Depression, apathy and impaired self-awareness following severe traumatic brain injury: a preliminary investigation

Factors associated with self-awareness impairment in an inpatient brain injury rehabilitation cohort

BACKGROUND

Self-awareness impairment is common following acquired brain injury and can impact rehabilitation outcomes. Knowledge of factors associated with impaired self-awareness may assist with rehabilitation planning.

OBJECTIVES

To identify factors associated with self-awareness and determine predictors of self-awareness impairment for adults with traumatic brain injury (TBI) and stroke.

DESIGN AND METHODS

A retrospective cohort study of rehabilitation inpatients was conducted by medical record audit. Self-awareness was measured using the Self-awareness of Deficits Interview (SADI). Relationships between SADI scores and demographic and clinical variables were identified with non-parametric statistics. Predictors of SADI scores were identified using ordinal regression analyses for TBI and stroke groups.

RESULTS

Participants were 149 adults (18-70 years) with TBI (n = 110) and stroke (n = 39). For TBI, longer post-traumatic amnesia (PTA), lower functional cognition/communication, and behaviors of concern (BoC) were significantly associated with higher SADI scores (i.e. impaired self-awareness). For stroke, lower functional cognition/communication and motor scores were associated with higher SADI scores. Impaired self-awareness was predicted by PTA duration, acute length of stay and presence of BoC for the TBI group, and by functional cognition/communication for the stroke group.

CONCLUSION

Different factors were associated with impaired self-awareness for individuals with TBI and stroke during inpatient rehabilitation.

The Cognitive Awareness Scale for Basic and Instrumental activities of daily living to measure self-awareness after acquired brain injury: Preliminary evidence of its validity

Objective: There is a crucial need for reliable tools to measure impaired self-awareness (ISA) in patients with acquired brain injury (ABI) across cognitive-functional domains. The aim of this study was to assess the psychometric properties of the Cog-Awareness ADL Scale, which is a novel self-proxy discrepancy method for measuring ISA in both basic and instrumental activities of daily living. Methods: This multicenter study included 54 patients (no-low ISA n = 33; severe ISA, n = 21) from four outpatient rehabilitation units in Málaga-Granada, Spain, and 51 healthy controls. The participants and proxy raters completed the Cog-Awareness ADL Scale and the Patient Competency Rating Scale (PCRS). Agreement between both scales was assessed using Spearman's correlations and the Bland-Altman plot. Group comparisons were made on measures of SA, cognitive abilities and demographic variables. Sensitivity and specificity were analysed by ROC curve analysis. Results: Convergent validity was supported by strong correlations with the PCRS and its subscales (rho's ranging from 0.51 to 0.80, p < 0.01 for all). The Bland-Altman plot confirmed measurement agreement (only 3.70% of the scores were outside the 95% limits). External validity was demonstrated by effectively discriminating between healthy controls and ABI patients with no-low and severe ISA on each discrepancy index while controlling for cognitive/demographic variables. The Cog-Awareness ADL Scale showed optimal diagnostic accuracy (AUC = 0.95, sensitivity = 0.90, specificity = 0.90). Conclusions: The Cog-Awareness ADL Scale proved to be a feasible, valid, and clinical tool to assess ISA across different cognitive-functional domains, in Spanish ABI-patients.

Neurobehavioral Symptom Profiles for the Behavioral Assessment Screening Tool in Chronic Traumatic Brain Injury

OBJECTIVE

To identify neurobehavioral symptom profiles among persons with chronic traumatic brain injury (TBI) using the Behavioral Assessment Screening Tool (BAST) and to consider participant characteristics that differ between profile groups.

SETTING

Community.

PARTICIPANTS

Participants (n = 615) were English-speaking adults (≥18) and had a self-reported history of at least one TBI of any severity.

DESIGN

Secondary analysis of cross-sectional data.

MAIN MEASURES

The BAST measures neurobehavioral symptoms in the domains of Negative Affect, Fatigue, Executive Dysfunction, Impulsivity, and Substance Misuse.

