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Distinct trajectories of neuropsychiatric symptoms in the 12 months following traumatic brain injury (TBI): a TRACK-TBI study
- Karen A. Martinez, Ehri Ryu, Christopher J. Patrick, Nancy R. Temkin, Murray B. Stein, Brooke E. Magnus, Michael A. McCrea, Geoffrey T. Manley, Lindsay D. Nelson, the TRACK-TBI Investigators
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- Journal:
- Psychological Medicine , First View
- Published online by Cambridge University Press:
- 04 September 2024, pp. 1-10
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Background
Neuropsychiatric symptoms are common after traumatic brain injury (TBI) and often resolve within 3 months post-injury. However, the degree to which individual patients follow this course is unknown. We characterized trajectories of neuropsychiatric symptoms over 12 months post-TBI. We hypothesized that a substantial proportion of individuals would display trajectories distinct from the group-average course, with some exhibiting less favorable courses.
MethodsParticipants were level 1 trauma center patients with TBI (n = 1943), orthopedic trauma controls (n = 257), and non-injured friend controls (n = 300). Trajectories of six symptom dimensions (Depression, Anxiety, Fear, Sleep, Physical, and Pain) were identified using growth mixture modeling from 2 weeks to 12 months post-injury.
ResultsDepression, Anxiety, Fear, and Physical symptoms displayed three trajectories: Stable-Low (86.2–88.6%), Worsening (5.6–10.9%), and Improving (2.6–6.4%). Among symptomatic trajectories (Worsening, Improving), lower-severity TBI was associated with higher prevalence of elevated symptoms at 2 weeks that steadily resolved over 12 months compared to all other groups, whereas higher-severity TBI was associated with higher prevalence of symptoms that gradually worsened from 3–12 months. Sleep and Pain displayed more variable recovery courses, and the most common trajectory entailed an average level of problems that remained stable over time (Stable-Average; 46.7–82.6%). Symptomatic Sleep and Pain trajectories (Stable-Average, Improving) were more common in traumatically injured groups.
ConclusionsFindings illustrate the nature and rates of distinct neuropsychiatric symptom trajectories and their relationship to traumatic injuries. Providers may use these results as a referent for gauging typical v. atypical recovery in the first 12 months post-injury.
Chapter 8 - Psychopharmacology of Chronic Aggression and Violence in Forensic Settings
- Edited by Mary Davoren, Broadmoor Hospital and West London NHS Trust, Harry G. Kennedy, Trinity College Dublin
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- Seminars in Forensic Psychiatry
- Published online:
- 06 June 2024
- Print publication:
- 13 June 2024, pp 208-228
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Summary
The goal of this chapter is to show the reader a systematic approach to the assessment and treatment of aggression and violence arising from psychosis and a review of evidence-based pharmacological interventions for aggression and violence arising from impulsivity in the context of traumatic brain injury or neurocognitive disorder. In turn, we consider an algorithmic approach to the assessment and treatment of psychotically driven aggression and violence, the approach to treatment-resistance in schizophrenia spectrum disorders, data-supported treatment of aggression and violence related to traumatic brain injury, and, finally, data-supported pharmacological treatment of aggression and violence in the context of major neurocognitive disorder.
Integrated Care in Neurology: The Current Landscape and Future Directions
- Tanya L. Feng, A. Jon Stoessl, Rebecca A. Harrison
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- Canadian Journal of Neurological Sciences , First View
- Published online by Cambridge University Press:
- 29 April 2024, pp. 1-9
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The rising burden of neurological disorders poses significant challenges to healthcare systems worldwide. There has been an increasing momentum to apply integrated approaches to the management of several chronic illnesses in order to address systemic healthcare challenges and improve the quality of care for patients. The aim of this paper is to provide a narrative review of the current landscape of integrated care in neurology. We identified a growing body of research from countries around the world applying a variety of integrated care models to the treatment of common neurological conditions. Based on our findings, we discuss opportunities for further study in this area. Finally, we discuss the future of integrated care in Canada, including unique geographic, historical, and economic considerations, and the role that integrated care may play in addressing challenges we face in our current healthcare system.
Brain Injury Associated Shock: An Under-Recognized and Challenging Prehospital Phenomenon
- Christopher Partyka, Alexander Alexiou, John Williams, Jimmy Bliss, Matthew Miller, Ian Ferguson
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- Prehospital and Disaster Medicine , First View
- Published online by Cambridge University Press:
- 29 April 2024, pp. 1-6
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Objective:
Hemodynamic collapse in multi-trauma patients with severe traumatic brain injury (TBI) poses both a diagnostic and therapeutic challenge for prehospital clinicians. Brain injury associated shock (BIAS), likely resulting from catecholamine storm, can cause both ventricular dysfunction and vasoplegia but may present clinically in a manner similar to hemorrhagic shock. Despite different treatment strategies, few studies exist describing this phenomenon in the early post-injury phase. This retrospective observational study aimed to describe the frequency of shock in isolated TBI in prehospital trauma patients and to compare their clinical characteristics to those patients with hemorrhagic shock and TBI without shock.
Methods:All prehospital trauma patients intubated by prehospital medical teams from New South Wales Ambulance Aeromedical Operations (NSWA-AO) with an initial Glasgow Coma Scale (GCS) of 12 or less were investigated. Shock was defined as a pre-intubation systolic blood pressure under 90mmHg and the administration of blood products or vasopressors. Injuries were classified from in-hospital computed tomography (CT) reports. From this, three study groups were derived: BIAS, hemorrhagic shock, and isolated TBI without shock. Descriptive statistics were then produced for clinical and treatment variables.
Results:Of 1,292 intubated patients, 423 had an initial GCS of 12 or less, 24 patients (5.7% of the original cohort) had shock with an isolated TBI, and 39 patients had hemorrhagic shock. The hemodynamic parameters were similar amongst these groups, including values of tachycardia, hypotension, and elevated shock index. Prehospital clinical interventions including blood transfusion and total fluids administered were also similar, suggesting they were indistinguishable to prehospital clinicians.
