The Insight Interview: A new tool for measuring deficits in awareness after traumatic brain injury

Identifying and Addressing Functional Communication Challenges in Patients With Behavioral Variant Frontotemporal Dementia

PURPOSE

We describe the communication challenges of four patients with a neurodegenerative disorder consistent with behavioral variant frontotemporal dementia (bvFTD), characterized by early behavioral and personality changes. By describing their clinical profiles, we identify common barriers to functional communication in this population and provide recommendations for how speech-language pathologists (SLPs) might contribute to minimizing them.

METHOD

Four patients with bvFTD were selected from a cohort of patients with progressive communication impairments. Three of them returned for at least one follow-up visit. Case histories are presented along with the results of comprehensive speech and language, neuropsychological, and neurological testing.

RESULTS

At the time of initial evaluation, patients were between the ages of 54 and 66 years and had been experiencing symptoms for 1.5-6 years. Consistent with their bvFTD diagnoses, all patients had prominent behavioral and personality changes that impacted communication. Patients 1 and 2 also had mild aphasia at enrollment, primarily characterized by anomia and loss of word meaning. Patients 3 and 4 both had apraxia of speech and moderate-to-severe aphasia at enrollment with prominent anomia and agrammatism. All four patients had impaired executive functioning and relative sparing of visuospatial skills; episodic memory was also impaired for Patients 2 and 4. Even though functional communication was progressively limited for all patients, none of them received regular support from an SLP.

CONCLUSIONS

This case series adds to a scant, but growing, literature demonstrating that patients with bvFTD have communication impairments. SLPs are uniquely positioned to identify barriers to functional communication and to provide tailored strategy training to the patients and their care partners over the course of their disease. Systematic evaluation of the efficacy of treatment in this population would be valuable.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.25933762.

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.

Online awareness: a concept analysis and review of assessment approaches for adults with neurological conditions

PURPOSE

Self-awareness is a multifaceted phenomenon that comprises two main concepts: general awareness and online awareness. The latter is an emerging concept that requires further consensus on its definition. The aim of this paper is to define the key components of online awareness and identify approaches for measuring this concept for adults with neurological conditions.

MATERIALS AND METHODS

Concept analysis using Rodgers' evolutionary method was used to systematically review and summarise relevant literature. Papers were included if they provided a definition of online awareness or method for assessing online awareness for an adult neurological population.

RESULTS

Fifty-six papers were included in this review, with 21 online awareness assessment approaches identified. Online awareness was described to occur within the context of task performance, with the definition framework comprising four main aspects: 1/appraisal; 2/anticipation and prediction; 3/monitoring; and 4/self-evaluation. Self-regulation is a related concept that is considered to sit outside the conceptual boundaries of online awareness.

CONCLUSIONS

The findings of this analysis highlight the complexity of online awareness and its importance in rehabilitation. Psychometrically robust measures of online awareness that are inclusive of the essential elements of this concept are needed to advance practice in this area.

Assessment of impaired self-awareness after moderate-to-severe traumatic brain injury: a comparison of assessment tools

OBJECTIVE

To compare different assessment methods of impaired self-awareness (ISA).

METHODS

We included 37 patients with moderate-to-severe traumatic brain injury (TBI) at a subacute/chronic stage, and 33 healthy controls. ISA was assessed with three methods: discrepancy scores (comparison between patient and proxy ratings) on three scales (Patient Competency Rating Scale (PCRS), Awareness Questionnaire (AQ) and Dysexecutive Questionnaire (DEX)); clinician rating with the Self-Awareness of Deficits Interview (SADI); and the difference between prediction or estimation of performance and actual performance on two cognitive tasks.

RESULTS

Clinician-patient discrepancy scores appeared more sensitive than relative-patient discrepancy. The AQ was the most sensitive. The discrepancy scores were strongly correlated one with each other. Correlations with the SADI were weaker. Patients did not overestimate their performance on cognitive tasks, and the prediction did not significantly correlate with other measures of ISA.

DISCUSSION/CONCLUSION

Results support the multidimensional nature of ISA: discrepancy scores assess meta-cognitive knowledge (understanding that a function/skill is affected), while the SADI takes into account anticipatory awareness (ability to set realistic goals) and estimation of performance assesses anticipatory and situational awareness. Assessment of these different domains may provide a comprehensive overview of an individual's self-awareness.

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

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

Measures of self-regulation used in adult rehabilitation populations: A systematic review and content screening

Objective

We aimed to identify generic measures of self-regulation and to examine the degree to which these measures fit a recently developed conceptual model of self-regulation in a rehabilitation context.

Data sources

Pubmed, Embase, PsycInfo, and CINAHL were searched.

Review methods

Articles were included if they were published between January 2015 and August 2020 and reported on empirical studies (trials and observational studies) using a measure of self-regulation or a related concept, in an adult rehabilitation population. Main content was analysed by linking all items of the selected measures to one or more of the six sub-themes of self-regulation: (1) insight into physical and cognitive impairments, (2) insight into the consequences of the impairments, (3) insight into abilities, (4) to be able to communicate limitations, (5) trust in body and functioning, and (6) make use of abilities.

