Delirium following traumatic brain injury in adolescents: Symptomatology and prediction of ability to return to school or employment 1-year post-injury.

BACKGROUND: There is a limited evidence-base describing clinical features of delirium in youth. What is known is largely extrapolated from studies of adults or samples with heterogeneous etiologies. It is unclear if the symptoms experienced by adolescents differ from those experienced by adults, or the degree to which delirium impacts the ability of adolescents to return to school or work. OBJECTIVE: To describe delirium symptomatology among adolescents following a severe traumatic brain injury (TBI). Symptoms were compared by adolescent delirium status and across age groups. Delirium and its relationship with adolescent employability 1 year post-injury was also examined. DESIGN: Exploratory secondary analysis of prospectively collected data. SETTING: Free-standing rehabilitation hospital. PATIENTS: Severely injured TBI Model Systems neurorehabilitation admissions (n = 243; median Glasgow Coma Scale = 7). The sample was divided into three age groups (adolescents, 16-21 years, n = 63; adults 22-49 years, n = 133; older adults ≥50 years, n = 47). INTERVENTIONS: Not applicable. MEASURES: We assessed patients using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria and the Delirium Rating Scale-Revised 98 (DRS-R-98). The employability item from the Disability Rating Scale was the primary 1-year outcome. RESULTS: Most items on the DRS-R-98 differentiated delirious from non-delirious adolescents. Only "delusions" differed among age groups. Among adolescents, delirium status 1 month post-TBI provided acceptable classification of employability prediction 1 year later (area under the curve [AUC]: 0.80, 95% confidence interval [CI]: 0.69-0.91, p < .001). Delirium symptom severity (AUC: 0.86, 95% CI: 0.68-1.03, SE: 0.09; p < .001) and days of post-traumatic amnesia (AUC: 0.85, 95% CI: 0.68-1.01, SE: 0.08; p < .001) provided excellent prediction of outcomes for TBI patients in delirium. CONCLUSIONS: Delirium symptomatology was similar among age groups and useful in differentiating the delirium status within the adolescent TBI group. Delirium and symptom severity at 1 month post-TBI were highly predictive of poor outcomes. Findings from this study support the utility of DRS-R-98 at 1 month post-injury to inform treatment and planning.

The Relationship Between Sleep-Wake Cycle Disturbance and Trajectory of Cognitive Recovery During Acute Traumatic Brain Injury.

OBJECTIVE: Following traumatic brain injury, both sleep dysfunction and cognitive impairment are common. Unfortunately, little is known regarding the potential associations between these 2 symptoms during acute recovery. This study sought to prospectively examine the relationship between ratings of sleep dysfunction and serial cognitive assessments among traumatic brain injury acute neurorehabilitation admissions. METHODS: Participants were consecutive admissions to a free-standing rehabilitation hospital following moderate to severe traumatic brain injury (Median Emergency Department Glasgow Coma Scale = 7). Participants were assessed for sleep-wake cycle disturbance (SWCD) and cognitive functioning at admission and with subsequent weekly examinations. Participants were grouped on the basis of presence (SWCD+) or absence (SWCD-) of sleep dysfunction for each examination; groups were equivalent on demographic and injury variables. Individual Growth Curve modeling was used to examine course of Cognitive Test for Delirium performance across examinations. RESULTS: Individual Growth Curve modeling revealed a significant interaction between examination number (ie, time) and SWCD group (ß = -4.03, P < .001) on total Cognitive Test for Delirium score. The SWCD+ ratings on later examinations were predicted to result in lower Cognitive Test for Delirium scores and greater cognitive impairment over time. CONCLUSIONS: This study has implications for improving neurorehabilitation treatment, as targeting sleep dysfunction for early intervention may facilitate cognitive recovery.

Prospective evaluation of the nature, course, and impact of acute sleep abnormality after traumatic brain injury.

