The influence of victim characteristics on potential jurors' perceptions of brain damage in mild traumatic brain injury.

PRIMARY OBJECTIVE: To determine the influence of victim/plaintiff sex, occupation and intoxication status at the time of injury on potential jurors' judgement about the presence of brain damage in mild traumatic brain injury (MTBI). RESEARCH DESIGN: Survey. METHODS AND PROCEDURES: One of eight scenarios describing a MTBI from a motor vehicle accident was presented to 460 participants at a Department of Motor Vehicles. Victim sex, occupation (accountant or cafeteria worker) and alcohol intoxication status at the time of injury (sober or intoxicated) were manipulated across eight scenarios. Participants rated whether the victim's complaints at 6 months post-injury were the result of brain damage. MAIN OUTCOMES AND RESULTS: Ratings were influenced by victim occupation and intoxication status (chi2>5.3, p<0.03), but not the sex of the victim. CONCLUSIONS: The occupational and intoxication status of MTBI victims may influence potential jurors' decision about the presence of brain damage.

Dopaminergic therapy with carbidopa L-dopa for left neglect after stroke: a case series.

OBJECTIVE: To evaluate the efficacy of carbidopa L-dopa (Sinemet) in reducing left spatial neglect after stroke. DESIGN: Case series. SETTING: Inpatient neurorehabilitation unit in a regional rehabilitation center. PARTICIPANTS: A convenience sample of 4 women with right brain strokes and left neglect. INTERVENTION: A trial of carbidopa L-dopa to treat left neglect, if indicated by selected subtests of the Behavioral Inattention Test (BIT). MAIN OUTCOME MEASURES: Baseline and posttreatment evaluation with the modified BIT and the FIM instrument. RESULTS: Three of 4 subjects had significant improvements in their modified BIT scores (8%, 12%, 27%, respectively) and their functional status on the FIM. CONCLUSION: With further study, carbidopa L-dopa may be shown to reduce unilateral spatial neglect and thereby improve rehabilitation outcomes.

Promoting smoking cessation in the rehabilitation setting.

Cigarette smoking is a known risk factor in patients with ischemic and hemorrhagic stroke. Smoking also increases the risk of cardiovascular disease, chronic bronchitis, emphysema, peptic ulcers, and cancer of several organs among middle-aged individuals and the elderly. In the elderly, smoking has also been associated with a general decline in physical functioning as a result of the increased incidence of chronic illnesses. The prevalence of smoking among community-dwelling adults aged 65 to 74 yr has been estimated to be 18% for men and 15% for women. More than 30% of Americans who are hospitalized each year are smokers. Although there are no published studies that have established the prevalence of smoking in a rehabilitation population, these data and our own clinical experience suggest that smoking continues to be a significant health problem for many persons who enter the inpatient rehabilitation setting. Because most hospitals have adopted a smoke-free policy, hospitalization itself may initiate a period of nonsmoking in patients who were smokers at the time of their admission. In addition, some smokers choose to quit smoking after stroke or other medical crisis caused by the health risks associated with cigarette smoking. However, research has also revealed a rather low-smoking cessation rate (30%) among smokers who have had a transient ischemic attack despite the health benefits associated with smoking cessation. Given the significant health risks associated with cigarette smoking, particularly in the elderly and those with cerebrovascular compromise, the effects of smoking on the patient's health should be discussed with the patient during inpatient rehabilitation. Unfortunately, given the current healthcare demands of reducing lengths of hospitalization and the focus on functional outcomes, health promotion issues, such as smoking cessation, nutrition, exercise, may not receive the attention that they deserve. Despite these constraints, we believe that the inpatient rehabilitation setting provides an opportunity for a "teachable moment" to introduce the idea of smoking cessation to the active smoker or to encourage continued smoking cessation and relapse prevention to those patients who have not smoked since their admission to the acute care hospital. If instituted in an effective manner, we believe that there could be significant healthcare benefits in establishing a formal smoking cessation or relapse prevention program in the rehabilitation setting.

Comparison of time and error rates on the trail making test among patients with head injuries, experimental malingerers, patients with suspect effort on testing, and normal controls.

Clinical utility of completion time and performance errors was investigated for the Trail Making Test (TMT; Reitan, 1958). Archival neuropsychological files for patients with mild and moderate/severe head injuries, as well as patients with suspect effort on neuropsychological testing, were examined and compared to controls and experimental malingerers. Time-to-completion scores differentiated the participants who were malingering and who gave suspect effort from those patients with head injuries. There were no differences in error rates among the head-injury groups or controls for either the TMT-A or TMT-B. Errors were also not uncommon among normal controls; 12% and 35% of the controls made at least one error on TMT-A and TMT-B, respectively. However, error rates for both the suspect-effort and malingering groups were inflated on TMT-B as compared to the head-injured and control groups. Results suggest that performance errors on the TMT lack diagnostic utility for persons with head injuries, and time-to-completion is still the best indicator of neuropathology. However, performance errors, in conjunction with inflated time scores on the TMT, may be useful in the assessment of malingering.

