Prospective memory rehabilitation for adults with traumatic brain injury: A compensatory training programme

The Effect of Traumatic Brain Injury on Memory

Having a good memory is essential for carrying out daily tasks. People cannot study, plan, remember or navigate life effectively if they are memoryless. People may be at risk when mistakes made in the past will be repeated and lessons regarding danger cannot be learned. In the community, traumatic brain injury (TBI) is common and individuals with TBI frequently have memory problems. It is crucial to study how TBI affects memory to better understand the underlying mechanism and to tailor rehabilitation for patients with a range of pathologies and severity levels. Thus, this paper aimed to review studies related to TBI's effect on memory. This review examined recent studies to learn more regarding and comprehend the connection between TBI and memory, including short-term memory (STM), working memory (WM) and long-term memory (LTM). This will undoubtedly have a big impact on how memory problems that may arise after TBI will be addressed. Virtual reality and other technological advancements have given the medical community a new way to investigate rehabilitative therapy.

Impact of Early Personal Resources on Long-Term Psychosocial Outcomes After Moderate-to-Severe Traumatic Brain Injury: A Systematic Review

OBJECTIVE

To investigate the relationship between preinjury or early personal resources and long-term psychosocial outcomes following moderate-to-severe traumatic brain injury (TBI) and examine evidence for the stability of personal resources over time.

METHODS

The review protocol was registered with the International Register of Systematic Reviews (PROSPERO, Registration No. CRD4202341056). A search of PsycINFO, Cumulative Index to Allied Health Literature (CINAHL), MEDLINE, Scopus, and Web of Science was conducted from inception to February 23, 2023, for longitudinal studies involving adults with moderate-to-severe TBI that examined: (1) the relationship between preinjury or early personal resources (measured ≤6 months postinjury) and later psychosocial outcomes or (2) stability of personal resources over time with a minimum reassessment interval of 3 months. Two reviewers independently assessed eligibility and rated methodological quality of studies using a checklist informed by Strengthening the Reporting of Observational Studies in Epidemiology.

RESULTS

A narrative synthesis was conducted on 14 eligible articles summarizing 12 studies (N = 826). Nine studies examined the impact of preinjury or early personal resources on long-term psychosocial outcomes, most typically at 12 months postdischarge. Out of 9 studies 7 indicated that self-reported preinjury or early personal resources, including productive coping, higher self-esteem and resilience, and lower neuroticism, were associated with better psychosocial outcomes. Evidence from 7 studies examining the stability of personal resources over time was generally mixed, with personality changes (eg, neuroticism, conscientiousness, and extraversion) more evident from informant ratings than self-ratings.

CONCLUSION

Preinjury or early personal resources may influence later psychosocial outcomes after TBI. Further research is needed to investigate the stability of personal resources and factors mediating or moderating change across the adjustment trajectory.

Behavioral disinhibition in stroke

Background

Post-stroke behavioral disinhibition (PSBD) is common in stroke survivors and often presents as impulsive, tactless or vulgar behavior. However, it often remains undiagnosed and thus untreated, even though it can lead to a longer length of stay in a rehabilitation facility. The proposed study will aim to evaluate the clinical, neuropsychological and magnetic resonance imaging (MRI) correlates of PSBD in a cohort of stroke survivors and describe its 12-month course.

Methods

This prospective cohort study will recruit 237 patients and will be conducted at the Neurology Unit of the Prince of Wales Hospital. The project duration will be 24 months. The patients will be examined by multiple MRI methods, including diffusion-weighted imaging, within 1 week after stroke onset. The patients and their caregivers will receive a detailed assessment at a research clinic at 3, 9 and 15 months after stroke onset (T1, T2 and T3, respectively). The disinhibition subscale of the Frontal Systems Behavior Scale (FrSBe) will be completed by each subject and caregiver, and scores ≥65 will be considered to indicate PSBD.A stepwise logistic regression will be performed to assess the importance of lesions in the regions of interest (ROIs), together with other significant variables identified in the univariate analyses. For patients with PSBD at T1, the FrSBe disinhibition scores will be compared between the groups of patients with and without ROI infarcts, using covariance analysis. The demographic, clinical and MRI variables of remitters and non-remitters will be examined again at T2 and T3 by logistic regression.

Discussion

This project will be the first MRI study on PSBD in stroke survivors. The results will shed light on the associations of lesions in the orbitofrontal cortex, anterior temporal lobe and subcortical brain structures with the risk of PSBD. The obtained data will advance our understanding of the pathogenesis and clinical course of PSBD in stroke, as well as other neurological conditions. The findings are thus likely to be applicable to the large population of patients with neurological disorders at risk of PSBD and are expected to stimulate further research in this field.

The perspectives of participants with traumatic brain injury on prospective memory rehabilitation incorporating compensatory and metacognitive skills training

OBJECTIVE

Patient feedback is rarely gathered systematically in cognitive rehabilitation research. This study examined the perceptions and experiences of people with traumatic brain injury (TBI) who participated in a trial of a 6-session educational program for the rehabilitation of prospective memory (PM) impairment.

METHODS

A mixed methods design was used with 47 participants with TBI who completed a compensatory strategy training program (COMP) or COMP plus metacognitive strategy training program (COMP-MST) delivered by an occupational therapist. Data were collected via a participant survey, extracts from progress notes, and audiotaped discussions about learnings from the program during the final session.

RESULTS

Participants from both programs were highly satisfied and perceived improvements in everyday PM performance post-intervention. Elements that were highly valued include setting individualised client-centred goals, repetitive training of strategy use, establishing habits and routines, and receiving experiential, verbal, and written feedback.Changes including more therapy sessions were recommended.

CONCLUSIONS

Both the COMP and COMP-MST programs were perceived as effective by participants with TBI in improving their PM performance in everyday life using compensatory strategies such as assistive technology.

PRACTICE IMPLICATIONS

Routine collection of patient feedback on cognitive rehabilitation can provide valuable information to support person-centred implementation of clinical practice guidelines.

Profiling self-awareness in brain injury rehabilitation: A mixed methods study

ABSTRACTImpaired self-awareness impacts outcomes for individuals with brain injury. Self-awareness is a complex construct, with little known about how its presentation differs across diagnostic groups, or how brain injury-related changes are expressed by individuals in the early phase post-brain injury. This study aims to identify differences and similarities in patterns of self-awareness between patients with different brain injury diagnoses, and provide a clinical account of how individuals with ABI describe changes to themselves arising from brain injury. This is a mixed methods retrospective cohort study involving an audit of medical files that included extraction of data from the Self-Awareness of Deficits Interview. Quantitative and qualitative techniques were used to analyse data from 173 participants. Individuals identified a range of brain injury-related impairments across domains, with greatest difficulty noted with linking impairments to functional implications and setting realistic goals. There were similarities and distinct differences in the expression of changes across diagnostic groups. Two main themes that aligned with self-awareness theory were identified from the data: 1/ Development of self-awareness; and 2/ Dimensions of self-awareness. These interrelated themes demonstrated the multifaceted nature of the clinical presentation of self-awareness, and highlight the need for an individualized approach to cognitive rehabilitation.

Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

Early mobile app training proficiency predicts how well memory-impaired individuals learn to use digital memory aids in the real world

Functional memory impairment following acquired brain injury can lead to decreased independence. External memory aids such as smartphones can be highly effective compensation tools, but cognitive deficits may create barriers to implementation in daily life. The present study examined predictors of real-world use of mobile calendar applications for memory compensation in an acquired brain injury sample. A retrospective chart review was completed from an outpatient rehabilitation program, extending 15 years into the past, yielding data from 34 eligible participants. All participants demonstrated skill learning of the calendar function in their digital device and subsequently completed the generalization phase of training, which is focused on real-world implementation (measured through prospective memory tasks). The results showed that the length of time required for skill learning of mobile calendars (event entry or responding to alerts) was not predictive of the duration of generalization training. Initial training performance for responding to alerts, but not event entry, was a significant predictor of the duration of generalization training needed to complete the program. A secondary analysis with a subset of the data revealed that individuals with additional executive deficits took significantly longer to complete generalization training compared to those with a more focal memory impairment.