OBJECTIVE: To prospectively characterize the prevalence, course, and impact of acute sleep abnormality among traumatic brain injury (TBI) neurorehabilitation admissions. DESIGN: Prospective observational study. SETTING: Freestanding rehabilitation hospital. PARTICIPANTS: Primarily severe TBI (median emergency department Glasgow Coma Scale [GCS] score=7; N=205) patients who were mostly men (71%) and white (68%) were evaluated during acute neurorehabilitation. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Delirium Rating Scale-Revised-98 (DelRS-R98) was administered weekly throughout rehabilitation hospitalization. DelRS-R98 item 1 was used to classify severity of sleep-wake cycle disturbance (SWCD) as none, mild, moderate, or severe. SWCD ratings were analyzed both serially and at 1 month postinjury. RESULTS: For the entire sample, 66% (mild to severe) had SWCD at 1 month postinjury. The course of the SWCD using a subset (n=152) revealed that 84% had SWCD on rehabilitation admission, with 63% having moderate to severe ratings (median, 24d postinjury). By the third serial exam (median, 35d postinjury), 59% remained with SWCD, and 28% had moderate to severe ratings. Using general linear modeling and adjusting for age, emergency department GCS score, and days postinjury, presence of moderate to severe SWCD at 1 month postinjury made significant contributions in predicting duration of posttraumatic amnesia (P<.01) and rehabilitation hospital length of stay (P<.01). CONCLUSIONS: Results suggest that sleep abnormalities after TBI are prevalent and decrease over time. However, a high percent remained with SWCD throughout the course of rehabilitation intervention. Given the brevity of inpatient neurorehabilitation, future studies may explore targeting SWCD to improve early outcomes, such as cognitive functioning and economic impact, after TBI.

Assessment of executive functioning in brain injury: collaboration between speech-language pathology and neuropsychology for an integrative neuropsychological perspective.

BACKGROUND: Executive functioning (EF) deficits are common sequelae of traumatic brain injury (TBI). These deficits extend beyond the acute stages of recovery and pose a significant challenge in rehabilitation efforts. Current theories of EF propose a multidimensional construct. This paper provides an integrative theoretical framework with interactive dimensions for the assessment and treatment of EF that can assist the interdisciplinary team to successfully manage EF deficits secondary to TBI. METHODS: This paper is a review of pertinent literature related to assessment of EF. It concludes with a case presentation that illustrates the utility of the proposed theoretical framework in the rehabilitation context. CONCLUSIONS: Formal neuropsychological, standardized psychometric measures and informal clinical observations, particularly as they relate to contextual assessment, should be incorporated in order to effectively assess EF difficulties in survivors of TBI. The paper concludes with recommendations for effective assessment and treatment of EF by the interdisciplinary team consisting of speech-language pathologists and neuropsychologists.

Posttraumatic confusion predicts patient cooperation during traumatic brain injury rehabilitation.

Scant research has examined the relationship between posttraumatic confusion (PTC) and cooperation during rehabilitation from moderate to severe traumatic brain injury. In this study, PTC and cooperation were examined in a prospective cohort of 74 inpatients with traumatic Brain Injury. Confusion was measured using the Confusion Assessment Protocol. Cooperation was rated on a 0-100 scale by rehabilitation therapists. Using multiple regression analysis, PTC significantly predicted cooperation (R(2) = 0.33, P < 0.001). Age at injury, education, days since injury, and Glasgow Come Scale scores were not significant predictors. Bivariate analyses indicated that four PTC symptoms significantly predicted poorer cooperation: daytime hypersomnolence (ρ = -0.42, P < 0.001), agitation (ρ = -0.39, P = 0.001), psychosis (ρ = -0.39, P = 0.001), and cognitive impairment (ρ = -0.24, P = 0.04). Results provide empirical support that PTC is associated with poorer cooperation and empirical justification for interventions to manage confusion during early recovery from traumatic brain injury.

Multilevel modeling of self-esteem change during acute inpatient stroke rehabilitation.

OBJECTIVE: To explore self-esteem change during inpatient stroke rehabilitation and moderators of change. RESEARCH METHOD: One hundred twenty survivors of stroke serially completed the State Self-Esteem Scale (SSES) during inpatient rehabilitation, as well as measures of mood and perceived recovery as potential moderators of change. Age, gender, prior stroke, prestroke depression, stroke laterality, and admission Functional Independence Measure (FIM) self-care, mobility, and cognitive scores were also included as moderators. RESULTS: Multilevel modeling of the repeated administrations of the SSES indicated that self-esteem significantly improved during rehabilitation. Female gender, left hemisphere stroke, prior stroke, and lower admission FIM cognitive scores were associated with lower self-esteem ratings at admission, but only age and admission FIM self-care and mobility scores were associated with self-esteem change. Older individuals showed less self-esteem improvement than younger individuals, and higher self-care and mobility scores at admission were associated with greater self-esteem improvement. While mood change significantly covaried with self-esteem, the rate of mood change did not appear to influence rate of self-esteem change. Greater improvement in self-esteem over time was related to lower levels of perceived recovery, but this was likely because of the relationship between perceived recovery and self-esteem at rehabilitation admission. IMPLICATIONS: These results suggest that self-esteem improves during inpatient rehabilitation, and this change may be partially dependent on functional status. Implications for facilitating self-esteem change by the clinician are discussed, as well as future research directions.