RESULTS

Using latent profile analysis (LPA), we identified 3 different neurobehavioral profiles. Overall symptom frequency and differences in the pattern of symptom frequency across domains differentiated the profile groups. Average domain scores differed significantly across the profiles (P < .001) for all domains except Fatigue (P = .076). Those in profile 3 (High-Risk group) reported the most frequent symptoms across all domains (similar Negative Affect frequency as profile 1). Substance Misuse was especially high in this group. Compared to profile 2 (High Negative Affect group), participants in profile 1 (Moderate-Risk group) endorsed significantly more frequent (and more variable) symptoms across all BAST domains, particularly Impulsivity and Substance Misuse. Participants in profile 2 endorsed the least frequent symptoms across all domains. Demographic comparison showed that groups differed based on gender, age, and injury severity (mild vs moderate-severe), with profile 3 composed of the most men and the most persons in early adulthood, and profile 2 composed of the most women and those with mild TBI.

CONCLUSIONS

We differentiated 3 neurobehavioral symptom profiles among persons with chronic TBI and determined differences in sociodemographic factors between the groups. Future research should focus on validating these profiles in another sample of individuals with chronic TBI. Characterizing persons according to multidimensional symptom profiles could allow for more tailored approaches to predict and prevent long-term negative outcomes.

Self-awareness and quality of relationships after acquired brain injury: Systematic review without meta-analysis (SWiM)

BACKGROUND

Relational aspects of self-awareness following Acquired Brain Injury (ABI) are increasingly being recognized. However, research underpinning the nature of the association between self-awareness and quality of relationships has yet to be synthesized.

METHOD

Searches, which were completed between February 2022 and February 2023, consisted of combining terms related to ABI, self-awareness, and quality of relationships. Data were analyzed using the Synthesis Without Meta-Analysis (SWiM) approach.

RESULTS

Associations between self-awareness and relationship quality across eight studies identified for this review differed in direction and significance. A more consistent pattern emerged, however, when studies assessing the quality of specific types of relationships i.e., spousal (N = 1) and therapeutic (N = 3), were compared to studies assessing the quality of a person's broader network of relationships (N = 4). In particular, good awareness was positively associated with the quality of specific relationships (r = 0.66) whereas it was negatively associated with the quality of a person's broader network of relationships (r = -0.35).

CONCLUSION

Results are discussed with consideration given to measures assessing the quality of specific relationships. In particular, such measures may tap into important patterns of interaction between two individuals, such as those related to attunement or communication, which may be valuable preconditions for improving awareness.

Studying lack of awareness of cognitive decline in neurodegenerative diseases requires measures of both anosognosia and denial

The cause(s) of lack of awareness of cognitive decline in neurodegenerative diseases can be multifactorial. Yet neurologically oriented research on anosognosia of cognitive decline almost exclusively assumes that the underlying disturbance of neuro-networks that support various cognitive functions accounts for the reduced self-awareness. Cultural and psychosocial factors, including the person's emotional state, however, can contribute to the underreporting or avoidance of admitting to cognitive impairments in neurodegenerative diseases. Research on the causes of lack of awareness of cognitive decline in neurodegenerative disorders needs to include these variables. We briefly present two case examples of underreporting or "unawareness" of memory difficulties in persons with mild cognitive impairment (MCI) (or minor neurocognitive disorder). One presented with classic anosognosia for memory impairment, while the other initially reported no memory impairment but later admitted to "denying" her memory difficulties secondary to anxiety. Based on these patients' clinical presentations and available research, we suggest three potential screening items that may help identify probable denial of memory impairments when studying anosognosia in MCI.

Components of self-awareness affecting caregiver burden: a long-term follow-up study

OBJECTIVE

Studies utilizing the discrepancy model of the Mayo-Portland Adaptability Inventory-4 (MPAI-4) have commonly used the cognitive and physical domains to estimate self-awareness. This study included other aspects of self-awareness such as awareness of one's social and emotional status and daily functioning to explore their effects on caregiver burden for ABI survivors.

METHODS

We studied 64 patient-caregiver pairs up to 29 years post-discharge from a holistic, milieu-oriented outpatient neurorehabilitation program. Discrepancy scores between ABI survivors' and caregivers' reports on the MPAI-4 subscales (i.e. Abilities, Adjustment, and Participation) and Total Score were used to determine self-awareness. Caregiver burden was measured using the Zarit Burden Interview (ZBI).

RESULTS

Exploratory linear regression analyses revealed that caregiver burden derived from the ZBI was predicted by the discrepancy scores generated from the Abilities (p < 0.0001), Adjustment (p < 0.01), Participation subscales (p = 0.01), and Total Score (p < 0.001), respectively. Among the exploratory models generated, the Total Score model had the highest predictive value (R2 = .33) for caregiver burden.

