Investigating the discrepancy between subjective and objective cognitive impairment following acquired brain injury: The role of psychological affect

Attribution of neuropsychiatric symptoms and prioritisation of evidence in the diagnosis of neuropsychiatric lupus: mixed methods analysis of patient and clinician perspectives from the international INSPIRE study

OBJECTIVE

Neuropsychiatric lupus (NPSLE) is challenging to diagnose. Many neuropsychiatric symptoms, such as headache and hallucinations, cannot be verified by tests or clinician assessment. We investigated prioritisations of methods for diagnosing NPSLE and attributional views.

METHODS

Thematic and comparative analyses were used to investigate how clinicians prioritise sources of evidence from a 13-item list, and explore discordances in clinician and patient perspectives on attribution.

RESULTS

We identified high levels of variability and uncertainty in clinicians' assessments of neuropsychiatric symptoms in SLE patients. In attributional decisions, clinicians (surveys n = 400, interviews n = 50) ranked clinicians' assessments above diagnostic tests (many of which they reported were often unenlightening in NPSLE). Clinicians ranked patient opinion of disease activity last, and 46% of patients reported never/rarely having been asked if their SLE was flaring, despite experienced patients often having "attributional insight". SLE Patients (surveys n = 676, interviews n = 27) estimated higher attributability of neuropsychiatric symptoms to the direct effects of SLE on the nervous system than clinicians (p < 0.001 for all symptoms excluding mania), and 24% reported that their self-assessment of disease activity was never/rarely concordant with their clinicians. Reports of misattributions were common, particularly of non-verifiable diffuse symptoms. Terminology differed between clinicians and influenced attribution estimates.

CONCLUSION

NPSLE diagnostic tests and clinician assessments have numerous limitations, particularly in detecting diffuse neuropsychiatric symptoms that can be directly attributable and benefit from immunosuppression. Our findings suggest that incorporating patient attributional insights-although also subject to limitations-may improve attribution decision-making. Consensus regarding terminology and interpretations of "direct attributability" is required.

Long-term cognitive performance and its relation to anti-inflammatory therapy in a cohort of survivors of severe COVID-19

Background and objectives

Long-term cognitive performance data in former critically ill COVID-19 patients are sparse. Current evidence suggests that cognitive decline is related to neuroinflammation, which might be attenuated by COVID-19 related anti-inflammatory therapies. The objective of this prospective cohort study was to study long term cognitive outcomes following severe COVID-19 and the relation to anti-inflammatory therapies.

Methods

Prospective observational cohort of patients that survived an intensive care unit (ICU) admission due to severe COVID-19. Six months after hospital discharge, we extensively assessed both objective cognitive functioning and subjective cognitive complaints. Furthermore, patients were stratified in cohorts according to their anti-inflammatory treatment (i.e. no immunomodulatory therapy, dexamethasone, or both dexamethasone and interleukin-6 receptor antagonist tocilizumab).

Results

96 patients were included (March 2020–June 2021, median [IQR] age 61 [55–69] years). 91% received invasive mechanical ventilation, and mean ± SD severity-of-disease APACHE–II–score at admission was 15.8 ± 4.1. After 6.5 ± 1.3 months, 27% of patients scored cognitively impaired. Patients that did or did not develop cognitive impairments were similar in ICU-admission parameters, clinical course and delirium incidence. Patients with subjective cognitive complaints (20%) were more likely women (61% vs 26%), and had a shorter ICU stay (median [IQR] 8 [5–15] vs 18 [9–31], p = 0.002). Objective cognitive dysfunction did not correlate with subjective cognitive dysfunction. 27% of the participants received dexamethasone during intensive care admission, 44% received additional tocilizumab and 29% received neither. Overall occurrence and severity of cognitive dysfunction were not affected by anti-inflammatory therapy, although patients treated with both dexamethasone and tocilizumab had worse executive functioning scores (Trail Making Test interference) than patients without anti-inflammatory treatment (T-score 40.3 ± 13.5 vs 49.1 ± 9.3, p = 0.007).

