Independent contributions of social cognition and depression to functional status after moderate or severe traumatic brain injury

Treating social cognition impairment with the online therapy 'SoCoBo': A randomized controlled trial including traumatic brain injury patients

OBJECTIVE

Acquired brain injuries (ABIs), such as traumatic brain injuries (TBIs), often entail impairments of general cognition (e.g., memory, attention or executive functions) and social cognition (e.g. emotion recognition, theory of mind [ToM], social problem-solving). The availability of fully computerized interventions targeting sociocognitive deficits specifically in neurologically impaired patients is extremely limited. Therefore, the Treatment Program for Deficits in Social Cognition and Social Competencies of the Ruhr University Bochum (SoCoBo), a fully computerized online therapy designed for ABI patients was evaluated in a randomized controlled trial involving TBI patients.

METHOD

Sixty-four patients with TBI were randomly assigned to two groups with 43 patients fully completing either SoCoBo (N = 27) or a commercially available computerized program for cognitive rehabilitation (RehaCom®, N = 16). All participants underwent comprehensive pre-post online neuropsychological assessment and worked with their respective rehabilitation programs for four days a week during a scheduled period of 12 weeks.

RESULTS

After treatment, the SoCoBo group, but not the RehaCom® group showed significant improvements in facial emotion recognition and self-rated empathy. Moreover, in the SoCoBo group, an increase in empathy was also associated with increased life satisfaction after treatment. There were no improvements in ToM and social problem-solving. Furthermore, general cognition did not improve in any of the groups.

CONCLUSIONS

SoCoBo represents an effective new online therapy for the amelioration of deficits in key domains of social cognition. Its implementation in clinical practice will serve as a meaningful addition to the existing fully computerized approaches specifically in neurological patient groups.

A pre-existing Toxoplasma gondii infection exacerbates the pathophysiological response and extent of brain damage after traumatic brain injury in mice

Traumatic brain injury (TBI) is a key contributor to global morbidity that lacks effective treatments. Microbial infections are common in TBI patients, and their presence could modify the physiological response to TBI. It is estimated that one-third of the human population is incurably infected with the feline-borne parasite, Toxoplasma gondii, which can invade the central nervous system and result in chronic low-grade neuroinflammation, oxidative stress, and excitotoxicity-all of which are also important pathophysiological processes in TBI. Considering the large number of TBI patients that have a pre-existing T. gondii infection prior to injury, and the potential mechanistic synergies between the conditions, this study investigated how a pre-existing T. gondii infection modified TBI outcomes across acute, sub-acute and chronic recovery in male and female mice. Gene expression analysis of brain tissue found that neuroinflammation and immune cell markers were amplified in the combined T. gondii + TBI setting in both males and females as early as 2-h post-injury. Glutamatergic, neurotoxic, and oxidative stress markers were altered in a sex-specific manner in T. gondii + TBI mice. Structural MRI found that male, but not female, T. gondii + TBI mice had a significantly larger lesion size compared to their uninfected counterparts at 18-weeks post-injury. Similarly, diffusion MRI revealed that T. gondii + TBI mice had exacerbated white matter tract abnormalities, particularly in male mice. These novel findings indicate that a pre-existing T. gondii infection affects the pathophysiological aftermath of TBI in a sex-dependent manner, and may be an important modifier to consider in the care and prognostication of TBI patients.

Exploring social cognition in individuals with neuropsychiatric symptoms following acquired brain injury

In this study, we explored the social cognitive skills of individuals with neuropsychiatric symptoms following acquired brain injury (ABI). To this end, a retrospective chart review was carried out. We examined scores on social cognition tests that were administered as part of routine neuropsychological assessment at a Dutch specialized care facility for patients with neuropsychiatric symptoms following ABI. In addition, correlations with time post injury were explored. Aspects of social cognition (emotion recognition, Theory of Mind (ToM) and empathy) were measured using the Emotion Recognition Task (n = 40), the Ekman 60-Faces Test of the Facial Expression of Emotion: Stimuli and Tests (n = 11) and the Faux Pas Test (n = 36). 72.5% to 81.8% of participants scored very low or low on emotion recognition. Participants' scores for ToM and empathy were lower than those reported recently for samples of Dutch stroke and traumatic brain injury patients. Correlations between social cognition scores and time since injury were non-significant or negative. While further research is necessary, our results indicate that social cognitive problems are prevalent and persistent in individuals who display neuropsychiatric symptoms after ABI. Future studies should employ a prospective approach in order to confirm our exploratory findings.

