A Biopsychosocial Framework for Apathy Following Moderate to Severe Traumatic Brain Injury: A Systematic Review and Meta-analysis

Apathy, the deficit of goal-directed behaviour, is well recognised as one of the most debilitating syndromes after moderate-to-severe traumatic brain injury (TBI). However, mechanisms underlying apathy, or at least factors associated with apathy, are sporadically reported. Based on a biopsychosocial framework, this systematic review and meta-analysis synthesised evidence regarding neurobiological, socio-environmental and individual factors associated with apathy. Our searches identified 21 studies satisfying inclusion and exclusion criteria. Results showed that the majority of work has focused on cognitive dysfunction, TBI-related factors, demographic variables and psychological correlates of apathy, while evidence for neural substrates and socio-cultural and premorbid aspects is scant. Overall, the current literature suggests that TBI-related and patient demographic factors did not contribute to apathy after TBI, whereas complex neurocognitive alterations, socio-environmental and cultural factors as well as patients' self-related factors may be important components. The evidence points to the multifaceted interplay of certain biopsychosocial contributors to apathy and suggests future investigations of more complex behavioural traits, cultural elements and pre-injury levels to better characterise the aetiology of this detrimental impairment after TBI.

Consciousness Recovery in Traumatic Brain Injury: A Systematic Review Comparing Modafinil and Amantadine

OBJECTIVES

Acute traumatic brain injury is one of the most common causes of death and disability. Reduction in the level of consciousness is a significant complication that can impact morbidity. Glasgow Coma Scale (GCS) is the most widely used method of assessing the level of consciousness. Neurostimulants such as amantadine and modafinil are common pharmacologic agents that increase GCS in patients with brain trauma. This study aimed to compare the effectiveness of these 2 drugs.

METHODS

This systematic review obtained articles from Google Scholar, PubMed, Scopus, Embase, and MEDLINE databases. Extensive searches were conducted separately by 4 individuals in 3 stages. Ultimately, 16 clinical trials, cohort studies, case reports, and case series articles were obtained after reading the title, abstract, and full text and considering the exclusion criteria. The data of the final article were entered into the analysis table. This study was registered with PROSPERO (registration number CRD42022334409) and conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Amantadine seems to be associated with a higher overall response rate. In contrast, modafinil is associated with the most remarkable change in GCS score during treatment. However, the number of clinical trials with high quality and sample size has not been satisfactory to compare the effectiveness of these 2 drugs and their potential side effects.

CONCLUSIONS

The authors recommend additional double-blind clinical trials are needed to be conducted with a larger sample size, comparing amantadine with modafinil to delineate the efficacy and adverse effects, both short and long term.

Calling on clinicians to get social and emotional

OBJECTIVE

Disorders of social cognition, such as difficulties with emotion perception, alexithymia, Theory of Mind (ToM), empathy and disorders of emotion regulation, are prevalent and pervasive problems across many neurological, neurodevelopmental and neuropsychiatric conditions. Clinicians are familiar with how these difficulties present but assessment and treatment has lagged behind other traditional cognitive domains, such as memory, language and executive functioning.

METHOD

In this paper, we review the prevalence and degree of impairment associated with disorders of social cognition and emotion regulation across a range of clinical conditions, with particular emphasis on their relationship to cognitive deficits and also real-world functioning. We reported effects sizes from published meta-analyses for a range of clinical disorders and also review test usage and available tests.

RESULTS

In general, many clinical conditions are associated with impairments in social cognition and emotion regulation. Effect sizes range from small to very large and are comparable to effect sizes for impairments in nonsocial cognition. Socio-emotional impairments are also associated with social and adaptive functioning. In reviewing prior research, it is apparent that the standardized assessment of social cognition, in particular, is not routine in clinical practice. This is despite the fact that there are a range of tools available and accruing evidence for the efficacy of interventions for social cognitive impairments.

CONCLUSION

We are using this information to urge and call for clinicians to factor social cognition into their clinical assessments and treatment planning, as to provide rigorous, holistic and comprehensive person-centred care.

Pharmacological management of neuropsychiatric symptoms in geriatric traumatic brain injury: a scoping review

OBJECTIVE

This scoping review aimed to summarize the existing knowledge base on the pharmacological management of neuropsychiatric symptoms in geriatric TBI and identify gaps in the literature to guide future research.

METHODS

Seven electronic databases and nine gray literature databases were systematically searched for articles that examined pharmacological management of neuropsychiatric symptoms in adults aged 65 years and over with TBI. The search was guided by four main concepts and selected based on inclusion criteria. Unpublished studies and abstract-only articles were excluded.