Discussion

A relevant proportion of critically ill COVID-19 patients shows deficits in long-term cognitive functioning. Apart from more pronounced executive dysfunction, overall, anti-inflammatory therapy appeared not to affect long-term cognitive performance. Our findings provide insight in long-term cognitive outcomes in patients who survived COVID-19, that may facilitate health-care providers counseling patients and their caregivers.

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Up to a third of survivors of severe COVID-19 develops long-term cognitive impairment.

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Subjective cognitive complaints six months following severe COVID-19 do not correlate with objective cognitive impairment.

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COVID-19 related immunomodulatory therapy is not associated with the overall incidence of cognitive dysfunction.

The effectiveness of cognitive behaviour therapy for reducing anxiety symptoms following traumatic brain injury: A meta-analysis and systematic review

BACKGROUND

Anxiety is a common neuropsychological sequela following traumatic brain injury (TBI). Cognitive Behaviour Therapy (CBT) is a recommended, first-line intervention for anxiety disorders in the non-TBI clinical population, however its effectiveness after TBI remains unclear and findings are inconsistent.

OBJECTIVE

There are no current meta-analyses exploring the efficacy of CBT as an intervention for anxiety symptoms following TBI, using controlled trials. The aim of the current study, therefore, was to systematically review and synthesize the evidence from controlled trials for the effectiveness of CBT for anxiety, specifically within the TBI population.

METHOD

Three electronic databases (Web of Science, PubMed and PsycInfo) were searched and a systematic review of intervention studies utilising CBT and anxiety related outcome measures in a TBI population was performed through searching three electronic databases. Studies were further evaluated for quality of evidence based on Reichow's (2011) quality appraisal tool. Baseline and outcome data were extracted from the 10 controlled trials that met the inclusion criteria, and effect sizes were calculated.

RESULTS

A random effects meta-analysis identified a small overall effect size (Cohen's d) of d = -0.26 (95%CI -0.41 to -0.11) of CBT interventions reducing anxiety symptoms following TBI.

CONCLUSIONS

This meta-analysis tentatively supports the view that CBT interventions may be effective in reducing anxiety symptoms in some patients following TBI, however the effect sizes are smaller than those reported for non-TBI clinical populations. Clinical implications and limitations of the current meta-analysis are discussed.

Subjective cognitive rigidity and attention to detail: A cross-cultural validation of the Detail and Flexibility Questionnaire (DFlex) in a French clinical sample

Introduction: People diagnosed with Anorexia Nervosa (AN) are at risk for poor cognitive flexibility and excessive attention to detail. These difficulties are traditionally quantified using neuropsychological tests. These tests do not capture the subjective repercussions of these cognitive styles. The Detail and Flexibility Questionnaire (DFlex) has been specifically developed to measure these repercussions. The aim of this study was to evaluate the psychometric properties of the French version of this scale (F-DFlex) and to adapt it if needed. Methods: The instrument factor structure, internal consistency, convergent, and discriminant validity were assessed in a sample of 107 French women AN inpatients. For convergent validity, associations between F-DFlex scores, perceived levels of autistic traits (Autism Quotient questionnaire - AQ) and eating disorders symptomatology (Eating Disorder Examination Questionnaire - EDE-Q), as well as neuropsychological evaluations (Wisconsin Card Sorting Test - WCST, Rey Complex Figure - RCF) were tested. Discriminant validity was assessed by comparing F-DFlex scores of the patients with a chronic versus non-chronic illness. Results: The results of the exploratory factorial analysis led to the removal of four items. Internal consistency indices of this shortened version were good. Correlation coefficients directions and values between F-DFlex factors and relevant AQ Switching and Detail subscores were satisfactory, indicating good convergent validity. F-DFlex Rigidity scores were associated with the WCST percentage of perseverative errors, but the F-DFlex Attention to Detail scores were not associated with the RCF central coherence index. F-DFlex scores were associated with the severity of eating disorders symptomatology independently of BMI, illness duration, or anxiety, and depression. Conclusion: This study indicates good psychometric properties of this new version of the DFlex. The F-DFlex appears as a promising self-report screening tool of important cognitive dimensions for use in clinical management of people diagnosed with AN.