CONCLUSIONS

Measures of self-awareness should be comprehensive by considering diverse components of self-awareness. Increasing ABI survivors' self-awareness in different domains has the potential to effectively alleviate caregiver burden.

Disinhibited and angry: Investigating the relationship between social disinhibition and the components of aggression following severe TBI

Social disinhibition and aggression share many similarities. But unlike with aggression, research evidence about social disinhibition following severe traumatic brain injury (TBI) is limited and treatments are missing. Establishing the association between aggression and social disinhibition would facilitate a better conceptualization of these disorders. This study aimed to determine the relationship between social disinhibition and aggression following severe TBI.In this case-control study, 25 individuals with severe TBI and 25 control participants completed the Buss-Perry Aggression Questionnaire (BPAQ), Frontal Systems Behaviour Scale (FrSBe), and Social Disinhibition Interview (SDI).Hierarchical multiple regression analyses revealed that, when controlling for covariates, the inclusion of BPAQ Anger in the model led to a 13% increase in proportion of explained variance of social disinhibition (Adjusted R2 increased from .243 to .363, p < .005). BPAQ Anger was not a significant predictor of SDI scores. Similarly, BPAQ Physical aggression scores did not contribute to the prediction of FrSBe Disinhibition or SDI scores.In conclusion, higher levels of self-reported anger (but no other components of aggression) are associated with higher levels of self-reported social disinhibition. While these findings have potential implications for the treatment of social disinhibition, further research into the possible relationship with aggression should be conducted.

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.

Self- and observer ratings of capacity limitations in patients with neurological conditions

OBJECTIVE

The purpose of this study was to compare the self- and observer ratings of capacity limitations in patients with neurological conditions. Research on this topic is relevant for assessing the patients' ability to participate in work and social life and improving collaborative patient-clinician relationships.

METHOD

The self- and observer ratings of capacity limitations in a sample of N = 245 patients with neurological conditions from a rehabilitation facility were compared and assessed using the short rating of activity limitations and participation restrictions in mental disorders according to the International Classification of Functioning, Disability and Health (Mini-ICF-APP) and the equivalent self-rating questionnaire (Mini-ICF-APP-S).

RESULTS

Paired-samples t-tests revealed significant differences between the self- and observer ratings for six out of 13 capacity dimensions. On average, the patients rated the capacity dimensions adherence to regulations, planning and structuring of tasks, professional competency and endurance as significantly less limited, in comparison to the observers (small to medium effect sizes). The self-ratings for limitation of contact with others and self-care were only marginally higher than the observer ratings.

CONCLUSIONS

The findings show that psychological capacity limitations occur in patients with neurological conditions. In clinical practice, limitations in each capacity dimension and discrepancies in patient- and clinician-ratings should be thoroughly assessed. This is especially relevant in patients with neurological conditions who have a potential tendency to underestimate or deny their disability.

Awareness through relationships in individuals undergoing rehabilitation following acquired brain injury

AIM

This cross-sectional study investigated the association between self-awareness and quality of therapeutic relationships following acquired brain injury (ABI) while controlling for the potential impact of cognitive problems. It also aimed to investigate attachment as a potential moderator.

METHOD

83 adults with ABI were recruited alongside a key member of their community neurorehabilitation team. The Scale to Assess Therapeutic Relationships (STAR) was used to measure therapeutic relationship quality and attachment was measured using the Experiences in Close Relationships - Relationship Structure (ECR-RS) questionnaire. Awareness was measured using the Patient Competency Rating Scale (PCRS) and the Mayo-Portland Adaptability Inventory (MPAI-4) provided a measure of cognitive problems. The MPAI-4 also provided an additional measure of awareness.

RESULTS

A significant association between self-awareness and therapeutic relationships was found in some regression models such that higher-quality relationships were associated with better awareness, after controlling for the impact of cognitive problems. Neither childhood parental attachment nor participants' attachment towards their rehabilitation staff were moderators.

CONCLUSION

The observed associations between awareness in clients and therapeutic relationships with rehabilitation staff may have importance for rehabilitation in this context. Results highlight the value of continuing to prioritize the therapeutic relational environment in ABI rehabilitation and research.

Using Machine Learning to Examine Suicidal Ideation After Traumatic Brain Injury: A Traumatic Brain Injury Model Systems National Database Study

OBJECTIVE

The aim of the study was to predict suicidal ideation 1 yr after moderate to severe traumatic brain injury.

