Psychosocial functioning during the year following severe traumatic brain injury.

The psychosocial functioning of a group of 65 adults with severe traumatic brain injury was assessed at 6 months and 1 year post-injury. Aspects of emotional, behavioural, and social functioning were investigated. The prevalence of depression remained constant (24%) over time, although there was some individual variation in the reporting of symptoms. Impatience was the most frequently reported behavioural problem at both assessments. Whilst there was a slight increase in the number of behavioural problems and level of distress reported over time, the most obvious change was in the type of behavioural problems that caused distress. At 1 year post-injury, problems with emotional control were found to be most distressing for the patients. A comparison with pre-morbid social functioning showed the loss of employment to be 70%, 30% returned to live with their parents, and relationship breakdown occurred for 38%. There was also a significant and ongoing decrease in all five aspects of social and leisure activities.

Neuropsychological functioning during the year following severe traumatic brain injury.

The neuropsychological functioning of a group of 65 adults with severe traumatic brain injury was assessed at 6 months and 1 year post-injury. The cognitive domains assessed were pre-morbid intellectual level, current level of general intellectual functioning, simple and complex attention, verbal memory, executive functioning, and perceptual functioning. At least 40%, and up to 74%, of the TBI patients displayed some degree of impairment on tests administered at 6 months. Improvement was found to occur in all areas of cognitive functioning over the first year following injury. Despite this improvement at least 31%, and up to 63%, of TBI patients displayed some degree of impairment on tests administered at 1 year post-injury. The various types of neuropsychological functioning were affected to different degrees, indicating that different aspects of cognition are more susceptible to injury, and that recovery takes place at a differential rate across functions. The implications of these findings for the appropriate planning and allocation of treatment and rehabilitation resources, and the development of effective rehabilitation interventions are outlined.

Observer error and prediction of outcome--grading of head injury based on computerised tomography.

OBJECTIVE: To measure inter-observer error of a recently reported computerised tomography scoring system and to assess the ability of the scoring system to predict outcome in head injury patients. METHODS: Two radiologists independently graded all CT scans performed during the admission of all head injured patients. They were blinded to the clinical condition of the patient. Patients were followed up at 12 months and given a Glasgow outcome score. Outcomes were matched to the 2 independent assessments done on the first CT scan for each patient. RESULTS: A total of 123 head injury patients were studied. For the diffuse injury categories, there were 410 gradings made. Of these, 32% differed by at least one category. Where at least one of the radiologists identified non-evacuated mass lesions there were 148 gradings. Of these, one radiologist reported an un-evacuated mass lesion in 47%, which was not reported by the other. The first CT scan was evaluated on 119 patients. Using the Chi-Squared test, the diffuse injury IV category was the only one to show a strong relationship with outcome as measured by the Glasgow outcome score. CONCLUSIONS: The prediction of outcome for head injury patients based on CT scans has significant shortcomings. In our study, there was significant variation in grading by experienced radiologists. The separate categories were also poor predictors of outcome at 12 months except for diffuse injury IV. The classification of mass lesions needs modification to be useful.

Cognitive and psychosocial outcome in survivors of severe traumatic brain injury: correlations with cerebral perfusion pressure, frontal lobe damage and somatosensory evoked potentials.

OBJECTIVE: To correlate neuropsychological outcome in patients after severe traumatic head injury, with neurophysiological and neuroradiological data collected during the intensive care unit (ICU) period of care. METHODS: Patients admitted to Waikato Hospital ICU with severe traumatic head injury were studied. Respiratory difficulty at the accident site, admission Glasgow Coma Score (GCS), anatomic traumatic brain disruption as quantified by a cerebral computed tomography score, prolongation of the central conduction time (CCT) of somatosensory evoked potentials and the percentage time that the cerebral perfusion pressure was less than 70 mmHg (%CPP < 70) were measured. Neuropsychological outcome was assessed, in terms of cognitive and behavioural function, by the Controlled Oral Word Association (COWA) test (performed by the patient) and Head Injury Behaviour rating scale (HIBS, performed by their caregiver) respectively, one year following injury. RESULTS: Sixty-eight patients with a median post-resuscitation GCS of 6 were able to complete the neuropsychological follow up. Most patients had significantly impaired cognitive and behavioural function (mean COWA = 32 and HIBS = 9.7). Cognitive function did not correlate significantly with behavioural function (COWA vs HIBS, r = -0.14, p = 0.27). There were no significant correlations between either GCS (r = 0.15, p = 0.28) or estimates of respiratory difficulty at the accident scene and neuropsychological outcome. Poor cognitive outcome (COWA) was correlated with %CPP < 70 (r =-0.41, p = 0.005) and prolonged CCT (r = 0.26, p = 0.03). There was an insignificant correlation between the CT score and cognitive outcome (frontal lobe score vs COWA, r = -0.12, p = 0.33). However, the group of patients with the most severe frontal lobe injury tended to have a worse behavioural outcome as assessed by the HIBS. CONCLUSIONS: Behavioural outcome as quantified by the caregiver (HIBS) does not correlate well with the degree of cognitive impairment as measured directly from the patient (COWA). Severely head injured patients with poor neurophysiological indicators (%CPP < 70 or prolonged CCT) have a poor neuropsychological outcome. However, anatomical disruption of the brain as estimated by the frontal lobe CT score correlated poorly with outcome.