RESULTS

Eight studies met full inclusion criteria. Patterns of psychotropic medication prescription and prescribing principles for geriatric TBI were elucidated. There were no clear or consistent prescribing guidance. Therefore, prescribing recommendations could not be addressed. Current management is inferred from research primarily done in younger adults, or extrapolated from the literature and practice of treating other psychiatric and neurological disorders.

CONCLUSION

There are significant gaps in knowledge and no evidence-based guidelines for the treatment of neuropsychiatric symptoms in geriatric TBI. TBI among older adults is distinct from those of younger adults and thereby demands a unique approach to treatment and research. The authors' proposed guideline is an important first step in facilitating guideline development and future research.

Neurological Symptoms and Their Associations With Inflammatory Biomarkers in the Chronic Phase Following Traumatic Brain Injuries

BACKGROUND

The underlying biological mechanisms for neurological symptoms following a traumatic brain injury (TBI) remain poorly understood. This study investigated the associations between serum inflammatory biomarkers and neurological symptoms in the chronic phase following moderate to severe TBI.

METHODS

The serum interleukin [IL]-1β, IL-4, IL-5, IL-6, IL-7, IL-8, IL-10, IL-12p70, and the tumor necrosis factor [TNF]-α in 72 TBI patients 6 months to 2 years post injury were measured. Neurological symptoms including depression, chronic headache, sleep disturbance, irritability, anxiety, and global neurological disability was assessed. The associations between the biomarkers and the neurological symptoms were assessed using correlation and regression analysis.

RESULTS

It was found that the most common post-injury symptom was sleep disturbance (84.7%), followed by chronic headaches (59.7%), irritability (55.6%), and depression (54.2%). TNF-α was a protective factor for chronic headache (OR = 0.473, 95% CI = 0.235-0.952). IL-6 was positively associated with sleep disturbance (r = 0.274, p = 0.021), while IL-5 and IL-12p70 were negatively associated with the degree of global neurological disability (r = -0.325, p = 0.006; r = -0.319, p = 0.007).

CONCLUSION

This study provides preliminary evidence for the association between chronic inflammation with neurological symptoms following a TBI, which suggests that anti-inflammatory could be a potential target for post-TBI neurological rehabilitation. Further research with larger sample sizes and more related biomarkers are still needed, however, to elucidate the inflammatory mechanisms for this association.

Carbamazepine for Irritability and Aggression after Traumatic Brain Injury: A Randomized, Placebo-Controlled Study

This study tested the hypothesis that carbamazepine (CBZ) reduces irritability/aggression among individuals >6 months post-traumatic brain injury (TBI). Seventy individuals were enrolled in a parallel-group, randomized, double-blind, placebo-controlled, forced-titration trial of CBZ (n = 35) versus placebo (n = 35). Participants were randomly assigned to receive CBZ or placebo 42 days with outcome assessed at baseline and Day 42. Dose was titrated up to 400 mg CBZ or placebo equivalent two times daily. Symptoms of irritability and aggression were measured using the Neuropsychiatric Inventory Irritability (NPI-I) and Aggression (NPI-A) domains as a composite measure (NPI-I/A). Global impression of change was recorded from participant, observer, and study clinician. The CBZ group did not differ significantly from the placebo group (p = 0.60 and 0.59 for NPI-I/A observer and participant ratings, respectively). High placebo effects were observed with minimal clinically important difference in observer NPI-I/A 57% in CBZ group and 77% in placebo group (p = 0.09). Findings were similar for participant ratings. Eighteen of 35 had therapeutic CBZ level ≥4. Therapeutic sample analysis revealed similar high placebo response and non-significant differences except clinician ratings favoring CBZ. Non-serious adverse events occurred more frequently in the CBZ group with greater nervous system effects. CBZ up to 400 mg two times daily was not superior to placebo at reducing irritability/aggression according observers and participants. Large placebo effects may have masked the detection of differences. Clinician rating metrics suggest benefit, and thus, CBZ should remain a treatment option for the experienced brain injury clinician. Data are provided that may aid treatment decisions.

