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Head injury: looking beyond the patient
... Various research methodologies were considered before the choosing the appropriate one for this investigation [35,37,40,7,5,17]. One method of conducting scientific research in a new area of study with a new tool is to use the tool with a group of participants and to collect data from the performance of tasks with the tool [19,30]. The data then display trends that allow other questions to be formed. ...
... Severe brain injuries of traumatic (TBI) or non-traumatic (NTBI) aetiology are among the major causes of death and long-term morbidity among younger age groups in the Western world [1, 2]. In 2002, 1693 incidences of contusions, diffuse shearing lesions and traumatic intracranial haemorrhage were registered in Denmark [3] and 1048 cases of non-traumatic brain injury caused by subarachnoid haemorrhage, resuscitation after cardiac arrest, electrical shock, near drowning or suffocation were reported [4] . ...
To investigate emotional distress and quality of life in a sample of Danish relatives of patients with severe brain injury at admission to intensive rehabilitation in the sub-acute phase.
Clinical convenience sample.
Participants included 31 primary relatives of patients with severe brain injury. The participants were recruited at admission to Traumatic Brain Injury Unit, Copenhagen University Hospital, Glostrup. All relatives completed the depression and anxiety scales from SCL-90-R (Symptom Checklist) and the Role Emotional, Social Function, Mental Health and Vitality scale of the SF-36 approximately 36 days after injury. Data concerning severity of injury, the patients' level of consciousness and function was also collected.
The participants had significantly lower scores on all quality of life scales (p < 0.01) and significantly more symptoms of anxiety (p < 0.01) and depression (p < 0.01) than normal reference populations. Correlations were found between the patients' condition and the level of anxiety and depression in relatives.
The majority of relatives had severely impaired quality of life and symptoms of anxiety and depression at the time of admission. Future research should focus on developing and evaluating interventions in the acute phase.
Psychiatric liaison and how it improves the QoL of neurosurgical patients.
Round table lecture.
Quality of life: a key component of decision – making for neurosurgical patients.
Thanos Ch. Didaskalou, MD.
Department of Psychiatry, Hippocrateion Gen. Hospital, Thessaloniki, Greece.
ABSTRACT
Described are several diagnostic entities of neurosurgical diseases regarding the improvement of their QoL after a routine psychiatric consultation. Comments extracted from our experience are given on the following domains : traumatic brain injury (TBI), brain tumours, intraranial aneurysms and haemorrhages, spinal surgery, epilepsy and a general approach of the normal stress reaction to trauma.
We propose specific manipulations on every individual case, bearing in mind the type of the injury, the localisation of the lesion and the premorbid personality of the patient.
"The good doctor can no longer be content without this knowledge:
that his object is not only to save a life, but also,
to make the life he saves worth living"
(Vasicka et al, 1958).
The QoL of neurosurgical patients is a multidimensional domain. Several qualities of well-being are affected, such as physical, psychological, social, etc, depending upon the type of the injury, the pathology of the disease, the localisation of the lesion. All the above are briefly described as follows (Table1):
TABLE 1
•Physical Well Being
•Neurological sequelae
•Neuropsychiatric sequelae
•Aches/Pains
•Sexual problems
•Memory
•Other impairments
•Psychological Well Being
•Happiness/Satisfaction
•Coping
•Anxiety/Depression
•Concentration/Memory
•Pain
•Social Well Being
•Family Distress
•Employment
•Personal relationships
•Home activities
•Sexuality •Social Well Being
•Family Distress
•Employment
•Personal relationships
•Home activities
•Sexuality
According to our experience, and bearing in mind the above Table 1, we believe that patients would likely benefit from being encouraged to set and maintain realistic goals concerning their prognosis and treatment process, following the schedule:
•Diagnosis: description of the condition or problem
•Treatment: nature & purpose of proposed treatment
•Consequences: risks & benefits of the proposed treatments
•Alternatives: viable alternatives to the proposed treatment including risks & benefits
•Prognosis: projected outcome with & without treatment
A main issue to face is recovery. Among the possible factors influencing recovery are the following (Kapur 1997):
• Severity of insult
• Number of insults
• Spacing of insults
• Age at time of insult
• Premorbid cognitive status of brain
• Extent to which one function can be subsumed by another
• Integrity of the rest of brain
• Individual idiosyncrasies of brain structure
• Motivation
• Emotional factors
• Extent and quality of rehabilitation
Brain Injury
Some comments about the outcome of some common conditions of brain injury (Table 2):
TABLE 2
Non-progressive brain injury About two-thirds remained unchanged in their general memory functioning Most patients compensated by using memory aids
Head injury from missile wounds Generally good outcome despite specific deficits from localised lesions
Head injury Age and coma duration predict recovery
In conditions of Traumatic Brain Injury (TBI) we propose that employment shows a strong and consistent relationship with perceived QoL, social integration within the community, and home and leisure activities. Part-time employment may have been superior to full-time employment for individuals with TBI: part-time workers have fewer unmet needs, are more socially integrated, and are more engaged in home activities than full-time workers. Loss of consciousness, as a measure of severity, is unexpectedly predictive of diminished sense of QoL for individuals with less severe injuries. In conclusion: Being employed contributes to one’s sense of well being, social integration, and pursuit of leisure and home activities3-25.