Self-esteem level and stability, admission functional status, and depressive symptoms in acute inpatient stroke rehabilitation.

OBJECTIVES: Explore the relationship of self-esteem level, self-esteem stability, and admission functional status on discharge depressive symptoms in acute stroke rehabilitation. RESEARCH METHOD: One hundred twenty stroke survivors serially completed a measure of state self-esteem during inpatient rehabilitation and completed a measure of depressive symptoms at discharge. Functional status was rated at admission using the Functional Independence Measure (FIM). Regressions explored main effects and interactions of self-esteem level and stability and admission FIM self-care, mobility, and cognitive functioning on discharge depressive symptoms. RESULTS: After controlling for potential moderating variables, self-esteem level interacted with FIM self-care and cognitive functioning to predict discharge depressive symptoms, such that survivors with lower self-rated self-esteem and poorer functional status indicated higher levels of depressive symptoms. Self-esteem stability interacted with FIM mobility functioning, such that self-esteem instability in the presence of lower mobility functioning at admission was related to higher depressive symptoms at discharge. IMPLICATIONS: These results suggest that self-esteem variables may moderate the relationship between functional status and depressive symptoms. Self-esteem level and stability may differentially moderate functional domains, although this conclusion requires further empirical support.

Self-esteem stability and depressive symptoms in acute stroke rehabilitation: methodological and conceptual expansion.

OBJECTIVES: Explore the relationship of self-esteem level, self-esteem stability, and other moderating variables with depressive symptoms in acute stroke rehabilitation. MEASURES: One hundred twenty participants completed measures of state self-esteem, perceived recovery, hospitalization-based hassles, impairment-related distress, and tendency to overgeneralize negative self-connotations of bad events. Self-report of depressive symptoms was collected at admission and on discharge. Four regression analyses explored the relationship of self-esteem level and stability and each of 4 moderating variables (perceived recovery, hassles, impairment-related distress, and overgeneralization) with depressive symptoms at discharge. RESULTS: Analyses indicated significant 3-way interactions in the 4 regression models. In general, individuals with unstable high self-esteem endorsed greater depressive symptoms under conditions of vulnerability (e.g., lower perceived recovery) than did individuals with stable high self-esteem. Under conditions of vulnerability, participants with stable low self-esteem indicated the highest levels of depressive symptoms. IMPLICATIONS: Self-esteem level and stability interact with psychological, environmental, and stroke-specific variables to predict depressive symptoms at discharge from stroke rehabilitation. This suggests the viability of self-esteem stability in exploring depressive symptoms in this setting and the complexity of emotional adjustment early after stroke.

Classification schema of posttraumatic amnesia duration-based injury severity relative to 1-year outcome: analysis of individuals with moderate and severe traumatic brain injury.

OBJECTIVE: Early investigations classified traumatic brain injury (TBI) severity according to posttraumatic amnesia (PTA) duration, designating "greater than 7 days" as the most severe. PTA durations of more than 7 days are common in neurorehabilitation populations. Moreover, no study has derived a PTA severity schema anchored to late outcome. The purpose of this study was to develop a PTA severity classification schema. DESIGN: Prospective observational study. SETTING: Rehabilitation hospital. PARTICIPANTS: Sample included TBI Model System participants (N=280) with known or imputed PTA duration during acute hospitalization and 1-year productivity status. Participants were primarily male (70%), median age of 27 years; and the most common mechanism of injury was motor vehicle collisions (79%). For study purposes, 4 injury severity groups were identified by observing differences in productivity associated with different PTA durations. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Productivity status at 1 year postinjury. RESULTS: Fisher exact test comparisons revealed significant differences among 3 of the groups. Most individuals with PTA fewer than 14 days had favorable 1-year outcome (68% productive), whereas worse outcomes were associated with PTA more than 28 days (18% productive). CONCLUSIONS: If validated by other investigators, the proposed schema will be useful in determining prognosis for late functional status based on PTA duration.

Evaluation of an interdisciplinary team intervention to improve therapeutic alliance in post-acute brain injury rehabilitation.

OBJECTIVE: Evaluate an intervention to improve an alliance between an interdisciplinary team and clients with traumatic brain injury attending post-acute brain injury rehabilitation. DESIGN: Prospective design, 2 consecutive samples-historical control (CNT) and treatment (TX). METHODS: Sample of 104 clients (69 CNT, 35 TX) admitted to post-acute brain injury rehabilitation completed admit/discharge questionnaires. RESULTS: The TX group had higher functional status at discharge than the CNT group. Stronger team alliance was associated with program completion, return to productivity, stronger client alliance, less family discord, and fewer depressive symptoms. CONCLUSIONS: Findings provide direction for a larger study examining the effectiveness of this intervention to improve outcome after traumatic brain injury.