Understanding the Barriers of Implementing a Self-Awareness Assessment in Occupational Therapy Practice within a Brain Injury Population: An Exploratory Study

Background

Self-awareness is seldom formally assessed by occupational therapists among individuals with traumatic brain injury (TBI). However, impaired self-awareness is prevalent and has a significant impact on rehabilitation outcomes. There is a need to understand clinician perspectives on self-awareness assessments and promote evidence-based practice in clinical settings.

Aims

(1) Explore how an education session impacts knowledge and use of self-awareness assessments in occupational therapists working with people with TBI; (2) Understand the barriers that occupational therapists experience when assessing self-awareness in clinical practice.

Materials and Methods

A single-group pre-post session design with an integrated knowledge translation approach was used. Occupational therapists working in neurorehabilitation were recruited from two rehabilitation centres through convenience sampling. Participants completed questionnaires before, after, and three months following an education session about the Self-Awareness of Deficits (SADI) assessment.

Results

14 occupational therapists participated in this study. A statistically significant increase in knowledge and confidence in using the SADI was observed both post-session and at 3-month follow-up.

Conclusion

Targeted and ongoing education promotes confidence and knowledge retention among occupational therapists. Further research should explore strategies to promote behaviour change. Significance. The barriers identified in this study can provide insights for knowledge translation across clinical contexts.

The Impact of Two Telerehabilitation Supervision Schedules on Physical Activity, Mobility, and Balance Among People with Moderate to Severe Traumatic Brain Injury: A Mixed-Method Single-Subject Design

Background

Many individuals who experience a moderate or severe traumatic brain injury (TBI) have long-term deficits in physical activity, balance, and mobility requiring specialized care. New delivery models are being investigated for interventions to address challenges caused by living in remote communities, difficulties with transportation, and/or physical distancing requirements. Determining the effectiveness of telerehabilitation is critical given the current movement toward remote health care delivery.

Objective

We investigated the effectiveness of two teletherapy supervision schedules used to deliver a home-based, intensive exercise programme on 1) physical activity, mobility, balance, participation, and 2) concerns with falling, and satisfaction with life.

Methods

A mixed methods approach with alternating single subject design (SSD) and interviews was used. Five individuals who experienced a moderate or severe TBI completed two intensive home-based telerehabilitation programmes. Programmes differed only by supervision schedule - daily or weekly. Impacts on objective and patient-reported outcomes were measured.

Results

Four individuals demonstrated clinically significant improvements in physical activity level, balance, and mobility. One individual experienced less concerns with falling after both schedules, while two other individuals showed a trend in that direction after the weekly remote supervision. Important functional gains (i.e., improved balance and decreased fatigue) were also perceived and reported by family partners regardless of supervision schedule.

Conclusion

Although the study has limitations, the findings indicate that exercise programmes delivered via telerehabilitation can improve balance and mobility as well as positively affect concerns with falling and physical activity levels for this population. No clear differences were seen between the two telerehabilitation supervision schedules.

Which training methods are effective for learning new smartphone memory apps after acquired brain injury? A pilot randomized controlled trial comparing trial and error, systematic instruction and error-based learning

This study aimed to compare the efficacy of three skills training methods (Trial and error TEL; systematic instruction SI; and error-based learning EBL) for training the use of a smartphone reminder app in individuals with an acquired brain injury. Participants (N = 38, M_age = 61.21 years, 71.1% stroke) were randomly allocated to one of three training conditions and trained over one two-hour session. Proficiency of performance with the trained app (primary outcome) was assessed immediately post-training, one- and six-weeks post-intervention. Secondary outcomes included generalization of skills, error commission, smartphone use frequency and confidence, and subjective memory complaints. Proficiency with the trained app after TEL was higher than SI immediately after the training (d = 0.87) and EBL at the one-week follow-up (d = 0.98). No differences were found six-weeks post-training. Smartphone use confidence increased at the six-week follow-up after TEL (d = 1.12) and EBL training (d = 0.91) but not after SI (d = 0.26). Self-reported memory complaints decreased across time for all groups (η_p² = 0.30). There was no clearly superior training method for optimizing proficiency with the reminder app. The expected benefits of SI and EBL may not have emerged due to the single-session format of the training. However, smartphone training via TEL or EBL has the potential to address confidence-related barriers to smartphone use.

Utility of a novel tablet computer software for memory impairment in participants with brain injuries: A randomized control trial

This study examined the effectiveness of a novel information and communication technology (ICT) tool developed for external memory compensation to improve memory function in participants with brain injuries. In this 3-month randomized control study, participants with memory impairment secondary to brain injury were randomly assigned on a 1:1 basis to either intervention (the ICT tool [ARATA]) or 3-month waitlist control groups. This study's primary outcome measure was memory-related difficulties in everyday life, assessed using the Everyday Memory Checklist (EMC). Secondary outcomes included tests for memory function and psychosocial status, all of which were administered by blinded assessors. Seventy-eight participants (53 males, 25 females; mean age, 43.5 ± 12.7 [SD] years) were enrolled and 39 participants were allocated to each group (intervention and control). There was no significant difference in EMC scores between the two groups throughout the study (mean 0.26; 95% CI: -2.55-3.07; p=0.853); however, the intervention group scored significantly higher on the Rivermead Behavioural Memory and General Self-Efficacy tests compared to the control group. While the ICT tool did not improve the primary study outcome, evidence suggests that the ICT tool can improve memory functions related to activities of daily living.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part V: Memory

INTRODUCTION

Memory impairments affecting encoding, acquisition, and retrieval of information after moderate-to-severe traumatic brain injury (TBI) have debilitating and enduring functional consequences. The interventional research reviewed primarily focused on mild to severe memory impairments in episodic and prospective memory. As memory is a common focus of cognitive rehabilitation, clinicians should understand and use the latest evidence. Therefore, the INCOG ("International Cognitive") 2014 clinical practice guidelines were updated.

METHODS

An expert panel of clinicians/researchers reviewed evidence published since 2014 and developed updated recommendations for intervention for memory impairments post-TBI, a decision-making algorithm, and an audit tool for review of clinical practice.

RESULTS

The interventional research approaches for episodic and prospective memory from 2014 are synthesized into 8 recommendations (6 updated and 2 new). Six recommendations are based on level A evidence and 2 on level B. In summary, they include the efficacy of choosing individual or multiple internal compensatory strategies, which can be delivered in a structured or individualized program. Of the external compensatory strategies, which should be the primary strategy for severe memory impairment, electronic reminder systems such as smartphone technology are preferred, with technological advances increasing their viability over traditional systems. Furthermore, microprompting personal digital assistant technology is recommended to cue completion of complex tasks. Memory strategies should be taught using instruction that considers the individual's functional and contextual needs while constraining errors. Memory rehabilitation programs can be delivered in an individualized or mixed format using group instruction. Computer cognitive training should be conducted with therapist guidance. Limited evidence exists to suggest that acetylcholinesterase inhibitors improve memory, so trials should include measures to assess impact. The use of transcranial direct current stimulation (tDCS) is not recommended for memory rehabilitation.

CONCLUSION

These recommendations for memory rehabilitation post-TBI reflect the current evidence and highlight the limitations of group instruction with heterogeneous populations of TBI. Further research is needed on the role of medications and tDCS to enhance memory.

Impaired self-awareness and denial of disability in a community sample of people with traumatic brain injury

PURPOSE

To examine the nature and severity of impaired self-awareness (ISA) and denial of disability (DD) in a community-dwelling traumatic brain injury (TBI) population. Additionally, to investigate reliability, internal consistency, and feasibility of the Clinician's Rating Scale for evaluating Impaired Self-Awareness and Denial of Disability after brain injury (CRS-ISA-DD).