Brain tumours
The individual response to a cerebral tumour will play a part in determining the mental symptoms. The importance of this probably emerges less forcibly in most published studies than its true influence would warrant.
Patient’s response will be largely shaped by his pre-morbid personality and will reflect his habitual modes of reaction to stress. It will also be modified to a very considerable extent by the handling the patient receives from medical and nursing personnel. Such highly individual factors may be expected to modify the psychological effects of a cerebral lesion whatever it is situated.
Patients with brain tumours have satisfactory consent to the treatment; however, they feel disability to cope with social life.
On discharge, they showed a better mood state compared to that on admission, but the mood state turned for the worse again during the follow-up period.
It is evident that patients with brain tumours are exposed to severe stress even after the completion of the treatment. This stress which may have an influence on their quality of life (QoL). All the above necessitate our taking patients’ mental health into consideration for our treatment protocol17, 26,27.
Intracranial aneurysms
Patients who had undergone surgery for a left-sided middle cerebral artery (MCA) aneurysm complained of significantly more impairments in social contact, communication, and cognition than those treated for a right-sided MCA aneurysm.
Multiple aneurysms, intraoperative aneurysm rupture, and partial resection of the gyrus rectus had no adverse effects on later daily life. Only temporary clipping was associated with increased complaints in some QoL areas.
Disturbances of the circulation of cerebrospinal fluid and the presence of intraventricular haemorrhage led to more impairments in daily life.
Specific effects of the anatomical pattern of the bleeding could be identified, but adverse effects of vasospasm were very important.
Multivariate analyses revealed, in particular, that patient age and admission neurological status (Hunt and Hess grade) are substantial predictors of the psychosocial sequelae of subarachnoid haemorrhage (SAH)17, 28.
Spinal surgery
A number of different conditions are included under this heading.
For the psychosocial outcome of patients undergoing spinal surgery we consider the following factors:
• Pain intensity
• Depression
• Pain disability
• Sensory & emotional perception of pain
• Working distress
The social status, an important element of their well being is influenced by the occupational characterisation and the duration of inability to work.
Coping factors include :
1. Acceptance (revaluation of life values)
2. Fighting spirit (efforts to minimise the effects of the lesion)
3. Social reliance (a tendency towards dependent behaviour).
The outcome factors considered are dependent upon conditions like:
1. Helplessness
2. Low self-esteem
3. Intrusion (bitterness, brooding)
4. Personal growth (positive outcomes of life crisis)17.
Epilepsy
For such patients we comment that surgical intervention should occur before patients are subjected to the psychological conflicts and social handicaps associated with chronic intractable epilepsy.
The aim of the psychiatric intervention is to narrow the disparities between individuals’ expectations and actually occurs.
The improvement of QoL, then, can either be achieved by modifying a patient’s expectations to meet realistic goals or improving their current experience17, 29, 30.
Normal stress reactions after trauma
Table 3 outlines some common acute stress reactions, very common to neurosurgical patients31.
TABLE 3
Anticipation phase Anticipatory anxiety/fear; denial
Immediate Shock, numbness, disbelief. Acute distress. Dissociation & denial
Short term (1-6wks) High levels of arousal, intrusive phenomena, flashbacks, nightmares. Poor concentration, disturbed sleep, appetite, libido. Irritability.
Long term (6wks to 6 mo) Features described above persist but decreased in intensity & frequency. Substance abuse is common.
Conlusion
The individual response to a cerebral tumour will play a part in determining the mental symptoms. The importance of this probably emerges less forcibly in most published studies than its true influence would warrant.
Patient’s response will be largely shaped by his pre-morbid personality and will reflect his habitual modes of reaction to stress. It will also be modified to a very considerable extent by the handling the patient receives from medical and nursing personnel. Such highly individual factors may be expected to modify the psychological effects of a cerebral lesion whatever it is situated.
