The Neurobehavioural Rating Scale: replication in an acute, inpatient rehabilitation setting

Injured brain regions associated with anxiety in Vietnam veterans

Anxiety negatively affects quality of life and psychosocial functioning. Previous research has shown that anxiety symptoms in healthy individuals are associated with variations in the volume of brain regions, such as the amygdala, hippocampus, and the bed nucleus of the stria terminalis. Brain lesion data also suggests the hemisphere damaged may affect levels of anxiety. We studied a sample of 182 male Vietnam War veterans with penetrating brain injuries, using a semi-automated voxel-based lesion-symptom mapping (VLSM) approach. VLSM reveals significant associations between a symptom such as anxiety and the location of brain lesions, and does not require a broad, subjective assignment of patients into categories based on lesion location. We found that lesioned brain regions in cortical and limbic areas of the left hemisphere, including middle, inferior and superior temporal lobe, hippocampus, and fusiform regions, along with smaller areas in the inferior occipital lobe, parahippocampus, amygdala, and insula, were associated with increased anxiety symptoms as measured by the Neurobehavioral Rating Scale (NRS). These results were corroborated by similar findings using Neuropsychiatric Inventory (NPI) anxiety scores, which supports these regions' role in regulating anxiety. In summary, using a semi-automated analysis tool, we detected an effect of focal brain damage on the presentation of anxiety. We also separated the effects of brain injury and war experience by including a control group of combat veterans without brain injury. We compared this control group against veterans with brain lesions in areas associated with anxiety, and against veterans with lesions only in other brain areas.

Neural correlates of apathy revealed by lesion mapping in participants with traumatic brain injuries

Apathy, common in neurological disorders, is defined as disinterest and loss of motivation, with a reduction in self-initiated activity. Research in diseased populations has shown that apathy is associated with variations in the volume of brain regions such as the anterior cingulate and the frontal lobes. The goal of this study was to determine the neural signatures of apathy in people with penetrating traumatic brain injuries (pTBIs), as to our knowledge, these have not been studied in this sample. We studied 176 male Vietnam War veterans with pTBIs using voxel-based lesion-symptom mapping (VLSM) and apathy scores from the UCLA Neuropsychiatric Inventory (NPI), a structured inventory of symptoms completed by a caregiver. Our results revealed that increased apathy symptoms were associated with brain damage in limbic and cortical areas of the left hemisphere including the anterior cingulate, inferior, middle, and superior frontal regions, insula, and supplementary motor area. Our results are consistent with the literature, and extend them to people with focal pTBI. Apathy is a significant symptom since it can reduce participation of the patient in family and other social interactions, and diminish affective decision-making.

Neurobehavioural deficits after severe traumatic brain injury (TBI)

OBJECTIVES

Debilitating neurobehavioural sequalae often complicate traumatic brain injury (TBI). Cognitive deficits, particularly of attention, memory, information-processing speed and problems in self-perception, are very common following severe TBI.

METHOD

The Neurobehavioural Rating Scale (NRS) is a multi-dimensional clinical-based assessment instrument designed and validated to measure neurobehavioural disturbances following TBI. This study examined 41 patients who were admitted to the intensive care unit of the Department of General Neurosurgery at Cologne University Hospital after severe TBI between January 1995 and July 2003. All 27 items of the NRS were assessed 6 and 12 months post-injury.

RESULTS

Subjects after severe TBI (GCS<9) showed relatively high overall scores on the NRS, reflecting a high degree of overall neurobehavioural dysfunction. NRS items did not change significantly between 6 and 12 months post-trauma for anxiety, expressive deficit, emotional withdrawal, depressive mood, hostility, suspiciousness, fatigability, hallucinatory behaviour, motor retardation, unusual thought content, liability of mood and comprehension deficit. There was a tendency of improvement for inattention, somatic concern, disorientation, guilt feelings, excitement, poor planning and articulation deficits. For conceptual disorganization, disinhibition, memory deficit, agitation, inaccurate self-appraisal, decreased initiative, blunted affect and tension even a tendency for further deterioration in the post-traumatic follow-up was detected. Changes between 6 and 12 months post-TBI were statistically significant for disorientation (improvement), inattention/reduced alertness (improvement) and excitement (deterioration).

