Cognitive Behavioral Therapy for Sleep Disturbance and Fatigue Following Acquired Brain Injury: Predictors of Treatment Response.

OBJECTIVE: To identify factors associated with treatment response to cognitive behavioral therapy for sleep disturbance and fatigue (CBT-SF) after acquired brain injury (ABI). SETTING: Community dwelling. PARTICIPANTS: Thirty participants with a traumatic brain injury or stroke randomized to receive CBT-SF in a parent randomized controlled trial. DESIGN: Participants took part in a parallel-groups, parent randomized controlled trial with blinded outcome assessment, comparing an 8-week CBT-SF program with an attentionally equivalent health education control. They were assessed at baseline, post-treatment, 2 months post-treatment, and 4 months post-treatment. The study was completed either face-to-face or via telehealth (videoconferencing). Following this trial, a secondary analysis of variables associated with treatment response to CBT-SF was conducted, including: demographic variables; injury-related variables; neuropsychological characteristics; pretreatment sleep disturbance, fatigue, depression, anxiety and pain; and mode of treatment delivery (face-to-face or telehealth). MAIN MEASURES: Pittsburgh Sleep Quality Index (PSQI) and Fatigue Severity Scale (FSS). RESULTS: Greater treatment response to CBT-SF at 4-month follow-up was associated with higher baseline sleep and fatigue symptoms. Reductions in fatigue on the FSS were also related to injury mechanism, where those with a traumatic brain injury had a more rapid and short-lasting improvement in fatigue, compared with those with stroke, who had a delayed but longer-term reduction in fatigue. Mode of treatment delivery did not significantly impact CBT-SF outcomes. CONCLUSION: Our findings highlight potential differences between fatigue trajectories in traumatic brain injury and stroke, and also provide preliminary support for the equivalence of face-to-face and telehealth delivery of CBT-SF in individuals with ABI.

Cognitive behavioural therapy versus health education for sleep disturbance and fatigue after acquired brain injury: A pilot randomised trial.

BACKGROUND: Sleep disturbance and fatigue are highly prevalent after acquired brain injury (ABI) and are associated with poor functional outcomes. Cognitive behavioural therapy (CBT) is a promising treatment for sleep and fatigue problems after ABI, although comparison with an active control is needed to establish efficacy. OBJECTIVES: We compared CBT for sleep disturbance and fatigue (CBT-SF) with a health education (HE) intervention to control for non-specific therapy effects. METHODS: In a parallel-group, pilot randomised controlled trial, 51 individuals with traumatic brain injury (n = 22) and stroke (n = 29) and clinically significant sleep and/or fatigue problems were randomised 2:1 to 8 weeks of a CBT-SF (n = 34) or HE intervention (n = 17), both adapted for cognitive impairments. Participants were assessed at baseline, post-treatment, and 2 and 4 months post-treatment. The primary outcome was the Pittsburgh Sleep Quality Index; secondary outcomes included measures of fatigue, sleepiness, mood, quality of life, activity levels, self-efficacy and actigraphy sleep measures. RESULTS: The CBT-SF led to significantly greater improvements in sleep quality as compared with HE, during treatment and at 2 months [95% confidence interval (CI) -24.83; -7.71], as well as significant reductions in fatigue maintained at all time points, which were not evident with HE (95% CI -1.86; 0.23). HE led to delayed improvement in sleep quality at 4 months post-treatment and in depression (95% CI -1.37; -0.09) at 2 months post-treatment. CBT-SF led to significant gains in self-efficacy (95% CI 0.15; 0.53) and mental health (95% CI 1.82; 65.06). CONCLUSIONS: CBT-SF can be an effective treatment option for sleep disturbance and fatigue after ABI, over and above HE. HE may provide delayed benefit for sleep, possibly by improving mood. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry: ACTRN12617000879369 (registered 15/06/2017) and ACTRN12617000878370 (registered 15/06/2017).

Confabulation: a spontaneous and fantastic review.

Confabulation can be of two types: provoked or spontaneous. The former is the more common and can occur on challenge to an amnesic patient's memory. Spontaneous confabulation involves an unprovoked outpouring of unbelievable autobiographical claims. The purpose of the present paper is to synthesize the current literature on confabulation for the use of treating clinicians. There is a focus on the spontaneous form, which is less common, but more memorable when encountered. In this paper the history, phenomenology, incidence, anatomical underpinnings and theoretical mechanisms of spontaneous confabulations will be reviewed, and then the paper will conclude by addressing prognostic and treatment issues. A systematic literature review of electronic databases was conducted to identify the key articles, reviews and books that have shaped the understanding of spontaneous confabulation.

Course and causes of suspected dementia in young adults: a longitudinal study.

The authors performed a prospective, unbiased analysis of a cohort of young patients assessed consecutively with the question of dementia. The onset of patients' cognitive symptoms was prior to the age of 65 years. A study group of 226 patients was followed for a mean duration of 4.59 +/- 2.23 years (1 SD; range, 0.04-7.86 years). The diagnoses were established using published diagnostic criteria. A diagnosis of dementia was made in 112 patients (49.56%). Psychiatric disease was the most common diagnosis in those who did not have dementia (24.3%) followed by frontotemporal lobar degeneration (19.0%), Alzheimer's disease (11.9%), patients with cognitive symptoms who obtained normal neuropsychometric profiles (10.6%), nonneurological disorders (eg, obstructive sleep apnea [8.4%]), neurological disorders (eg, Parkinson's disease [4.9%]), and mild cognitive impairment (4.9%). The frequencies of frontotemporal lobar degeneration and psychiatric disease were higher than Alzheimer's disease, unlike in older populations.

The clinical differentiation of fronto-temporal dementia from psychiatric disease.

OBJECTIVE: Frontal and/or temporal lobar atrophy (F/TA) is sometimes detected on neuroimaging in patients with psychiatric disease. This observation leads to difficulty in distinguishing whether patients have fronto-temporal dementia (FTD) or psychiatric illness. This paper sets out to develop clinical profiles that might be useful at first presentation to distinguish these two populations. METHODS: 29 patients were selected from a database of 250 current patients attending young onset dementia clinic. Control and experimental patient groups were established using DSM-5 criteria: (i) those without selective atrophy who had a psychiatric disorder (N = 5); (ii) patients who had FTD using consensus criteria (N = 13); and (iii) an experimental group of patients who had F/TA on neuroimaging, a psychiatric diagnosis and referral with possibility of a neurodegenerative disorder (N = 11). Profiles suggestive of FTD and psychiatric disease were established in the control groups utilising information from medical records, the neurological examination, the natural history and neuropsychometry to develop criteria to distinguish reliably FTD from psychiatric disease. These criteria were then applied to the experimental group. Patients were followed for five years. RESULTS: The developed criteria resulted in 3 patients being classified as FTD and 8 having psychiatric diagnoses in the experimental group. At follow-up, all the psychiatric patients remained functionally stable, whereas the FTD patients had deteriorated. CONCLUSION: Characteristic profiles may prove useful in the diagnosis of patients with F/TA on imaging with a psychiatric illness and help to distinguish them from patients with FTD. At first presentation F/TA has been found in some patients with psychiatric disease who do not develop evidence of neurodegeneration. This suggests that F/TA on neuroimaging might be a feature of a subgroup of patients with psychiatric diseases.