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Meyer EJ, Correa ET, Monuteaux MC, Mannix R, Hatoun J, Vernacchio L, Lyons TW. Patterns and Predictors of Health Care Utilization After Pediatric Concussion: A Retrospective Cohort Study. Acad Pediatr 2024; 24:51-58. [PMID: 37148968 DOI: 10.1016/j.acap.2023.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE To characterize types, duration, and intensity of health care utilization following pediatric concussion and to identify risk factors for increased post-concussion utilization. METHODS A retrospective cohort study of children 5 to 17 years old diagnosed with acute concussion at a quaternary center pediatric emergency department or network of associated primary care clinics. Index concussion visits were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. We analyzed patterns of health care visits 6 months before and after the index visit using interrupted time-series analyses. The primary outcome was prolonged concussion-related utilization, defined as having ≥1 follow-up visits with a concussion diagnosis more than 28 days after the index visit. We used logistic regressions to identify predictors of prolonged concussion-related utilization. RESULTS Eight hundred nineteen index visits (median [interquartile range] age, 14 [11-16] years; 395 [48.2%] female) were included. There was a spike in utilization during the first 28 days after the index visit compared to the pre-injury period. Premorbid headache/migraine disorder (adjusted odds ratio (aOR) 2.05, 95% confidence interval [CI] 1.09-3.89) and top quartile pre-injury utilization (aOR 1.90, 95% CI 1.02-3.52) predicted prolonged concussion-related utilization. Premorbid depression/anxiety (aOR 1.55, 95% CI 1.31-1.83) and top quartile pre-injury utilization (aOR 2.29, 95% CI 1.95-2.69) predicted increased utilization intensity. CONCLUSIONS Health care utilization is increased during the first 28 days after pediatric concussion. Children with premorbid headache/migraine disorders, premorbid depression/anxiety, and high baseline utilization are more likely to have increased post-injury health care utilization. This study will inform patient-centered treatment but may be limited by incomplete capture of post-injury utilization and generalizability.
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Affiliation(s)
- Erin J Meyer
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass.
| | - Emily Trudell Correa
- Pediatric Physicians' Organization at Children's (ET Correa, J Hatoun, and L Vernacchio), Wellesley, Mass
| | - Michael C Monuteaux
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass
| | - Rebekah Mannix
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass
| | - Jonathan Hatoun
- Pediatric Physicians' Organization at Children's (ET Correa, J Hatoun, and L Vernacchio), Wellesley, Mass; Department of Pediatrics (J Hatoun and L Vernacchio), Boston Children's Hospital and Harvard Medical School, Mass
| | - Louis Vernacchio
- Pediatric Physicians' Organization at Children's (ET Correa, J Hatoun, and L Vernacchio), Wellesley, Mass; Department of Pediatrics (J Hatoun and L Vernacchio), Boston Children's Hospital and Harvard Medical School, Mass
| | - Todd W Lyons
- Division of Emergency Medicine (EJ Meyer, MC Monuteaux, R Mannix, and TW Lyons), Boston Children's Hospital and Harvard Medical School, Mass
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Kane NB, Broderick N, Rao E, Ruck Keene A, Rao RT. Shades of grey: choice, control and capacity in alcohol-related brain damage. BJPsych Bull 2023:1-6. [PMID: 37947128 DOI: 10.1192/bjb.2023.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
Liaison psychiatrists have identified that conducting capacity assessments in general hospital patients with alcohol-related brain damage (ARBD) can be challenging. This educational article uses the fictitious case of a man with ARBD, alcohol dependence and significant self-neglect, focusing on assessment of his capacity to decide about moving into a care home on discharge. We provide an overview of clinical, legal and ethical literature relevant to decision-making and capacity assessment in individuals with ARBD, with the aim of guiding clinicians approaching complex capacity assessments.
