Associations between significant head injury in male juveniles in prison in Scotland UK and cognitive function, disability and crime: A cross sectional study.

BACKGROUND: Although the prevalence of head injury is estimated to be high in juveniles in prison, the extent of persisting disability is unknown and relationships with offending uncertain. This limited understanding makes it difficult to develop effective management strategies and interventions to improve health or reduce recidivism. This study investigates effects of significant head injury (SHI) on cognitive function, disability and offending in juvenile prisoners, and considers relationships with common comorbidities. METHODS: This cross-sectional study recruited male juvenile prisoners in Scotland from Her Majesty's Young Offenders Institute (HMYOI) Polmont (detaining approximately 305 of 310 male juveniles in prison in Scotland). To be included juveniles had to be 16 years or older, fluent in English, able to participate in assessment, provide informed consent and not have a severe acute disorder of cognition or communication. Head injury, cognition, disability, history of abuse, mental health and problematic substance use were assessed by interview and questionnaire. RESULTS: We recruited 103 (34%) of 305 juvenile males in HMYOI Polmont. The sample was demographically representative of juvenile males in prisons for young offenders in Scotland. SHI was found in 82/103 (80%) and head injury repeated over long periods of time in 69/82 (85%). Disability was associated with SHI in 11/82 (13%) and was significantly associated with mental health problems, particularly anxiety. Group differences on cognitive tests were not found. However the SHI group reported poorer behavioural control on the Dysexecutive Questionnaire and were more often reported for incidents in prison than those without SHI. Characteristics of offending, including violence, did not differ between groups. CONCLUSIONS: Although SHI is highly prevalent in juvenile prisoners, associated disability was relatively uncommon. There was no evidence for differences in cognitive test performance or offending in juveniles with and without SHI. However, signs of poorer behavioural control and greater psychological distress in juveniles with SHI suggest that they may be at greater risk of recidivism and of potentially becoming lifelong offenders. This implies a need for remedial programmes for juvenile prisoners to take account of persisting effects of SHI on mental health and self-control and education and to improve their understanding of the effects of SHI reduce the likelihood of cumulative effects from further SHI.

The lifetime prevalence of hospitalised head injury in Scottish prisons: A population study.

BACKGROUND: There is mounting evidence that associates brain injury and offending behaviour, and there is a need to understand the epidemiology of head injury in prisoners in order to plan interventions to reduce associated disability and risk of reoffending. This is the first study to determine the lifetime prevalence of hospitalised head injury (HHI) in a national population of current prison inmates. In addition characteristics of prisoners with HHI and were compared to prisoners without HHI to discover whether those with HI differed demographically. METHODS: Whole life hospital records of everyone aged 35 years or younger and resident in a prison in Scotland on a census date in 2015 were electronically linked via their unique NHS identifier and checked for ICD-9 and 10 codes for head injury. Using a case-control design, these data were compared with a sample from the general population matched 3:1 for age, gender and area-based social deprivation. Comparison of demographic variables was made between prisoners with and without HHI. RESULTS: HHI was found in 24.7% (1,080/4,374) of prisoners and was significantly more prevalent than found in the matched general population sample (18.2%; 2394/13122; OR 2.10; 95%CI 1.87, 2.16). The prevalence of HHI in prisoners and controls was similar with the exception of a higher risk of HHI in prisoners in lower deprivation quintiles. Having three or more HHI was more common in prisoners (OR 3.04; 95%CI 2.33, 3.97) as were HHI with ICD codes for intracranial injuries (OR 1.81; 95% CI 1.54, 2.11), suggesting that more severe HHI is more prevalent in prisoners than the general population. The distributions within demographic variables and the characteristics of HHI admissions in prisoners with and without a history of HHI were similar. CONCLUSION: Prisoners in Scotland aged 35 years or younger have a higher lifetime prevalence of HHI than the general population and are more likely to have had repeated HI or intracranial injuries. Further work is required to elucidate the correspondence between self-report of HI and hospitalised records and to ascertain persisting effects of HI in prisoners and the need for services to reduce associated disability and risk of reoffending.