MATERIALS AND METHODS

ISA and DD were studied using the CRS-ISA-DD in a cross-sectional study with 78 TBI patients (3.1 years post-injury).

RESULTS

42% of individuals approached consented to participate in this study. Most participants showed one or more symptoms of ISA and DD, but severity scores were in the lower range (ISA: 13.2 ± 16.2; DD: 9.4 ± 10.7). The CRS-ISA-DD takes <10 min to complete, has excellent inter-rater reliability (ISA: ICC(2,1) = 0.928; DD: ICC(2,1) = 0.835), and acceptable-good internal consistency (ISA: α = 0.819; DD: α = 0.645). ISA severity correlated with neuropsychological test scores (r_s = -0.30 to -0.47) and injury severity. DD severity correlated with anxiety (r_s = -0.22) but not with avoidance coping or defense mechanisms.

CONCLUSIONS

Low levels of ISA and DD occurred in this sample of TBI patients. The CRS-ISA-DD is a reliable and feasible instrument. We recommend using it as a diagnostic tool to differentiate between ISA and DD once self-awareness problems have been identified.IMPLICATIONS FOR REHABILITATIONUnawareness of deficits can persist into the chronic stage when rehabilitation treatment has ended.The two main factors of unawareness, impaired self-awareness and denial of disability, are related to different neurological and psychological mechanisms.The Clinician's Rating Scale for evaluating Impaired Self-Awareness and Denial of Disability after brain injury (CRS-ISA-DD) can be used to distinguish the two main factors of unawareness.

Anosognosia in moderate-to-severe traumatic brain injury: A review of prevalence, clinical correlates, and diversity considerations

METHOD

A comprehensive search of peer-reviewed articles was conducted from September to November 2020 using Google Scholar and PubMed databases. Key terms included "anosognosia," "self-awareness," "traumatic brain injury," and variants thereof. Our search was restricted to articles published in English within the last 25 years, although a few historical articles were included due to scientific merit. Articles were chosen based on methodological quality, inclusion of solely or predominantly msevTBI sample, and relevance to the current topic.

CONCLUSIONS

Anosognosia is a multifaceted and domain-specific construct that affects the majority of those with msevTBI. It is related to TBI severity, injuries in right-hemispheric and cortical midline regions, specific aspects of executive function, psychological function, and cultural factors. We offer pragmatic advice for clinicians working with this population and discuss implications for the field regarding "best practices" of anosognosia assessment and intervention.

Clinician reports of self-awareness after traumatic brain injury: a retrospective chart review

BACKGROUND

Impaired self-awareness (i.e., a lack of insight) is experienced by most individuals who have sustained a moderate to severe traumatic brain injury (TBI). During the early recovery period post-injury, these individuals may not be able to recognize their abilities and limitations, hence, negatively impacting their daily life and function. Although there are assessments and interventions to improve self-awareness after TBI, little is known about how clinicians assess and address this impairment in an inpatient rehabilitation setting.

OBJECTIVE

To examine how clinicians assess, report, and provide interventions for impaired self-awareness after TBI.

METHODS

A retrospective chart review was conducted on interdisciplinary rehabilitation clinician entries for individuals with TBI (n = 67) who received inpatient rehabilitation within a five-year period (2014-2019). A reflexive thematic analysis was used to identify themes pertaining to self-awareness.

RESULTS

Three themes were generated to explore clinician responses to their clients' impaired self-awareness: 1) 'recalling and understanding' described clinician observations of client behaviors and expressions of self-awareness, 2) 'applying and analyzing' identified clinicians providing relevant tasks and advice to clients, and 3) 'evaluating and creating' described clinicians actively interacting with clients by providing feedback, guided prompts, and a follow-up plan.

CONCLUSION

Clinicians produced varied responses to clients' impaired self-awareness after TBI. Findings may help to develop research priorities and integrated knowledge translation initiatives to increase evidence-based practice for impaired self-awareness after TBI.

The effects of implementation intentions on prospective memory in young and older adults

Prospective memory (PM) is the ability to perform a planned action at a future time, while carrying on with other unrelated tasks. Implementation Intentions (II) is a promising metacognitive strategy for improving PM in older adults, though its generalization and longer-term effects are not well-understood. We examined the effects of II on PM in 48 community-dwelling older adults (77% female, M_age = 71.52) and 59 young adults (75% female, M_age = 19.86). Participants were randomly allocated to a conventional instruction or II group and administered a laboratory-based PM task in the first session. In the second session, participants returned to complete a similar but new laboratory-based PM task and an ecological PM task without prompts to use a strategy. We found strong age effects on PM performance whereby older adults performed worse than young adults across all PM tasks. While the overall facilitation effect of II was not statistically significant, there was a trend that this strategy facilitated PM performance on the laboratory-based PM task in the first session for older adults with a medium sized effect (d = 0.37). The generalization and longer-term effect of II were not significant for either the similar laboratory-based or the ecological PM task. These results suggest that a single-session II intervention may not be sufficient to elicit transfer to other similar new PM tasks in healthy populations.

Storytelling as an intervention in traumatic brain injury rehabilitation: a scoping review

PURPOSE

Storytelling interventions are increasingly being proposed as a tool for rehabilitation after Traumatic Brain Injury (TBI). This review aimed to systematically map intervention details as described in the TBI rehabilitation/recovery literature to better understand why, when and how storytelling is being used in rehabilitation.

METHODS

The review team included a storyteller-performer with lived experience of severe TBI, and two academics. Literature searching followed a pre-defined protocol with systematic search strategies and inclusion/exclusion criteria developed through discussion and literature scoping. Included interventions described a deliberate process of creation and sharing of the story.

FINDINGS

Thirteen studies met inclusion criteria, describing eleven distinct interventions fitting into four categories: film production, visual art, written publication and song composition. Rationale for the interventions included identity reconstruction, emotional processing, sense-making, and community (re)engagement. Varying levels of specialist materials and facilities were utilized. Most required facilitation by professionals trained in specialist areas such as narrative, art or music therapy.

CONCLUSION

Intervention models suggest that storytelling is intended for self-identity reconstruction after TBI and that it can create socially acceptable ways to process difficult experiences and (re)connect with peers, clinicians, families, and communities. Larger-scale trials that test intervention efficacy in relation to documented outcomes are needed.IMPLICATIONS FOR REHABILITATIONStorytelling as part of traumatic brain injury rehabilitation is used to assist with self-identity reconstruction, emotional processing, and clinical issues such as communication and executive functioning.Categories of storytelling intervention include film, visual art, written work and song writing.Collaborative facilitation is key to this process for a traumatic brain injury population.

Relationships of self-awareness and facial affect recognition to social communication ability in persons with traumatic brain injury

Traumatic brain injury (TBI) can cause changes to the injured person's physical ability, cognitive functioning, and social interactions. Since these attributes largely determine a person's concept of who they are, TBI poses a threat to sense of self. Due to the importance of social communication skills for community integration, impairment of these skills is a particular threat to sense of self. The present investigation sought to explore characteristics that influence social communication abilities. We hypothesized that both ability to interpret facial affect and self-awareness would be associated with communication ability. We also expected that facial affect recognition would influence self-awareness and that the effect of facial affect recognition on social communication would be partially mediated by self-awareness. For this prospective cohort study, participants were 77 individuals with documented TBI. Of these, 65% were male and 83% sustained severe injuries. The hypothesized association of facial affect recognition with social communication was demonstrated with path analysis as was the effect of facial affect recognition on self-awareness. However, the effect of facial affect recognition on social communication was not mediated by self-awareness. In addition, social communication was associated with employment, social integration, and loneliness. Findings highlighted the importance of social communication after TBI.