Conclusions:Hemodynamic compromise in the setting of isolated severe TBI is a rare clinical entity. Current prehospital physiological data available to clinicians do not allow for easy delineation between these patients from those with hemorrhagic shock.
Chapter 8 - Neuropsychiatric Disorders
- Edited by David Kingdon, University of Southampton, Paul Rowlands, Derbyshire Healthcare NHS foundation Trust, George Stein, Emeritus of the Princess Royal University Hospital
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- Book:
- Seminars in General Adult Psychiatry
- Published online:
- 04 April 2024
- Print publication:
- 18 April 2024, pp 460-526
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Summary
Neuropsychiatry has a long and fascinating history as a discipline at the interface between neurology and psychiatry that combines clinical observations with modern investigational techniques. Historically, organic psychiatry has focused on clinical syndromes with regional connections affecting the four cortical lobes and the corpus callosum. Behavioural neurology has developed from early observations of classical neurocognitive syndromes, including aphasia, alexia, apraxia, agnosia and Gerstmann syndrome. A number of common neurological conditions often present with specific psychiatric symptoms: traumatic brain injury, cerebrovascular disease, brain tumours, epilepsy, movement disorders, infectious diseases and autoimmune neurological disorders such as multiple sclerosis, systemic lupus erythematosus and autoimmune encephalopathies. The differential diagnosis between delirium, dementia and pseudodementia can pose significant challenges. Finally, several toxic, metabolic and endocrine disorders can have clinically relevant neuropsychiatric manifestations.
Breaking barriers in trauma research: A narrative review of opportunities to leverage veterinary trauma for accelerated translation to clinical solutions for pets and people
- Kelly E. Hall, Claire Tucker, Julie A. Dunn, Tracy Webb, Sarah A. Watts, Emrys Kirkman, Julien Guillaumin, Guillaume L. Hoareau, Heather F. Pidcoke
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- Journal:
- Journal of Clinical and Translational Science / Volume 8 / Issue 1 / 2024
- Published online by Cambridge University Press:
- 05 April 2024, e74
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Trauma is a common cause of morbidity and mortality in humans and companion animals. Recent efforts in procedural development, training, quality systems, data collection, and research have positively impacted patient outcomes; however, significant unmet need still exists. Coordinated efforts by collaborative, translational, multidisciplinary teams to advance trauma care and improve outcomes have the potential to benefit both human and veterinary patient populations. Strategic use of veterinary clinical trials informed by expertise along the research spectrum (i.e., benchtop discovery, applied science and engineering, large laboratory animal models, clinical veterinary studies, and human randomized trials) can lead to increased therapeutic options for animals while accelerating and enhancing translation by providing early data to reduce the cost and the risk of failed human clinical trials. Active topics of collaboration across the translational continuum include advancements in resuscitation (including austere environments), acute traumatic coagulopathy, trauma-induced coagulopathy, traumatic brain injury, systems biology, and trauma immunology. Mechanisms to improve funding and support innovative team science approaches to current problems in trauma care can accelerate needed, sustainable, and impactful progress in the field. This review article summarizes our current understanding of veterinary and human trauma, thereby identifying knowledge gaps and opportunities for collaborative, translational research to improve multispecies outcomes. This translational trauma group of MDs, PhDs, and DVMs posit that a common understanding of injury patterns and resulting cellular dysregulation in humans and companion animals has the potential to accelerate translation of research findings into clinical solutions.
Chapter 24 - The Complex Needs Patient
- Edited by Roland Dix, Gloucestershire Health and Care NHS Foundation Trust, Gloucester, Stephen Dye, Norfolk and Suffolk Foundation Trust, Ipswich, Stephen M. Pereira, Keats House, London
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- Psychiatric Intensive Care
- Published online:
- 15 March 2024
- Print publication:
- 28 March 2024, pp 295-306
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Summary
The phrase ‘complex needs patient’ is often used by clinicians to describe a patient who presents with challenges and needs that require management approaches that are resource intensive and multi-focused. These individuals are often passed from service to service, with high costs to services across the board. In this chapter, we seek to define ‘complex needs patients’, recognising that for many clinicians the phrase refers to those individuals who present with severe mental illnesses together with other comorbid challenges including, but not limited to, serious physical illness, substance misuse or addiction, social problems including a lack of support, homelessness as well as problematic, absent or abusive relationships and the presence of another comorbid mental illness. This chapter explores the possible aetiological factors of complexity as well as its background and characteristics and discusses useful treatment modalities. Lastly, it considers the impact that the Covid-19 pandemic has had both in terms of disease presentation and the impact it has had on services.
Impact of Automated Prognostication on Traumatic Brain Injury Care: A Focus Group Study
- Atsuhiro Hibi, Michael D. Cusimano, Alexander Bilbily, Rahul G. Krishnan, Pascal N. Tyrrell
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- Canadian Journal of Neurological Sciences , First View
- Published online by Cambridge University Press:
- 05 March 2024, pp. 1-9
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Background:
Prognosticating outcomes for traumatic brain injury (TBI) patients is challenging due to the required specialized skills and variability among clinicians. Recent attempts to standardize TBI prognosis have leveraged machine learning (ML) methodologies. This study evaluates the necessity and influence of ML-assisted TBI prognostication through healthcare professionals’ perspectives via focus group discussions.
Methods:Two virtual focus groups included ten key TBI care stakeholders (one neurosurgeon, two emergency clinicians, one internist, two radiologists, one registered nurse, two researchers in ML and healthcare and one patient representative). They answered six open-ended questions about their perceptions and potential ML use in TBI prognostication. Transcribed focus group discussions were thematically analyzed using qualitative data analysis software.