Long-term health outcomes after exposure to repeated concussion in elite level: rugby union players.

BACKGROUND: There is continuing concern about effects of concussion in athletes, including risk of the neurodegenerative disease chronic traumatic encephalopathy. However, information on long-term health and wellbeing in former athletes is limited. METHOD: Outcome after exposure to repeated brain injury was investigated in 52 retired male Scottish international rugby players (RIRP) and 29 male controls who were similar in age and social deprivation. Assessment included history of playing rugby and traumatic brain injury, general and mental health, life stress, concussion symptoms, cognitive function, disability and markers of chronic stress (allostatic load). RESULTS: The estimated number of concussions in RIRP averaged 14 (median=7; IQR 5-40). Performance was poorer in RIRP than controls on a test of verbal learning (p=0.022) and of fine co-ordination of the dominant hand (p=0.038) and not significantly different on other cognitive tests (p>0.05). There were no significant associations between number of concussions and performance on cognitive tests. Other than a higher incidence of cardiovascular disease in controls, no group differences were detected in general or mental health or estimates of allostatic load. In RIRP, persisting symptoms attributed to concussion were more common if reporting more than nine concussions (p=0.028), although these symptoms were not perceived to affect social or work functioning. CONCLUSIONS: Despite a high number of concussions in RIRP, differences in mental health, social or work functioning were not found late after injury. Subtle group differences were detected on two cognitive tests, the cause of which is uncertain. Prospective group comparison studies on representative cohorts are required.

Head injury in asylum seekers and refugees referred with psychological trauma.

OBJECTIVE: Individuals who seek asylum are frequently fleeing violent persecution and may experience head injury (HI). However, little is known about the prevalence of HI in asylum seekers and refugees (ASR) despite the potential for HI to significantly affect cognitive and emotional functioning and to compromise asylum outcomes. This preliminary study investigates the prevalence of HI in ASR referred to a complex psychological trauma service. METHOD: Participants were 115 adult ASR referred to a community psychological trauma service with moderate to severe mental health problems associated with psychological trauma. They were screened for a history of HI using a questionnaire developed for the study. Interpreters were used when required. RESULTS: The overall prevalence of HI was 51%. At least 38% of those with HI had a moderate-severe HI that could cause persisting disability. In 53% of those with HI, the cause was torture, human trafficking or domestic violence. Repeat HI can have cumulative effects on function; it was common, and was reported in 68% of those with HI. An injury to the head was not known to mental health clinicians prior to screening in 64% of cases. CONCLUSION: The emotional and cognitive consequences of HI in ASR may increase the vulnerability of this disadvantaged group, and can be associated with neurobehavioural problems affecting daily life and may compromise asylum outcomes. Routine screening for HI in ASR is needed, as are links to neuropsychology and brain injury services for advice, assessment and intervention.

Mortality and morbidity 15 years after hospital admission with mild head injury: a prospective case-controlled population study.

OBJECTIVE: To investigate mortality rate in a population of adults admitted to hospital with mild head injury (MHI) 15 years later. DESIGN: A prospective case control, record linkage study. PARTICIPANTS: 2428 adults with MHI and an equal number of community controls (CC) were case-matched for age, gender and social deprivation. A further control group admitted with a non-head injury was in addition matched for duration of hospital admission. Controls with a history of head injury prior to study entry were excluded. MAIN OUTCOME MEASURES: Death or survival 15 years poststudy entry. RESULTS: Mortality per 1000 per year after MHI (24.49; 95% CI 23.21 to 25.79) was higher than in CC (13.34; 95% CI 12.29 to 14.44; p<0.0001) or 'other injury' controls (OIC) (19.63; 95% CI 18.43 to 20.87; p<0.0001). Age at injury was important: younger adults (15-54 years) with MHI had a 4.2-fold greater risk of death than CC; in adults aged over 54, the risk was 1.4 times higher. Gender and social deprivation showed a similar association with death in the MHI and control groups. Repeated head injury was a risk factor for death in the MHI group. The frequency of hospital admission with systemic disease preinjury and postinjury was higher in both injury groups than in CC and higher in MHI than OIC. Prospective data in the MHI group suggest an association between preinjury lifestyle and mortality. Causes of death after MHI were similar to those of the control groups. CONCLUSIONS: Adults hospitalised with MHI had greater risk of death in the following 15 years than matched controls. The extent to which lifestyle and potential chronic changes in neuropathology explain these findings is unclear. Lifestyle factors do contribute to risk of death after MHI and this finding has implications for lifestyle management interventions.