Important-performance analysis to conceptualize goal priorities in community dwelling stroke survivors

BACKGROUND

It is important for clinicians to have a better understanding of stroke survivor's goals. Important performance analysis (IPA) is a tool that could be utilized to identify goal priorities in rehabilitation.

OBJECTIVES

To examine the utility of the IPA method to identify goal priorities in a diverse group of community dwelling stroke survivors.

METHODS

Thirty-eight stroke survivors completed private structured interviews and were asked to rate their perceived importance and performance of 37 goal areas. Important-performance analysis (IPA) was utilized to determine goal priorities for the overall sample. Different IPA methods used to identify goal priorities were compared. Goal priorities were also compared by age (dichotomized as <65 and ≥65 years) and sex (male or female).

RESULTS

The IPA method effectively separated the goals into the four quadrants, and distinguished which goals were a priority for the sample of stroke survivors. The five goals that were consistently identified as a focus area were: hand function, driving, balance, memory, and arm strength. Men rated mood control as more important than women (p = .046). The two goals rated as being more important for those older than 65 were home accessibility (p = .008) and skin health (p < .001).

CONCLUSIONS

Stroke survivors continue to have goals related to their stroke recovery in the years after their stroke. Both current performance as well as perceived importance should be considered during goal discussions with stroke survivors. IPA can help identify goal priorities in this population.

The Chinese version of the Memory for Intentions Test (MIST): development and evaluation of its reliability and concurrent validity

This study aims to develop a simplified Chinese version of the "Memory for Intentions Test" (MIST), evaluate its reliability and concurrent validity, explore the inter-relationships among the MIST variables and the relationships between the MIST variables and socio-demographic factors.

Two hundred healthy, Chinese-speaking adults of the Han community participated in this study. Form A of the Chinese MIST and two prospective items of the Rivermead Behavioural Memory Test, Second Edition (RBMT-II, Chinese version) were administered to all participants to evaluate internal consistency, split-half reliability, and concurrent validity. Twenty of these participants were assessed twice on Form A with a two-week interval to examine test-retest reliability. They were also assessed on both Form A and Form B to examine alternate-form reliability.

The findings of the study indicated good internal consistency (Cronbach's α = .833) and excellent split-half reliability (r = .924-.930) among the six subscales of the Chinese MIST, although the internal consistency was low (Cronbach's α = .129) for individual PM trials. We also found adequate concurrent validity (ρ = .722, p< .001), test-retest reliability (ρ = .716, p < .001), and alternate-form reliability (ρ= .828, p < .001).

The Chinese MIST demonstrated suitable reliability and concurrent validity in the Chinese-speaking population. The present study provides a new standardized prospective memory test for the Chinese population, which would enhance future clinical research in this field on the Chinese mainland.

Assessing prospective and retrospective metacognitive accuracy following traumatic brain injury remotely across cognitive domains

The ability to monitor one's behaviour is frequently impaired following TBI, impacting on patients' rehabilitation. Inaccuracies in judgement or self-reflection of one's performance provides a useful marker of metacognition. However, metacognition is rarely measured during routine neuropsychology assessments and how it varies across cognitive domains is unclear. A cohort of participants consisting of 111 TBI patients [mean age = 45.32(14.15), female = 29] and 84 controls [mean age = 31.51(12.27), female = 43] was studied. Participants completed cognitive assessments via a bespoke digital platform on their smartphones. Included in the assessment were a prospective evaluation of memory and attention, and retrospective confidence judgements of task performance. Metacognitive accuracy was calculated from the difference between confidence judgement of task performance and actual performance. Prospective judgment of attention and memory was correlated with task performance in these domains for controls but not patients. TBI patients had lower task performance in processing speed, executive functioning and working memory compared to controls, maintaining high confidence, resulting in overestimation of cognitive performance compared to controls. Additional judgments of task performance complement neuropsychological assessments with little additional time-cost. These results have important theoretical and practical implications for evaluation of metacognitive impairment in TBI patients and neurorehabilitation.

Modification of the Patient Competency Rating Scale to Measure Anosodiaphoria after Severe Acquired Brain Injury: Preliminary Findings

OBJECTIVE

Impaired self-awareness (ISA) of altered functional capacities is a common sequelae of severe acquired brain injury that can severely hamper neuro-rehabilitation in this clinical population. ISA is frequently associated with anosodiaphoria and/or apathy. Although several scales are available to measure apathy, no tools have been published to specifically assess anosodiaphoria after acquired brain injury. In this paper, we reported an initial effort to develop an anosodiaphoria subscale in a commonly used measure of ISA, that is, the Patient Competency Rating scale-neurorehabilitation form (PCRS-NR).

METHOD

A sample of 46 participants with severe acquired brain injury completed a functional, ISA, apathy, and anosodiaphoria assessment. One informal caregiver of each patient participated in the study. Thus, we were able to obtain external data on his/her level of functional competencies, and self-awareness, which allowed separating patients with low self-awareness (LSA) from those with high self-awareness (HSA). Finally, the patients were compared with 44 healthy age-gender-years of formal education matched control participants (HCs).

RESULTS

Compared to both patients with HSA and HCs, patients with LSA demonstrated greater anosodiapvhoria and lower levels of functioning than both HSA patients and HCs. A stronger relationship emerged between ISA and anosodiaphoria rather than with apathy.

CONCLUSIONS

These initial findings provide support that PCRS scale can be adapted to measure anosodiaphoria as well as ISA. The findings reveal a stronger correlation between this measure of anosodiaphoria and ISA compared with the correlation of apathy to ISA. The present method for measuring anosodiaphoria takes into account the actual levels of patients' functioning.

Conceptualization of self-awareness in adults with acquired brain injury: A qualitative systematic review

Self-awareness is an important consideration in cognitive rehabilitation for clinicians working with individuals following acquired brain injury (ABI), with impaired self-awareness linked to poor outcomes. To appropriately target assessment and intervention for self-awareness, its theoretical foundation and definition must be considered. The aim was to identify the definitions, theoretical models and conceptual frameworks of self-awareness in adults with ABI, and how self-awareness is conceptualized within those models. A qualitative systematic review was completed using search terms related to descriptions of models/frameworks, ABI and self-awareness. Data were analysed by narrative synthesis. Thirty-five papers were included in the review. Within these, 13 models, 12 conceptual frameworks and 2 theories were described. The main themes and subthemes conceptualized in the synthesis were: Clinical presentation of self-awareness (classifications and dimensions of self-awareness), development of self-awareness (knowledge, feedback mechanisms, temporal aspects, self-evaluation, enablers, barriers), understanding (dys)function (cognitive processing mechanisms, neurological foundations, causal factors), and practice guidance (assessment and intervention). This review identified an extensive theoretical basis to support conceptualization of self-awareness following ABI, underpinned by a distinction between intellectual awareness, on-line awareness, and psychological denial. Clinical application of an evaluation process that includes these elements would be beneficial to inform the rehabilitation process.

Measuring domain-specific deficits in self-awareness in children and adolescents with acquired brain injury: Component analysis of the Paediatric Awareness Questionnaire

Self-awareness has been found to vary across different functional domains for adults with acquired brain injury (ABI); however, domain-specific self-awareness is yet to be investigated following paediatric ABI. This study aimed to validate the Paediatric Awareness Questionnaire (PAQ) as a multi-domain measure of self-awareness and to investigate domain-specific self-awareness in children with ABI. One hundred and ninety-seven children and adolescents (8-16 years, M = 12.44, SD = 2.62) with mixed causes of ABI (70% with traumatic brain injury) and their parents (n = 197) were recruited through consecutive rehabilitation appointments and completed the PAQ. The 37 items of the parent version of the PAQ were subjected to a principal component analysis with varimax rotation. A five-component solution (29 items) explained 64% of the variance in the PAQ items. Components revealed five domains of self-awareness: socio-emotional functioning, activities of daily living (ADLs), cognition, physical functioning, and communication. Internal consistency of the components ranged from acceptable to excellent (α = .70-.95). The analysis identified that children had poorer self-awareness of cognitive functioning than socio-emotional functioning, ADLs, and communication skills. Overall, the findings identify five components (i.e., functional domains) of self-awareness and provide some support that self-awareness varies across domains following paediatric ABI.

