries return to alcohol use earlier than those with more severe injuries. Given that substance use may alter recovery, preventive recommendations and systematic follow-ups are warranted regardless of injury severity and access to rehabilitation.

Prognostic value of neuron-specific enolase (NSE) for prediction of post-concussion symptoms following a mild traumatic brain injury: a systematic review.

BACKGROUND: This systematic review aimed to determine the prognostic value of neuron-specific enolase (NSE) to predict post-concussion symptoms following mild traumatic brain injury (TBI). METHODS: Seven databases were searched for studies evaluating the association between NSE levels and post-concussion symptoms assessed ≥ 3 months (persistent) or ≥ 7 days < 3 months (early) after mild TBI. Two researchers independently screened studies for inclusion, extracted data and appraised quality using the Quality in Prognostic Studies (QUIPS) tool. RESULTS: The search strategy yielded a total of 23,298 citations from which 8 cohorts presented in 10 studies were included. Studies included between 45 and 141 patients (total 608 patients). The outcomes most frequently assessed were post-concussion syndrome (PCS, 12 assessments) and neuropsychological performance deficits (10 assessments). No association was found between an elevated NSE serum level and PCS. Only one study reported a statistically significant association between a higher NSE serum level and alteration of at least three cognitive domains at 2 weeks but this association was no longer significant at 6 weeks. Overall, risk of bias of the included studies was considered moderate. CONCLUSIONS: Early NSE serum level is not a strong independent predictor of post-concussion symptoms following mild TBI.

Fatigue in the first year after traumatic brain injury: course, relationship with injury severity, and correlates.

The objectives of this study were to document the evolution of fatigue in the first year after traumatic brain injury (TBI), and to explore correlates of fatigue. Participants were 210 adults who were hospitalised following a TBI. They completed questionnaires 4, 8, and 12 months post-injury, including the Multidimensional Fatigue Inventory (MFI). Participants with severe TBI presented greater mental and physical fatigue, and reduced activity compared to participants with moderate TBI. For all MFI subscales except reduced motivation, the general pattern was a reduction of fatigue levels over time after mild TBI, an increase of fatigue after severe TBI, and stable fatigue after moderate TBI. Fatigue was significantly associated with depression, insomnia, cognitive difficulties, and pain at 4 months; the same variables and work status at 8 months; and depression, insomnia, cognitive difficulties, and work status at 12 months. These findings suggest that injury severity could have an impact on the course of fatigue in the first year post-TBI. Depression, insomnia, and cognitive difficulties remain strong correlates of fatigue, while for pain and work status the association with fatigue evolves over time. This could influence the development of intervention strategies for fatigue, implemented at specific times for each severity subgroup.

Using dual task walking as an aid to assess executive dysfunction ecologically in neurological populations: A narrative review.

Within rehabilitation, clinical assessment plays a crucial role in diagnosis, prognostication and making decisions about return to function. The ecological validity of the assessment of executive dysfunction has become a particular focus in neuropsychology and is gaining interest in mobility research and neurological rehabilitation of acquired brain injury or degenerative neurological diseases. In this narrative review, we look at how the task of walking and the inseparable cognitive demands and interference of the surrounding environment are exploited in dual task walking (DTW) paradigms to expose executive dysfunction. While quite a number of studies and reviews have recently focused on the utility of DTW for gait assessment, particularly to assess fall risk, very little consideration has been given to the level of ecological validity required. This paper directly addresses this issue with discussion of evidence and lacunas related to task, personal and technological factors that should be addressed in order to exploit fully DTW paradigms as an ecological assessment tool.

Correlates of cognitive functioning in independent elderly patients discharged home from the emergency department after a minor injury.

BACKGROUND: The objective of this study was to explore correlates of cognitive functioning of older adults visiting the emergency department (ED) after a minor injury. METHODS: These results are derived from a large prospective study in three Canadian EDs. Participants were aged ≥ 65 years and independent in basic activities of daily living, visiting the ED for minor injuries and discharged home within 48 hours (those with known dementia, confusion, and delirium were excluded). They completed the Montreal Cognitive Assessment (MoCA). Potential correlates included sociodemographic and injury variables, and measures of psychological and physical health, social support, mobility, falls, and functional status. RESULTS: Multivariate analyses revealed that male sex, age ≥ 85 years, higher depression scores, slower walking speed, and self-reported memory problems were significantly associated with lower baseline MoCA scores. CONCLUSIONS: These characteristics could help ED professionals identify patients who might need additional cognitive evaluations or follow-ups after their passage through the ED. Obtaining information on these characteristics is potentially feasible in the ED context and could help professionals alter favorably elderly's trajectory of care. Since a significant proportion of elderly patients consulting at an ED have cognitive impairment, the ED is an opportunity to prevent functional and cognitive decline.