DESIGN

This study used a cross-sectional design with data collected through the prospective, longitudinal Traumatic Brain Injury Model Systems network at hospitalization and 1 yr after injury. Participants who completed the Patient Health Questionnaire-9 suicide item at year 1 follow-up ( N = 4328) were included.

RESULTS

A gradient boosting machine algorithm demonstrated the best performance in predicting suicidal ideation 1 yr after traumatic brain injury. Predictors were Patient Health Questionnaire-9 items (except suicidality), Generalized Anxiety Disorder-7 items, and a measure of heavy drinking. Results of the 10-fold cross-validation gradient boosting machine analysis indicated excellent classification performance with an area under the curve of 0.882. Sensitivity was 0.85 and specificity was 0.77. Accuracy was 0.78 (95% confidence interval, 0.77-0.79). Feature importance analyses revealed that depressed mood and guilt were the most important predictors of suicidal ideation, followed by anhedonia, concentration difficulties, and psychomotor disturbance.

CONCLUSIONS

Overall, depression symptoms were most predictive of suicidal ideation. Despite the limited clinical impact of the present findings, machine learning has potential to improve prediction of suicidal behavior, leveraging electronic health record data, to identify individuals at greatest risk, thereby facilitating intervention and optimization of long-term outcomes after traumatic brain injury.

Trichotillomania in Dementia: A Case Report and Literature Review

Introduction: Dementia presents with a variety of behavioral and psychiatric disorders, including a range of psychosis, anxiety, depression, behavioral aggression, and delirium. Case Presentation: This study aimed to report a 74-year-old man showing gradually progressive deterioration in his memory for five years. The patient developed trichotillomania (TTM) subsequent to his dementia. Neuropsychological examination indicated the deficits to be more predominantly in the frontal lobe. Conclusions: This study reviewed the literature on TTM in dementia case reports that had mostly investigated the cases of right-handed men aged > 65 years. TTM Patients with underlying disease had not any improvement. Although there was some heterogeneous evidence for the presence of brain abnormalities in individuals with hair-pulling behavior, no definitive conclusion was drawn. Mild to severe generalized atrophy in the cerebral cortex was observed in the frontal, parietal, temporal, occipital, and cingulate lobes.

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.

The Effect of Dual-Task Motor-Cognitive Training in Adults with Neurological Diseases Who Are at Risk of Falling

Falls are common in patients with neurological diseases and can be very problematic. Recently, there has been an increase in fall prevention research in people with neurological diseases; however, these studies are usually condition-specific (e.g., only MS, PD or stroke). Here, our aim was to evaluate and compare the efficacy of an advanced and innovative dual-task, motor-cognitive rehabilitation program in individuals with different neurological diseases who are at risk of falling. We recruited 95 consecutive adults with neurological diseases who are at risk of falling and divided them into four groups: 31 with cerebrovascular disease (CVD), 20 with Parkinson’s disease (PD), 23 with traumatic brain injury (TBI) and 21 with other neurological diseases (OND). Each patient completed a dual-task, motor-cognitive training program and underwent two test evaluations to assess balance, gait, fear of falling and walking performance at the pre-and post-intervention. We found that our experimental motor-cognitive, dual-task rehabilitation program was an effective method for improving walking balance, gait, walking endurance and speed, and fear of falling, and that it reduced the risk of falls in patients with different neurological diseases. This study presents an alternative approach for people with chronic neurological diseases and provides innovative data for managing this population.

Extracting Apathy From Depression Syndrome in Traumatic Brain Injury by Using a Clustering Method

OBJECTIVE

Depression and apathy are common after traumatic brain injury (TBI), and different intervention strategies are recommended for each. However, a differential diagnosis can be difficult in clinical settings, especially given that apathy is considered to be a symptom of depression. In this study, the investigators aimed to isolate apathy from depression among patients with TBI and to examine whether apathy is exclusively associated with the amount of daily activity, as previously reported in the literature.

METHODS

Eighty-eight patients with chronic TBI completed the Japanese versions of the 21-item Beck Depression Inventory-II (BDI-II) and the Starkstein Apathy Scale (AS). Daily activity was measured with a 24-hour life log. A hierarchical cluster analysis was applied to divide the BDI-II data into separable components, and components' correlations with results of the AS and 24-hour life log scale were evaluated.