The effect of severe traumatic brain injury on social cognition, emotion regulation, and mood

This chapter provides a review of the emotional and psychosocial consequences of moderate to severe traumatic brain injury (TBI). Many of the disorders affecting socioemotional function arise from damage to frontotemporal systems, exacerbated by white matter injury. They include disorders of social cognition, such as the ability to recognize emotions in others, the ability to attribute mental states to others, and the ability to experience empathy. Patients with TBI also often have disorders of emotion regulation. Disorders of drive or apathy can manifest across cognitive, emotional, and behavioral domains. Likewise, disorders of control can lead to dysregulated emotions and behavior. Other disorders, such as loss of self-awareness, are also implicated in poor psychosocial recovery. Finally, this chapter overviews psychiatric disorders associated with TBI, especially anxiety and depression. For each kind of disorder, the nature of the disorder and its prevalence, as well as theoretical considerations and impact on every day functions, are reviewed.

The quality of measurement properties of neurocognitive assessment in brain tumor clinical trials over the last 30 years: a COSMIN checklist-based approach

PURPOSE

To provide an exhaustive review of the neuropsychological examination as conducted in brain tumor clinical trials over the last 30 years and to provide objective ratings about the reliability and suitability of such tests in neurooncological research and clinical practice.

METHODS

Methodologies and tools provided by the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) were exploited in order to assess the measurement properties of questionnaires and performance-based instruments used to evaluate cognitive functioning in brain tumor clinical trials from 1997 to 2017.

RESULTS

Twenty-six brain tumor clinical trials were analyzed and an overall set of 10 neuropsychological tests was identified. A list of 24 studies concerning the reliability of such tests was analyzed. Reliability and level of evidence scores for each study and for each test were obtained. The results revealed relevant faults about the quality of measurements and the suitability of the neurocognitive assessment batteries most commonly used in brain tumor clinical trials.

CONCLUSION

Our findings suggest that the cognitive assessment in brain tumor clinical trials should be implemented according to specific endpoints and should be addressed to investigate all the cognitive domains known to be affected by brain tumor and treatment.

Assessing aggression following Acquired Brain Injury (ABI): a systematic review of assessment measures

Objective: To conduct a systematic review to identify and examine the reliability and validity of standardized measures used to assess aggression in people with ABI. Data sources: Systematic searches of PsychInfo, Medline, Embase, PubMed and CINAHL databases along with hand searching of gray literature and review articles. Study selection: Studies were included if the sample had an ABI, and the measure included assessment of aggression. Data extraction: Sample and measure characteristics and psychometric properties were extracted. Measure quality was assessed using the COSMIN checklist. Data synthesis: Of 5,100 abstracts screened, 78 were reviewed in full against the inclusion and exclusion criteria, and 25 articles met the criteria for analysis. Included articles assessed the psychometric properties of 17 different measures of aggression in adults with ABI. Quality of evidence was often low. Four measures (MBPC-1990R, NFI, SASNOS and KSMS) demonstrated positive evidence of at least one psychometric property with good quality evidence. Conclusions: Although a large number of general measures were available, there are few measures that only assess post-ABI aggression, and many are not well-validated. Future research should assess the psychometric properties of these measures.

Prevalence and characteristics of neuropsychiatric symptoms, quality of life and psychotropics in people with acquired brain injury in long-term care

Aim

Establishing the prevalence of neuropsychiatric symptoms (NPS), quality of life and psychotropic drug use in people aged ≤65 years with acquired brain injury in nursing homes.

Design

Cross‐sectional, observational study among patients aged 18–≤65 years with acquired brain injury admitted to special care units in Dutch nursing homes.

Methods

According to the Committee on Research Involving Human Subjects in January 2017 this study did not require ethics approval. Nursing homes will be recruited through the national acquired brain injury expertise network for patients with severe brain injury, the regional brain injury teams and by searching the internet. Patient characteristics will be collected through digital questionnaires. Neuropsychiatric symptoms will be assessed with the NeuroPsychiatric Inventory‐Nursing Home version, the Cohen–Mansfield Agitation Inventory and the St. Andrews Sexual Behaviour Assessment; cognition with the Mini‐Mental State Examination, quality of life with the Quality of Life after Brain Injury Overall Scale and activities of daily living with the Disability Rating Scale. Medication will be retrieved from the electronic prescription system. Data collection commenced in 2017 and will be followed by data analysis in 2019. Reporting will be completed in 2020.

Discussion

Little is known about NPS among patients with acquired brain injury in nursing homes. In patients up to the age of 65 years, only six studies were found on prevalence rates of NPS.

Impact

Patients with severe acquired brain injury experience lifelong consequences, that have a high impact on them and their environment. Although there is increasing attention for the survival of this vulnerable group of patients, it is also important to enlarge awareness on long‐term consequences, specifically the NPS, quality of life and psychotropic drug use in acquired brain injury. Insight into the magnitude of these issues is necessary to achieve appropriate care for these patients.