Outcome of rehabilitation for neurobehavioural disorders.

BACKGROUND: The evidence base on neurobehavioural disorders and their rehabilitation has been growing for four decades. Over that time understanding of the need for effective interventions for a range of handicaps in personal, interpersonal and employment spheres has developed. There is a continuing need to demonstrate whether interventions, are effective and cost-sensitive. Moreover, in pursuing effectiveness, clinicians need to be able to predict which individuals are likely to benefit from a programme and here, clinical experience needs to be informed by research evidence. OBJECTIVE: To review the outcome of rehabilitation for neurobehavioural disorders. METHODS: This review initially considers the background to neurobehavioural rehabilitation and discusses methodological issues. It reviews the evidence for neurobehavioural interventions for severe head injury with emphasis on holistic models of care, behavioural treatments, interventions in non-specialist settings and for emotion perception and self-awareness. RESULTS: In general, there is a need for further high quality studies with longer follow-ups and evidence for generalisation in the community. However, there is a growing consensus that intensive holistic rehabilitation programmes can improve community reintegration and self-efficacy. For behaviour disturbance the evidence base largely comprises studies with weaker (single group or single case) designs. Overall studies here provide limited evidence in support of behavioural approaches for externalised behaviour such as aggression. Further RCT or group comparison studies are needed. In terms of negative behaviours such as apathy, there are few studies on head injury and conclusions cannot be made with confidence. Self awareness is a key issue associated with good outcome in general and research to date supports use of interventions that focus in on-task behaviour and education. The correct perception of emotions in others is a precursor to successful social interaction, and here there is very little evidence although early studies are encouraging. CONCLUSION: There is mounting evidence to support the effectiveness of non-pharmacological interventions for neurobehavioural disorders. Successful outcomes are often associated with intensive and prolonged interventions involving multidisciplinary working.

Can deficits in empathy after head injury be improved by compassionate imagery?

Severe head injury (SHI) can result in problems in empathising, which in turn is associated with social difficulties. Compassionate imagery can increase compassion in non-brain injured people and can alter how they relate to themselves and others. This preliminary study investigates whether compassionate imagery can increase empathy in those with low empathy after SHI. A between-group repeated measures design was used wth 24 participants with severe SHI and low empathy, randomly allocated to a single treatment session of compassionate imagery or a control condition of relaxation. Empathy, self-compassion and relaxation were assessed pre- and post-intervention and fear of compassion pre-intervention as a potential covariate. A group effect of compassionate imagery on empathy was not found, F(1, 21) = 0.12, p = .73. A non-specific increase in self-compassion approached significance, T = 78.00, p = 0.07, r = -.26. Fear of compassion did not correlate significantly with changes in self-compassion or empathy. Demographic and injury factors associated with SHI that may impact on treatment effectiveness are discussed. Further research that takes these factors into account is warranted.

Death after head injury: the 13 year outcome of a case control study.

BACKGROUND: Head injury is common, and the risk of subsequent disability and death is high. Increased risk of death years after injury might be explained by factors associated with, but not a consequence of, the head injury. This unique prospective study investigates mortality over 13 years after injury. METHODS: A cohort of n=767 with head injury was compared with two case control groups, matched for age, gender and deprivation, and in one control group, matched for duration of hospital admission following (non-head) injury. RESULTS: Two-fifths of the head injury cohort had died. The death rate (30.99 per 1000 per year) was much higher than in community controls (13.72 per 1000 per year). More than 1 year after injury, the death rate in younger (15-54 years) adults was much higher than in community controls (17.36 vs. 2.36 per 1000 per year) whereas in older adults the difference was more marginal (61.47 vs. 42.36). Death rate was elevated after mild and after more severe head injury, including in younger adults after mild head injury (14.82 per 1000 per year mild head injury vs. 2.21 community). Female gender and greater deprivation were not associated with increased death rates after head injury. Late after injury, deaths occurred from the same main causes as for the general population. CONCLUSION: Head injury is associated with increased vulnerability to death from a variety of causes for at least 13 years after hospital admission. There is a need to understand how head injury influences mortality, particularly in younger adults and after mild head injury.