Results:The study captured diverse perceptions and interests in TBI prognostication across clinical specialties. Notably, certain clinicians who currently do not prognosticate expressed an interest in doing so independently provided they had access to ML support. Concerns included ML’s accuracy and the need for proficient ML researchers in clinical settings. The consensus suggested using ML as a secondary consultation tool and promoting collaboration with internal or external research resources. Participants believed ML prognostication could enhance disposition planning and standardize care regardless of clinician expertise or injury severity. There was no evidence of perceived bias or interference during the discussions.
Conclusion:Our findings revealed an overall positive attitude toward ML-based prognostication. Despite raising multiple concerns, the focus group discussions were particularly valuable in underscoring the potential of ML in democratizing and standardizing TBI prognosis practices.
Suicides in degenerative neurocognitive disorders and traumatic brain injuries
- Tiina Talaslahti, Milena Ginters, Anniina Palm, Hannu Kautiainen, Risto Vataja, Henrik Elonheimo, Jaana Suvisaari, Hannu Koponen, Nina Lindberg
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- Journal:
- European Psychiatry / Volume 67 / Issue 1 / 2024
- Published online by Cambridge University Press:
- 17 January 2024, e10
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Background
Neuropsychiatric symptoms in major neurocognitive disorders have been strongly associated with suicidality.
MethodsThe objectives were to explore suicide rates in degenerative neurocognitive disorders (DNDs), alcohol-related neurocognitive disorders (ARNDs), and traumatic brain injuries (TBIs). Patients who received these diagnoses between 1998 and 2015 (N = 231,817) were identified from nationwide registers, and their mortality was followed up until December 31, 2018. We calculated incidences of suicides per 100,000 person-years, types of suicides, and suicide rates compared with the general population (standardized mortality ratio [SMR]).
ResultsDuring the follow-up, 0.3% (95% confidence interval [95% CI]: 0.2–0.5) of patients with DNDs, 1.1% (0.7–1.8) with ARNDs, and 1.0% (0.7–1.3) with TBIs committed suicide. Suicide mortality rate was higher in men (58.9, 51.3, to 67.4 per 100,000) than in women (9.8, 7.5, to 12.5 per 100,000). The highest suicide rate was in ARNDs (98.8, 65.1, to 143.8 per 100,000), followed by TBIs (82.0, 62.4, to 105.8 per 100,000), and DNDs (21.2, 18.3, to 24.5 per 100,000). The SMRs (95% CI) were 3.69 (2.53–5.38), 2.99 (2.31–3.86), and 1.31 (1.13–1.51), respectively, and no sex difference emerged. The most common cause of death was self-inflicted injury by hanging or drowning (12.4, 10.3, to 14.8 per 100,000).
ConclusionsSuicide rates were higher in all three patient groups than the general population. Suicide risk remained elevated for more than 10 years after diagnosis. The suicide methods were mostly violent.
9 Serum Neurofilament is Associated with Diffusion Kurtosis Imaging in Chronic Mild-Moderate Traumatic Brain Injury
- Erin R Trifilio, Robert D Claar, Aditi Venkatesh, Sarah Bottari, David Barton, Claudia S Robertson, Richard Rubenstein, Amy K Wagner, Kevin K W Wang, Damon G Lamb, John B Williamson
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, p. 121
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Objective:
To determine the association between blood markers of white matter injury (e.g., serum neurofilament light and phosphorylated neurofilament heavy) and a novel neuroimaging technique measuring microstructural white matter changes (e.g., diffusion kurtosis imaging) in regions (e.g., anterior thalamic radiation and uncinate fasciculus) known to be impacted in traumatic brain injury (TBI) and associated with symptoms common in those with chronic TBI (e.g., sleep disruption, cognitive and emotional disinhibition) in a heterogeneous sample of Veterans and non-Veterans with a history of remote TBI (i.e., >6 months).
Participants and Methods:Participants with complete imaging and blood data (N=24) were sampled from a larger multisite study of chronic mild-moderate TBI. Participants ranged in age from young to middle-aged (mean age = 34.17, SD age = 10.96, range = 19-58) and primarily male (66.7%). The number of distinct TBIs ranged from 1-5 and the time since most recent TBI ranged from 0-30 years. Scores on a cognitive screener (MoCA) ranged from 22-30 (mean = 26.75). We performed bivariate correlations with mean kurtosis (MK) in the anterior thalamic radiation (ATR; left, right) uncinate fasciculus (UF; left, right), and serum neurofilament light (NFL), and phosphorylated neurofilament heavy (pNFH). Both were log transformed for non-normality. Significance threshold was set at p<0.05.
Results:pNFH was significantly and negatively correlated to MK in the right (r=-0.446) and left (r=-0.599) UF and right (r=-0.531) and left (r=-0.469) ATR. NFL showed moderate associations with MK in the right (r=-0.345) and left (r=-0.361) UF and little to small association in the right (r=-0.063) and left (r=-0.215) ATR. In post-hoc analyses, MK in both the left (r=0.434) and right (r=0.514) UF was positively associated with performance on a frontally-mediated list-learning task (California Verbal Learning Test, 2nd Edition; Trials 1-5 total).
Conclusions:Results suggest that serum pNFH may be a more sensitive blood marker of microstructural complexity in white matter regions frequently impacted by TBI in a chronic mild-moderate TBI sample. Further, it suggests that even years after a mild-moderate TBI, levels of pNFH may be informative regarding white matter integrity in regions related to executive functioning and emotional disinhibition, both of which are common presenting problems when these patients are seen in a clinical setting.
20 The Influence of Brain Injury Severity, Anxiety, and Depression on Objective and Subjective Prospective Memory Problems
- Gabrielle Tetreault, Sarah-Jade Roy, Julie Audy, Isabelle Rouleau, Marie-Julie Potvin
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 129-130
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Objective:
Following a traumatic brain injury (TBI), the majority of patients report difficulties with prospective memory (PM). However, there is not always a significant relationship between subjective and objective PM measures. Several variables may influence the degree of severity of perceived difficulties, including the severity of the injury and psychoemotional status. The aim of this study was to determine whether the severity of the TBI and anxiety and depressive symptoms were related to objective and subjective difficulties of PM.