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Affiliation(s)
| | | | - Emily Rao
- University of California San Diego, La Jolla, California, USA
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Russell AM, Shepherd V, Woolfall K, Young B, Gillies K, Volkmer A, Jayes M, Huxtable R, Perkins A, Noor NM, Nickolls B, Wade J. Complex and alternate consent pathways in clinical trials: methodological and ethical challenges encountered by underserved groups and a call to action. Trials 2023; 24:151. [PMID: 36855178 PMCID: PMC9973248 DOI: 10.1186/s13063-023-07159-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/09/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Informed consent is considered a fundamental requirement for participation in trials, yet obtaining consent is challenging in a number of populations and settings. This may be due to participants having communication or other disabilities, their capacity to consent fluctuates or they lack capacity, or in emergency situations where their medical condition or the urgent nature of the treatment precludes seeking consent from either the participant or a representative. These challenges, and the subsequent complexity of designing and conducting trials where alternative consent pathways are required, contribute to these populations being underserved in research. Recognising and addressing these challenges is essential to support trials involving these populations and ensure that they have an equitable opportunity to participate in, and benefit from, research. Given the complex nature of these challenges, which are encountered by both adults and children, a cross-disciplinary approach is required. DISCUSSION A UK-wide collaboration, a sub-group of the Trial Conduct Working Group in the MRC-NIHR Trial Methodology Research Partnership, was formed to collectively address these challenges. Members are drawn from disciplines including bioethics, qualitative research, trials methodology, healthcare professions, and social sciences. This commentary draws on our collective expertise to identify key populations where particular methodological and ethical challenges around consent are encountered, articulate the specific issues arising in each population, summarise ongoing and completed research, and identify targets for future research. Key populations include people with communication or other disabilities, people whose capacity to consent fluctuates, adults who lack the capacity to consent, and adults and children in emergency and urgent care settings. Work is ongoing by the sub-group to create a database of resources, to update NIHR guidance, and to develop proposals to address identified research gaps. CONCLUSION Collaboration across disciplines, sectors, organisations, and countries is essential if the ethical and methodological challenges surrounding trials involving complex and alternate consent pathways are to be addressed. Explicating these challenges, sharing resources, and identifying gaps for future research is an essential first step. We hope that doing so will serve as a call to action for others seeking ways to address the current consent-based exclusion of underserved populations from trials.
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Affiliation(s)
- Amy M Russell
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Victoria Shepherd
- Centre for Trials Research, Cardiff University, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Bridget Young
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Anna Volkmer
- Department of Psychology and Language Sciences, University College London, London, UK
| | - Mark Jayes
- Department of Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alexander Perkins
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Nurulamin M Noor
- Medical Research Council Clinical Trials Unit at University College London (MRC CTU at UCL), Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Beverley Nickolls
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University London, London, UK
| | - Julia Wade
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
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Taylor AA, McCauley SR, Strutt AM. Postconcussional Syndrome. Neurol Clin 2022; 41:161-176. [DOI: 10.1016/j.ncl.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Unexpected role of stress as a possible resilience mechanism upon mild traumatic brain injury (mTBI) in mice. Mol Cell Neurosci 2020; 111:103586. [PMID: 33358995 DOI: 10.1016/j.mcn.2020.103586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 12/07/2020] [Accepted: 12/11/2020] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Mild traumatic brain injury (mTBI) is common and associated with cognitive impairment. Stress and mTBI are known to modulate the neural function. The present study aims at exploring the effect of prior stress exposure on cognitive function following mTBI. METHODS Eight weeks old male ICR mice were subjected to either stress induced by forced swimming stress alone, stress followed by an immediate mTBI, or stress followed by 30 min break and then mTBI. We had two control groups: SHAM group - a control group which was not exposed to stress nor to mTBI and control mTBI group - a control group which was exposed only to TBI with no stress. Mice were weighed prior and at 12, 24 h and 1 week following interventions. Motor evaluation was conducted by rotarod. Behavioral changes were evaluated using open field, Y maze, elevated plus maze and staircase tests, at 12 h and 1 week following interventions. Brain levels of NMDAR subunits (R1, R2A, R2B), GABABR1, glucocorticoid and mineralocorticoid receptors (GR, MR) were evaluated using western blot. RESULTS Stress alone, mTBI alone, and stress followed by immediate mTBI resulted in a significant weight loss compared to control (p < 0.05). Stress 30 min prior to mTBI had a protective effect on weight (p = 0.14 compared to control). The stress and mTBI alone groups showed reduced time at the center of the open field arena 1 week after intervention (p < 0.05 for both). Time in the novel arm of the Y maze was significantly shorter in the mTBI and stress followed by delayed mTBI (p = 0.02). Immediate stress prior to mTBI had normalized times in the novel arm (p = 0.95 compared to control). Combination of stress and mTBI significantly modified NMDAR subunits levels (increased NMDAR1, p < 0.008, decreased NMDAR2A p = 0.02) as well as increased MR levels (p = 0.04). CONCLUSION Exposure to stress prior to mTBI may improve the cognitive consequences of mTBI. These data may point towards a novel, unexpected role of stress as a possible resilience mechanism in the setting of mTBI.
