An exploration of clinical dementia phenotypes among individuals with and without traumatic brain injury.

OBJECTIVE: To characterize the clinical profiles of individuals with dementia who do and do not report a history of TBI. INTRODUCTION: Some evidence suggests that a history of traumatic brain injury (TBI) is associated with an increased risk of dementia later in life. The clinical features of dementia associated with TBI have not been well investigated. While there is some evidence that TBI is associated with increased risk of Alzheimer's disease (AD), there are also indications that dementia associated with TBI has prominent behavioral, affective, and motor symptoms, making it distinct from AD. METHODS: The current study involves secondary analysis of baseline data from the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (UDS). RESULTS: Individuals with dementia who reported a history of TBI had higher fluency and verbal memory scores and later onset of decline, but they are on more medications, had worse cardiovascular and cerebrovascular health, were more likely to have received medical attention for depression, and were more likely to have a gait disorder, falls, and motor slowness. CONCLUSION: These findings suggest that dementia among individuals with a history of TBI may represent a unique clinical phenotype that is distinct from known dementia subtypes.

The Traumatic Brain Injury Model Systems: a longitudinal database, research, collaboration and knowledge translation.

In 1988, the National Institute on Disability and Rehabilitation Research (NIDRR) launched the Traumatic Brain Injury Model Systems (TBIMS) program, creating the longest and largest longitudinal database on individuals with moderate-to-severe traumatic brain injury (TBI) available today. In addition to sustaining the longitudinal database, centers that successfully compete to be part of the TBIMS centers are also expected to complete local and collaborative research projects to further scientific knowledge about TBI. The research has focused on areas of the NIDRR Long Range Plan which emphasizes employment, health and function, technology for access and function, independent living and community integration, and other associated disability research areas. Centers compete for funded participation in the TBIMS on a 5-year cycle. Dissemination of scientific knowledge gained through the TBIMS is the responsibility of both individual centers and the TBIMS as a whole. This is accomplished through multiple venues that target a broad audience of those who need to receive the information and learn how to best apply it to practice. The sites produce many useful websites, manuals, publications and other materials to accomplish this translation of knowledge to practice.

Long-term recovery course after traumatic brain injury: a comparison of the functional independence measure and disability rating scale.

OBJECTIVES: To study group changes over time after traumatic brain injury (TBI). DESIGN: Prospective cohort. SETTING AND PARTICIPANTS: TBI Model System Database with 1160 subjects using cohort with complete data. MAIN OUTCOME MEASURES: Functional Independence Measure (FIM) and Disability Rating Scale (DRS) at rehabilitation discharge and annually after injury. RESULTS: Statistically significant differences existed between FIM-total, FIM-Motor, FIM-Cognitive subscales, and DRS at rehabilitation discharge and year 1. Comparisons of year-to-year intervals, years 1 and 3, 1 and 5, and 3 and 5, revealed no statistically significant differences except between years 1 and 3 and 1 and 5 with DRS, and years 1 and 5 with FIM. Including only those more dependent at year 1 revealed statistically significant differences between years 1 and 2 and 1 and 5 on FIM-Cognitive and DRS, but not the FIM-Motor. The proportion of change for FIM and DRS items from year 1 to years 2 and 5 revealed DRS Level of Functioning and Employability items accounted for most DRS change, whereas FIM change was more spread across its components. CONCLUSIONS: DRS is more sensitive to changes during a shorter time period than FIM and seems to be more appropriate for detecting long-term deficits. However, research studies aimed at detecting meaningful changes year to year after TBI may need to use other tools or consider changes among individuals instead of group changes. DRS Level of Function and Employability Items represent complex functions expected to recover later than the more basic DRS items. Sole use of these two DRS items might provide an efficient means of measuring long-term recovery when resources are limited, whereas expansion of these two items might allow greater sensitivity and detail.

Use of injury severity variables in determining disability and community integration after traumatic brain injury.

BACKGROUND: Long-term outcome is important in managing traumatic brain injury (TBI), an epidemic in the United States. Many injury severity variables have been shown to predict major morbidity and mortality. Less is known about their relationship with specific long-term outcomes. METHODS: Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score, and Trauma and Injury Severity Score, along with other demographic and premorbid values, were obtained for 378 consecutive patients hospitalized after TBI at a Level I trauma center between September 1997 and May 1998. Of this cohort, 120 patients were contacted for 1-year follow-up assessment with the Disability Rating Scale, Community Integration Questionnaire, and employment data. RESULTS: Univariate analyses showed these to be significant single predictors of 1-year outcome. Multivariate analyses revealed that the Revised Trauma Score and Glasgow Coma Scale had significant additive value in predicting injury variables Disability Rating Scale scores when combined with other demographic and premorbid variables studied. Predictive models of 1-year outcome were developed. CONCLUSION: Injury severity variables are significant single outcome predictors and, in combination with premorbid and demographic variables, help predict long-term disability and community integration for individuals hospitalized with TBI.

