Apathy and depressed mood in acquired brain damage: relationship to lesion localization and psychophysiological reactivity

BACKGROUND

Apathy is a frequent neurobehavioural sequel in patients with acquired brain damage and it may seriously affect outcome of rehabilitation.

METHODS

Patients with traumatic brain injury, cerebrovascular insults and hypoxic brain injury, categorized into four lesion localization groups: left hemisphere damage (LHD); right hemisphere damage (RHD); bilateral hemispheric damage (BHD); and subcortical damage (SCD) were assessed with the Apathy Evaluation Scale (AES) and Montgomery and Asberg Depression Rating Scale (MADRS). Heart rate and electrodermal activity were recorded in an experimental situation that exposed the patients to mental stressors in order to measure psychophysiological reactivity.

RESULTS

Significant differences in level of apathy were found between diagnostic groups as well as between localization subgroups. SCD and RHD patients displayed most apathy. Factor analysis of MADRS revealed a three-factor solution; depressed mood, somatic symptoms and negative symptoms. Apathy was significantly correlated with negative symptoms in all localization subgroups, except among the BHD patients. Apathy was not correlated with depressed mood or somatic symptoms. Moreover, apathy was significantly correlated with heart rate reactivity, but not with electrodermal reactivity.

CONCLUSION

Apathy is common, its severity depending on diagnosis and localization of lesion. Apathy and depression in brain damaged patients share common features, but may be differentiated. The significant relationship between apathy and heart rate may provide a psychophysiological correlation of the disengagement, lack of interest and absence of emotional responsivity typically seen in apathy. The results have implications for the theoretical understanding of apathy and related negative symptoms, and for rehabilitation practice.

[Hypoxic brain damage after carbon monoxide poisoning. Visual agnosia, reduced initiative and memory and delayed sequelae]

Four patients with hypoxic brain damage caused by carbon monoxide poisoning are described. Three of these had attempted suicide with car exhaust fumes. Two patients had visual agnosia due to lesions in the parieto-occipital cortex. Three patients had temporary Parkinsonian symptoms. In two of these patients CT and MRI showed lesions in the globus pallidus. They also showed reduced initiative, and in one patient this was combined with minor tics and obsessive symptoms. One patient had impaired memory as the only symptom. The patient with the longest lasting exposure developed delayed sequelae; three weeks after the poisoning he became apathetic and confused, with failing memory, Parkinsonian symptoms, and urinary and faecal incontinence. MRI showed demyelination in the periventricular white matter. His condition started to improve two months after the accident.

[Delayed symptoms of hypoxic brain damage after temporary improvement]

A shipyard worker was doing welding work inside a pipe with argon as cover gas. After taking a break he fainted while controlling the weld, also inside the pipe. He was rescued after 15-20 minutes and regained consciousness after a few hours. Two days later he was discharged from hospital in apparently good health. After a week he returned to the hospital suffering from confusion, failing memory, aphasia, apraxia and urinary incontinence. MR showed elevated signal intensity bilaterally in the caudate nucleus. He improved gradually and six months later was given less demanding work. The course of his illness is consistent with delayed neuropsychiatric sequelae after hypoxia, probably due to displacement of oxygen by argon. Delayed symptoms are caused by demyelination in the subcortical white matter.

Team development and memory training in traumatic brain injury rehabilitation: two birds with one stone

The need for developing team cooperation procedures when treating patients with traumatic brain injury (TBI) is stated. One approach in promoting team cooperation is to combine team development with a specific training programme. A memory training programme used in a subacute TBI rehabilitation unit is described. A combination of a team development procedure and memory training programme was performed in the unit. A questionnaire to assess team members' attitudes to team cooperation was administered before and after team development, and memory training procedures were implemented. The post-training questionnaire administration indicated a more positive perception among team members of how the team functioned. The efficacy of memory training showed variable results. The programme described may illustrate the advantages of combining a specific treatment programme with efforts to promote team development.

Self-reported social networks and interpersonal support 2 years after severe traumatic brain injury

Fifty-four patients with traumatic brain injury (TBI) consecutively admitted to a rehabilitation hospital were examined 2 years post-injury. Social interaction and support, subjective complaints, and functional status were assessed. A large variability in social interaction and support patterns was found. Most patients had more interaction and received more support from family members than from friends and neighbours. Thirty-one patients (57.4%) reported that their social networks had markedly declined subsequent to injury. Relatively short duration of coma (< 1 week) and severe sequelae in terms of low functional status and poor emotional adjustment at follow-up, especially in terms of deficits in initiating behaviour, were found to be related to little interaction and support. The importance of both provider and patient initiative in order to establish and preserve a social support network is suggested, and clinical implications briefly discussed.

[Regaining of function following severe head injury. From primary rehabilitation to 2 years after the injury]

72 patients with sequelae after severe traumatic brain injury were studied during primary rehabilitation and two years post-injury. The patients were grouped into two main categories, one dependent as regards activities of daily living (ADL) and one mainly independent group. Most of the dependent patients, except seven low level patients close to a vegetative state, showed marked functional recovery. Among the independent patients, those who were admitted to primary rehabilitation relatively early (< 60 days post-injury) and those who were allowed a longer stay upon first admission to hospital showed better progress in functional level scores than those who were admitted later and were allowed a shorter stay during primary inpatient rehabilitation.