Results

Two reviewers independently screened 7808 abstracts, resulting in the inclusion of 236 articles. In these articles, 80 different measures were used to assess self-regulation or related concept. Nineteen of these measures met the inclusion criteria and were included for the content analyses. Nine of these were self-efficacy measures. No measures covered four or more of the six sub-themes of self-regulation. The three sub-themes on gaining insights were covered less compared to the sub-domains ‘trust’ and ‘make use of abilities’.

Conclusions

Many measures on self-regulation exist None of these measures cover all six sub-themes of self-regulation considered important to measure self-regulation as a rehabilitation outcome.

Assessing alexithymia in adults with acquired brain injury: Psychometric properties of the Perth Alexithymia Questionnaire

BACKGROUND

Alexithymia is a multidimensional personality trait comprised of difficulty identifying feelings, difficulty describing feelings, and externally orientated thinking. The assessment of alexithymia in people with acquired brain injury (ABI) is of clinical interest because alexithymia is linked to poor psychosocial functioning and community reintegration after ABI. To date, alexithymia measures have not been psychometrically investigated/validated in an ABI sample, restricting confident empirical work in this area. We aimed to fill this gap by assessing the psychometric properties of the Perth Alexithymia Questionnaire (PAQ) in adults with ABI and determining whether the alexithymia construct manifests similarly in ABI samples compared to the general community.

METHODS

The PAQ and Depression Anxiety Stress Scales-21 were administered to an ABI sample (N = 350) and a community sample (N = 1012). Factor structure, measurement invariance, internal consistency reliability, and concurrent/discriminant validity were explored.

RESULTS

Our confirmatory factor analysis of the PAQ supported the intended five-factor correlated model as the best solution, where items loaded well onto the five intended subscales. This factor structure was invariant across ABI and community samples. Good reliability and concurrent and discriminant validity were also established.

LIMITATIONS

The PAQ is a self-report measure and may be impacted by insight deficits known to occur after ABI.

CONCLUSION

Our data suggests that the PAQ has good validity and reliability as a measure of alexithymia. The latent structure of alexithymia manifests similarly in ABI and community samples. This study provides the first psychometric foundation for confident assessment of alexithymia in ABI.

Intellectual awareness of naming abilities in people with chronic post-stroke aphasia

Anosognosia, or lack of self-awareness, is often present following neurological injury and can result in poor functional outcomes. The specific phenomenon of intellectual awareness, the knowledge that a function is impaired in oneself, has not been widely studied in post-stroke aphasia. We aim to identify behavioral and neural correlates of intellectual awareness by comparing stroke survivors' self-reports of anomia to objective naming performance and examining lesion sites. Fifty-three participants with chronic aphasia without severe comprehension deficits rated their naming ability and completed a battery of behavioral tests. We calculated the reliability and accuracy of participant self-ratings, then examined the relationship of poor intellectual awareness to speech, language, and cognitive measures. We used support vector regression lesion-symptom mapping (SVR-LSM) to determine lesion locations associated with impaired and preserved intellectual awareness. Reliability and accuracy of self-ratings varied across the participants. Poor intellectual awareness was associated with reduced performance on tasks that rely on semantics. Our SVR-LSM results demonstrated that anterior inferior frontal lesions were associated with poor awareness, while mid-superior temporal lesions were associated with preserved awareness. An anterior-posterior gradient was evident in the unthresholded lesion-symptom maps. While many people with chronic aphasia and relatively intact comprehension can accurately and reliably report the severity of their anomia, others overestimate, underestimate, or inconsistently estimate their naming abilities. Clinicians should consider this when administering self-rating scales, particularly when semantic deficits or anterior inferior frontal lesions are present. Administering self-ratings on multiple days may be useful to check the reliability of patient perceptions.

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.

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

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

Entrevista semi-estructurada para la evaluación de la conciencia de enfermedad oncológica E-CEO. Estudio de fiabilidad sobre una muestra de pacientes con enfermedad avanzada

Objetivo: La comunicación entre pacientes oncológicos y profesionales de la salud se considera uno de los aspectos más importantes del cuidado, especialmente en fases avanzadas de la enfermedad. La conciencia de enfermedad consistiría en un proceso dinámico y cambiante en el tiempo, influenciado por la cantidad y calidad de la información y el significado que cada sujeto le asigna. En el presente trabajo se describe el proceso de diseño, validación y cálculo de la fiabilidad de una entrevista semiestructurada (Entrevista sobre la Conciencia de Enfermedad Oncológica E-CEO). Este instrumento, escasamente invasivo y no revelador de información, permite situar a los sujetos a lo largo de un continuum en base a su percepción de severidad de la enfermedad. Método: En una primera fase se realizó una entrevista abierta sobre 15 pacientes y se elaboró un listado de expresiones clave, que fueron agrupadas en cinco categorías. En una segunda fase se aplicó un modelo de entrevista semiestructurada a 42 pacientes ingresados con diagnóstico de enfermedad oncológica avanzada (estadio clínico IV) en la Unidad de Hospitalización de Oncología del Hospital de A Coruña. Resultados: La fiabilidad obtenida entre diferentes observadores muestra que se trata de un instrumento de elevada calidad (Kappa=0,70). Los datos reflejan una discrepancia amplia entre el estado de salud de los pacientes y su propia consideración. Más del 50% consideraron su enfermedad “controlada”. Conclusiones: Se trata de un instrumento de sencilla aplicación que permitirá en futuras investigaciones profundizar en el estudio de los procesos de integración de información en este tipo de pacientes.