Executive dysfunction following a mild traumatic brain injury revealed in early adolescence with locomotor-cognitive dual-tasks.

OBJECTIVE: To compare gait parameters between children in early adolescence (EA) with and without a mild traumatic brain injury (mTBI) during dual-task walking (DTW). METHODS: Children in EA with mTBI (n = 14; six girls) were compared to those without (n = 13; five girls) while walking in different combinations of obstacle avoidance and cognitive dual-tasks. Gait speed and fluidity and their related dual-task costs (DTC) were analysed along with foot clearance and proximity to the obstacle. RESULTS: No group effects were found for gait speed, proximity or clearance, but were found for fluidity DTC, specifically during the dual Stroop task and when crossing the deeper obstacle. There were also group differences for fluidity during the planning of obstacle avoidance for the narrow obstacle combined with the verbal fluency task and the deep obstacle with no cognitive task. Finally, gait fluidity showed group differences across unobstructed dual-task situations. CONCLUSIONS: Gait fluidity may be a more sensitive variable than gait speed for revealing executive dysfunction following mTBI in EA. Assessing DTW in level walking also seems to show a potential to reveal executive dysfunctions in this age group. These results provide direction for future research on clinical assessment using DTW post-mTBI in adolescents.

Measuring the impact of cognitive and psychosocial interventions in persons with mild cognitive impairment with a randomized single-blind controlled trial: rationale and design of the MEMO+ study.

BACKGROUND: Several studies have suggested that cognitive training is a potentially effective way to improve cognition and postpone cognitive decline in older adults with mild cognitive impairment (MCI). The MEMO+ study is a randomized, controlled, single-blind trial designed to test the efficacy, specificity, and long-term effect of a cognitive training intervention and a psychosocial intervention in persons with MCI. METHODS: One hundred and sixty-two participants with MCI will be recruited. They will be randomized into three groups: cognitive training, psychosocial intervention, and no-contact. Each intervention will last for eight weeks (one session per week) and a booster training session will be provided three months after the end of the intervention. Various proximal and distal outcomes will be measured at pre-intervention as well as at one week, three months, and six months post-training. Proximal outcomes include memory and psychological health measures. Distal outcomes focus on self-rated functioning in complex daily activities and strategies used in daily life to enhance function. Socio-demographic factors (age, gender, and education), general cognition, personality traits, engagement in activities, and self-efficacy will be used as moderators. Enrolment began in April 2012 and will be completed by December 2014. CONCLUSIONS: This study is likely to have a significant impact on the well-being of persons with MCI by contributing to the development of adapted and scientifically supported cognitive and psychosocial interventions.

The impact of poor sleep on cognition and activities of daily living after traumatic brain injury: a review.

BACKGROUND/AIM: Patients frequently report sleep disruptions or insomnia during their hospital stay, particularly after a traumatic brain injury (TBI). The consequences of these sleep disturbances on everyday activities are not well documented and are therefore not considered in the evaluation of independence in activities of daily living (ADLs). The goal of this narrative review is to explore the consequences of poor sleep quality on cognition and ADLs in the acute and subacute stages of a moderate and severe TBI, when patients are in acute care or inpatient rehabilitation. METHODS: We will present an overview of normal sleep and its role in cognitive functioning, and then present the findings of studies that have investigated sleep characteristics in hospital settings and the consequences of sleep disturbances on ADLs. RESULTS: During hospitalisation, TBI patients present severe sleep disturbances such as insomnia and sleep fragmentation, which are probably influenced by both the medical condition and the hospital or rehabilitation environment. Sleep disruption is associated with several cognitive deficits, including attention, memory and executive function impairments. Poor quality and/or insufficient quantity of sleep in acute TBI probably affect general functioning and ADLs calling for these cognitive functions. CONCLUSIONS AND SIGNIFICANCE: The cognitive impairments present following TBI are probably exacerbated by poor sleep quality and sleep deprivation during hospitalisation, which in turn impact ADLs among this population. Health-care personnel should further consider sleep disturbances among people with TBI and a sleep protocol should be established.