Effects of a Multi-Component Training Program on Healthy Older Adults' Prospective Memory Performance: Assessing Change Over Time

Prospective Memory (PM) is a cognitive function affected by aging. PM is the memory of future intentions and is significantly involved in everyday life, especially among older adults. Nevertheless, there are a few studies focused on PM training among healthy older adults and these studies did not report the optimal duration of training regarding improving PM performance among older adults. The present study aimed to determine the effective duration for training PM performance among healthy older adults. The current study was a randomized, controlled, single-blind, within-participants crossover trial including a training program with a duration of 12 h. The sample of 25 older adults aged 55 to 74 years recruited from the active members of the University of the Third Age (U3A), Kuala Lumpur/Selangor, their family members, and friends. The study design ensured some participants would receive the training after baseline while others would wait for 6 weeks after the baseline before receiving the training. All participants were evaluated five times: at baseline, 6, 12, 16, and at 24 weeks post-baseline. Moreover, the training program ensured all participants were assessed after each training session. The minimum number of hours to achieve training effects for this multi-component training program was eight. Results supported the efficacy of the training program in improving PM performance among healthy older adults. Also, the optimal duration for the multicomponent training program on PM performance among healthy older adults was obtained. This trial is registered at isrctn.com (#ISRCTN57600070).

The experience and acceptability of smartphone reminder app training for people with acquired brain injury: a mixed methods study

Smartphones are useful compensatory memory aids, yet training on how to use them is seldom offered as part of rehabilitation for acquired brain injuries (ABIs). We aimed to explore the experience and acceptability of a smartphone training intervention in 26 people with ABI who participated in a pilot randomized controlled trial comparing three skills training approaches. Participants completed questionnaire ratings and a semi-structured interview, six weeks post-training. Most participants rated the training as enjoyable (80.8%) and reasonable in duration (88.5%). Others reported that more than one training session was needed to learn the app (34.6%). Five themes were identified from qualitative data through thematic analysis: (1) Attitudes and pre-existing factors, (2) Experiencing the intervention, (3) Tailoring the intervention to the individual, (4) Facilitators and barriers to implementation and (5) Enhancing smartphone use in everyday life. These themes were juxtaposed with a theoretical framework of acceptability, which indicated that some elements (e.g., having a structured session and a supportive trainer) contributed to the acceptability of the intervention by minimizing training burden and increasing self-efficacy. Tailoring the training to the individual's technological skills and lifestyle, providing post-training resources and involving family members were identified as factors that could improve intervention acceptability.

Awareness of deficit following traumatic brain injury: A systematic review of current methods of assessment

Background: Awareness of deficit plays an important role in adjustment following a brain injury and has been noted to impact on engagement with and outcome of rehabilitation. However, there are challenges associated with the assessment of awareness. Aim: To systematically review all instruments used to assess intellectual awareness of deficits following Traumatic Brain Injury (TBI) in adults, and evaluate instrument characteristics (e.g., the format and focus of measures of awareness) and assessment methods adopted. Results: Thirty-four studies, all rated as fair to good quality, were identified and within these twenty-three different assessment tools were adopted. The most common method of assessment was patient-proxy discrepancy, with three frequently used instruments employed in a total of 22 of the 34 studies. Across studies, variability was noted regarding the type of assessment method dependent on various sample demographics (e.g., age of sample) and injury characteristics (e.g., time post injury). Conclusions: There is no consensus on the preferred instrument to assess intellectual awareness of deficits after TBI. Continued instrument development should attempt to incorporate multiple perspectives and assessment should take into account demographic and injury-related factors. An insightful avenue for future research would be to determine which factors are likely to impact awareness measurement.

Insight into memory and functional abilities in individuals with amnestic mild cognitive impairment

OBJECTIVE

Accurate insight into one's abilities facilitates engagement in rehabilitation and implementation of compensatory strategies. In this study, self-awareness, self-monitoring, and a new self-updating construct of insight were examined in amnestic mild cognitive impairment (aMCI).

METHOD

Individuals with aMCI and healthy older adults (HOAs) completed a list-learning task in a laboratory setting, and a naturalistic task of everyday functioning in a campus apartment along with other standardized neuropsychological tests. Participants made predictions about performance on the memory and functional tasks prior to task experience (self-awareness), immediately after task experience (self-monitoring), and after a delay (self-updating).

RESULTS

Individuals with aMCI performed more poorly than HOAs on the memory task and other neuropsychological tests but not the functional task. For both the memory and functional task, performance predictions and prediction accuracy measures revealed that the aMCI group exhibited intact self-awareness, self-monitoring, and self-updating. Prediction accuracy measures showed some association with an executive composite but not a memory composite.

DISCUSSION

Participants with aMCI demonstrated intact self-awareness, self-monitoring, and self-updating for a memory and functional task despite exhibiting poorer performance on neurocognitive tests compared to HOAs. These findings suggest that, even as memory in aMCI degrades, executive abilities may help sustain insight into difficulties, enabling adoption of cognitive strategies to support difficulties.

Evaluation of an occupation-based metacognitive intervention targeting awareness, executive function and goal-related outcomes after traumatic brain injury using single-case experimental design methodology

Self-awareness is commonly impaired after traumatic brain injury and impacts on rehabilitation engagement and community re-integration outcomes. Interventions which incorporate metacognitive strategy instruction have the potential to improve rehabilitation engagement and outcomes. This study aimed to determine whether an occupation-based intervention incorporating metacognitive strategy instruction resulted in goal achievement and improved online awareness and executive function performance during goal-related tasks. A single-case experimental design using a multiple-baseline design across behaviours was used with two participants with severe traumatic brain injury to evaluate the effectiveness of the 6-week intervention. Repeated measures of goal-related performance, percentage of self-corrected errors and executive function were made via independent analysis of video footage and documentation logs. Data analysis involved 2SD bandwidth analysis and overlap data, reliable change index and evaluation of goal achievement across phases. There were improvements in self-corrected errors for one participant, which were maintained. Significant reductions in anxiety (RCI = ±5.98) were evident for both participants, with a significant reduction in stress (RCI = ±7.05) for one participant following the intervention. The occupation-based intervention incorporating metacognitive strategy instruction led to improvements compared to baseline performance in some targeted goals, online awareness and executive function performance during goal-related tasks and reduced stress and anxiety.

A comparison of systematic instruction, error-based learning and trial and error to train the use of smartphone memory apps after acquired brain injury: A three-armed phase II randomised controlled trial study protocol

Background:

The uptake of smartphones as external compensatory memory aids following an acquired brain injury (ABI) in rehabilitation settings is low. Potential reasons for this include professionals not having evidence-based guidelines regarding the best methods to train smartphone use and prospective users not being familiar with technology and/or having memory and learning difficulties. This paper describes the protocol of a study that aims to compare the efficacy of three training methods (Systematic Instruction, Error-based Learning and Trial-and-Error) for training the use of a smartphone reminder app, in people with ABI presenting with memory complaints.

Methods/Design:

This is a three-armed, assessor-blinded, Phase II randomised controlled trial. The estimated sample size is 51 participants aged >18 years, who are equally randomised to one of the three training groups. They are seen across four sessions: one to conduct baseline measures; one for training the use of an app and two for follow-up assessments (1- and 6-weeks post-training). The main outcome measure is proficiency of performance in tasks with the trained app. Secondary outcomes include generalisation of skills to other apps, number of errors committed while attempting the tasks, frequency of smartphone usage in general and as a memory aid and confidence in smartphone use and memory self-efficacy. Outcome measures are collected by an independent blinded assessor. Proficiency of performance, generalisation of skills and error commission are measured immediately post-training and at the two follow-up sessions. The other secondary measures are taken pre-intervention and at the two follow-up sessions.