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The capacity to consent to treatment in amyotrophic lateral sclerosis: a preliminary report. J Neurol 2020; 268:219-226. [PMID: 32766931 DOI: 10.1007/s00415-020-10136-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/28/2020] [Accepted: 07/30/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Facing the relentless worsening of their condition, ALS patients are required to make decisions on treatments and end-of-life care. A cognitive impairment showed to be a negative prognostic factor in ALS patients, perhaps affecting the ability to make informed decisions. Notwithstanding its crucial role, the capacity to consent to treatment (CCT) has never been evaluated in these patients. OBJECTIVES To assess the CCT in an ALS cohort in comparison to a control group, and to study the effects of demographic and clinical variables on this high-level cognitive function. METHODS 102 ALS patients and 106 healthy controls (HC) were enrolled. CCT was assessed using the MacArthur Competence Assessment Tool for Treatment (MAC-CAT-T) and the performance was classified into the three CCT outcomes (full credit, partial credit, no credit). Cognitive and psychological variables were assessed by MMSE, phonemic fluencies, Frontal System Behavioural Scale (FrSBe), and ALS Depression Inventory (ADI). Clinical and demographic variables were analyzed as possible predictors of the MAC-CAT-T outcomes. After a 1-year follow-up, CCT and neuropsychological assessments were repeated. RESULTS Most ALS patients (i.e., from 75 to 83% according to the different sub-items) retain full CCT. However, a subpopulation of the ALS patients showed a reduced CCT with respect to the HC. Age, education, phonemic fluency, and depression appeared related to the CCT outcomes. After 1 year, only the reasoning items worsened. CONCLUSIONS This is a preliminary report suggesting that the large majority of ALS patients can retain full ability to choose between treatment options. However, demographic and neuropsychological variables may affect CCT, pointing to the need for special attention to the consent disclosure in this disease.
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Steward KA, Kennedy R, Novack TA, Crowe M, Marson DC, Triebel KL. The Role of Cognitive Reserve in Recovery From Traumatic Brain Injury. J Head Trauma Rehabil 2019; 33:E18-E27. [PMID: 28520675 PMCID: PMC5693786 DOI: 10.1097/htr.0000000000000325] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine whether cognitive reserve (CR) attenuates the initial impact of traumatic brain injury (TBI) on cognitive performance (neural reserve) and results in faster cognitive recovery rates in the first year postinjury (neural compensation), and whether the advantage of CR differs on the basis of the severity of TBI. SETTING Inpatient/outpatient clinics at an academic medical center. PARTICIPANTS Adults with mild TBI (mTBI; n = 28), complicated mild TBI (cmTBI; n = 24), and moderate to severe TBI (msevTBI; n = 57), and demographically matched controls (n = 66). DESIGN Retrospective, longitudinal cohort assessed at 1, 6, and 12 months postinjury. MAIN MEASURES Outcomes were 3 cognitive domains: processing speed/executive function, verbal fluency, and memory. Premorbid IQ, estimated with the Wechsler Test of Adult Reading, served as CR proxy. RESULTS Higher premorbid IQ was associated with better performance on cognitive domains at 1 month postinjury, and the effect of IQ was similarly beneficial for all groups. Cognitive recovery rate was moderated only by TBI severity; those with more severe TBI had faster recovery in the first year. CONCLUSION Results support only the neural reserve theory of CR within a TBI population and indicate that CR is neuroprotective, regardless of the degree of TBI. Higher premorbid CR does not allow for more rapid adaptation and recovery from injury.
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Affiliation(s)
- Kayla A. Steward
- Department of Psychology, University of Alabama at Birmingham,
Birmingham, AL, USA
| | - Richard Kennedy
- Department of Medicine, University of Alabama at Birmingham,
Birmingham, AL, USA
| | - Thomas A. Novack
- Department of Physical Medicine and Rehabilitation, University of
Alabama at Birmingham, Birmingham, AL, USA
| | - Michael Crowe
- Department of Psychology, University of Alabama at Birmingham,
Birmingham, AL, USA
| | - Daniel C. Marson
- Department of Neurology, University of Alabama at Birmingham,
Birmingham, AL, USA
| | - Kristen L. Triebel
- Department of Neurology, University of Alabama at Birmingham,
Birmingham, AL, USA
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Neurocognitive Models of Medical Decision-Making Capacity in Traumatic Brain Injury Across Injury Severity. J Head Trauma Rehabil 2018; 31:E49-59. [PMID: 26394290 DOI: 10.1097/htr.0000000000000163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify neurocognitive predictors of medical decision-making capacity (MDC) in participants with mild and moderate/severe traumatic brain injury (TBI). SETTING Academic medical center. PARTICIPANTS Sixty adult controls and 104 adults with TBI (49 mild, 55 moderate/severe) evaluated within 6 weeks of injury. DESIGN Prospective cross-sectional study. MAIN MEASURES Participants completed the Capacity to Consent to Treatment Instrument to assess MDC and a neuropsychological test battery. We used factor analysis to reduce the battery test measures into 4 cognitive composite scores (verbal memory, verbal fluency, academic skills, and processing speed/executive function). We identified cognitive predictors of the 3 most clinically relevant Capacity to Consent to Treatment Instrument consent standards (appreciation, reasoning, and understanding). RESULTS In controls, academic skills (word reading, arithmetic) and verbal memory predicted understanding; verbal fluency predicted reasoning; and no predictors emerged for appreciation. In the mild TBI group, verbal memory predicted understanding and reasoning, whereas academic skills predicted appreciation. In the moderate/severe TBI group, verbal memory and academic skills predicted understanding; academic skills predicted reasoning; and academic skills and verbal fluency predicted appreciation. CONCLUSIONS Verbal memory was a predictor of MDC in controls and persons with mild and moderate/severe TBI. In clinical practice, impaired verbal memory could serve as a "red flag" for diminished consent capacity in persons with recent TBI.