Readability of information leaflets given to attenders at hospital with a head injury.

BACKGROUND: It is common practice for information leaflets to be given to people attending hospital after a head injury. Their role is potentially important in alerting the patient or their family to possible undetected or late-emerging cerebral complications in addition to providing guidance aimed to reduce the risk of further injury, or negative social or employment outcomes during recovery. This study examines the readability of information sheets provided by emergency departments in all Scottish hospitals. METHODS: Discharge advice leaflets pertaining to head injury from every ED in Scotland were obtained (45 leaflets from 30 hospital sites). Readability was assessed using two recognised formulae (SMOG and FRE). Legibility was assessed using the Royal National Institute for the Blind Clear Print Guidelines. Content was compared to the Scottish Intercollegiate Guidelines Network (SIGN46) recommendations on the early management of head injury. RESULTS AND DISCUSSION: It is estimated that less than 30% of the population would understand more than 90% of the head injury leaflets. Fewer than half of the leaflets provide even half of the patient information recommended by SIGN46. Analyses of other indicators from clear print guidelines are presented, together with a recommended format for a head injury leaflet and a metric is proposed for evaluating the usefulness of patient information leaflets in general.

Errorless learning is superior to trial and error when learning a practical skill in rehabilitation: a randomized controlled trial.

OBJECTIVE: Errorless learning is an effective strategy for the cognitive rehabilitation of memory impairment, but there is little evidence to support its use for skill learning. This preliminary study investigates whether errorless learning is superior to treatment as usual (trial and error), when teaching people with amputations and comorbid risk of vascular cognitive impairment to fit a prosthetic limb. DESIGN: A randomized control design. SETTING: A regional limb-fitting clinic at the West of Scotland Mobility and Rehabilitation Centre in Glasgow. PARTICIPANTS: Thirty adults with transtibial amputations, recruited from a regional limb-fitting clinic. Of these 42% were cognitively impaired. INTERVENTION: Random assignment to an errorless learning intervention (n = 15) or a treatment as usual control (n = 15). There were five training trials within a single session. Participants were then asked to fit their limb without assistance. MAIN MEASURES: Performance was scored from videotape recording of the first occasion when the participant attempted to fit their limb without assistance. Addenbrookes Cognitive Examination-Revised (ACE-R) was used to assess general cognitive functioning. RESULTS: The errorless learning group remembered more correct steps (mean 90.9, SD 12.1) than the control group (77.9; 8.4; P<0.001) and made fewer errors (mean 0.93, SD 1.3) than controls (2.1; 0.95); P =0.002). CONCLUSIONS: Errorless learning can benefit people with amputations in learning the practical skill of fitting a prosthetic limb. Further study that includes follow-up is warranted.

Head injury attenders in the emergency department: the impact of advice and factors associated with early symptom outcome.

PRIMARY OBJECTIVE: Many who attend hospital after head injury are not admitted to a hospital bed. This study explores the views of hospital attenders about advice received, predictors of memory for and compliance with advice and factors associated with early symptom persistence and outcome that might identify those requiring follow-up. DESIGN: A single group prospective follow-up design. METHODS AND PROCEDURE: Relationships between information obtained by emergency department (ED) staff during admission and about satisfaction with and memory for advice and about symptom persistence was compared in 200 attenders with head injury who were not admitted to hospital. The telephone interview comprised a structured interview and the Post-Concussional Symptoms Checklist. RESULTS: Satisfaction with advice was high. Despite this, a minority remembered advice (alcohol/drugs 44%; medication 38%; rest/sleep 56%; work 36%; sport 36%). At follow-up, symptom complaints were not predicted by information obtained in the ED. Attenders with retrospectively assessed post-traumatic amnesia (PTA) for more than 5 minutes reported more symptoms and poorer memory for advice at follow-up. CONCLUSIONS: Although satisfaction with advice was high, memory for advice was relatively poor and was associated with longer durations of PTA. Attenders with PTA > 5 minutes should be targeted for follow-up or inpatient admission.