Participants and Methods:50 patients (mean age = 31,3 years old) with a TBI (20 mild and 30 moderate/severe) in the post-acute phase of recovery and 15 matched healthy control participants (mean age = 32,3 years old) were recruited. They completed inventories assessing the presence of anxiety (BAI) and depressive (BDI) symptoms and performed the Ecological test of prospective memory (TEMP), an objective measure of PM. The Comprehensive Assessment of PM (CAPM), a subjective measure of PM, was also filled out by participants and their relatives.
Results:In patients with moderate/severe TBI, significant correlations were found between the CAPM and the BDI (r =.601, p<.001) and the BAI (r =.507, p=.004). A negative correlation was also observed between the relatives’ CAPM scores and the performance of the patients on the TEMP (r= -.374, p=.042). In patients with mild TBI, there was only a strong significant correlation between the CAPM and the BAI scores (r =.574, p=.008). However, no other correlation was significant between this group of patients and their relatives. Additionally, results on the TEMP were not significantly correlated with the CAMP completed by healthy control participants or their relatives. A linear regression conducted in the group of participants with TBI showed that BAI and BDI scores are the only significant predictors of the results on the CAPM (31% of the variance), while TBI severity is the only significant predictor of the results on the TEMP (37% of the variance).
Conclusions:The perception of PM difficulties in patients with a TBI does not seem to be related to their objective performance. Anxiety and depressive symptoms appear to influence their perception more than their objective performance. As suggested by their relatives, a decrease in self-awareness could explain the lack of relationship between subjective PM difficulties of patients with moderate/severe TBI and their objective performance. On the other hand, TBI severity is more strongly related to objective performance on PM tests. These results highlight the importance of using different measures to accurately assess PM and the various factors influencing this construct.
36 Exploring Neuropsychological Care for Pediatric Patients in Neurocritical Care and Outpatient Follow-Up
- Paige E Naylor, Andrea Jagusch, Emma Basel, Michelle Loman, Elisabeth Vogt
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 143-144
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Objective:
Integration of neuropsychological services into multidisciplinary clinics for pediatric patients requiring neurocritical care has previously been shown to improve access to care and promote connection to vital services for children recovering from traumatic brain injuries or other serious insults or infections impacting the brain. As such, the objective of this study is two-fold. First, to explore the unique model of care provided by a neuropsychological inpatient service at the Medical College of Wisconsin/Children’s Wisconsin. Secondly, to describe the benefit of neuropsychology in the Brain Recovery Assessment and Interdisciplinary Needs Clinic (BRAIN) a neurocritical care outpatient follow-up multidisciplinary clinic.
Participants and Methods:Participants include N =298 pediatric inpatients from a Level 1 Pediatric Trauma center referred to the neuropsychological inpatient consultation service from February 2020 to July 2022. Qualitative methods were used to describe the flow and number of patients initially referred to the neuropsychological inpatient service and then those who followed up in outpatient neuropsychological care prior to and after the implementation of a multi-disciplinary clinic for children admitted to the Neurocritical Care Unit. Rates of follow-up with neuropsychological care were compared pre- and post-establishment of the multidisciplinary clinic. Additional analyses were conducted to explore factors known to impact follow-up with care post-hospitalization (e.g., socioeconomic status, race, ethnicity).
Results:Prior to the establishment of the BRAIN clinic, approximately 60 to 70% of patients were referred for outpatient neuropsychological follow-up. Approximately 30% of patients referred to the inpatient neuropsychological service following the establishment of the BRAIN clinic were referred for multidisciplinary care, while 20% did not require additional intervention and 50% were referred for outpatient neuropsychological follow-up. Analyses indicated increased follow-up rates with neuropsychological care following the establishment of the BRAIN clinic.
Conclusions:Integration of neuropsychology into inpatient care and subsequent multidisciplinary settings for pediatric patients with traumatic brain injuries or other serious insults and CNS infections increased access to neuropsychological care. Additional clinical implications will be discussed.
22 The Effect of Ibogaine on Cognitive Functioning
- Kirsten N. Cherian, Afik Faerman, Lauren A. Anker, Randi E. Brown, Or Keynan, TJ, Ford, Jennifer Keller, Nolan R. Williams
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 898-899
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Objective:
To determine the effects of the non-classic psychedelic, ibogaine, on cognitive functioning. Ibogaine is an indole alkaloid derived from the Tabernanthe Iboga plant family, indigenous to Africa, and traditionally used in spiritual and healing ceremonies. Ibogaine has primarily been studied with respect to its clinical efficacy in reducing substance addiction. There are, however, indications that it also may enhance recovery from traumatic experiences. Ibogaine is a Schedule 1 substance in the USA.
ParticipSabants and Methods:Participants were U.S. Special Operations Veterans who had independently and voluntarily referred themselves for an ibogaine retreat at a specialized clinic outside the USA prior to learning about this observational study. After meeting rigorous screening requirements, 30 participants were enrolled, all endorsing histories of combat and repeated blast exposure, as well as traumatic brain injury. Participants were seen in person pre-treatment, post-treatment, and one-month post-treatment for neuropsychological testing, neuroimaging, and collection of clinical outcome measures. All 30 participants were seen pre- and post-treatment, of whom 27 were also able to return one-month post-treatment.
The neuropsychological battery included the the Hopkins Verbal Learning Test (HVLT), the Brief Visuospatial Memory Test - Revised (BVMT-R), the Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV) Working Memory Index (Digit Span and Arithmetic) and Processing Speed Index (Symbol Search and Coding), and the Delis-Kaplan Executive Function System (D-KEFS) tests of Verbal Fluency (VF), Trail Making (TMT), Color Word (CW), and Tower Test (TT). For repeated measures, alternate forms were used whenever possible.