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Mayo CD, Scarapicchia V, Robinson LK, Gawryluk JR. Neuropsychological assessment of traumatic brain injury: Current ethical challenges and recommendations for future practice. APPLIED NEUROPSYCHOLOGY-ADULT 2018; 26:383-391. [PMID: 29313718 DOI: 10.1080/23279095.2017.1416472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Numerous ethical challenges may arise over the course of neuropsychological assessment. This paper highlights the ethical considerations associated with neuropsychological assessment of individuals with traumatic brain injury. Issues regarding professional competency, providing and obtaining informed consent, neuropsychological test selection and administration, effectively communicating assessment results, and working as part of a multidisciplinary team are discussed with practical recommendations. Ultimately, a comprehensive understanding of these issues as well as an integration of resources to guide clinical practice will contribute to ethical decision-making and strong professional practice.
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Affiliation(s)
- Chantel D Mayo
- a Department of Psychology , University of Victoria , Victoria , British Columbia , Canada
| | - Vanessa Scarapicchia
- a Department of Psychology , University of Victoria , Victoria , British Columbia , Canada
| | - Lara K Robinson
- a Department of Psychology , University of Victoria , Victoria , British Columbia , Canada
| | - Jodie R Gawryluk
- a Department of Psychology , University of Victoria , Victoria , British Columbia , Canada
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Saber A, Tabatabaei SM, Akasheh G, Sehat M, Zanjani Z, Larijani B. Face and Content Validity of the MacArthur Competence Assessment Tool for the Treatment of Iranian Patients. Int J Prev Med 2017; 8:75. [PMID: 29026507 PMCID: PMC5634061 DOI: 10.4103/ijpvm.ijpvm_367_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 07/08/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There is not a valid Persian tool for measuring the decision-making competency of patients. The aim of this study is to evaluate the face and content validity of the MacArthur Competence Assessment Tool for the treatment of Iranian Persian-speaking patients. METHODS To assess the validity of the Persian version of the tool, a self-administrated questionnaire was designed. The Lawshe method was also used for assessing each item. Content validity ratio (CVR) and content validity index (CVI) were used to assess the content validity quantitatively. According to the experts' judgment, questions with a CVR ≥0.62 and CVR <0.62 were maintainable and unmaintainable, respectively. RESULTS The questions were designed in a manner to achieve the desirable result (CVR ≥0.62). The CVI scale (S-CVI) and CVI (S-CVI/Ave) were 0.94 (higher than 0.79). Thus, the content validity was confirmed. CONCLUSIONS Since capacity assessments are usually based on physician's subjective judgment, they are likely to bias and therefore, with this suitably validated tool, we can improve judgment of physicians and health-care providers in out- and in-patient cases.
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Affiliation(s)
- Ali Saber
- PhD in Medical Ethics, Kashan University of Medical Sciences, Kashan, Iran
| | - Seyed Mahmoud Tabatabaei
- Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Godarz Akasheh
- Department of Psychiatry, Kashan University of Medical Sciences, Kashan, Iran
| | - Mojtaba Sehat
- Department of Epidemiology, Kashan University of Medical Sciences, Kashan, Iran
| | - Zahra Zanjani
- Department of Psychology, Medical Faculty, Kashan University of Medical Sciences, Kashan, Iran
| | - Bagher Larijani
- Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
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Gerstenecker A, Lowry K, Myers T, Bashir K, Triebel KL, Martin RC, Marson DC. Medical decision-making capacity and its cognitive predictors in progressive MS: Preliminary evidence. J Neurol Sci 2017; 380:38-43. [PMID: 28870585 DOI: 10.1016/j.jns.2017.06.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/01/2017] [Accepted: 06/28/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Medical decision-making capacity (MDC) refers to the ability to make informed decisions about treatment and declines in cognition are associated with declines in MDC across multiple disease entities. However, although it is well known that cognitive impairment is prevalent in multiple sclerosis (MS), little is known about MDC in the disease. METHODS Data from 22 persons with progressive MS and 18 healthy controls were analyzed. All diagnoses were made by a board-certified neurologist with experience in MS. All study participants were administered a vignette-based measure of MDC and also a neuropsychological battery. RESULTS Performance on three MDC consent standards (i.e., Appreciation, Reasoning, Understanding) was significantly lower for people with progressive MS as compared to healthy controls. In the progressive MS group, verbal fluency was the primary cognitive predictor for both Reasoning and Understanding consent standards. Verbal learning and memory was the primary cognitive predictor for Appreciation. MS severity was not significantly correlated with any MDC variable. CONCLUSION MDC is a complex and cognitively mediated functional ability that is impaired in many people with progressive MS. Verbal measures of fluency and memory are strongly associated with MDC performances in the current sample of people with MS and could potentially be utilized to quickly screen for MDC impairment in MS.