Discussion:

This study will provide initial evidence regarding the efficacy of three different methods to train ABI survivors with memory difficulties in how to use smartphone apps as compensatory memory aids. The results could inform a larger Phase III trial and advance knowledge concerning the advantages or disadvantages of using error-reducing and trial-and-error techniques. Further, the findings could determine the potential of error-based learning as an emerging training method for people with memory impairment within rehabilitation.

Speech-Language Pathology Practices for Adults With Right Hemisphere Stroke: What Are We Missing?

Purpose Limited evidence exists to guide the assessment and treatment of cognitive-communication disorders associated with right hemisphere stroke. The purpose of this study was to obtain information about speech-language pathologists' (SLPs') clinical practices and decision making for this population to understand what practices are being used and identify gaps in clinical practice. Method A survey was distributed via online ASHA Communities for the Special Interest Groups and other social media platforms. Respondents included 143 SLPs from across the United States representing 3-50 years of experience and a wide range of practice settings. Survey questions probed assessment practices including how tests are selected, what tests are used to diagnose specific deficits, and how confident SLPs were in their diagnoses. Treatment decisions were queried for a small set of disorders. Results SLPs routinely assess cognitive disorders using standardized tests. Communication disorders are less likely to be formally assessed. Three core right cerebral hemisphere deficits-anosognosia, aprosodia, and pragmatic deficits-are either not assessed or assessed only through observation by 80% of SLPs. Evidence-based treatments are commonly used for disorders of attention, awareness, and aprosodia. Conclusion Communication disorders are less likely to be formally assessed than cognitive disorders, creating a critical gap in care that cannot be filled by other allied health professionals. Suggestions for free or low-cost resources for evaluating pragmatics, prosody, and awareness are provided to aid SLPs in filling this gap. Supplemental Material https://doi.org/10.23641/asha.12159597.

Cognitive predictors of self-awareness in patients with acquired brain injury along neuropsychological rehabilitation

Previous research has identified a critical role of executive function and memory in self-awareness, a metacognitive capacity often impaired in acquired brain injury. Through this observational study, we aimed to explore the effect of cognitive rehabilitation on the predictive value of these variables, as also whether any of them can predict the level of self-awareness once the cognitive rehabilitation is completed. 69 patients underwent a neuropsychological assessment, including self-awareness, at admission to and discharge from a cognitive rehabilitation process. Regression analysis was performed at these two moments and a third one was conducted to evaluate whether any of the variables at admission predicted the level of self-awareness at discharge. Verbal fluency was found to be the best predictor of self-awareness, both at admission and discharge. In addition, inhibition and cognitive flexibility, as well as episodic memory, appeared as significant predictors of post-rehabilitation self-awareness. Finally, verbal fluency was revealed as the unique pre-rehabilitation predictor of subsequent level of self-awareness following rehabilitation. While post-acute self-awareness is predicted by non-specific executive measures, the cognitive improvement putatively induced by neuropsychological rehabilitation reveals the contribution of more specific executive and memory functions. Importantly, pre-rehabilitation verbal fluency scores predicted the level of self-awareness after cognitive rehabilitation.

Comparing different tests to detect early manifestation of prospective memory decline in aging

Objective: Prospective memory (PM) is the ability to remember to perform future intentions. Previous studies have demonstrated that, compared to a younger cohort, healthy older adults have impairments in PM. Considering the importance of early detection of age-related PM decline, the present study aims to compare the performance of healthy older adults using three well-known PM tests commonly used in clinical settings.Method: In the present study, we tested 70 older adults (65-95 years old) using the Cambridge Prospective Memory Test (CAMPROMPT), the Memory for Intentions Screening Test (MIST) and the Royal Prince Alfred Prospective Memory Test (RPA-ProMem). In order to compare performance across tests and the interaction between age and cues, we performed a linear mixed model with random intercept and random slopes. Moreover, additional mixed models with random intercept were run for analyzing the additional information provided by MIST and RPA-ProMem regarding delay responses, response modality effects and type of errors committed.Results: Our data showed a drop in PM performance as age increased detected by all three tests. Furthermore, CAMPROMPT was the most sensitive test to identify differences in PM for event-and time-based cues, at least for participants with 65-77 years old. When data were analyzed in term of delay responses, participants were more accurate for 2 min delay (MIST) and 30 in delay (RPA-ProMem). Participants were less accurate when response modality was "verbal" compared to "action" (MIST) and made more PM errors as age increased.Conclusions: Overall, the study provides important information regarding age-related PM decline and can help researchers as well as clinicians in deciding the preferred test to evaluate PM performance.

Metacognitive knowledge and functional outcomes in adults with acquired brain injury: A meta-analysis

Pronounced difficulties in functional outcomes often follow acquired brain injury (ABI), and may be due, in part, to deficits in metacognitive knowledge (being unaware of one's cognitive strengths and limitations). A meta-analytic review of the literature investigating the relationship between metacognitive knowledge and functional outcomes in ABI is timely, particularly given the presence of apparently inconsistent findings. Twenty-two articles revealed two distinct methods of measuring metacognitive knowledge: (1) absolute (the degree of inaccurate self-appraisal regardless of whether the error tends towards under- or over-confident estimations) and (2) relative (the degree and the direction of the inaccuracy) discrepancy. Separate meta-analyses were conducted for absolute and relative discrepancy studies to assess the relationship between metacognitive knowledge and functional outcomes (affect-related quality of life, family and community integration, and work outcomes). The pattern of results found suggested that better metacognitive knowledge is related to better overall functional outcomes, but the relationship may differ depending on the outcome domain. These findings generally support the importance of focusing on metacognitive knowledge to improve outcomes following ABI. Nonetheless, the relatively small effect sizes observed suggest that other predictors of functional outcome should be investigated, including other subdomains of metacognition.

Psychosocial Outcomes of Severe Traumatic Brain Injury in Relation to Discourse Recovery: A Longitudinal Study up to 1 Year Post-Injury

Purpose The interrelationship between psychosocial outcomes and discourse after severe traumatic brain injury remains largely unknown. This study examines outcomes relating to work, relationships, and independence within the context of discourse recovery across the 1st year post-injury. Method An inception cohort comprising 57 participants with severe traumatic brain injury was assessed at 3, 6, 9, and 12 months post-injury. Outcomes were measured with the Sydney Psychosocial Reintegration Scale-2 (Tate et al., 2012; Tate, Simpson, Loo, & Lane-Brown, 2011), and discourse was evaluated with Main Concept Analysis of a narrative retell. Correlation and linear regression analyses were utilized. Results Significant correlations were found between psychosocial outcomes reported by relatives and discourse performance across the 1st year. The 6-month discourse scores significantly predicted the 12-month psychosocial outcomes reported by relatives. Initial discourse severity and recovery pattern also informed outcomes. Conclusions Discourse disorders have a strong relationship with everyday outcomes relating to work, relationships, and independence as reported by relatives. Six months post-injury is a beneficial time for assessment, education, and service planning. Age, years of education, and aphasia may mediate recovery and outcomes. A clinical decision tree is offered to support goal setting. Supplemental Material https://doi.org/10.23641/asha.9755444.

Informant Report of Financial Capacity for Individuals With Chronic Acquired Brain Injury: An Assessment of Informant Accuracy

OBJECTIVE

Primarily, to investigate the association between informant report and objective performance on specific financial capacity (FC) tasks by adults with chronic, moderate to severe acquired brain injury, and to examine the nature of misestimates by the informants.

DESIGN

Cross-sectional design.

SETTING

A postacute, community-based rehabilitation center.