Results:Repeated-measures ANOVA revealed significant effects of time, with post-treatment improvements across multiple measures including processing speed (WAIS-IV PSI; F(2,25) = 26.957, p < .001), executive functions (CW Conditions 3 and 4: F(1.445,25) = 11.383, p < .001 and F(1.381,25) = 7.687, p = .004, respectively), verbal fluency (VF Condition 3 correct and accuracy: F(2,25) = 6.419, p = .003 and F(2,25) = 153.076, p < .001, respectively), and verbal learning (HVLT Total Recall (alternate forms used at each time point): F(1.563,23) = 6.958, p = .004). Score progression graphs are presented. Performance on all other cognitive measures did not significantly change following treatment.
Conclusions:To our knowledge, this is the first prospective study examining neuropsychological test performance following ibogaine use at post-treatment and one-month post-treatment time points. Our results indicated that several cognitive domains improved either post-treatment or one-month post-ibogaine treatment, suggesting ibogaine’s therapeutic potential for cognition in the context of traumatic brain injury and mood disorders. Potential explanations include neuroplastic changes, reduction of PTSD and mood-related effects on cognitive functioning, and practice effects. While we found no evidence of negative cognitive consequences for up to one-month post-single-ibogaine treatment, further study of this substance is necessary to clarify its clinical utility and safety parameters.
27 Apathy Associated with Cognition in Older Adults with Chronic Moderate to Severe Traumatic Brain Injury
- Samantha M Vervoordt, Umesh Venkatesan, Andrew Cwiek, Amanda Rabinowitz, Frank G. Hillary
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 135-136
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Objective:
Apathy, or loss of motivation and interest, is a common sequela of moderate to severe traumatic brain injury (msTBI) and has been associated with frontal lesions and with executive dysfunction in a sample an average of one year post injury (Andersson & Bergdalen, 2002). In older adults sustaining msTBI in particular, the appearance of apathy is more likely to be comorbid with depression when compared to injury in younger adults (Kant et al., 1998). However, studies have consistently shown an important dissociation between apathy and depression, despite overlapping symptoms, with apathy in particular associated with frontal lobe damage (Worthington & Wood, 2018). The present study holds two primary goals. First, to examine the relationship between current apathy ratings and cognition after controlling for ratings of depression and perceived changes in apathy, to account for the unique relationship of injury-related apathy on cognition. Second, to examine the potential variable role of APOE4 carrier status on depression and apathy ratings.
Participants and Methods:110 older adults with a lifetime history of msTBI (M=9.5 years post-injury) were included as part of a cross-sectional study. Apathy was measured using the Frontal Systems and Behaviors Scale (FrSBe) for both current apathy ratings and perceived change in apathy from pre- to post-injury. Depression was measured using the depression subscale of the Brief Symptom Inventory (BSI). Outcome measures included normed scores for learning (HVLT-R total recall), retention (HVLT-R percent retention), processing speed (Trails A), set-shifting and working memory (Trails B, Digit Span Backwards), and phonemic and category fluency (D-KEFS letter and category fluency). The main independent variable of interest was current apathy ratings. Depression and perceived apathy change were included as control variables for all analyses. Vif scores were calculated for all analyses to ensure that variables were not multicollinear. Finally, we ran an ANOVA to examine the relationship between apathy, depression, and APOE4 carrier status.
Results:When controlling for depression and perceived changes in apathy, current apathy ratings were associated with poorer performance on learning (p=.04, n2=.04), processing speed (p=.001, n2=.10), set-shifting (p=.02, n2=.05), attention (p=.04, n2=.04), phonemic fluency (p=.001, n2=.09), category fluency (p=.001, n2=.10). Current apathy ratings were not associated with retention or working memory. Apathy was significantly associated with depression (p <.001), but was not associated with APOE4 carrier status or the interaction between depression and carrier status.
Conclusions:Despite overlap between depressive symptoms and apathy questionnaires (i.e., loss of interest/pleasure), by controlling for depressive symptoms and perceived changes following injury, we demonstrate the significant independent association of apathy and cognition in an older sample with chronic msTBI. Further, although previous work has shown strong associations between depression and APOE4 carrier status in chronic msTBI samples (Vervoordt et al., 2021), there was no significant relation with apathy directly in our sample, providing further evidence that these are neurobiologically distinct syndromes.
1 Quantity or quality? Comparing objective and subjective participation measures to predict quality of life in aging msTBI.
- Andrew P Cwiek, Samantha Vervoordt, Emily E Carter, Frank G Hillary
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 113-114
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Objective:
Community reintegration and participation have been shown to be significantly correlated to improved Quality of Life (QoL) following moderate to severe traumatic brain injury (msTBI), yet these models often come with significant levels of unaccounted variability (Pierce and Hanks, 2006). Measures for community participation frequently employ objective measures of participation, such as number of outings in a week or current employment status (Migliorini et al., 2016), which may not adequately account for lifestyle differences, especially in aging populations. Less often integrated are subjective measures of an individual’s own belongingness and autonomy within the community (Heineman et al., 2011), also referred to as their participation enfranchisement (PE). The present study examines three questions pertinent to the potential clinical value of PE. First, do measures of objective participation significantly predict an individual’s PE ratings? Second, are both types of measures equally successful predictors of QoL for aging individuals with chronic-stage msTBI. Finally, would controlling for either objective or subjective integration ratings enable neurocognitive assessments to better predict QoL post injury?