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Administered the D. Meier et al (unpublished) Schedule for the Evaluation of Individual Quality of Life (SEIQOL) to 20 patients (aged 67–81 yrs) with mild dementia. Cognitive status was evaluated using the Mini-Mental State Examination and CAMCOG (from the M. Roth et al [1988] Cambridge Examination for Mental Disorders in the Elderly). All Ss were able to complete some elements of the SEIQOL, but only 6 were willing or able to complete the full procedure. Mean CAMCOG scores distinguished these 6 patients from the remaining 14. For these 6 dementia patients the mean interval variance, an estimate of construct validity, was .70, and the internal reliability coefficient was .74. It is concluded that in cases of mild cognitive impairment the SEIQOL can be a feasible, valid, and reliable instrument. As cognitive impairment increases, patients are less likely to be able or willing to complete the SEIQOL, and proxy responses may be a necessary alternative. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
To investigate the emotional well-being of relatives of patients with a severe brain injury in the acute setting, as well as risk factors associated with high anxiety and depression scores and impaired quality-of-life.
Clinical convenience sample.
Participants included 45 relatives of patients with severe brain injury recruited at a NICU. All relatives completed selected scales from the SCL-90-R and SF-36 ∼ 14 days after injury. Data concerning the condition of the patient were also collected.
Of the relatives, 51% and 69% reported anxiety and depression, respectively, as well as significantly impaired quality-of-life compared to normal reference populations. Regression analysis revealed that up to 20% of the variance in depression and anxiety scores could be explained by the CRASH 2 Mortality prediction.
The majority of the relatives had severely impaired quality-of-life and symptoms of anxiety and depression during the patient's NICU stay. Future research is required to explore stressors and evaluate effects of psychological intervention in the acute setting.
We present two studies that have advanced the design of brain-body interfaces for use in the rehabilitation of individuals with severe neurological impairment due to traumatic brain injury. We first developed and evaluated an adaptive cursor acceleration algorithm based on screen areas. This improved the initial design, but was too inflexible to let users make the most of their highly varied abilities. Only some individuals were well served by this adaptive interface. We therefore developed and evaluated an approach based on personalized tile layouts. The rationales for both designs are presented, along with details of their implementation. Evaluation studies for each are reported, which show that we have extended the user population who can use our interfaces relative to previous studies. We have also extended the usable functionality for some of our user group. We thus claim that personalized tiling with discrete acceleration has allowed us to extend the usable functionality of brain-body interfaces to a wider population with traumatic brain injury, thus creating new options for neurorehabiliation.
To appraise recent literature on the topic of perceived needs of family carers of head-injured adult relatives. MEDLINE (1966-2000), EMBASE PSYCHIATRY (1987-1999), CINAHL (1982-January 2000) and PSYCHLIT (1967-1999) databases were searched.
A total of 13 papers were reviewed, of which six employed standardized research methods. The remainder used researcher developed questionnaires. Needs described by carers as important were predominantly related to information. Most unmet needs were linked to the provision of emotional support. There were significant differences in the perceived needs and their fulfilment between parental and spousal carers. In addition, unfulfilled needs could be predicted by behavioural problems in patients.
The design and variation in methodology of most studies reviewed limits the generalization of reported data. Further research is required to fully identify both common and individual needs of family carers of the head-injured.
To investigate life satisfaction and health-related quality of life (SF-36) in a general population sample of middle-aged women and men. The effects of menopausal status and hormone replacement therapy (HRT) use upon life satisfaction and health-related quality of life (HrQOL) were also examined for the female sample.
All men and women aged 49-55 years from the age/sex register of a large general practice in London were contacted and asked to complete a questionnaire about their health.
A total of 103 women (55%) and 86 men (40%) participated; of the women, 15% were premenopausal, 68% peri- or postmenopausal and 17% taking HRT.
Women and men reported similar levels of HrQOL, life satisfaction and general health, although women reported more physical problems (SF-36). The significant predictors of HrQOL were serious illness, employment and marital status, but HRT use and menopausal status were not significantly associated with life satisfaction nor HrQOL (for women).
Gender differences in health and HrQOL may be less apparent during mid-life, although there were some subtle differences between men and women in reported health concerns and reasons given for (dis)satisfaction with their lives.
The incidence of head injury is increasing among younger people with more family members undertaking their life-long care. Many research studies have highlighted the emotional well-being of such family carers and their unmet needs, however only a few consider the formal help provided for carers. Using a longitudinal, mixed variable, within and between-subject design, this pilot study evaluated the impact of an educational programme for family carers and their head-injured relatives in reducing carer and patient psychological distress and improving their coping ability.
The study comprised experimental and control samples each with carer and patient groups. The experimental sample had eight sessions of educational input. All groups were assessed pre- and post-intervention and at 3 months follow-up. The patient sample was further assessed using cognitive measures. There was evidence of reduction in psychological distress in the experimental carer group following the educational input, but these results were not statistically significant. However, the experimental patient population at follow-up assessment showed statistically significant improvements.
A larger scale multi-centre study with a longer follow-up period of assessment is required for the generalization of findings. The pilot study identifies points for consideration in a potential main study.
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