RESULTS

The BDI-II and AS revealed that 37 patients (42.0%) had both depression and apathy. BDI-II data were classified into four separate clusters (somatic symptoms, loss of self-worth, affective symptoms, and apathy symptoms). Loss of self-worth and apathy symptoms subscores were significantly positively correlated with total AS score (r=0.32, p=0.002, and r=0.52, p<0.001, respectively). The apathy symptoms subscore was significantly correlated with the amount of daily activity (r=-0.29, p=0.009).

CONCLUSIONS

The findings suggest that the BDI-II can differentiate between apathy and depression among patients with TBI, which is essential when selecting intervention options. Moreover, apathy symptoms predicted patients' real-life daily activity.

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.

Two Ecological Tools for Testing Slowness of Information Processing in Italian Patients with Moderate-to-Severe Traumatic Brain Injury

Slowness of Information Processing (SIP) is frequently experienced after traumatic brain injury (TBI); however, the impact of SIP on everyday functioning may be underestimated by standard neuropsychological tests.

OBJECTIVE

we aimed to adapt two ecological instruments assessing SIP in Italian patients with moderate-to-severe TBI, as formerly proposed by Winkens and colleagues for persons with stroke, testing also its possible relation with other neuropsychological processes and functional outcomes.

METHOD

we performed an observational study on 37 patients with moderate-to-severe TBI and 35 demographically matched healthy controls, who underwent the Mental Slowness Observation Test (MSOT) and the Mental Slowness Questionnaire (MSQ), which had been adapted through a pilot study on independent sample of participants; extensive neuropsychological and functional evaluations were performed as well.

RESULTS

We found good clinical and psychometric properties of the Italian adaptation of the MSOT and MSQ; also, performance on MSOT significantly correlated with executive functions. Moreover, patients with TBI are significantly slower and less accurate than healthy controls on the MSOT, in particular in tasks with time limits. Even if the subjective feeling of SIP does not differ between patients and controls, we found a significant correlation between MSQ and MSOT. Finally, the performances on the MSOT correlated with measures of functional outcome and community integration.

CONCLUSIONS

the results support the use of the MSOT and the MSQ to measure SIP in an ecological fashion in patients with TBI, so that specific treatments for persons with acquired brain injury can be prescribed.

The Relationship Between Cognitive Functioning and Symptoms of Depression, Anxiety, and Post-Traumatic Stress Disorder in Adults with a Traumatic Brain Injury: a Meta-Analysis

A thorough understanding of the relationship between cognitive test performance and symptoms of depression, anxiety, or post-traumatic stress disorder (PTSD) in people with traumatic brain injury (TBI) is important given the high prevalence of these emotional symptoms following injury. It is also important to understand whether these relationships are affected by TBI severity, and the validity of test performance and symptom report. This meta-analysis was conducted to investigate whether these symptoms are associated with cognitive test performance alterations in adults with a TBI. This meta-analysis was prospectively registered on the PROSPERO International Prospective Register of Systematic Reviews website (registration number: CRD42018089194). The electronic databases Medline, PsycINFO, and CINAHL were searched for journal articles published up until May 2020. In total, 61 studies were included, which enabled calculation of pooled effect sizes for the cognitive domains of immediate memory (verbal and visual), recent memory (verbal and visual), attention, executive function, processing speed, and language. Depression had a small, negative relationship with most cognitive domains. These relationships remained, for the most part, when samples with mild TBI (mTBI)-only were analysed separately, but not for samples with more severe TBI (sTBI)-only. A similar pattern of results was found in the anxiety analysis. PTSD had a small, negative relationship with verbal memory, in samples with mTBI-only. No data were available for the PTSD analysis with sTBI samples. Moderator analyses indicated that the relationships between emotional symptoms and cognitive test performance may be impacted to some degree by exclusion of participants with atypical performance on performance validity tests (PVTs) or symptom validity tests (SVTs), however there were small study numbers and changes in effect size were not statistically significant. These findings are useful in synthesising what is currently known about the relationship between cognitive test performance and emotional symptoms in adults with TBI, demonstrating significant, albeit small, relationships between emotional symptoms and cognitive test performance in multiple domains, in non-military samples. Some of these relationships appeared to be mildly impacted by controlling for performance validity or symptom validity, however this was based on the relatively few studies using validity tests. More research including PVTs and SVTs whilst examining the relationship between emotional symptoms and cognitive outcomes is needed.