PARTICIPANTS

Data were obtained from 22 chronic acquired brain injury (CABI) adults, mean age of 46.6 years (SD = 8.67), mean years of education of 13.45 years (SD = 2.15), with moderate to severe acquired brain injury (86% had traumatic brain injury), with a mean postinjury period of 17.14 years (SD = 9.5). Whereas the CABI adults completed the Financial Competence Assessment Inventory interview-a combination of self-report and performance-based assessment, 22 informants completed a specifically designed parallel version of the interview.

RESULTS

Pearson correlations and 1-sample t tests based on the discrepancy scores between informant report and CABI group's performance were used. The CABI group's performance was not associated with its informant's perceptions. One-sample t tests revealed that informants both underestimated and overestimated CABI group's performance.

CONCLUSIONS

Results indicate lack of correspondence between self- and informant ratings. Further investigation revealed that misestimations by informants occurred in contrary directions with CABI adults' performance being inaccurately rated. These findings raise critical issues related to assuming that the informant report can be used as a "gold standard" for collecting functional data related to financial management, and the idea that obtaining objective data on financial tasks may represent a more valid method of assessing financial competency in adults with brain injury.

Prevalence of Cognitive Impairment and Association With Survival Among Older Patients With Hematologic Cancers

Importance

As the population ages, cognitive impairment has promised to become increasingly common among patients with cancer. Little is known about how specific domains of cognitive impairment may be associated with survival among older patients with hematologic cancers.

Objective

To determine the prevalence of domain-specific cognitive impairment and its association with overall survival among older patients with blood cancer.

Design, Setting, and Participants

This prospective observational cohort study included all patients 75 years and older who presented for initial consultation in the leukemia, myeloma, or lymphoma clinics of a large tertiary hospital in Boston, Massachusetts, from February 1, 2015, to March 31, 2017. Patients underwent screening for frailty and cognitive dysfunction and were followed up for survival.

Exposures

The Clock-in-the-Box (CIB) test was used to screen for executive dysfunction. A 5-word delayed recall test was used to screen for impairment in working memory. The Fried frailty phenotype and Rockwood cumulative deficit model of frailty were also assessed to characterize participants as robust, prefrail, or frail.

Results

Among 420 consecutive patients approached, 360 (85.7%) agreed to undergo frailty assessment (232 men [64.4%] and 128 women [35.6%]; mean [SD] age, 79.8 [3.9] years), and 341 of those (94.7%) completed both cognitive screening tests. One hundred twenty-seven patients (35.3%) had probable executive dysfunction on the CIB, and 62 (17.2%) had probable impairment in working memory on the 5-word delayed recall. Impairment in either domain was modestly correlated with the Fried frailty phenotype (CIB, ρ = 0.177; delayed recall, ρ = 0.170; P = .01 for both), and many phenotypically robust patients also had probable cognitive impairment (24 of 104 [23.1%] on CIB and 9 of 104 [8.7%] on delayed recall). Patients with impaired working memory had worse median survival (10.9 [SD, 12.9] vs 12.2 [SD, 14.7] months; log-rank P < .001), including when stratified by indolent cancer (log-rank P = .01) and aggressive cancer (P < .001) and in multivariate analysis when adjusting for age, comorbidities, and disease aggressiveness (odds ratio, 0.26; 95% CI, 0.13-0.50). Impaired working memory was also associated with worse survival for those undergoing intensive treatment (log-rank P < .001). Executive dysfunction was associated with worse survival only among patients who underwent intensive treatment (log-rank P = .03).

Conclusions and Relevance

These data suggest that domains of cognitive dysfunction may be prevalent in older patients with blood cancer and may have differential predictive value for survival. Targeted interventions are needed for this vulnerable patient population.

Application of an Intensive Rehabilitation Program After Very Late Recovery of Consciousness: A Single-Case Neurorehabilitation and Neuroimaging Study

Late recovery of consciousness in vegetative state is considered as an exceptional outcome and has been reported prevalently in patients who suffered a traumatic brain injury. In these patients, the benefits of prolonging the rehabilitation, aimed at the recovery of autonomy in basic everyday activities, has been demonstrated. Here, we describe the application of an intensive multi-professional rehabilitation program carried out on a young female patient, with exceptionally late recovery of consciousness, specifically, after 7 years of vegetative state due to severe brain hemorrhage. Neuropsychological and functional assessment was conducted before and after the end of the rehabilitation program. In addition, functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI)-based probabilistic tractography were performed. Two follow-up neuropsychological and functional assessments were also conducted 6 and 29 months after the conclusion of the program. Functional results showed an improvement, maintained over time, in walking with assistance, cognitive efficiency, visual acuity and visual field, dysarthria, and execution of activities of daily living. Moreover, functional and structural magnetic resonance imaging (MRI) data documented the existence of preserved neural networks involved in sensory, motor, and linguistic tasks, which in all likelihood support the recovery process. This report suggests the possibility of undertaking an intensive rehabilitation program in patients who remain for long periods in altered states of consciousness, in spite of early negative prognosis.

"To whom did I tell that information?": Relationship between destination memory and theory of mind in traumatic brain injury

Traumatic Brain Injury (TBI) has been widely associated with impairment of social cognition. We therefore investigated the relationship between the ability to infer and predict other's mental states (i.e., Theory of Mind, ToM) and the ability to remember to whom one has sent information (i.e., destination memory). We invited patients with TBI and control subjects, on a destination memory task, to tell proverbs to pictures of celebrities, so as to remember to which celebrity they had previously told the proverbs. Participants also performed affective (i.e., Reading the Mind in the Eyes) and cognitive (i.e., the false belief) tests of ToM. Results demonstrated lower destination memory, affective, and cognitive ToM performance in TBI patients than in control subjects. Critically, analysis demonstrated significant positive correlations between destination memory and first order and second cognitive order ToM in patients with TBI, but no significant correlations between destination memory and affective ToM in these patients. Our results demonstrate a relationship between difficulties of TBI patients to infer and predict cognitive states of interlocutors and difficulties to remember to which interlocutor information has been told.

Balance in chronic traumatic brain injury: correlations between clinical measures and a self-report measure

OBJECTIVE

To assess associations among commonly used self-report and clinical measures of balance in chronic TBI.

DESIGN

Cross-sectional analysis of balance in a convenience sample of individuals at least one year post TBI.

MAIN OUTCOME MEASURES

Activities-Specific Balance Confidence Scale (ABC) (self-reported balance impairment), Community Balance and Mobility Scale (CB&M) (clinical measure validated in TBI), and Balance Evaluation Systems Test (BESTest) (clinical measure not validated in TBI).

METHODS

Fifty-nine individuals (64% male, mean age 48.2 years) ambulating independently within the home participated in testing. Pearson correlation coefficients were used to quantify the direction and magnitude of the relationships among the three balance impairment measures.

RESULTS

A significant positive correlation was noted between the ABC and CB&M (r = 0.42, p = 0.0008), between the ABC and BESTest (r = 0.46, p = 0.0002), and between the CB&M and BESTest (r = 0.86, p < 0.0001).

CONCLUSIONS

This is the first study we are aware of in the chronic moderate to severe TBI population directly comparing patient's self-reported balance impairment with clinical measures. Positive correlations were found between the self-report measure and both clinical measures. Overall, individuals with chronic TBI tend to self-report less impaired balance than clinical measures indicate. These results provide preliminary evidence to support the need for validation of the BESTest in this population.

ABBREVIATIONS

ABC: Activities-specific balance confidence scale; BESTest: balance evaluation systems test; BOS: base of support; COM: center of mass; CB&M: community balance and mobility scale; CI: confidence interval; IQR: interquartile range; PTs: physical therapists; SD: standard deviation; SE: standard error; TBI: traumatic brain injury.

Self-awareness deficits associated with lower treatment motivation in cocaine addiction

BACKGROUND

Individuals with cocaine use disorder (CUD) often display behaviours that are paradoxically misaligned with their situation. Typical examples include poor treatment motivation and inconsistent self-reported craving. These behaviours may reflect impairments in the awareness of one's own behaviour.