Profile and cost of head injury patients admitted to the Waikato Hospital Intensive Care Unit.

AIMS: To examine the profile and hospital costs of head injury patients admitted to the Waikato Hospital Intensive Care Unit (ICU). METHODS: Data were collected on head injury patients admitted to ICU over 41 months and costs of head injury patients in ICU, the High Dependency Unit (HDU) and other wards were calculated. RESULTS: There were 286 head injury patients admitted to ICU, of whom 62% had a Glasgow Coma Score < or = 8. Times in the ICU and hospital were 1760 and 7352 days respectively. Costs per day were $2280 in ICU, $800 in HDU and $500 in other wards. The cost for ICU was $1,174,478 per year, and for the total hospital treatment, $2.05 million (83 head injury patients) per year. Admissions of head injury patients to all New Zealand ICUs were 777 over the year to June 1996. Thus, assuming similar costs to the Waikato Hospital, New Zealand hospitals spend each year approximately 10.9 million dollars on head injury patients in ICUs and 19 million dollars on overall hospital stays (including ICU). In a selected group of 123 severe head injury patients, the six month Glasgow Outcome Scores showed that 36% were in the moderate to severe disability categories and likely to cause major ongoing ACC costs. The costs of the 80% of head injury patients admitted to hospital but not admitted to ICU, and their prehospital and postdischarge costs were not studied. CONCLUSIONS: The New Zealand epidemic of head injuries continues to consume large amounts of the health money and produce major social costs.

Caregiver burden at 6 months following severe traumatic brain injury.

Sixty-nine primary caregivers of people with a severe traumatic brain injury (TBI) were assessed at 6 months post injury. Caregivers completed questionnaires on the physical, cognitive, emotional, behavioural, and social functioning of the persons with the TBI. Caregiver psychosocial functioning and levels of subjective and objective burden were also assessed. Clinically significant levels of anxiety, depression, and impairment in social adjustment were evident in over a third of the caregivers. The frequency with which various changes in the person with the TBI and types of objective burden were reported had little relationship to the degree of distress caused by these changes. The person with TBI's social isolation and negative emotional behaviours caused the greatest degree of stress for caregivers. Caregivers were also most distressed by the impact that caregiving had on their personal health and free time. The results from a multiple regression analysis suggest that it is the presence of behavioural problems in the person with the TBI that has the most severe and pervasive impact on all aspects of caregiver functioning. It is suggested that these findings be taken into account when providing rehabilitation services to people with TBI and their families.

Caregiver burden at 1 year following severe traumatic brain injury.

Sixty-nine primary caregivers of adults with a severe traumatic brain injury (TBI) were assessed at 1-year post-injury. Caregivers completed questionnaires on the physical, cognitive, emotional, behavioural, and social functioning of the person with TBI. Caregiver objective burden, psychosocial functioning, and subjective burden were also assessed. Clinically significant levels of anxiety and depression were evident in over a third of the caregivers. Similarly, a quarter of the caregivers reported poor social adjustment. There was no consistent relationship between the prevalence of various types of objective burden and the level of subjective distress that resulted from these changes. The person with TBI's emotional difficulties, in particular their anger, apathy, and dependency, caused the greatest distress for caregivers. With regard to the impact that caregiving had on their own lives, caregivers were most distressed by the loss of personal free time. Results from a regression analysis indicated that the person with TBI's physical impairment, number of behavioural problems, and social isolation were the strongest predictors of caregiver burden. The impact that caring for a person with severe TBI can have on the extended family unit is discussed.