Intentional traumatic brain injury: epidemiology, risk factors, and associations with injury severity and mortality.

BACKGROUND: Intentional injury is associated with significant morbidity and mortality and has been associated with certain demographic and socioeconomic groups. Less is known about the relationship of intentional traumatic brain injury (TBI) to injury severity, mortality, and demographic and socioeconomic profile. The objective of this study was to delineate demographic and event-related factors associated with intentional TBI and to evaluate the predictive value of intentional TBI on injury severity and mortality. METHODS: Prospective data were obtained for 2,637 adults sustaining TBIs between January 1994 and September 1998. Descriptive, univariate, and multivariate analyses were conducted to determine the predictive value of intentional TBI on injury severity and mortality. RESULTS: Gender, minority status, age, substance abuse, and residence in a zipcode with low average income were associated with intentional TBI. Multivariate analysis found minority status and substance abuse to be predictive of intentional injury after adjusting for other demographic variables studied. Intentional TBI was predictive of mortality and anatomic severity of injury to the head. Penetrating intentional TBI was predictive of injury severity with all injury severity markers studied. CONCLUSION: Many demographic variables are risk factors for intentional TBI, and such injury is a risk factor for both injury severity and mortality. Future studies are needed to definitively link intentional TBI to disability and functional outcome.

The value of trauma scores: predicting discharge after traumatic brain injury.

OBJECTIVE: To determine the association of acute variables with disposition after acute hospitalization. DESIGN: Revised Trauma Score (RTS), Injury Severity Score (ISS), and the Combined Trauma Score Injury Severity Score (TRISS(RTS)) were compared with discharge disposition after acute hospitalization of 378 consecutive patients who sustained a traumatic brain injury (TBI) and were treated at a level 1 trauma center between September 1997 and May 1998. RESULTS: Logistic regression modeling found TRISS(RTS) to predict discharge to home with or without home health assistance or inpatient rehabilitation vs. nursing home placement or death. Subsequent modeling, excluding patients who died or went to nursing homes, identified RTS and ISS as predictors of discharge to home with or without home health vs. inpatient rehabilitation. A sensitivity of 97.78% and 93.91% were achieved with these two models when tested on a population of 4,625 patients with TBI treated during the last 10 yr at the same facility. CONCLUSIONS: The results suggest that RTS, ISS, and TRISS(RTS) are predictors of discharge disposition after acute hospitalization with TBI and may be useful measures of rehabilitation services resource planning early in the course of TBI management.

Venous thromboembolism in the patient with acute traumatic brain injury: screening, diagnosis, prophylaxis, and treatment issues.

Venous thromboembolism is a life-threatening complication of traumatic brain injury. Consequently, knowledge of available screening, diagnostic, prophylactic, and treatment methods is critical to the management of the individual with traumatic brain injury. Venous thromboembolic risk varies among individuals, resulting in unique screening and prophylactic needs for each patient. In addition, anticoagulation, commonly employed for prophylaxis and treatment in other patient populations, may create an increased risk for intracranial hemorrhage when utilized following traumatic brain injury. The cost, sensitivity, specificity, efficacy, potential side effects, and alternatives for preventing, detecting, and treating venous thromboembolism are important considerations discussed in this article.

Risk factors for acute care transfer among traumatic brain injury patients.

OBJECTIVE: Acute inpatient traumatic brain injury (TBI) rehabilitation has seen a jump in complexity of medical patient care over the past several years, often necessitating transfer back to an acute care facility. The purpose of this study was to determine the association between selected clinical variables and transfer from inpatient rehabilitation to an acute care facility. DESIGN: A retrospective review of cases from 1992 to 1994. SETTING: A TBI unit in a freestanding rehabilitation hospital. PATIENTS: Twenty-two patients were identified as having received acute care transfer. This group was compared with 78 patients, admitted in the same interval, who did not require acute care transfer. The variables evaluated included recent surgery, pneumonia, fracture, intracranial blood, tracheostomy use, percutaneous feeding tube use, deep venous thrombosis, focal neurological examination, following simple commands, serum sodium level of < 135 mmol/L, serum white blood cell count of > 11,000 cells/microL, and serum hemoglobin level of < 10.0 g/dl. ANALYSIS: Chi-square analysis was performed on the association between acute care transfer and the noted variables. RESULTS: History of pneumonia (p < .03) and history of recent surgery (p < .02) were both associated with acute care transfer, and serum hemoglobin of < 10.0 g/dL had a trend towards association (p < .10). CONCLUSION: Physiatrists caring for the TBI patient may warrant more acute observation of individuals with these parameters to prevent the problems necessitating acute care transfer.