Self-esteem in an acute stroke rehabilitation sample: a control group comparison.

OBJECTIVE: To compare ratings of self-esteem and depressive mood in a sample of stroke survivors in an acute inpatient rehabilitation setting to those of a matched control group. DESIGN: Stroke survivors (n = 80) were matched on age and education to a group of neurologically intact community-dwelling control participants. Between-group analysis compared mean ratings of self-esteem and depressive measures. Within-group correlational analyses explored the relationship between self-esteem and mood. Between-group comparison of the correlations between self-esteem and mood explored differences in the strength of association between these constructs. Regression analyses explored the relationship of self-esteem measures after controlling for depressive mood. MAIN MEASURES: Visual Analogue Self-Esteem Scale, Rosenberg Self-Esteem Scale, Geriatric Depression Scale. RESULTS: Stroke survivors rated significantly lower mean levels of self-esteem on the Visual Analogue Self-Esteem Scale (37 versus 41) and the Rosenberg Self-Esteem Scale (21 versus 24) than the control group. Stroke survivors also rated higher mean levels of depressive mood on the Geriatric Depression Scale (9 versus 6). Significantly higher correlations between self-esteem and mood ratings were noted in the stroke group than in the control group. Lower self-esteem ratings do not appear to be a byproduct of depressive mood. CONCLUSIONS: Self-esteem is negatively impacted by stroke and is strongly, but independently, associated with depressive mood. Clinicians may better facilitate the emotional adjustment of the survivor by considering this facet of psychological impact and intervening to address self-esteem.

Therapeutic alliance in post-acute brain injury rehabilitation: predictors of strength of alliance and impact of alliance on outcome.

PRIMARY OBJECTIVE: To determine factors that influence the strength of therapeutic alliance for patients with traumatic brain injury (TBI) attending post-acute brain injury rehabilitation (PABIR) and to examine the association of therapeutic alliance with outcome after PABIR. RESEARCH DESIGN: Prospective cohort study. METHODS AND PROCEDURES: The study sample consisted of 69 of 95 patients with TBI admitted to the PABIR programme during the study period. Demographic and injury severity data were abstracted from medical records or obtained through interview. Study questionnaires (the modified California Psychotherapy Alliance Scales-patient, family and clinician forms; the Prigatano Alliance Scale; the Awareness Questionnaire; the Center for Epidemiologic Studies-Depression scale; and the Family Assessment Device-General Functioning Scale) were obtained within 2 weeks of patient admission to the PABIR programme. MAIN OUTCOMES AND RESULTS: Study outcomes were functional status (Disability Rating Scale), programme completion and employment status at discharge from PABIR. Higher levels of family discord were associated with poorer therapeutic alliance. Greater discrepancies between family and clinician ratings of patient functioning were associated with poorer therapeutic alliance and poorer effort in therapies. Poor participation was predictive of programme dropout. Productivity status at discharge was predicted by functional status at admission and degree of therapeutic alliance. CONCLUSIONS: Findings indicate that family perceptions and family functioning are important determinants of therapeutic alliance for patients in PABIR. These results indicate that therapists in PABIR programmes should address family perceptions and functioning to facilitate patient bonding with the programme.

Early impaired self-awareness, depression, and subjective well-being following traumatic brain injury.

OBJECTIVE: To examine the incidence and intercorrelation of early impaired self-awareness (ISA) and depression after traumatic brain injury (TBI), as well as their contributions to prediction of patients' subjective well-being at discharge from inpatient rehabilitation. DESIGN: Inception cohort. SETTING: Inpatient rehabilitation. PATIENTS: Subjects were 96 patients with TBI seen for inpatient rehabilitation at the Methodist Rehabilitation Center. All subjects had emerged from posttraumatic amnesia prior to assessment for this study. INTERVENTION: None. MAIN OUTCOME MEASURE: Subjective well-being as measured by the Satisfaction With Life Scale taken at discharge from inpatient rehabilitation. RESULTS: Multivariable linear regression analysis revealed that ISA and functional status (Disability Rating Scale total score) at rehabilitation admission made independent contributions to prediction of subjective well-being. Bivariable correlational analyses demonstrated that frequency of depressive symptoms was inversely correlated with Satisfaction With Life Scale scores. Impaired self-awareness and depression were not correlated in this sample. CONCLUSIONS: Results support the idea that ISA is an important factor in determining subjective well-being in patients with TBI at acute rehabilitation discharge. Early interventions to decrease ISA may improve patients' functional status at rehabilitation discharge.