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Affiliation(s)
- Adam Gerstenecker
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kathleen Lowry
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Terina Myers
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Khurram Bashir
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kristen L Triebel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Roy C Martin
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Daniel C Marson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States.
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Gerstenecker A, Myers T, Lowry K, Martin RC, Triebel KL, Bashir K, Marson DC. Financial Capacity and its Cognitive Predictors in Progressive Multiple Sclerosis. Arch Clin Neuropsychol 2017; 32:943-950. [DOI: 10.1093/arclin/acx039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 04/03/2017] [Indexed: 11/12/2022] Open
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Steward KA, Novack TA, Kennedy R, Crowe M, Marson DC, Triebel KL. The Wechsler Test of Adult Reading as a Measure of Premorbid Intelligence Following Traumatic Brain Injury. Arch Clin Neuropsychol 2016; 32:98-103. [PMID: 27799224 DOI: 10.1093/arclin/acw081] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The current study sought to determine whether the Wechsler Test of Adult Reading (WTAR) provides a stable estimate of premorbid intellectual ability in acutely injured patients recovering from traumatic brain injury (TBI). METHOD A total of 135 participants (43 mild TBI [mTBI], 40 moderate/severe TBI [msevTBI], 52 healthy controls) were administered the WTAR at 1 and 12 months post-injury. RESULTS Despite similar demographic profiles, participants with msevTBI performed significantly worse than controls on the WTAR at both time points. Moreover, the msevTBI group had a significant improvement in WTAR performance over the 1-year period. In contrast, those participants with mTBI did not significantly differ from healthy controls and both the mTBI and control groups demonstrated stability on the WTAR over time. CONCLUSIONS Results indicate that word-reading tests may underestimate premorbid intelligence during the immediate recovery period for patients with msevTBI. Clinicians should consider alternative estimation measures in this TBI subpopulation.
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Affiliation(s)
- Kayla A Steward
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Thomas A Novack
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Richard Kennedy
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael Crowe
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Daniel C Marson
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristen L Triebel
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
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Steward KA, Gerstenecker A, Triebel KL, Kennedy R, Novack TA, Dreer LE, Marson DC. Twelve-month recovery of medical decision-making capacity following traumatic brain injury. Neurology 2016; 87:1052-9. [PMID: 27511180 DOI: 10.1212/wnl.0000000000003079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 05/20/2016] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE To investigate recovery of medical decision-making capacity (MDC) over the first year following traumatic brain injury (TBI). METHODS A total of 177 participants (111 persons with TBI and 66 healthy controls) were recruited from an inpatient/outpatient TBI rehabilitation unit and outpatient neurology department. Participants with TBI were classified by injury severity into subgroups: mild TBI (mTBI; n = 28), complicated mild TBI (cmTBI; n = 23), and moderate/severe TBI (msevTBI; n = 60). Control and TBI groups were compared at 1 month (t1), 6 months (t2), and 12 months (t3) postinjury using the Capacity to Consent to Treatment Instrument (CCTI), which evaluates MDC using 5 consent standards: expressing choice, reasonable choice, appreciation, reasoning, and understanding. RESULTS Relative to controls, no TBI group displayed impairment on CCTI expressing choice or reasonable choice at any timepoint. Those with mTBI had reduced appreciation and understanding at t1, which resolved by t2. The cmTBI and msevTBI groups were impaired on all 3 complex consent standards at t1. While patients with cmTBI improved to a level similar to controls by t3, those with msevTBI remained impaired on reasoning and understanding. Across all TBI groups, notable MDC improvement only occurred over the first 6 months postinjury. CONCLUSIONS Over 1 year, most individuals with mTBI or cmTBI regain MDC, while many individuals with msevTBI have lingering deficits in reasoning and comprehension of treatment information. Clinical recovery of MDC occurs primarily during the first 6 months post-TBI regardless of injury severity. Clinicians can therefore identify MDC outcomes in TBI at 6 months postinjury.