A comparison of nine WAIS-R short forms in individuals with mild to severe traumatic brain injury.

Scores from nine WAIS-R short forms were calculated for a sample of 75 adults with mild to severe traumatic brain injury (TBI). Although all nine of the short forms were significantly correlated with the WAIS-R Full Scale IQ, three of the short forms (Vocabulary-Block Design; Vocabulary-Block Design-Arithmetic-Similarities; Vocabulary-Arithmetic-Picture Arrangement-Block Design) significantly overestimated the WAIS-R IQ and thus may be inappropriate to use with this population. The remaining six short forms did not differ significantly from the WAIS-R Full Scale IQ. Among these six, Ward s seven-subtest short form appeared to exhibit the least variability in predicting the WAIS-R Full Scale IQ. Information is presented and discussed regarding the absolute difference scores between short form IQ estimates and the WAIS-R as well as the proportion of short forms which significantly under- and overestimate the Full Scale IQ.

Sleep and pain complaints in symptomatic traumatic brain injury and neurologic populations.

OBJECTIVE: To compare the incidence of sleep and pain complaints in symptomatic traumatic brain injury (TBI) (mild vs moderate/severe) and neurologic populations. DESIGN: Case-control study. SETTING: Outpatient neuropsychology service at a university-affiliated tertiary care center. PATIENTS: A consecutive sample of mild (n = 127) and moderate to severe (n = 75) patients with TBI and a general neurologic (non-TBI) group (n = 123) referred for neuropsychological assessment. MAIN OUTCOME MEASURES: Patient report of sleep and/or pain problems. RESULTS: TBI subjects had significantly more insomnia (56.4% vs 30.9%) and pain complaints (58.9% vs 22%) than non-TBI subjects (p < .0001). For both subject groups, the presence of pain increased insomnia approximately twofold. Poor sleep maintainance was the most common sleep problem. In those subjects without pain, TBI patients reported more sleep complaints that non-TBI patients (p = .05). Mild TBI patients reported significantly (p < .0001) more pain than patients with a moderate to severe injury (70% vs 40%). In TBI subjects without pain, there were significantly more insomnia complaints in mild than in moderate to severe injuries (p < .01). CONCLUSIONS: TBI patients with persistent cognitive complaints have more sleep and pain concerns than general neurologic patients. Pain is strongly associated with sleep problems. Aggressive evaluation and treatment of pain and sleep problems in the TBI, especially mild TBI, population appears warranted and may contribute to increased disability. The etiology of greater sleep and pain problems in the mild than in the more severe TBI patients requires further study.

Order effects in the administration of a forced-choice procedure for detection of malingering in disability claimants' evaluations.

100 disability claimants of the Social Security Administration referred for neuropsychological evaluation and 40 undergraduate college students asked to simulate brain damage were administered a measure for the detection of malingering, an abbreviated version of the Hiscock Forced-choice Procedure, and other neuropsychological tests. Half of each group was administered the Hiscock Procedure at the beginning of the battery; the other half was administered this test last. For both groups, the results indicated poorer performance on the earlier administration of the abbreviated Hiscock Forced-choice Procedure. Formal measures for detection of malingering should be an integral and early part of any neuropsychological evaluation in which the subject has a financial incentive to perform poorly.

Folstein vs modified Mini-Mental State Examination in geriatric stroke. Stability, validity, and screening utility.

OBJECTIVE: Two studies were conducted with the Folstein Mini-Mental State Examination (MMS) and the Modified Mini-Mental State Examination (3MS) to examine whether the expanded version is a more useful screening tool in stroke populations. DESIGN: Clinical utility of screening tests (MMS and 3MS) was evaluated in reference to neuropsychological performance and functional outcome in rehabilitation. SETTING: Medical rehabilitation unit of university-affiliated hospital. PATIENTS: Two groups (n = 77, and n = 70) of patients who were admitted consecutively. MAIN OUTCOME MEASURES: Neuropsychological performance and functional outcome (functional independence measure). RESULTS: The reliability, stability, and validity of the 3MS were established in the stroke population. Classification accuracy did not differ between the MMS and 3MS, although the 3MS had higher sensitivity. In detecting cognitive impairment when compared with the extended neuropsychological battery, both instruments were adequate in patients with left-sided cerebrovascular accidents and were ineffective in patients with right-sided cerebrovascular accidents. The 3MS correlated with some cognitive domains missed by the MMS, thus adding useful clinical information. Finally, the 3MS was a significantly better predictor of functional outcome than the MMS. CONCLUSIONS: The 3MS was found to be a reliable, valid, and stable cognitive screening instrument in the stroke population. Classification accuracy indicates that both screening instruments are not strong in their ability to detect cognitive impairment in patients with stroke, especially in right-sided cerebrovascular accidents. The 3MS does have some advantages over the MMS; the expanded version of the screen not only provides additional cognitive information but also allows for better predicting of functional outcome.

Validity of neuropsychological test results in disability evaluations.