Can 'partial' PTSD explain differences in diagnosis of PTSD by questionnaire self-report and interview after head injury?

OBJECTIVE: Can the concept of 'partial' PTSD explain the disparity between the relatively high incidence of PTSD found using self-report questionnaires and the relatively low incidence using structured interview? It was hypothesized that self-report of greater PTSD symptom severity is associated with increased heart rate and movement when responding to questions about the traumatic event, if 'partial' PTSD is an explanation. RESEARCH DESIGN: A within participants single group design. METHODS: Twenty-one adults with head injury underwent self-report (Post-traumatic Stress Disorder Scale) and interview (Clinical Assessment of PTSD) assessments of PTSD, the Traumatic Memory Interview, self-report of mood (Hospital Anxiety and Depression Scale) and cognitive assessment (Wechsler Test of Adult Reading, Auditory Verbal Learning Test, Hayling Test, Digit Symbol Test), during which heart rate and motor activity were recorded. RESULTS: Self-report of greater PTSD symptom severity was not associated with increases in heart rate or movement during questions about the traumatic event. In fact, heart rate decreased from baseline in those with higher self-report scores for PTSD, consistent with curiosity about the traumatic event and not 'partial' PTSD. CONCLUSION: These preliminary findings agree with an emerging theme suggesting that, although PTSD can occur after head injury, it is easily over-diagnosed.

Sleep disturbances following mild traumatic brain injury in childhood.

OBJECTIVE: To examine objective and subjective reports of sleep disturbance in school-aged children who had sustained mild traumatic brain injury (TBI) at least 6 months prior to the study. METHODS: Eighteen children aged 7-12 years with a history of mild TBI (GCS 13-15. LOC < 15 min) were compared to 30 children with orthopedic injuries using actigraphy and parental and self-report sleep questionnaires. RESULTS: Parents reported greater sleep disturbance in the mild TBI group. No significant differences were found in parental ratings of daytime sleepiness, child-reported sleep difficulties, or objective (actigraph) sleep measures. CONCLUSIONS: The finding of greater parental reports of sleep disturbance following mild TBI 6 months after injury requires greater exploration and future research with a larger sample followed from the point of injury would seem appropriate.

Death rate is increased for at least 7 years after head injury: a prospective study.

Although a high mortality rate among patients recently admitted to hospital with severe head injury is well recognized, less is known about their later mortality and very little about the ensuing lifestyle and less-severe injuries that lead to death. The aims of this study were to determine the rate of death in the first and six subsequent years after head injury, in a prospectively identified cohort admitted to hospital, and investigate the factors associated with death--comparing these with general death rates in Scottish populations. A structured sample of 767 patients aged 14 years and over was identified at the time of admission to hospital after a head injury and followed up 7 years later. A trace exercise was conducted to identify those deceased. The General Register of Scotland confirmed death and provided information about cause of death. Seven years after head injury, 206/767 (27%) people had died. Compared to the Glasgow population, risk of death was high after head injury in months 1-2 (23 times), 3-12 (3 times) and 13-84 (2 times), and overall was especially raised in younger people, even late (13-84 months) after injury (7 times). Mortality was only associated with greater severity of head injury during year 1. Pre-injury medical history was associated both with earlier and later deaths, but risk of death remained higher in those with no such history. Later deaths were often associated with lifestyle post-injury. The primary causes of death after head injury were the same as those in the general population. Compared to the general population, the death rate after admission to hospital with head injury remains high for at least 7 years, and is particularly high for those aged under 55 years. Interventions aimed at change in lifestyle may reduce this continuing excess mortality.

Disability in young people and adults after head injury: 5-7 year follow up of a prospective cohort study.