CONCLUSION

The data shows that neurobehavioural deficits after TBI do not show a general tendency to disappear over time. Some aspects related to self-appraisal, conceptual disorganization and affect may even deteriorate, thereby presenting a challenging problem for both the patients and relatives. This is in contrast to the parallel improvement of post-traumatic sensomotoric deficits.

The neurobehavioural rating scale-revised: sensitivity and validity in closed head injury assessment

OBJECTIVES

To investigate the factor structure and psychometric properties of the neurobehavioural rating scale-revised (NRS-R) and to determine its usefulness in clinical trials.

METHODS

A consecutive series of patients sustaining severe closed head injury were evacuated to one of 11 large regional North American trauma centres and entered into a randomised, phase III, multicentre clinical trial investigating the therapeutic use of moderate hypothermia. Acute care personnel were blinded to outcome and outcome personnel were blinded to treatment condition. The Glasgow outcome scale (GOS) was the primary outcome measure. Secondary outcome measures included the disability rating scale (DRS) and the NRS-R.

RESULTS

Exploratory factor analysis of NRS-R data collected at 6 months after injury (n=210) resulted in a five factor model including: (1) executive/cognition, (2) positive symptoms, (3) negative symptoms, (4) mood/affect, and (5) oral/motor. These factors showed acceptable internal consistency (0.62 to 0.88), low to moderate interfactor correlations (0.19 to 0.61), and discriminated well between GOS defined groups. Factor validity was demonstrated by significant correlations with specific neuropsychological domains. Significant change was measured from 3 to 6 months after injury for the total score (sum of all 29 item ratings) and all factor scores except mood/affect and positive symptoms. The total score and all factor scores correlated significantly with concurrent GOS and DRS scores.

CONCLUSIONS

The NRS-R is well suited as a secondary outcome measure for clinical trials as its completion rate exceeds that of neuropsychological assessment and it provides important neurobehavioural information complementary to that provided by global outcome and neuropsychological measures.

Aggressive behaviour in the elderly

In this paper, the literature on aggressive behaviour in the elderly is reviewed, with emphasis on: definition; study samples; patient groups; study designs and methodology; data collection; instruments used to measure aggressive behaviour; social, clinical, demographic and biological correlates; prevalence and rates; precipitants; outcome; site; timing; daily and seasonal variation; patterns of usage of hospitals and other institutions; stuffing levels, staff morale, staff attitudes, staff training and other staffing factors.

Validity of the functional independence measure for persons with traumatic brain injury

OBJECTIVE

Replicate and extend studies of the construct validity of the Functional Independence Measure (FIM) for persons with traumatic brain injury (TBI).

DESIGN

A cross-sectional study of admissions to acute rehabilitation evaluated 6 months to 5 years after discharge.

SETTING

An inpatient brain injury rehabilitation unit in a large, academic medical center.

SUBJECTS

Ninety-five patients with primary diagnosis of TBI stratified by time postdischarge.

MAIN OUTCOME MEASURES

Prediction of (1) average daily minutes of assistance and (2) supervision required in comparison to the Sickness Impact Profile (SIP) and SF-36.

RESULTS

The FIM was highly predictive of minutes of assistance (83% accuracy), supervision (82% accuracy), and the need for either type of assistance (78% accuracy). Prediction was only minimally improved by measures of neurobehavioral impairment. The accuracy of the FIM was superior to the SIP and SF-36.

CONCLUSIONS

Results provided substantial support for the validity of the FIM as a measure of functional independence for persons with TBI. The importance of supervision as a type of assistance required after TBI was evident, with the FIM highly predictive of this need, as well.