Reduced Priming Effect for Visual-Spatial Perspective Taking in Patients With Severe Acquired Brain Injury

OBJECTIVE

Social cognition can be impaired after a severe acquired brain injury (sABI), but mechanisms potentially underlying these difficulties remain to be clarified. This study aimed at investigating perspective taking ability in individuals with sABI.

METHOD

Twenty individuals with sABI and 20 healthy controls (HCs) have been enrolled in this case-control study. All participants were submitted to an experimental visual-spatial priming memory procedure and a self-report assessment of perspective taking (i.e., the Interpersonal Reactivity Index [IRI]). Individuals with sABI were submitted to neuropsychological tests to assess executive subcomponents, working memory, and visual attention.

RESULTS

The analysis on self-report scales data documents a significant between groups difference in the IRI-Fantasy subscale, with HCs showing a higher tendency to imaginatively transpose oneself into fictional situations than individuals with sABI. Analysis of performance on the experimental procedure revealed the priming effect in HCs but not in sABI individuals. Moreover, individuals with sABI performed significantly poorer than HCs on the indices of the experimental procedure.

CONCLUSIONS

Our data preliminarily demonstrated that visual-spatial perspective taking is reduced after sABI. Findings above could give some clues for the rehabilitative intervention in sABI and suggest the possible application of the procedure here used in assessing perspective taking after sABI.

Apathetic symptoms and white matter integrity after traumatic brain injury

PRIMARY OBJECTIVE

The aim of the study was twofold. First, to study the relationship among apathy in the long term, initial clinical measures, and standard outcome scores after traumatic brain injury (TBI). Second, to describe white matter integrity correlates of apathy symptoms.

RESEARCH DESIGN

Correlational study. Methods and Procedures: Correlation and Bayesian networks analyses were performed in a sample of 40 patients with moderate to severe TBI in order to identify the relationship among clinical variables, functionality, and apathy. A diffusion tensor imaging study was developed in 25 participants to describe correlations between fractional anisotropy (FA) measures and apathetic symptoms.

MAIN OUTCOMES AND RESULTS

Correlation analysis revealed associations between pairs of variables as apathy in the long term and functional score at discharge from hospital. Bayesian network illustrated the relevant role of axonal injury mediating the relationship between apathy and initial clinical variables. FA in the superior longitudinal fasciculus, the inferior longitudinal fasciculus, and the internal capsule were negatively correlated with apathy measures. Widespread brain areas showed positive correlations between FA and apathy.

CONCLUSIONS

These results highlight the relevance of white matter integrity measures in initial assessment after TBI and its relationship with apathetic manifestations in the chronic phase.

Impaired self-awareness after traumatic brain injury: A systematic review. Part 2. Consequences and predictors of poor self-awareness

BACKGROUND

Impaired self-awareness (ISA) has frequently been found both frequent and deleterious in patients with moderate to severe traumatic brain injury (TBI).

OBJECTIVES

This is the second of a two-part systematic review on ISA after TBI, focusing on the consequences and predictors of ISA after TBI.

METHODS

Following the PRISMA guidelines, 95 articles meeting the inclusion criteria were included; 46 were specifically related to this second part of the review.

RESULTS

Among 16 studies that investigated the effect of ISA on outcome, most (n=13) found poor self-awareness associated with poor rehabilitation, functional, social and vocational outcome and with increased burden on relatives. Multiple factors have been found associated with increased frequency of ISA. ISA was found significantly related to injury severity in 8 of 10 studies, impaired executive functions in 12 of 15 studies, and poor social cognition in 3 studies, but paradoxically inverse associations were repeatedly found between self-awareness and emotional status (11 of 12 studies). Finally, although research in the field is still scarce, ISA seems associated with a dysfunction within brain networks involving the anterior cingulate cortex, anterior insula and fronto-parietal control network.

CONCLUSIONS

ISA is a complex and multifaceted disorder associated with poor rehabilitation outcome, severe injuries, and deficits of executive functions and social cognition but has an inverse association with mood impairments.

Impaired self-awareness after traumatic brain injury: a systematic review. Part 1: Assessment, clinical aspects and recovery

BACKGROUND

Impaired self-awareness (ISA) has frequently been found to be both frequent and deleterious in patients with moderate to severe traumatic brain injury (TBI).