BACKGROUND: Improvement 1-2 years after head injury is well established but the pattern thereafter is unclear. Past studies have not examined representative head injury populations and typically report findings in terms of functioning across social, psychological, neurobehavioural, or cognitive domains rather than global outcome. OBJECTIVE: To determine the late outcome of a representative cohort of participants admitted to hospital after a head injury 5-7 years previously and to identify early and late factors correlating with persisting disability and change between one and 5-7 years. METHODS: A representative cohort of head injured people whose outcome one year after injury was reported previously, were followed up 5-7 years after injury. Participants were assessed using structured and validated measures of global outcome (Glasgow Outcome Scale Extended), cognitive impairment, psychological wellbeing, health status, and social factors. RESULTS: Of 475 survivors studied at one year, 115 (24%) had died by seven years. In survivors at 5-7 years, disability remained frequent (53%); and the rate, similar to that found at one year (57%). Sixty three participants (29%) had improved but 55 (25%) deteriorated. The persistence of disability and its development after previous recovery each showed stronger associations with indices of depression, anxiety, and low self-esteem than with initial severity of injury or persisting cognitive impairment. CONCLUSIONS: Admission to hospital after head injury is followed 5-7 years later by disability in a high proportion of survivors. Persistence of disability and development of new disability are strongly associated with psychosocial factors that may be open to remediation, even late after injury.

Errors in self-report of post-traumatic stress disorder after severe traumatic brain injury.

Assessing PTSD by questionnaire can lead to false positive diagnosis after severe traumatic brain injury. Sumpter and McMillan, reported quantitative data on 34 people with severe TBI; 59% were PTSD 'cases' by questionnaire assessment, but only 3% using a structured interview. The present paper describes ways in which these individuals made errors on questionnaires. Some did not follow questionnaire instructions because of inattention and concrete thinking or instead reported effects of brain injury. Symptom overlap between TBI and PTSD, including insomnia, irritability and impaired concentration can cause errors. Brain injury can also provoke curiosity about loss of memory (during coma, retrograde and post-traumatic amnesia), decreased participation, social withdrawal and difficulty adjusting to injury that may be mistaken for fear-associated PTSD symptoms. Assessment of PTSD by questionnaire can lead to erroneous conclusions and factors related to brain injury must be carefully considered when investigating PTSD.

Opinion about post-concussion syndrome in health professionals.

OBJECTIVE: To compare opinion about post-concussion syndrome (PCS) in accident and emergency doctors, clinical neuropsychologists and neurosurgeons. METHOD: A UK postal survey was sent to all accident and emergency doctors, neurosurgeons and clinical neuropsychologists listed by their professional bodies. Predictions of symptom complaint were made from a vignette about minor traumatic brain injury and a questionnaire about PCS-symptoms, cause, recovery and treatment. RESULTS: All professional groups named headache, attention and memory difficulties as most common symptoms. Clinical neuropsychologists listed more symptoms at recall, more often achieved 'caseness' (Diagnostic and Statistical Manual-IV or International Classification of Diseases-10 criteria) and were more optimistic about treatment effectiveness. Neurosurgeons were more pessimistic about recovery. Organic factors were most frequently cited as the main cause of PCS, followed by emotional factors and then compensation factors. CONCLUSIONS: There was fair consistency between professional groups regarding PCS. Differences may reflect differing clinical roles between the professions, in terms of early care and late rehabilitation. The usefulness of the concept of PCS is discussed. All groups and particularly those working in acute settings may benefit from further information about minor brain injury including the effectiveness of psychological interventions.

Knowledge of post-concussional syndrome in naïve lay-people, general practitioners and people with minor traumatic brain injury.