Revised trauma score: an additive predictor of disability following traumatic brain injury?

Recent studies have clarified the role of hypoxic-ischemic damage as a secondary factor in traumatic brain injury (TBI). Many trauma centers are now consistently using the Revised Trauma Score (Glasgow Coma Scale, systolic blood pressure, and respiratory rate) to assist with triage of multitrauma patients. This study investigated the predictive power of the Revised Trauma Score (RTS) instead of the Glasgow Coma Scale (GCS) in determination of disability as measured by the Disability Rating Scale (DRS). Data were obtained as part of the National Institute for Disability and Rehabilitation Research TBI Model Systems database on 501 patients receiving acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial RTS and GCS were obtained on admission to the emergency department, along with the lowest GCS measured in the first 24 h. Analysis of initial RTS and GCS demonstrated modest, but statistically significant Pearson's correlations with DRS at rehabilitation admission (-0.18 and -0.25, respectively) and discharge (-0.22 and -0.24, respectively). Lowest GCS within the first 24 h postinjury also failed to show a strong relationship with DRS at rehabilitation admission (-0.28) and discharge (-0.24). Multiple regression analysis performed on RTS subsets for systolic blood pressure and respiratory rate did not reveal an added predictive value. Although RTS may be important in emergency triage for its ability to predict mortality, this study indicates its limited usefulness in prediction of disability.

Relationship between Glasgow coma scale and functional outcome.

The Glasgow Coma Scale (GCS) is routinely used in the acute care setting after traumatic brain injury (TBI) to guide decisions in triage, based on its ability to predict morbidity and mortality. Although the GCS has been previously demonstrated to predict mortality, efficacy in prediction of functional outcome has not been established. The purpose of this study was to assess the value of the acute GCS in predicting functional outcome in survivors of TBI. This study used the Multicenter National Institute on Disability and Rehabilitation Research TBI Model Systems database of 501 patients who had received acute medical care and inpatient rehabilitation within a coordinated neurotrauma program for treatment of TBI. Initial and lowest 24 hr GCS scores were correlated with the following outcome measures: the Disability Rating Scale (DRS), Rancho Los Amigos Levels of Cognitive Functioning Scale (LCFS), and cognitive and motor components of the Functional Independence Measure (FIM(SM)-COG and FIM(SM)-M). Outcome data were collected at admission to and discharge from the inpatient TBI rehabilitation unit. Correlation analysis revealed only modest, but statistically significant, relationships between initial and lowest GCS scores and outcome variables. Initial and lowest GCS score comparison with outcome demonstrated the following correlation coefficients: admission DRS, -0.25 and -0.28; discharge DRS, -0.24 and -0.24; admission LCFS, 0.31 and 0.33; discharge LCFS, 0.27 and 0.25; admission FIM-COG, 0.36 and 0.37; discharge FIM-COG, 0.23 and 0.23; admission FIM-M, 0.31 and 0.31; discharge FIM-M, 0.25 and 0.21. The GCS as a single variable may have limited value as a predictor of functional outcome.

Potential role of serum prolactin measurement in the diagnosis of late posttraumatic seizures. A case report.

Posttraumatic seizures are an important medical complication after traumatic brain injury. However, the diverse clinical presentation of posttraumatic seizures, combined with the cognitive and behavior deficits frequently seen in this patient population, can make the diagnosis of posttraumatic seizures particularly challenging. Electroencephalography and imaging studies are often abnormal and nonspecific. It has been reported that serum prolactin levels frequently rise after epileptic seizures. This case report describes the use of prolactin measurement to confirm two suspected posttraumatic seizure episodes in a 42-yr-old male with severe traumatic brain injury. Each episode lasted less than 1 min and involved conspicuously altered postural tone and respiratory pattern, followed by a change in verbal and motor responsiveness. No rhythmic extremity movements were observed. Diagnostic evaluation included electroencephalography and imaging studies, which demonstrated nonspecific abnormalities. Serum prolactin levels obtained within 20 to 40 min were markedly elevated and two to three times greater than the baseline level. The use of prolactin levels in the diagnosis of posttraumatic seizures is reviewed, accompanied by discussion of pertinent aspects of normal and abnormal states of prolactin secretion and regulation.

Predicting outcome in the slow to respond traumatically brain-injured patient: Acute and subacute parameters.

Prognostication of recovery in the slow to respond patient is difficult at best. Acute and subacute parameters have been employed to predict mortality. Variables have been identified that assist in prognostication of mortality and broadly categorized functional outcome. However, few studies have looked at specific functional outcome parameters. This review will attempt to describe and discuss the acute and subacute parameters most pertinent to the slow to respond patient.