A group of 50 disability claimants referred by the Social Security Administration for neuropsychological screening were administered a 36-item, forced-choice, digit-recognition method of detecting malingering to assess effort and motivation to perform well. This abbreviated form of the 1989 Hiscock and Hiscock Forced-choice Procedure has been shown to be quite easy even for individuals with severe organic brain dysfunction. A perfect performance of 36 correct on this digit-recognition task is obtained by most individuals with moderate to severe brain damage. A performance of less than 90% correct is due more likely to poor effort or even malingering rather than brain damage. In this sample, 18% (n = 9) obtained scores of less than 90% correct, i.e., < 33, which calls into question the reliability and validity of test data obtained. An additional 20% (n = 10) obtained intermediate scores of 33 to 35 correct. These intermediate scores are more difficult to interpret although at least some proportion of those scores reflects poor motivation. The results over-all indicate that nearly one-fifth of potential disability claimants produced invalid and uninterpretable neuropsychological test protocols and an additional one-fifth obtained protocols that should be well scrutinized for evidence of poor effort as well. Neuropsychologists conducting disability evaluations are urged to use measures designed specifically to assess effort and motivation.

Emotional dysfunction in a geriatric population: staff observations and patients' reports.

This study was designed to determine the following about a geriatric rehabilitation population: (1) the relationship between patients' self-reports of depression and anxiety and staff observations of compromised participation in treatment secondary to emotional dysfunction; (2) the relationship of observations among different disciplines; and (3) changes that may occur to staff observations during the patient's hospitalization. The Geriatric Depression Scale, the depression and anxiety subtests of the Brief Symptom Inventory, and the Modified Mini-Mental State Exam were administered to geriatric patients on admission to and discharge from two DRG-exempt acute rehabilitation units. In addition, day nurses, evening nurses, occupational therapists, and physical therapists rated the same geriatric patients on how frequently their emotional functioning interfered with rehabilitation. Significant correlations were obtained between staff observations and patients' reports of emotional dysfunction, with occupational therapists' ratings generally the most highly correlated with patients' reports. At admission, day and evening nurses reported significantly greater patient emotional dysfunction than did occupational therapists, who reported significantly greater emotional dysfunction than did physical therapists. These differences, however, were not evident by time of discharge. Thus, staff members can provide reliable information to mental health professionals in determining the effect of emotional functioning on rehabilitation participation. However, level of compromised participation secondary to emotional dysfunction reported by staff appears to be contingent on which rehabilitation discipline is asked and when during the patient's hospitalization the inquiry is made. Also, patients who generally participated less in treatment tended to be older, depressed women with less education and greater cognitive impairment.(ABSTRACT TRUNCATED AT 250 WORDS)

To say it's not so doesn't prove that it isn't: research on the detection of malingering. Reply to Bigler.

Research that directly examines clinicians' capacity to detect malingering creates doubt about their success in this endeavor and about confident self-appraisals of detective abilities. We argue that Bigler's counterassertions lack supportive evidence or conflict with research on such topics as clinicians' level of training and experience and their judgmental accuracy. We further note that lack of both base rate information and definitive outcome information compound doubts about clinicians' capacity to detect malingering.

A national survey of psychologists who offer neuropsychological services.

We conducted a national survey of psychologists who offer neuropsychological services to determine levels of training, current practices, and views on professional issues. All subjects were listed in the National Register of Health Service Providers in Psychology and/or the American Psychological Association Directory as having some affiliation with neuropsychology. Results suggest marked diversity within the field, with the modal practitioner being minimally involved in neuropsychological activities. We also compare clinicians with varying involvement and experience in neuropsychology and analyze the concentration of practitioners by geographic regions. We compare our results to those obtained in prior surveys and discuss implications of the findings.

Neuropsychologists' training, experience, and judgment accuracy.

It is often assumed that judgment accuracy improves as clinical training and experience increase, but the few studies on this topic within neuropsychology have yielded negative findings. In an extension of prior research, we obtained information on background training and experience from a nationally representative sample of clinical neuropsychologists and had each practitioner appraise one from among a series of 10 cases. Except for a possible tendency among more experienced practitioners to overdiagnose abnormality, no systematic relations were obtained between training, experience, and accuracy across a series of neuropsychologic judgments. Comparable results were obtained when analysis was limited to the top versus bottom 20% of the sample. This and other studies raise doubt that clinical neuropsychologists train and practice under conditions conducive to experiential learning. The potential benefits of further research on experience and judgment accuracy are discussed.

Baseline and comparative neuropsychological data on U.S. Army aviators.

The Wechsler Adult Intelligence Scale-Revised and the Halstead-Reitan Neuropsychological Test Battery were administered to 15 Army aviators and 15 non-aviators, matched for age and education, to identify functional differences between these populations and to begin to establish norms for unimpaired Army aviators. Results were generally nondiscriminatory although Army aviators performed in the high average range on a number of variables. No clinical inferences were drawn from this limited data but utilization of the tests for obtaining normative group and individual baseline data, as well as assisting flight surgeons in assessing intellectual abilities of aviators, appears to have some merit.