Participants and Methods:41 older-adults (M= 65.32; SD= 7.51) with a history of msTBI were included (M= 12.59 years post-injury;SD= 8.29) for analysis. Subjective community integration was measured through the Participation Enfranchisement Survey. The Participation Assessment with Recombined Tools-Objective (PART-O) provided the objective measurement of participation. Quality of life was assessed through the Quality of Life after Brain Injury (QOLIBRI). An estimate of neurocognitive performance was created through the Brief Test of Adult Cognition by Telephone (BTACT), which includes six domains including: verbal-learning and memory (immediate and delayed recall), working memory (digit-span backwards), reasoning (number sequencing), semantic fluency (category fluency), and processing speed (backwards counting). Performance on the BTACT, PE ratings, and PART-O scores were included as the dependent variables in stepwise, linear regression models predicting QoL ratings to assess the differential contribution of the dependent variables and potential interaction effects.
Results:While both the PART-O (f(1,39)=5.52;p=.024,n2=.124) and the PE survey (f(1,39)=14.31 ;p<.001,n2=.268) significantly predicted QoL, the addition of PE in the PART-O model resulted in significant (20.9%) reduction in unaccounted variance. Further in the model controlling for PE, PART-O no longer provides a significant (p=.15) contribution to the model estimating QoL (f(2,38)=8.41; p=.001). Performance on the BTACT correlated with PART-O (p<.0001), but not PE (p=.13) ratings. Finally, across two models controlling for BTACT performance, PE (p=.002,partial n2=.23), but not PART-O (p=.28,partial n2=.031) contributed significantly to QoL predictions. No significant interactions between PART-O, PE, and/or BTACT were observed when added to any model.
Conclusions:MsTBI impacts nearly every facet of an individual’s life, and as such, improving QoL post-injury requires a broad, yet well-considered approach. The objective ratings of participation, subjective PE, BTACT performance, all independently predicted quality of life in this sample. However, after controlling for neurocognitive assessment performance, PE was shown to independently contribute to quality of life, while the PART-O ratings no longer provided significant contribution. While community integration is a vital factor to consider for long-term rehabilitation, tailoring what “integration” means to the patient may hold significant potential to improve long-term quality of life.
33 Osteopontin as a Blood Biomarker for Executive Function Outcomes in Pediatric Traumatic Brain Injury
- Ezra Mauer, Iqbal Sayeed, Andrew Reisner, Laura Blackwell
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 141-142
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Objective:
Executive function (EF) is a self-regulatory construct well-established as a predictor of long-term academic achievement and socioemotional functioning in children (Best et al., 2009; Diamond, 2013; Zelazo & Carlson, 2020). Traumatic brain injury (TBI) in childhood frequently results in EF deficits (Beauchamp & Anderson, 2013; Levin & Hanten, 2005). In comparison to adults (Okonkwo et al., 2013), there is an absence of viable blood biomarkers for pediatric TBI to assist in diagnosis and prognosis. Osteopontin (OPN), an inflammatory cytokine, has recently been identified as a putative pediatric TBI blood biomarker (Gao et al., 2020). However, more work is needed to establish OPN’s utility in predicting functional outcomes. Thus, the present study aimed to test relations between OPN measured during the first 72 hours of hospitalization and EF 6-12 months post injury among a sample of pediatric TBI patients.
Participants and Methods:Sample consisted of 38 children (age at injury = 4.60-16.67 years, M age = 10.61 years, 65.8% male, lowest Glasgow Coma Scale [GCS] score = 3-15, M gcs = 9.97) with TBI whose parents completed the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF-2; Gioia et al., 2015) 6-12 months post injury. Plasma OPN was measured at hospital admission, 24 hours after admission, 48 hours after admission, and 72 hours after admission. 7-scores for each BRIEF-2 clinical scale (Inhibit, Self-Monitor, Shift, Emotional Control, Initiate, Working Memory, Plan/Organize, Task-Monitor, Organization of Materials) and composite index (Behavior Regulation Index, Emotion Regulation Index, Cognitive Regulation Index, Global Executive Composite) were used in analyses.
Results:Correlation analyses revealed large positive associations (rs = .50-.73, ps = <.001.039) between 48-hour OPN and all BRIEF-2 scales/indices except Initiate. OPN at 24 hours positively correlated with Task-Monitor (r = .40, p = .037). Bivariate logistic regression analyses testing whether OPN predicted at least mildly elevated BRIEF-2 t-scores (>60) did not yield significant associations. Additional supplementary analyses testing whether alternative injury markers - glial fibrillary acidic protein (GFAP), ubiquitin C-terminal Hydrolase-L1 (UCH-L1), S100 calcium binding protein B (S100B) - measured at all time points as well as lowest GCS score correlated with EF revealed the following: admission S100B positively correlated with Inhibit (r = .34, p = .045), 48-hour UCH-L1 negatively correlated with Initiate (r = -.49, p = .041) and Cognitive Regulation Index (r = -.48, p = .044), and 72-hour UCH-L1 negatively correlated with Initiate (r = -.47, p = .048).
Conclusions:Findings showed higher OPN at 48 hours post admission was broadly related to worse parent-reported EF 6-12 months later, with 24-hour OPN also showing limited associations. Higher levels of alternative injury markers likewise showed limited associations with EF outcomes. Null logistic regression findings may be due to few participants having elevated BRIEF-2 scores. Disrupted EF development may be more noticeable after longer time periods as children age and self-regulatory demands increase. Overall, OPN was found to more consistently predict EF outcomes than GCS score and other injury markers. This could be because OPN is a marker of inflammation, which may be particularly predictive of TBI cognitive outcomes.
26 Cognitive Correlates of Functional Assessment Tool in Veterans with Mild Traumatic Brain Injury
- Jillian M. Tessier, Gary Abrams, Tatjana Novakovic-Agopian
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 708-709
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Objective:
Limitations of traditional neuropsychological assessment include testing in a highly controlled environment designed to minimize distraction. While informative, it may not fully capture real-world cognitive functioning. This may be particularly important for individuals with mild traumatic brain injury (mTBI), a subset of whom report subtle challenges with complex cognitive functioning that are not consistently captured by neuropsychological assessment. The objective of this study was to extend previous work examining cognitive correlates of performance on functional assessment tool, the Goal Processing Sale (GPS), in a larger sample of Veterans with mTBI.