BACKGROUND: Expectations about effects of minor traumatic brain injury (MTBI) may play a role in maintaining symptoms, the ability to simulate post-concussion syndrome (PCS) and the extent to which professionals might associate patient complaints with MTBI. In turn, expectations will be related to knowledge about MTBI. This study investigates knowledge of PCS in people with MTBI compared with general practitioners (GPs) and lay-people, using recall (a vignette) and symptom guessing or recognition (checklists). METHODS: Thirty GPs, 30 people with MTBI, and 30 lay-people generated symptoms from a vignette describing a MTBI. They then completed a PCS checklist or a checklist containing PCS and 'bogus' items pertaining to the vignette. RESULTS: Only 1 of 90 participants reported enough PCS symptoms to indicate 'caseness' from the vignette alone. Using checklists, more GPs (60%) than controls (20%) ticked enough symptoms to attain PCS 'caseness'. Few people with MTBI who did not themselves achieve PCS 'caseness' by self-report using checklists achieved 'caseness' using the vignette and checklists. The frequency of non-physical symptom reporting was higher than for physical symptom reporting. The addition of 'bogus' items to checklists did not affect responding. CONCLUSIONS: It is unlikely that pre-injury expectations about MTBI maintain PCS symptoms. PCS was difficult to simulate without prompting, even by GPs and PCS 'cases'. The use of 'caseness', rather than simple symptom scores, and further development of checklists with 'bogus' items may provide a more valid assessment of MTBI effects. GPs may benefit from further information about PCS and available treatments.

Further recovery in a potential treatment withdrawal case 10 years after brain injury.

A young woman was rendered tetraplegic and anarthric as a result of a traumatic brain injury in 1993. Two years later, she was considered to be in a minimally conscious state and became the subject of legal debate in the UK with regard to withdrawal of artificial feeding and hydration. Before injury, she made a verbal advanced directive that she would not wish to continue living if ever becoming severely disabled. Neuropsychological assessment found statistically significant evidence for sentience and expression of a wish to live and the application to Court was withdrawn. Further meaningful recovery occurred between 7-10 years after injury. She now lives in the community with 24 hour care. She speaks, initiates conversation and actions, expresses clear and consistent preferences and has a spontaneous sense of humour. She uses an electric wheelchair, eats solid food and drinks through a straw. Her mood is variable and sometimes low. This case demonstrates the need for careful consideration of advanced directives and for specialist neuropsychological assessment in people with severe cognitive and communication difficulties. It supports the view that routine assessment and follow-up of people thought to be in minimally conscious states is important. In addition, it shows that recovery with reduction in disability and significant implications for quality of life can continue for at least 10 years after extremely severe traumatic brain injury.

Young adults with acquired brain injury in nursing homes in Glasgow.

OBJECTIVE: To survey the characteristics, level of disability and services received by young adults with acquired brain injury (ABI) resident in nursing homes in Greater Glasgow. DESIGN: Telephone survey of 75 nursing homes followed by a questionnaire survey and review of medication cardexes. Included were all people under 65 years with ABI resident in nursing homes in Greater Glasgow between 1 February 2000 and 31 January 2001. SETTING: Twenty-eight nursing homes in Greater Glasgow, Scotland (population 0.9 million). SUBJECTS: Young adults (16-64) with ABI. MAIN OUTCOME MEASURES: Structured questionnaire, Barthel Index, Office of Population Census Survey (OPCS) Disability Form, review of medication cardexes. RESULTS: Information was obtained on all cases identified in 75 nursing homes. There were 92 people with ABI in 28 nursing homes; 43/92 were in three homes. Only 42 had inpatient rehabilitation preadmission. Severe disability (OPCS categories 7-10) was found in 54 cases and minimal/minor disability (OPCS categories 1-2) in 18. Thirty-two exhibited challenging behaviour, nine of these were physically violent. Homes were staffed by unqualified assistants, supervised by nurses. No home itself offered rehabilitation, but some had accessed an NHS physical disability community team (28/92 cases) or other community teams (5/92). Proactive medical review was uncommon. Medication had been reviewed since admission in a minority (21/92). Most had regular visits from relatives. CONCLUSIONS: There is a wide range of disability in nursing home residents in Greater Glasgow. Proactive, routine review of medical, rehabilitation and medication needs is rare, as is rehabilitation pre and post discharge. This is serious given the likelihood of reduced intellectual and/or physical capacity in this population. Nursing homes should have hospital discharge reports that inform about immediate preadmission history, rationale for medication and placement. There is a need for regular and ongoing health service review of nursing home residents including potential for rehabilitation and return to community living.