Prevalence of neuropsychiatric symptoms and psychotropic drug use in patients with acquired brain injury in long-term care: a systematic review

OBJECTIVE

Little is known about the prevalence of neuropsychiatric symptoms (NPS) and psychotropic drug use (PDU) in patients below the age of 65 years with acquired brain injury (ABI) in long-term care. The objective of this study was to review the literature about the prevalence of NPS and PDU.

METHODS

A systematic literature search of English, Dutch and German articles in Pubmed, EMBASE, PsycINFO and CINAHL was performed with the use of MeSH and free-text terms.

RESULTS

Six articles met the inclusion criteria. The place of residence was mainly a nursing home and most studies were conducted in a population of patients with traumatic brain injury. Sample sizes varied from 40 to 26,472 residents and NPS were assessed with different assessment instruments. Depressive symptoms were most common with a prevalence ranging from 13.9% to 39.3%. Two studies reported PDU in which tranquillizers (59%) were the most prevalent psychotropic drugs followed by anticonvulsants (35%) and antidepressants (26-34%).

CONCLUSIONS

Patients with ABI experience lifelong consequences, regardless the cause of ABI, that have a high impact on them and their surroundings. More insight into the magnitude of NPS and PDU, through prevalence studies, is necessary to achieve suitable provision of care for these patients.

Social Disinhibition: Piloting a New Clinical Measure in Individuals with Traumatic Brain Injury

Social disinhibition difficulties are common following traumatic brain injury (TBI). However, clinically sensitive tools to objectively assess the difficulties are lacking. This study aimed to pilot a new clinical measure of social disinhibition, the social disinhibition task (SDT). Whether social disinhibition is dependent on the type of social information judgements required and whether disinhibited responses can be adjusted with additional guidance were also examined. Participants were 31 adults (25 Male) with moderate-to-severe TBI and 22 adult (17 Male) healthy control participants. Participants viewed scenes of complex social situations and were asked to describe a character in them (Part A), describe a character while inhibiting inappropriate or negative responses (Part B), and describe a character while not only inhibiting negative responses, but also providing positive responses (Part C). One-half of the items contained a faux pas requiring participants to make inferences about a character's mental state. TBI and control participants responded similarly to Part A, although control participants responded less positively than TBI participants in the faux pas items. TBI participants were significantly impaired on Part B indicating they experienced difficulties in inhibiting automatic responding. TBI participants were however able to adjust their responding in Part C so that they respond similarly to the control participants. Between group differences were not detected in reaction time. Overall, the SDT appears to be suitable to detect social inhibition difficulties in clinical settings and provides a new direction for remediation of the difficulties in individuals with TBI.

Amantadine Effect on Perceptions of Irritability after Traumatic Brain Injury: Results of the Amantadine Irritability Multisite Study

This study examines the effect of amantadine on irritability in persons in the post-acute period after traumatic brain injury (TBI). There were 168 persons ≥6 months post-TBI with irritability who were enrolled in a parallel-group, randomized, double-blind, placebo-controlled trial receiving either amantadine 100 mg twice daily or equivalent placebo for 60 days. Subjects were assessed at baseline and days 28 (primary end-point) and 60 of treatment using observer-rated and participant-rated Neuropsychiatric Inventory (NPI-I) Most Problematic item (primary outcome), NPI Most Aberrant item, and NPI-I Distress Scores, as well as physician-rated Clinical Global Impressions (CGI) scale. Observer ratings between the two groups were not statistically significantly different at day 28 or 60; however, observers rated the majority in both groups as having improved at both intervals. Participant ratings for day 60 demonstrated improvements in both groups with greater improvement in the amantadine group on NPI-I Most Problematic (p<0.04) and NPI-I Distress (p<0.04). These results were not significant with correction for multiple comparisons. CGI demonstrated greater improvement for amantadine than the placebo group (p<0.04). Adverse event occurrence did not differ between the two groups. While observers in both groups reported large improvements, significant group differences were not found for the primary outcome (observer ratings) at either day 28 or 60. This large placebo or nonspecific effect may have masked detection of a treatment effect. The result of this study of amantadine 100 mg every morning and noon to reduce irritability was not positive from the observer perspective, although there are indications of improvement at day 60 from the perspective of persons with TBI and clinicians that may warrant further investigation.

Emotional and behavioral dyscontrol after traumatic brain injury

Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol.