Participants and Methods:46 Veterans with chronic mTBI completed GPS and neuropsychological measures (mean age = 43.5; education = 15 years; 89% male). 93% of participants had clinically significant PTSD (PCL-M > 31). The GPS is an ecologically valid assessment in which participants plan and execute a complex task following specified rules under a time constraint. Performance is rated on a 0 (not able) to 10 (absolutely not a problem) scale in 8 domains: 1) Planning, 2) Initiation, 3) Self-Monitoring, 4) Maintenance of Attention, 5) Sequencing and Switching of Attention, 6) Flexible Problem Solving, 7) Task Execution, and 8) Learning and Memory. The GPS Overall Performance is average of 8 domain scores. Neuropsychological assessment data were scored using standardized norms and transformed into z-scores. Scores were averaged into 2 domains: 1) Overall Attention/Executive Function (4 subdomains: Working Memory [Auditory Consonant Trigrams, WAIS-III Letter Number Sequencing], Sustained Attention [Digit Vigilance Test], Inhibition [D-KEFS Stroop Inhibition], Mental Flexibility [Trail Making Test B, D-KEFS Stroop Inhibition Switching, Design Fluency Switching, Verbal Fluency Switching]) and 2) Overall Memory (2 subdomains: Total Recall [HVLT-R, BVMT-R], and Delayed Recall [HVLT-R, BVMT-R]).
Pearson correlation coefficients were used to determine relation between overall GPS and overall executive function performance, as well as 8 GPS subdomain and 8 neuropsychological domain/subdomain scores. To adjust for multiple comparisons, p < .01 was used.
Results:Overall GPS performance was statistically significantly related to Overall Attention/Executive Functioning and Overall Memory. Investigating further, multiple significant subdomain relations emerged. GPS Planning was related to Inhibition. GPS Self-Monitoring and GPS Task Execution were related to Mental Flexibility. GPS Maintenance of Attention and GPS Flexible Problem Solving were related to Mental Flexibility and Inhibition. GPS Sequencing and Switching of Attention was related to Mental Flexibility and Total Recall.
GPS Learning and Memory was related to Working Memory, Mental Flexibility, and Inhibition. GPS Initiation was not related to neuropsychological measures.
Conclusions:Current findings build upon prior work establishing validity of GPS functional assessment measure (Novakovic-Agopian et al., 2012). Seven of 8 GPS subdomains were related to at least one aspect of executive functioning assessed with neuropsychological measures, with the majority related to mental flexibility. Taken together, findings suggest that the GPS converges with traditional measures, offering a method to capture multiple aspects of executive functioning applied together. Further, it may also be useful tool capturing aspects of executive functioning in complex, ecologically-valid settings often not captured with traditional neuropsychological assessment.
7 Domain-Specific Assessments for Metacognition in Older Adults Sustaining Traumatic Brain Injury
- Emily C Grossner, Frank G Hillary
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 119-120
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Objective:
Metacognitive deficits are common following traumatic brain injury (TBI), and this has important implications for recovery, social relationships, and rehabilitative outcomes (Chiou et al., 2011; Flashman & McAllister, 2002; Ownsworth & Fleming, 2005). Metacognitive deficits have historically been measured using self-report (Allen & Ruff, 1990; Newman et al., 2000; Sherer et al., 1995; Sherer et al., 1998), which is problematic as individuals with an awareness of deficit cannot accurately reflect on their own condition (Akturk & Sahin, 2011). In the past two decades, studies have transitioned to using more objective measures to assess metacognition, including error monitoring tasks (McAvinue et al., 2005; Yeung & Summerfield, 2012) and tasks using retrospective confidence judgments (RCJs) (Busey et al., 2000). Importantly, both tasks are used to study “metacognition,” but clear distinctions as to what domains these tasks measure has not been elucidated. Additionally, both tasks have been linked to executive functioning broadly, but error detection tasks are uniquely associated with measures of attention and self-reported anxiety (Hoerold et al., 2008; O’Keefe et al., 2007), indicating that there may be distinct processes that comprise metacognition. It is a goal to determine what domains these tasks represent so proper assessments of metacognitive ability can be conducted in this population.
Participants and Methods:Participants included 23 older adults with moderate-severe TBI and 16 age, sex, and education matched healthy control (HC) individuals ages 53-80. All participants received identical neuropsychological test batteries, including two tasks of metacognition (error monitoring task, RCJ task), neurocognitive tasks of attention (Digit Span - Forward, Trail Making Test A) and executive functioning (Digit Span - Backward, Trail Making Test B), and a self-report measure of anxiety (Brief Symptom Inventory - Anxiety subscale). To determine overlapping constructs measured by the two metacognitive tasks, these tasks were correlated with each other and with an attention composite, executive functioning (EF) composite, and anxiety measure in the TBI and HC groups.
Results:In the TBI group, the metacognitive tasks were significantly correlated with each other (r=-0.47, p=0.022). The RCJ task was associated with EF (r=0.47, p=0.025), but not with attention (r=0.20, p=0.358) or anxiety (r=0.25, p=0.248). The error detection task was associated with EF (r=-0.48, p=0.021) and attention (r=-0.46, p=0.026), but not with anxiety (r=-0.19, p=0.383). In the HC group, there were no significant associations between the metacognitive tasks, or between either metacognitive task and EF, attention, or anxiety.
Conclusions:For older adults sustaining TBI, tasks of error detection and tasks using retrospective confidence judgments measured an overlapping construct, with both having an association with executive functioning and only the error detection task being associated with attention. Interestingly, these associations were not found in a healthy control sample of older adults. Both metacognitive tasks have been used in the literature to measure errors of awareness, but this study provides insight that these tasks are measuring different domains of metacognitive ability in older individuals with TBI. Use of multiple tasks of metacognitive ability in this population can help to describe where the deficits of awareness occur following TBI.