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Affiliation(s)
- Kayla A Steward
- From the Departments of Psychology (K.A.S.), Neurology (A.G., K.L.T., D.C.M.), Medicine (R.K.), Physical Medicine and Rehabilitation (T.A.N.), and Ophthalmology (L.E.D.), University of Alabama at Birmingham
| | - Adam Gerstenecker
- From the Departments of Psychology (K.A.S.), Neurology (A.G., K.L.T., D.C.M.), Medicine (R.K.), Physical Medicine and Rehabilitation (T.A.N.), and Ophthalmology (L.E.D.), University of Alabama at Birmingham
| | - Kristen L Triebel
- From the Departments of Psychology (K.A.S.), Neurology (A.G., K.L.T., D.C.M.), Medicine (R.K.), Physical Medicine and Rehabilitation (T.A.N.), and Ophthalmology (L.E.D.), University of Alabama at Birmingham
| | - Richard Kennedy
- From the Departments of Psychology (K.A.S.), Neurology (A.G., K.L.T., D.C.M.), Medicine (R.K.), Physical Medicine and Rehabilitation (T.A.N.), and Ophthalmology (L.E.D.), University of Alabama at Birmingham
| | - Thomas A Novack
- From the Departments of Psychology (K.A.S.), Neurology (A.G., K.L.T., D.C.M.), Medicine (R.K.), Physical Medicine and Rehabilitation (T.A.N.), and Ophthalmology (L.E.D.), University of Alabama at Birmingham
| | - Laura E Dreer
- From the Departments of Psychology (K.A.S.), Neurology (A.G., K.L.T., D.C.M.), Medicine (R.K.), Physical Medicine and Rehabilitation (T.A.N.), and Ophthalmology (L.E.D.), University of Alabama at Birmingham
| | - Daniel C Marson
- From the Departments of Psychology (K.A.S.), Neurology (A.G., K.L.T., D.C.M.), Medicine (R.K.), Physical Medicine and Rehabilitation (T.A.N.), and Ophthalmology (L.E.D.), University of Alabama at Birmingham.
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15
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Saber A, Tabatabaei SM, Akasheh G, Sehat M, Zanjani Z, Larijani B. Cross-Cultural Adaptations of the MacArthur Competence Assessment Tool for Treatment in Iran. ARCHIVES OF TRAUMA RESEARCH 2016; 5:e33464. [PMID: 27148503 PMCID: PMC4853637 DOI: 10.5812/atr.33464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 10/25/2015] [Accepted: 11/02/2015] [Indexed: 11/16/2022]
Abstract
Background According to general ethical and legal principles, valid consent must be obtained before starting any procedure. Objectives Due to the lack of a standard tool for assessing patients’ capacity to consent to medical treatment in Iran, the present study was carried out aiming to devise a Persian version of a cross-cultural adaptation of the MacArthur competence assessment tool. Patients and Methods By reviewing different methods of cultural translation and adaptation for assessment tools, and due to the lack of consensus on its processes, we selected Wild’s model as one of the most comprehensive methods in this regard. Wild’s (2005) 10-stage model includes preparation, forward translation, reconciliation of the forward translation, back translation of reconciliation, back translation review, cognitive debriefing and cognitive review, and finalization, proofreading and final reporting. Using this model, we translated the MacArthur assessment tool and made it adaptable to Iranian patients. Results The MacArthur assessment tool is not dependent on any specific culture and language. As a result, if translation and its scientific adaptation are done based on an integrated and detailed model, the tool can be used for every culture and language. In other words, this tool is not culture-specific; so, it is applicable in cases where a translation is needed, and it can be culturally adapted to suit different societies. Conclusions In the present study, we are able to focus on and prove the efficacy and benefits of this measurement tool.