Dynamic Emotion Recognition and Social Inference Ability in Traumatic Brain Injury: An Eye-Tracking Comparison Study

Emotion recognition and social inference impairments are well-documented features of post-traumatic brain injury (TBI), yet the mechanisms underpinning these are not fully understood. We examined dynamic emotion recognition, social inference abilities, and eye fixation patterns between adults with and without TBI. Eighteen individuals with TBI and 18 matched non-TBI participants were recruited and underwent all three components of The Assessment of Social Inference Test (TASIT). The TBI group were less accurate in identifying emotions compared to the non-TBI group. Individuals with TBI also scored lower when distinguishing sincere and sarcastic conversations, but scored similarly to those without TBI during lie vignettes. Finally, those with TBI also had difficulty understanding the actor's intentions, feelings, and beliefs compared to participants without TBI. No group differences were found for eye fixation patterns, and there were no associations between fixations and behavioural accuracy scores. This conflicts with previous studies, and might be related to an important distinction between static and dynamic stimuli. Visual strategies appeared goal- and stimulus-driven, with attention being distributed to the most diagnostic area of the face for each emotion. These findings suggest that low-level visual deficits may not be modulating emotion recognition and social inference disturbances post-TBI.

Moderated-mediation analysis of multimorbidity and health-related quality of life among the Chinese elderly: The role of functional status and cognitive function

OBJECTIVES

To investigate the relationship between multimorbidity and health-related quality of life (HRQoL), and explore the effects of functional status and cognitive function on Chinses elderly behind this relationship.

METHODS

The Multivariate logistic regression and Tobit regression models were used to determine the influence of multimorbidity on HRQoL. Bootstrap analysis was used to probe the mediating effects of functional status and the moderating role of cognition on multimorbidity and HRQoL.

RESULTS

Results of the 2,887 participants age  ≥ 60  years included in the analysis, 51.69% had chronic diseases. Stroke (β = -0.190; 95% confidence interval [CI], -0.232, -0.149; p < 0.001) and the combination of hypertension and stroke (β = -0.210; 95% CI, -0.259, -0.160; p < 0.001) had the greatest influence on HRQoL. Functional status partially mediated the relationship between the number of non-communicable diseases (No. of NCDs) and HRQoL, while cognitive function had a moderating effect not only in the A-path (No. of NCDs to functional status, β = 0.143; t = 7.18; p < 0.001) and but also in the C-path (No. of NCDs to HRQoL, β = 0.007; t = 6.08; p < 0.001).

CONCLUSION

Functional status partially mediated the relationship between multimorbidity and HRQoL in older adults. And cognitive function, if declined, may strengthen this relationship. These findings suggested that improving cognitive function and functional status in those who developed multimorbidity could be a viable prevention or treatment strategy to improve HRQoL in elderly patients.

Risk Factors for High Symptom Burden Three Months after Traumatic Brain Injury and Implications for Clinical Trial Design: A Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study

More than 75% of patients presenting to level I trauma centers in the United States with suspicion of TBI sufficient to require a clinical computed tomography scan report injury-related symptoms 3 months later. There are currently no approved treatments, and few clinical trials have evaluated possible treatments. Efficient trials will require subject inclusion and exclusion criteria that balance cost-effective recruitment with enrolling individuals with a higher chance of benefiting from the interventions. Using data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, we examined the relationship of 3-month symptoms to pre-injury, demographic, and acute characteristics as well as 2-week symptoms and blood-based biomarkers to identify and evaluate factors that may be used for sample enrichment for clinical trials. Many of the risk factors for TBI symptoms reported in the literature were supported, but the effect sizes of each were small or moderate (< 0.5). The only factors with large effect sizes when predicting 3-month symptom burden were TBI-related (i.e., post-concussive) and post-traumatic stress symptom levels at 2 weeks (respective effect sizes 1.13 and 1.34). TBI severity was not significantly associated with 3-month symptom burden (p = 0.37). Using simulated data to evaluate the effect of enrichment, we showed that including only people with high symptom burden at 2 weeks would permit trials to reduce the sample size by half, with minimal increase in screening, as compared with enrolling an unenriched sample. Clinical trials aimed at reducing symptoms after TBI can be efficiently conducted by enriching the included sample with people reporting a high early symptom burden.