Building the bond: Predictors of the alliance in neurorehabilitation

BACKGROUND

Neurorehabilitation services are often delivered through group psycho-education programmes. However, little is known about the therapeutic process at work during such sessions. The present study is the first to gain insight into the therapeutic alliance, during a seven-session group programme. In addition, cognitive, emotional, and demographic predictors of the alliance, and participants' feelings towards their group members, were investigated, together with predictors of patient engagement.

METHODS

Forty-five participants with an acquired brain injury completed a series of questionnaires, and neuropsychological assessment, following group psycho-education. The group facilitator completed a parallel therapeutic alliance questionnaire, and rated participants' engagement.

RESULTS

Results demonstrated that a strong alliance can be formed in seven group sessions. Notably, no demographic or cognitive factors appear to pose a barrier to developing a therapeutic alliance, nor to group attraction.

CONCLUSION

High levels of depression, however, may be a challenge, and clinicians may need to tailor their clinical skills to ensure a good therapeutic relationship with such patients. To promote engagement, clinicians may also need to provide additional support to patients with lower levels of education, working memory, and episodic memory impairment.

Subjective Cognitive Decline and Related Cognitive Deficits

Since late stage dementia, including Alzheimer's disease (AD), cannot be reversed by any available drugs, there is increasing research interest in the preclinical stage of AD, i.e., subjective cognitive decline (SCD). SCD is characterized by self-perceptive cognitive decline but is difficult to detect using objective tests. At SCD stage, the cognitive deficits can be more easily reversed compared to that of mild cognitive impairment (MCI) and AD only if accurate diagnosis of SCD and early intervention can be developed. In this paper, we review the recent progress of SCD research including current assessment tools, biomarkers, neuroimaging, intervention and expected prognosis, and the potential relevance to traumatic brain injury (TBI)-induced cognitive deficits.

Exendin-4 attenuates pain-induced cognitive impairment by alleviating hippocampal neuroinflammation in a rat model of spinal nerve ligation

Glucagon-like peptide-1 receptor has anti-apoptotic, anti-inflammatory, and neuroprotective effects. It is now recognized that the occurrence and development of chronic pain are strongly associated with anti-inflammatory responses; however, it is not clear whether glucagon-like peptide-1 receptor regulates chronic pain via anti-inflammatory mechanisms. We explored the effects of glucagon-like peptide-1 receptor on nociception, cognition, and neuroinflammation in chronic pain. A rat model of chronic pain was established using left L5 spinal nerve ligation. The glucagon-like peptide-1 receptor agonist exendin-4 was intrathecally injected into rats from 10 to 21 days after spinal nerve ligation. Electrophysiological examinations showed that, after treatment with exendin-4, paw withdrawal frequency of the left limb was significantly reduced, and pain was relieved. In addition, in the Morris water maze test, escape latency increased and the time to reach the platform decreased following exendin-4 treatment. Immunohistochemical staining and western blot assays revealed an increase in the numbers of activated microglia and astrocytes in the dentate gyrus of rat hippocampus, as well as an increase in the expression of tumor necrosis factor alpha, interleukin 1 beta, and interleukin 6. All of these effects could be reversed by exendin-4 treatment. These findings suggest that exendin-4 can alleviate pain-induced neuroinflammatory responses and promote the recovery of cognitive function via the glucagon-like peptide-1 receptor pathway. All experimental procedures and protocols were approved by the Experimental Animal Ethics Committee of Renmin Hospital of Wuhan University of China (approval No. WDRM 20171214) on September 22, 2017.