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Affiliation(s)
- Ali Saber
- Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Seyed Mahmoud Tabatabaei
- Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
| | - Goodarz Akasheh
- Department of Psychiatry, Kashan University of Medical Sciences, Kashan, IR Iran
| | - Mojtaba Sehat
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, IR Iran
| | - Zahra Zanjani
- Department of Psychology, Kashan University of Medical Sciences, Kashan, IR Iran
| | - Bagher Larijani
- Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
- Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Bagher Larijani, Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences, Tehran, IR Iran. Tel: +98-2166419661, Fax: +98-2166953832, E-mail:
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16
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Triebel KL, Gerstenecker A, Meneses K, Fiveash JB, Meyers CA, Cutter G, Marson DC, Martin RC, Eakin A, Watts O, Nabors LB. Capacity of patients with brain metastases to make treatment decisions. Psychooncology 2015; 24:1448-55. [PMID: 25613039 PMCID: PMC4512930 DOI: 10.1002/pon.3753] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 11/21/2014] [Accepted: 12/18/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to investigate medical decision-making capacity (MDC) in patients with brain metastases. METHODS Participants were 41 adults with brain metastases with Karnofsky Performance Status scores of ≥70 who were recruited from an academic medical center and 41 demographically matched controls recruited from the community. We evaluated MDC using the Capacity to Consent to Treatment Instrument and its four clinically relevant consent standards (expressing a treatment choice, appreciation, reasoning, and understanding). Capacity impairment ratings (no impairment, mild/moderate impairment, and severe impairment) on the consent standards were also assigned to each participant with brain metastasis using cutoff scores derived statistically from the performance of the control group. RESULTS The brain metastasis patient group performed significantly below controls on consent standards of understanding and reasoning. Capacity compromise was defined as performance ≤1.5 standard deviations below the control group mean. Using this definition, approximately 60% of the participants with brain metastases demonstrated capacity compromise on at least one MDC standard. CONCLUSION When defining capacity compromise as performance ≤1.5 standard deviation below the control group mean, over half of patients with brain metastases have reduced capacity to make treatment decisions. This impairment is demonstrated shortly after initial diagnosis of brain metastases and highlights the importance of routine clinical assessment of MDC following diagnosis of brain metastasis. These results also indicate a need for the development and investigation of interventions to support or improve MDC in this patient population.
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Affiliation(s)
- Kristen L. Triebel
- Department of Neurology, UAB, Birmingham, AL
- Comprehensive Cancer Center, UAB, Birmingham, AL
| | | | - Karen Meneses
- Comprehensive Cancer Center, UAB, Birmingham, AL
- School of Nursing, UAB, Birmingham, AL
| | - John B. Fiveash
- Comprehensive Cancer Center, UAB, Birmingham, AL
- Department of Radiation Oncology, UAB, Birmingham, AL
| | - Christina A. Meyers
- Department of Neuro-Oncology, M.D. Anderson Cancer Center, Houston, TX (retired)
| | - Gary Cutter
- Department of Biostatistics, School of Public Health, UAB, Birmingham, AL
| | | | | | | | - Olivia Watts
- Department of Psychology, Boston University, Boston, MA
| | - Louis B. Nabors
- Department of Neurology, UAB, Birmingham, AL
- Comprehensive Cancer Center, UAB, Birmingham, AL
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17
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Gerstenecker A, Niccolai L, Marson D, Triebel KL. Enhancing Medical Decision-Making Evaluations: Introduction of Normative Data for the Capacity to Consent to Treatment Instrument. Assessment 2015; 23:232-9. [PMID: 26282778 DOI: 10.1177/1073191115599053] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A number of measures have been developed to assess medical decision-making capacity (MDC) in adults. However, their clinical utility is limited by a lack of available normative data. In the current study, we introduce age-independent and age-adjusted normative data for a measure of MDC: the Capacity to Consent to Treatment Instrument. The sample consisted of 308 cognitively normal, community-dwelling adults ranging in age from 19 to 86 years. For age-adjusted norms, individual raw scores were first converted to age-corrected scaled scores based on position within a cumulative frequency distribution and then grouped according to empirically supported age ranges. For age-independent norms, the same method was utilized but without age-corrections being applied or participants being grouped into age ranges. This study has the potential to enhance MDC evaluations by allowing clinicians to compare a patient's performance on the Capacity to Consent to Treatment Instrument with that of adults regardless of age as well as to same age peers. Tables containing normative corrections are supplementary material available online at http://asm.sagepub.com/supplemental.
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18
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Triebel KL, Martin RC, Novack TA, Dreer LE, Turner C, Kennedy R, Marson DC. Recovery over 6 months of medical decision-making capacity after traumatic brain injury. Arch Phys Med Rehabil 2014; 95:2296-303. [PMID: 25152169 DOI: 10.1016/j.apmr.2014.07.413] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 07/14/2014] [Accepted: 07/23/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate recovery of medical decision-making capacity (MDC) over 6 months in persons with traumatic brain injury (TBI) stratified by injury severity. DESIGN Longitudinal study comparing controls and patients with TBI 1 month after injury (t1) and 6 months after injury (t2). SETTING Inpatient TBI rehabilitation unit and outpatient neurology department. PARTICIPANTS Participants (N=151) consisted of control subjects (n=60) and patients with TBI (n=91) stratified by injury severity: mild TBI (mTBI; n=27), complicated mild TBI (cmTBI; n=20), and moderate/severe TBI (msevTBI; n=44). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We used the Capacity to Consent to Treatment Instrument to evaluate MDC performance on 5 consent standards (expressing choice, reasonable choice, appreciation, reasoning, and understanding). We also assigned capacity impairment ratings on the consent standards to each participant with TBI using cut scores referenced to control performance. RESULTS Control performance was stable across time on the consent standards. Patients with mTBI and cmTBI performed below controls on the understanding standard at t1 but not t2. Patients with msevTBI performed below controls on appreciation, reasoning, and understanding at t1, and on appreciation and understanding at t2, but showed substantial improvement over time. CONCLUSIONS Regardless of injury severity, all groups with TBI demonstrated baseline impairment of MDC with subsequent partial or full recovery of MDC over a 6-month period. However, a sizeable proportion of individual patients with TBI in each group continued to demonstrate capacity compromise at 6 months postinjury. Clinically, this finding suggests that individuals with TBI, regardless of injury severity, need continued monitoring regarding MDC for at least 6 months after injury.