Symptom Frequency and Persistence in the First Year after Traumatic Brain Injury: A TRACK-TBI Study

Symptom endorsement after traumatic brain injury (TBI) is common acutely post-injury and is associated with other adverse outcomes. Prevalence of persistent symptoms has been debated, especially in mild TBI (mTBI). A cohort of participants ≥17 years with TBI (n = 2039), 257 orthopedic trauma controls (OTCs), and 300 friend controls (FCs) were enrolled in the TRACK-TBI study and evaluated at 2 weeks and 3, 6, and 12 months post-injury using the Rivermead Post-Concussion Symptoms Questionnaire (RPQ). TBI participants had significantly higher symptom burden than OTCs or FCs at all times, with average scores more than double. TBI cases showed significant decreases in RPQ score between each evaluation (p < 0.001), decreasing ∼1.7 points per month between 2 weeks and 3 months and 0.2 points per month after that. More than 50% of the TBI sample, including >50% of each of the mild and moderate/severe TBI subsamples, continued to endorse three or more symptoms as worse than pre-injury through 12 months post-injury. A majority of TBI participants who endorsed a symptom at 3 months or later did so at the next evaluation as well. Contrary to reviews that report symptom resolution by 3 months post-injury among those with mTBI, this study of participants treated at level 1 trauma centers and having a computed tomography ordered found that persistent symptoms are common to at least a year after TBI. Additionally, although symptom endorsement was not specific to TBI given that they were also reported by OTC and FC participants, TBI participants endorsed over twice the symptom burden compared with the other groups.

Apathy, Executive Function, and Emotion Recognition Are the Main Drivers of Functional Impairment in Behavioral Variant of Frontotemporal Dementia

Background: The cognitive and neuropsychiatric deficits present in patients with behavioral variant frontotemporal dementia (bvFTD) are associated with loss of functionality in the activities of daily living (ADLs). The main purpose of this study was to examine and explore the association between the cognitive and neuropsychiatric features that might prompt functional impairment of basic, instrumental, and advanced ADL domains in patients with bvFTD. Methods: A retrospective cross-sectional study was conducted with 27 patients with bvFTD in its early stage (<2 years of evolution) and 32 healthy control subjects. A neuropsychological assessment was carried out wherein measures of cognitive function and neuropsychiatric symptoms were obtained. The informant-report Technology-Activities of Daily Living Questionnaire was used to assess the percentage of functional impairment in the different ADL domains. To identify the best determinants, three separate multiple regression analyses were performed, considering each functional impairment as the dependent variable and executive function, emotion recognition, disinhibition, and apathy as independent variables. Results: For the basic ADLs, a model that explains 28.2% of the variability was found, in which the presence of apathy (β = 0.33, p = 0.02) and disinhibition (β = 0.29, p = 0.04) were significant factors. Concerning instrumental ADLs, the model produced accounted for 63.7% of the functional variability, with the presence of apathy (β = 0.71, p < 0.001), deficits in executive function (β = -0.36, p = 0.002), and lack of emotion recognition (β = 0.28, p = 0.017) as the main contributors. Finally, in terms of advanced ADLs, the model found explained 52.6% of the variance, wherein only the presence of apathy acted as a significant factor (β = 0.59, p < 0.001). Conclusions: The results of this study show the prominent and transverse effect of apathy in the loss of functionality throughout all the ADL domains. Apart from that, this is the first study that shows that the factors associated with loss of functionality differ according to the functional domain in patients with bvFTD in its early stage. Finally, no other study has analyzed the impact of the lack of emotion recognition in the functionality of ADLs. These results could guide the planning of tailored interventions that might enhance everyday activities and the improvement of quality of life.

Part 2: Bypassing TBI-Metabolic Surgery and the Link Between Obesity and Traumatic Brain Injury-A Review

Obesity is a common outcome of traumatic brain injury (TBI) that exacerbates principal TBI symptom domains identified as common areas of post-TBI long-term dysfunction. Obesity is also associated with increased risk of later-life dementia and Alzheimer's disease. Patients with obesity and chronic TBI may be more vulnerable to long-term mental abnormalities. This review explores the question of whether weight loss induced by bariatric surgery could delay or perhaps even reverse the progression of mental deterioration. Bariatric surgery, with its induction of weight loss, remission of type 2 diabetes, and other expressions of the metabolic syndrome, improves metabolic efficiency, leads to reversal of brain lesions seen on imaging studies, and improves function. These observations suggest that metabolic/bariatric surgery may be the most effective therapy for TBI.

Bypassing TBI: Metabolic Surgery and the Link between Obesity and Traumatic Brain Injury-a Review

Obesity is a common outcome of traumatic brain injury (TBI) that exacerbates principal TBI symptom domains identified as common areas of post-TBI long-term dysfunction. Obesity is also associated with increased risk of later-life dementia and Alzheimer's disease. Patients with obesity and chronic TBI may be more vulnerable to long-term mental abnormalities. This review explores the question of whether weight loss induced by bariatric surgery could delay or perhaps even reverse the progression of mental deterioration. Bariatric surgery, with its induction of weight loss, remission of type 2 diabetes, and other expressions of the metabolic syndrome, improves metabolic efficiency, leads to reversal of brain lesions seen on imaging studies, and improves function. These observations suggest that metabolic/bariatric surgery may be a most effective therapy for TBI.