[Psychopatological evaluation of traumatic brain injury patients with the Neuropsychiatric Inventory]

INTRODUCTION

The Neuropsychiatric Inventory (NPI) is a scale that assesses psychiatric symptoms in patients with neurological disorders, principally dementia. Despite its advantages, there are few published studies in traumatic brain injury (TBI) patients. With the NPI information we are going to describe the psychopatologic disorders in a group of TBI chronic patients and look the possible association with psychiatric history and outcome measures.

METHOD

The NPI was applied to caregivers of 53 patients with severe TBI in chronic phase. We also collected functional and community integration scales.

RESULTS

92.5% of patients had some neuropsychiatric symptom, according to NPI. The most frequents were irritability/lability, apathy and depression/dysphoria. Those patients with drugs abuse history had more psychiatric symptoms. Presence of agitation/aggression, apathy and disinhibition were correlated with more disability.

CONCLUSIONS

Psychiatric disorders are common between patients with TBI. The NPI is a scale that systematically assesses the behavioral and emotional disorders more common in these patients. Some of the symptoms negatively influence the degree of disability.

Apathy After Traumatic Brain Injury: An Overview of the Current State of Play

Apathy is a decrease in behavioural, cognitive and emotional components of goal-directed behaviour. Clinically, it is characterised by diminished initiation, reduced concern, and decreased activity. Apathy is a common occurrence following traumatic brain injury (TBI), occurring in around 60% of people. Consequences are widespread, negatively impacting independence, social integration, rehabilitation outcome, vocational outcome, coping and caregiver burden. The current knowledge base on apathy following TBI is presented, with implications for clinical practice. This includes a review of clinical presentations, neuroanatomical and neurochemical substrates associated with apathy, and differential diagnoses. Instruments to measure apathy are presented, highlighting those with demonstrated reliability and validity for the TBI population. Current evidence for pharmacological and non-pharmacological methods of treatment is described, with a model for non-pharmacological interventions provided and discussion of challenges faced by clinicians when treating the patient with apathy. In the TBI arena, greater understanding of apathy and methods of treatment is pivotal given the frequency of occurrence and widespread negative consequences.

Traumatic brain injury affects the frontomedian cortex--an event-related fMRI study on evaluative judgments

Traumatic brain injuries represent the leading cause of death and disability in young adults in industrialized countries. Recently, it has been suggested that dysfunctions of the frontomedian cortex, which enables social cognition, are responsible for clinical deficits in the long-term. To validate this hypothesis, we examined brain activation in seven young adults suffering from diffuse axonal injury during a cognitive task that specifically depends on frontomedian structures, namely evaluative judgments, contrasted with semantic memory retrieval. Brain activation in patients was compared with healthy age and gender matched control subjects using event-related functional magnetic resonance imaging. Evaluative judgments were related to a neural network discussed in the context of self-referential processing and theory of mind. More precisely, the neural network consisted of frontomedian regions, the temporal pole, and the posterior superior temporal gyrus and sulcus/angular gyrus. Patients showed higher activations in this network and the inferior frontal gyrus, whereas healthy control subjects activated more dopaminergic structures, namely the ventral tegmental area, during evaluative judgments. One possible interpretation of the data is that deficits in the ventral tegmental area, and consequently the mesocorticolimbic projection system, have to be compensated for by higher brain activations in the frontomedian and anterior cingulate cortex in patients with diffuse axonal injury. In conclusion, our study supports the hypothesis that traumatic brain injury is characterized by frontomedian dysfunctions, which may be responsible for clinical deficits in the long-term and which might be modified by rehabilitative strategies in the future.

Diffuse axonal injury due to traumatic brain injury alters inhibition of imitative response tendencies

It is well known that traumatic brain injury particularly affects the frontal lobes. Consequently, patients often suffer from executive dysfunction and behavioral disturbances. Accordingly, our study aimed at investigating patients after traumatic brain injury with two tasks involving different functional processes and structural networks supported by the frontal lobes. Two paradigms were applied: the Stroop color-word task and a task in which subjects had to inhibit imitative response tendencies. We selected a patient group solely with diffuse axonal injury, as this type of injury is homogenous and is correlated with cognitive dysfunction more than focal contusions. To evaluate long-term effects most relevant for rehabilitation, we selected a patient group whose brain injuries dated back several years. Our results show that patients with diffuse axonal injury inhibited imitative responses more successfully than control subjects, whereas executive processes examined with the Stroop task were unaltered. Interestingly, impairments were tightly correlated both with the length of the post-traumatic amnesia predicting outcome in traumatic brain injury and with behavioral disturbances. Impairments in the imitation-inhibition task may indicate alterations in an anterior frontomedian neural network even years after traumatic brain injury.