Objective and subjective cognitive functioning in relation to psychopathology among women with early psychosis

BACKGROUND

Subjective cognitive impairment (SCI) among early psychosis is under-recognized and under-studied. However, SCI is as important as objective impairment to be understood, since it assesses cognitive difficulties in real-life situations from a personal perspective and is therefore an essence of individualized medicine. This study aims to explore the associations between the objective and subjective measures of cognitive impairments and to identify factors contributing to SCI among people with early psychosis.

METHODS

Participants were 60 females (mean age 24.57 ± 8.28) who had a diagnosis of psychotic-spectrum disorder within 5 years. They completed a battery of neuropsychological tests assessing a range of cognitive functions including verbal learning, memory, attention, and executive functions. The Subjective Cognitive Impairment Scale (SCIS) was used to assess their perceived cognitive decline. Psychotic symptoms and depression were also assessed.

RESULTS

SCIS was not correlated with any of the objective cognitive tests results. It was positively correlated with depression and positive symptoms. A hierarchical multiple regression model revealed that positive symptoms and depression together explained 31.9% of the total variance in SCIS and only depression significantly predicted SCI. Performances on the memory tests were correlated with, and predicted by negative symptoms.

CONCLUSIONS

There was no correlation between SCI and objective cognitive performances in patients with early psychosis. Treatments should not only focus on symptomatic remission and performance of cognitive tests, but also place emphasis on improving moods and subjective cognitive functions of individuals with early psychosis.

Clinical and cost effectiveness of memory rehabilitation following traumatic brain injury: a pragmatic cluster randomized controlled trial

OBJECTIVE

To evaluate the clinical and cost effectiveness of a group-based memory rehabilitation programme for people with traumatic brain injury.

DESIGN

Multicentre, pragmatic, observer-blinded, randomized controlled trial in England.

SETTING

Community.

PARTICIPANTS

People with memory problems following traumatic brain injury, aged 18-69 years, able to travel to group sessions, communicate in English, and give consent.

INTERVENTIONS

A total of 10 weekly group sessions of manualized memory rehabilitation plus usual care (intervention) vs. usual care alone (control).

MAIN MEASURES

The primary outcome was the patient-reported Everyday Memory Questionnaire (EMQ-p) at six months post randomization. Secondary outcomes were assessed at 6 and 12 months post randomization.

RESULTS

We randomized 328 participants. There were no clinically important differences in the primary outcome between arms at six-month follow-up (mean EMQ-p score: 38.8 (SD 26.1) in intervention and 44.1 (SD 24.6) in control arms, adjusted difference in means: -2.1, 95% confidence interval (CI): -6.7 to 2.5, p = 0.37) or 12-month follow-up. Objectively assessed memory ability favoured the memory rehabilitation arm at the 6-month, but not at the 12-month outcome. There were no between-arm differences in mood, experience of brain injury, or relative/friend assessment of patient's everyday memory outcomes, but goal attainment scores favoured the memory rehabilitation arm at both outcome time points. Health economic analyses suggested that the intervention was unlikely to be cost effective. No safety concerns were raised.

CONCLUSION

This memory rehabilitation programme did not lead to reduced forgetting in daily life for a heterogeneous sample of people with traumatic brain injury. Further research will need to examine who benefits most from such interventions.

Depression, memory and electroconvulsive therapy

SummaryCurrent neuroscience suggests that although short-term memory difficulties frequently occur immediately after electroconvulsive therapy (ECT), longer-term problems are less common. However, gaps in our knowledge remain regarding longer-term cognitive problems after ECT, including memory function. Some of these relate to the complexities surrounding cognitive testing and interpretation of test results. An important question in clinical decision-making is why, despite current evidence suggesting long-term memory problems are less frequent, some patients still report subjective memory difficulties. To further advance clinical practice and the neuroscience surrounding post-ECT cognitive function, assessment of cognitive function, possibly including neuropsychological testing, should potentially become more routine as part of clinical practice.Declaration of interestNone.