15 Examining Unmet Needs in a Brain Injury Sample, Consisting of Various Races/Ethnicities, Referred to Resource Facilitation
- Kiriana P Parker, Patricia Garcia, Devan Parrott, Stephanie Crockett, Cori Conner, Kira Thomas
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 125-126
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Objective:
To investigate differences of the perceived unmet needs in a post-acute brain injury sample when referred to Resource Facilitation (RF) among various race/ethnic groups.
Participants and Methods:The methodology utilizied within this study consisted of a retrospective chart review, which was sourced from a clinical database serving chronic outpatients in the Midwest region. The main outcome measure was the Service of Unmet Needs & Service Use (SUNSU). The sample consisted of N = 455 subjects, which included a small sample size of Hispanics (N=7). Therefore, African American and Hispanic groups were combined for a total minority sample (N=84). Clinical disorders included within the study was an ABI from either stroke, anoxic injury, ruptured aneurysm, or tumor resection surgery. Eligibility criteria included participants’ admission into a RF program, a vocational goal, and a diagnosis of a moderate to severe TBI or other ABI. Lastly, key sociodemographic features included age, race, ethnicity, education, and sex.
Results:Significant differences were found between ethnic groups (white non-Hispanics and minority group) in terms of years of education (p=<.01). White non-Hispanics had higher education (M=13.39, SD=2.23), reported significantly more rural addresses (40.2%, p=<.01), and had private insurance coverage more frequently than the minority group (33.7%, p=<.01). The full model was statistically significant, R2=.077 = F(4,450) = 9.387, p<.0001; adjusted R2 = .069. The addition of ethnicity led to a statistically significant increase in R2 of .019, F(1,450) =9.025, p<.0005.
Conclusions:Ethnicity was found to be a predictive factor for greater unmet needs even after controlling for insurance, employment status, and urbanicity. It is currently unknown RF’s success rate in providing culturally competent services to different racial/ethnic groups, which consider factors such as primary language spoken, immigration status, and additional ethnocultural factors that could deter accurate reporting of unmet needs by minoritized groups. Future studies should investigate barriers in referring and meeting eligibility for this program and analyze post-treatment data to determine if the impact of racial, geographic, and insurance disparities is mitigated with RF treatment.
5 LIfestyle for BRAin Health (LIBRA) Modifiable Factors Risk Score and Concussion History Associations with Cognition in Older Former National Football League Players.
- Benjamin L Brett, Neelum T Aggarwal, Avinash Chandran, Zachary Y Kerr, Samuel R Walton, J.D. DeFreese, Kevin M Guskiewicz, Ruben J Echemendia, William P Meehan III, Michael A McCrea, Rebekah Mannix
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 305-306
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Objective:
Traumatic brain injury is one of several recognized risk factors for cognitive decline and neurodegenerative disease. Currently, risk scores involving modifiable risk/protective factors for dementia have not incorporated head injury history as part of their overall weighted risk calculation. We investigated the association between the LIfestyle for BRAin Health (LIBRA) risk score with odds of mild cognitive impairment (MCI) diagnosis and cognitive function in older former National Football League (NFL) players, both with and without the influence of concussion history.
Participants and Methods:Former NFL players, ages ≥ 50 (N=1050; mean age=61.1±5.4-years), completed a general health survey including self-reported medical history and ratings of function across several domains. LIBRA factors (weighted value) included cardiovascular disease (+1.0), hypertension (+1.6), hyperlipidemia (+1.4), diabetes (+1.3), kidney disease (+1.1), cigarette use history (+1.5), obesity (+1.6), depression (+2.1), social/cognitive activity (-3.2), physical inactivity (+1.1), low/moderate alcohol use (-1.0), healthy diet (-1.7). Within Group 1 (n=761), logistic regression models assessed the association of LIBRA scores and independent contribution of concussion history with the odds of MCI diagnosis. A modified-LIBRA score incorporated concussion history at the level planned contrasts showed significant associations across concussion history groups (0, 1-2, 3-5, 6-9, 10+). The weighted value for concussion history (+1.9) within the modified-LIBRA score was based on its proportional contribution to dementia relative to other LIBRA risk factors, as proposed by the 2020 Lancet Commission Report on Dementia Prevention. Associations of the modified-LIBRA score with odds of MCI and cognitive function were assessed via logistic and linear regression, respectively, in a subset of the sample (Group 2; n=289) who also completed the Brief Test of Adult Cognition by Telephone (BTACT). Race was included as a covariate in all models.
Results:The median LIBRA score in the Group 1 was 1.6(IQR= -1, 3.6). Standard and modified-LIBRA median scores were 1.1(IQR= -1.3, 3.3) and 2(IQR= -0.4, 4.6), respectively, within Group 2. In Group 1, LIBRA score was significantly associated with odds of MCI diagnosis (odds ratio[95% confidence interval]=1.27[1.19, 1.28], p <.001). Concussion history provided additional information beyond LIBRA scores and was independently associated with odds of MCI; specifically, odds of MCI were higher among those with 6-9 (Odds Ratio[95% confidence interval]; OR=2.54[1.21, 5.32], p<.001), and 10+ (OR=4.55;[2.21, 9.36], p<.001) concussions, compared with those with no prior concussions. Within Group 2, the modified-LIBRA score was associated with higher odds of MCI (OR=1.61[1.15, 2.25]), and incrementally improved model information (0.04 increase in Nagelkerke R2) above standard LIBRA scores in the same model. Modified-LIBRA scores were inversely associated with BTACT Executive Function (B=-0.53[0.08], p=.002) and Episodic Memory scores (B=-0.53[0.08], p=.002).
Conclusions:Numerous modifiable risk/protective factors for dementia are reported in former professional football players, but incorporating concussion history may aid the multifactorial appraisal of cognitive decline risk and identification of areas for prevention and intervention. Integration of multi-modal biomarkers will advance this person-centered, holistic approach toward dementia reduction, detection, and intervention.