OBJECTIVES

We examined whether impaired self-awareness of addiction-related frontostriatal dysfunction (i.e., symptoms of apathy, disinhibition, and executive dysfunction) was associated with treatment motivation and craving.

METHODS

Sixty-five outpatients with CUD (57 male) and their informants (those who knew the patient well) completed parallel self and informant versions of the Frontal Systems Behaviour Scale. Self-awareness was indexed through the discrepancy between self and informant scores in the three sub-scales; apathy, disinhibition and executive dysfunction. The University Rhode Island Change Assessment Scale assessed treatment motivation. Self-reported craving was assessed using a visual analogue scale. Multiple linear regression models examined associations between self-awareness and treatment motivation and craving, adjusting for sociodemographic factors and lifetime drug use.

RESULTS

We found an inverse relationship between self-awareness of symptoms of disinhibition and treatment motivation maintenance. Although impaired awareness of disinhibition was also correlated with craving, this association was not significant after adjusting for sociodemographic factors and drug use. The apathy and executive dysfunction awareness scores were not associated with treatment motivation or craving.

CONCLUSION

We show that people with lower insight into their disinhibition problems (e.g., impulsivity, mood instability) have more problems maintaining motivation when initiating treatment. Findings suggest that self-awareness interventions could be useful to prevent premature treatment dropout and improve addiction treatment outcomes.

Assessment of Patient Self-awareness and Related Neural Correlates in Frontotemporal Dementia and Corticobasal Syndrome

OBJECTIVE

We compared two different methods of assessing self-awareness (clinician-rated vs. self- and caregiver report) in participants with neurodegenerative conditions. Additionally, we examined the contribution of memory dysfunction to assessment of self-awareness.

METHOD

Sixty-seven participants with various neurodegenerative disorders participated in this study. Data were collected on brain volume, neurocognitive function, demographic characteristics, and two measures of patient self-awareness, defined as (1) the discrepancy between patient and caregiver ratings of dysexecutive syndrome and (2) clinician-observed rating of patient insight. Penalized regression with best subset variable selection and 10-fold cross-validation was used to evaluate three neurocognitive frameworks: self-regulation, language, and perspective-taking, each predicting the results from the two methods of self-awareness measurement.

RESULTS

The self-regulation framework was more robustly predictive for both the clinician rating and discrepancy method than language or perspective-taking. Frameworks in which the clinician rating was the criterion were more robust than those with the discrepancy method as criterion. When a measure of memory functioning was added to the framework, there was no appreciable improvement in the prediction of self-awareness.

CONCLUSIONS

A self-regulation neurocognitive framework, consisting of regions of interest and neuropsychological test scores, was more effective in understanding patient self-awareness than perspective-taking or language frameworks. Compared to the discrepancy method, a clinician rating of self-awareness was more robustly associated with relevant clinical variables of regional brain volume and neuropsychological performance, suggesting it may be a useful measure to aid clinical diagnosis.

Examining the relationship and clinical management between traumatic brain injury and pain in military and civilian populations

In this review, we discuss the comorbidity of traumatic brain injury (TBI) and pain among civilians and military members, the common causes of pain resulting from TBI, and offer insight about the therapeutic management of TBI symptoms and pain. Traumatic brain injury (TBI) is a debilitating health problem and one of the most common post-TBI symptoms is pain, which can contribute to psychological issues such as Post-traumatic stress disorder (PTSD) and depression. Headache pain appears to be the most common type of pain that results from TBI, yet pain can also be more widespread. Managing TBI symptoms and pain simultaneously is difficult because extensive randomized control and clinical studies assessing the effectiveness of therapeutic approaches are lacking. Pharmacological agents such as antidepressants and Triptans and nonpharmacological therapies such as cognitive rehabilitation and physical therapies are commonly used yet it is unknown how effective these therapies are in the long-term. A combination of pharmacological and non-pharmacological therapies is often more effective for managing TBI symptoms and pain than either treatment alone. However, future research is needed to determine the most therapeutic approaches for managing the comorbidity of pain and TBI symptoms in the long term. This review offers suggestions for such future studies.

Evaluating an intervention to increase meaningful activity after severe traumatic brain injury: A single-case experimental design with direct inter-subject and systematic replications

Severe traumatic brain injury (sTBI) often results in significant morbidity, with fewer than 50% returning to work and only a minority resuming leisure and social activity. Yet few effective interventions are available for non-vocational activity. The aim of the study was to develop a new goal-directed intervention, the Programme for Engagement, Participation and Activities (PEPA), and evaluate its effect. The research design was a multiple-baseline design across behaviours, with direct inter-subject and systematic replications. Seven participants with sTBI, neurobehavioural impairment including apathy, inability to work, and limited leisure/social activities were categorised into two groups. Group 1 (n = 4) had cognitive impairments but were functionally independent. Systematic replication was conducted in a further three participants (group 2) with major neurobehavioural impairments and functional disability. Generalisation measures evaluated other life domains in group 1 participants (e.g., mood, community participation). Results of the weighted average Tau-U across the tiers was significant for six out of seven participants, with large effect sizes (≥.64) for five participants. Generalisation effects extended to other domains of life. The PEPA thus shows promise as an effective intervention to increase non-vocational activity and improve mental health outcomes in people with neurobehavioural disability after sTBI. These results add to the evidence for the effectiveness of goal-directed interventions.

Effectiveness and feasibility of Socratic feedback to increase awareness of deficits in patients with acquired brain injury: Four single-case experimental design (SCED) studies

OBJECTIVE

To investigate the effectiveness and feasibility of a Socratic feedback programme to improve awareness of deficits in patients with acquired brain injury (ABI).

SETTING

Rehabilitation centre.

PARTICIPANTS

Four patients with ABI with awareness problems.

DESIGN

A series of single-case experimental design studies with random intervention starting points (A-B + maintenance design).

MAIN MEASURES

Rate of trainer-feedback and self-control behaviour on everyday tasks, patient competency rating scale (PCRS), self-regulating skills interview (SRSI), hospital anxiety and depression scale.

RESULTS

All patients needed less trainer feedback, the change was significant in 3 out of 4. One patient increased in overt self-corrective behaviour. SRSI performance increased in all patients (medium to strong effect size), and PCRS performance increased in two patients (medium and strong effect size). Mood and anxiety levels were elevated in one patient at the beginning of the training and decreased to normal levels at the end of the training. The feasibility of the programme was scored 9 out of 10.

CONCLUSIONS

The Socratic feedback method is a promising intervention for improving awareness of deficits in patients with ABI. Controlled studies with larger populations are needed to draw more solid conclusions about the effect of this method.

A review of prospective memory in individuals with acquired brain injury

OBJECTIVE

Prospective memory (PM) deficits have emerged as an important predictor of difficulty in daily life for individuals with acquired brain injury (BI). This review examines the variables that have been found to influence PM performance in this population. In addition, current methods of assessment are reviewed with a focus on clinical measures. Finally, cognitive rehabilitation therapies are reviewed, including compensatory, restorative and metacognitive approaches.

METHOD

Preferred reporting items for systematic reviews and meta-analyses guidelines were used to identify studies. Studies were added that were identified from the reference lists of these.

RESULTS

Research has begun to elucidate the contributing variables to PM deficits after BI, such as attention, executive function and retrospective memory components. Imaging studies have identified prefrontal deficits, especially in the region of BA10 as contributing to these deficits. There are now several clinical measures available with good psychometric properties. Rehabilitation techniques have mostly focused on compensatory strategies, but, in addition, some restorative and metacognitive approaches have shown preliminary promise.

CONCLUSIONS

PM deficits are a common and important deficit after BI. Clinical evaluation is recommended and further understanding of rehabilitation techniques is needed.