Indicators of long-term family functioning following severe traumatic brain injury in adults

This study investigated the degree of association between four sets of predictor variables (demographic, injury-related, patient functioning, and caregiver functioning variables) and the criterion variable of long-term family functioning following severe traumatic brain injury (TBI). Thirty families participated in the study and a minimum of 3.5 years had elapsed since the time of injury. The mean length of post-traumatic amnesia (PTA) for the brain-injured individuals was 92.4 days. Data collection took place in the family home and both the brain-injured family members and primary caregivers were involved. Standard regression analyses revealed that two sets of variables accounted for a significant amount of variance in long-term family functioning. The largest amount of variance, 55% (44% adjusted), was accounted for by the caregivers' self-report variables which measured caregivers' depression, social support, and coping as well as caregivers' preceptions of patient competency. Overall, measures of severity of injury (PTA), residual neurobehavioural function, and adequacy of social support for caregivers proved to be reliable and significant indicators of family functioning. These findings are discussed with respect to their implications for service delivery and long-term provision of support for caregivers of severely brain-injured individuals living with their families.

The agitated brain injured patient. Part 1: Definitions, differential diagnosis, and assessment

This two-part review provides a critical analysis of the scientific and clinical literature on the agitated brain injured patient. Part 1 reviews nomenclature and classification issues, differential diagnosis, and assessment instruments designed for evaluation of the patient. Pathophysiology and treatment approaches will be discussed in Part 2 in a subsequent issue of the Archives. The review was unfortunately hampered by a lack of consistency in definitions, little scientific study of the neuroanatomic and neurochemical basis for the disorder, few outcome studies, and no randomized controlled treatment trials. Part 1 sets forth an interdisciplinary definition of agitation, establishes a differential diagnostic approach, and describes and critiques the assessment instruments available for clinical evaluation of the agitated patient. Part 2 will address treatment interventions including pharmacological, environmental, and behavioral approaches to this patient population.

The Neurobehavioral Rating Scale: reliability in patients with dementia

Precise measurement of cognitive, psychiatric, and behavioral symptoms is essential to understanding clinical, pathophysiologic, and treatment aspects of Alzheimer's disease and other dementing illnesses. The Neurobehavioral Rating Scale (NRS) is a 28-item observer-rated instrument that measures a broad range of cognitive and noncognitive symptoms. The interrater reliability of the NRS was examined in 15 patients with dementia. The correlation coefficient for the NRS total scores was .93. Coefficients for NRS factor scores and individual item scores were also satisfactory. Correlations for measures of subjectively experienced symptoms were acceptable, but less robust than measures of cognition and observable behavior. These results support the reliability of the NRS for multidimensional assessment of patients with dementia.

Assessment of cognitive, psychiatric, and behavioral disturbances in patients with dementia: the Neurobehavioral Rating Scale

OBJECTIVE

To assess the validity of the Neurobehavioral Rating Scale (NRS) in patients with Alzheimer's disease (AD) or multi-infarct dementia (MID) and to characterize the cognitive, psychiatric, and behavioral disturbances that occur in these patients.

DESIGN

Cross-sectional evaluation.

SETTING

West Los Angeles VAMC Geropsychiatry Inpatient Unit, Neurobehavior Inpatient Unit, and Dementia Clinic; UCLA Alzheimer's Disease Clinic.

PATIENTS

Convenience sample of 61 patients with AD and 22 patients with MID.

MAIN OUTCOME MEASURE

The NRS, a 27-item observer-rated instrument that measures cognitive, psychiatric, and behavioral disturbances.

RESULTS

The NRS demonstrated content and convergent validity in this patient group. Principal components analysis of the NRS ratings identified a six-factor solution, and each factor contained clinically related symptoms. The factors were Cognition/Insight, Agitation/Disinhibition, Behavioral Retardation, Anxiety/Depression, Verbal Output Disturbance, and Psychosis. Among the patients with AD, agitation, disinhibition, hostility, poor insight, poor motivation, suspiciousness, and delusions were more severe in patients with more advanced dementia. Depressive symptoms occurred with equal severity in patients with mild and advanced dementia, but depressed mood was more severe in patients with earlier age of onset of AD.

CONCLUSION

The NRS is a useful instrument for structured assessment of a broad range of cognitive, psychiatric, and behavioral disturbances in patients with dementia.