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Affiliation(s)
- Kristen L Triebel
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Roy C Martin
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Thomas A Novack
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL
| | - Laura E Dreer
- Department of Ophthalmology, University of Alabama at Birmingham, Birmingham, AL
| | - Crystal Turner
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Richard Kennedy
- Division of Gerontology, Geriatrics and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Daniel C Marson
- Division of Neuropsychology, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL.
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19
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Ham TE, Bonnelle V, Hellyer P, Jilka S, Robertson IH, Leech R, Sharp DJ. The neural basis of impaired self-awareness after traumatic brain injury. ACTA ACUST UNITED AC 2013; 137:586-97. [PMID: 24371217 DOI: 10.1093/brain/awt350] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Self-awareness is commonly impaired after traumatic brain injury. This is an important clinical issue as awareness affects long-term outcome and limits attempts at rehabilitation. It can be investigated by studying how patients respond to their errors and monitor their performance on tasks. As awareness is thought to be an emergent property of network activity, we tested the hypothesis that impaired self-awareness is associated with abnormal brain network function. We investigated a group of subjects with traumatic brain injury (n = 63) split into low and high performance-monitoring groups based on their ability to recognize and correct their own errors. Brain network function was assessed using resting-state and event-related functional magnetic resonance imaging. This allowed us to investigate baseline network function, as well as the evoked response of networks to specific events including errors. The low performance-monitoring group underestimated their disability and showed broad attentional deficits. Neural activity within what has been termed the fronto-parietal control network was abnormal in patients with impaired self-awareness. The dorsal anterior cingulate cortex is a key part of this network that is involved in performance-monitoring. This region showed reduced functional connectivity to the rest of the fronto-parietal control network at 'rest'. In addition, the anterior insulae, which are normally tightly linked to the dorsal anterior cingulate cortex, showed increased activity following errors in the impaired group. Interestingly, the traumatic brain injury patient group with normal performance-monitoring showed abnormally high activation of the right middle frontal gyrus, putamen and caudate in response to errors. The impairment of self-awareness was not explained either by the location of focal brain injury, or the amount of traumatic axonal injury as demonstrated by diffusion tensor imaging. The results suggest that impairments of self-awareness after traumatic brain injury result from breakdown of functional interactions between nodes within the fronto-parietal control network.
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Affiliation(s)
- Timothy E Ham
- 1 C3NL, Centre for Restorative Neuroscience, Division of Brain Sciences, Department of Medicine, Imperial College London, Hammersmith Hospital Campus, Du Cane Road, London, W12 0NN, UK
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20
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Aggarwal NK, Ford E. The neuroethics and neurolaw of brain injury. BEHAVIORAL SCIENCES & THE LAW 2013; 31:789-802. [PMID: 24123245 DOI: 10.1002/bsl.2086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 07/18/2013] [Accepted: 07/30/2013] [Indexed: 06/02/2023]
Abstract
Neuroethics and neurolaw are fields of study that involve the interface of neuroscience with clinical and legal decision-making. The past two decades have seen increasing attention being paid to both fields, in large part because of the advances in neuroimaging techniques and improved ability to visualize and measure brain structure and function. Traumatic brain injury (TBI), along with its acute and chronic sequelae, has emerged as a focus of neuroethical issues, such as informed consent for treatment and research, diagnostic and prognostic uncertainties, and the subjectivity of interpretation of data. The law has also more frequently considered TBI in criminal settings for exculpation, mitigation and sentencing purposes and in tort and administrative law for personal injury, disability and worker's compensation cases. This article provides an overview of these topics with an emphasis on the current challenges that the neuroscience of TBI faces in the medicolegal arena.
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Affiliation(s)
- Neil Krishan Aggarwal
- New York State Psychiatric Institute, 1051 Riverside Drive, Unit 11, New York, NY, 10032, U.S.A.; Department of Psychiatry, Columbia University, 1051 Riverside Drive, Unit 11, New York, NY, 10032, U.S.A
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