OBJECTIVES

The present paper is the first of a two-part systematic review of ISA after traumatic brain injury (TBI), focusing on assessment methods, clinical aspects and recovery.

METHODS

Following the PRISMA guidelines, 95 articles meeting the inclusion criteria were included.

RESULTS

ISA occurs in 30% to 50% of patients with moderate to severe TBI, although it tends to improve with time. There is no one single gold-standard measure of ISA. Self-proxy discrepancy scores, with scales such as the Patient Competency Rating Scale or the Awareness Questionnaire, or a structured interview such as the Self Awareness of Deficits Interview, are the most frequently used assessment methods, with adequate psychometric properties. Scores on these different scales correlate only moderately with each other, which suggests that they may address different aspects of self-awareness. ISA mainly concerns cognitive and behavioral problems rather than physical or sensory impairments and may concern different areas of functioning, such as anticipatory, emergent or meta-cognitive awareness.

CONCLUSION

ISA is a complex and multifaceted issue that should be systematically assessed in rehabilitation settings using a range of relatively well-validated tools. The consequences and predictors of ISA after TBI will be addressed in a companion paper.

Barriers and facilitators linked to discharge destination following inpatient rehabilitation after traumatic brain injury in older adults: a qualitative study

PURPOSE

To identify facilitators and barriers associated with returning home for older adults having received inpatient rehabilitation after traumatic brain injury (TBI).

METHODS

A qualitative design was used. Five older patients with TBI and four family caregivers were interviewed and six healthcare professionals participated in a focus group.

RESULTS

Main facilitators to returning home highlighted by all participants were: (1) Patient's adequate health condition and functional status, (2) Access to health and other services at home, (3) Availability of help from a family caregiver. Conversely, if one of these factors was not met, it represented a barrier. Other facilitators identified were (4) Attachment to one's home, (5) Feeling of commitment toward a loved one, (6) Having the possibility of going through a transitional phase, (7) United front between the patient and the family caregiver towards a return home. Additional barriers to returning home included: (8) Incongruent perspectives, and (9) Unclear knowledge about available health and other services at home.

CONCLUSION

The results of this study could be translated into a practical tool to guide patients, families and professionals in the decision about returning home or exploring an alternative option after inpatient rehabilitation for TBI in older adults.IMPLICATIONS FOR REHABILITATIONWhen orienting an older patient home or to an alternative living environment after a traumatic brain injury (TBI), the perspective of rehabilitation professionals can differ from that of patients and caregivers.Professionals tend to emphasize security, whereas patients and caregivers' focus on the well-being associated with home and on the importance of being with their loved one.Integrating the views, values and wishes of older patients with TBI and their caregivers will support a shared decision-making approach for orientation after rehabilitation.

Predictive Factors of Self-Reported Quality of Life in Acquired Brain Injury: One-Year Follow-Up

Background: The sequelae and disabilities that follow an acquired brain injury (ABI) may negatively affect quality of life (QoL). The main objective of the study is to describe the QoL after an ABI and identify the predictors of a better QoL. Methods: Prospective cohort study with follow-up measurement after one-year. The sample comprised 203 adults with ABIs (64% male) aged 18–86 years (M = 53.01, SD = 14.44). Stroke was the main etiology of the injury (55.7%), followed by a TBI (32.8%), and the average time since injury was 8 years (M = 8.25, SD = 7.83, range = 0.5–47.5). Patients assessed their QoL through the scale Calidad de Vida en Daño Cerebral (CAVIDACE self-reported version; “quality of life in brain injury” in English), an ABI-specific tool based on the eight-domain QoL model. Other variables measured were: depression, self-awareness, community integration, resilience, and social support at baseline and one-year follow-up. Results: The studied factors showed few significant changes over time. The analyses showed statistically significant differences in QoL scores in several sociodemographic (age, civil status, education, legal capacity, and dependency), injury-related (time, location, and comorbidity), rehabilitation, and personal-social variables (self-awareness, depression, social support, resilience, and community integration). The levels of dependency, depression, and satisfaction with social support were independent predictors of the total QoL score one-year follow-up. Conclusions: QoL after ABI depends on multiple elements that must be considered. There are factors such as satisfaction with social support, depression, community integration, and resilience that must be monitored throughout the rehabilitation process.

Self-Awareness Moderates the Association Between Executive Dysfunction and Functional Independence After Acquired Brain Injury

OBJECTIVE

Impaired self-awareness (SA) is a common symptom after suffering acquired brain injury (ABI) which interferes with patient's rehabilitation and their functional independence. SA is associated with executive function and declarative memory, two cognitive functions that are related to participants' daily living functionality. Through this observational study, we aim to explore whether SA may play a moderator role in the relation between these two cognitive processes and functional independence.

METHOD

A sample of 69 participants with ABI completed a neuropsychological assessment focused on executive function and declarative memory which also included a measure of SA and functional independence. Two separated linear models were performed including functional independence, SA, and two neuropsychological factors (declarative memory and executive function) derived from a previous principal component analysis.

RESULTS

Moderation analysis show a significant interaction between SA and executive function, reflecting an association between lower executive functioning and poorer functional outcome, only in participants with low levels of SA. Notwithstanding, declarative memory do not show a significant interaction with SA, even though higher declarative memory scores were associated with better functional independence.

CONCLUSIONS

SA seems to play a moderator effect between executive function, but not declarative memory, and functional independence. Accordingly, participants with executive deficits and low levels of SA might benefit from receiving specific SA interventions in the first instance, which would in turn positively impact on their functional independence.

The Self-Awareness Multilevel Assessment Scale, a New Tool for the Assessment of Self-Awareness After Severe Acquired Brain Injury: Preliminary Findings

Self-awareness (SA) is frequently impaired after severe acquired brain injury (sABI) and may lead to reduced subject's compliance to treatment, worse functional outcome, and high caregiver distress. Considering the multifaceted nature of SA, a specific and effective assessment is crucial to address treatment of impairment of SA (ISA). Many tools can currently assess ISA; however, they have some important limits. In the present study, we proposed the Self-Awareness Multilevel Assessment Scale (SAMAS), a new scale for assessment of SA at different levels (i.e., declarative, emergent, and anticipatory) across all domains of functioning. The SAMAS has been designed to be administered by the cognitive/behavioral therapist with the involvement of a patient's relative. Findings showed that the SAMAS allowed specifically assessing SA at a declarative level and on all possible functional domains. More interestingly, it seems also able to assess both emergent and anticipatory SA, thus overcoming some important limits of other current assessment methods. Our findings are consistent with a holistic perspective of the patient with sABI because thanks to the combined use of assessing tools, the SAMAS can provide an accurate diagnosis of ISA, thus better addressing the neurorehabilitation treatment and, accordingly, reducing the possible occurrence of its primary and secondary implications.

Impaired Self-Awareness and Denial During the Postacute Phases After Moderate to Severe Traumatic Brain Injury

While a number of empirical studies have appeared on impaired self-awareness (ISA) after traumatic brain injury (TBI) over the last 20 years, the relative role of denial (as a psychological method of coping) has typically not been addressed in these studies. We propose that this failure has limited our understanding of how ISA and denial differentially affect efforts to rehabilitate persons with TBI. In this selective review paper, we summarize early findings in the field and integrate those findings with more recent observations (i.e., 1999–2019). We believe that this synthesis of information and expert clinical opinion will inform future research on ISA and denial as well as approaches to rehabilitation for persons with TBI.

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.

Gait Quality Assessment in Survivors from Severe Traumatic Brain Injury: An Instrumented Approach Based on Inertial Sensors

Despite existing evidence that gait disorders are a common consequence of severe traumatic brain injury (sTBI), the literature describing gait instability in sTBI survivors is scant. Thus, the present study aims at quantifying gait patterns in sTBI through wearable inertial sensors and investigating the association of sensor-based gait quality indices with the scores of commonly administered clinical scales. Twenty healthy adults (control group, CG) and 20 people who suffered from a sTBI were recruited. The Berg balance scale, community balance and mobility scale, and dynamic gait index (DGI) were administered to sTBI participants, who were further divided into two subgroups, severe and very severe, according to their score in the DGI. Participants performed the 10 m walk, the Figure-of-8 walk, and the Fukuda stepping tests, while wearing five inertial sensors. Significant differences were found among the three groups, discriminating not only between CG and sTBI, but also for walking ability levels. Several indices displayed a significant correlation with clinical scales scores, especially in the 10 m walking and Figure-of-8 walk tests. Results show that the use of wearable sensors allows the obtainment of quantitative information about a patient’s gait disorders and discrimination between different levels of walking abilities, supporting the rehabilitative staff in designing tailored therapeutic interventions.