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Association of age with long-term psychosocial outcome following traumatic brain injury
Abstract
Objective: To examine the association of age with long-term psychosocial outcome following traumatic brain injury.Participants: One hundred and twelve participants with mild to very severe traumatic brain injury, aged 26-89 years at 5-22 years post-injury, 112 significant others and 112 healthy controls matched for current age, gender, education and estimated IQ.Methods: Changes in occupational activity, interpersonal relationships and independent living skills were assessed in participants with traumatic brain injury using the Sydney Psychosocial Reintegration Scale (SPRS). Employment status of participants with traumatic brain injury and control participants was compared at the time of assessment.Results: No age effects were demonstrated on the 3 SPRS domains. However, compared with healthy individuals, older participants with traumatic brain injury showed greater likelihood of unemployment relative to younger participants with traumatic brain injury.Conclusion: By using matched controls this study has demonstrated that older individuals with traumatic brain injury are less likely to return to the workforce than younger individuals with traumatic brain injury. Other aspects of psychosocial outcome appeared to be less affected by age, although specific domains require closer examination in relation to healthy age-matched controls.
... Injury severity was defined by Glasgow Coma Scale (GCS) scores. Five of the 11 studies included participants with mild, moderate, and severe TBIs, 15,16,[19][20][21] 2 studies had participants with mild to moderate TBIs only, 14,17 and 2 studies included participants with moderate to severe TBIs only. 8, 13 Corrigan et al 18 stated that 64% of the sample had scores within the severe range, but GCS scores were available for only 89% of the total 218 participants. ...
... After applying the standardized review formation, a total of 11 studies (10 observational and 1 phenomenological) was identified for analysis of older adults needs after TBI. The evidence suggests that after TBI, older people have poorer CI outcomes than their younger counterparts 8, 13,15,16,55 ; for example, in 1 study, older participants had greater difficulty getting places, shopping, and managing money. 13 Five of the good quality studies found significantly poorer CI outcomes for people who were older. ...
... 13 Five of the good quality studies found significantly poorer CI outcomes for people who were older. 8, 13,15,16,20 In contrast, Rapport et al 14 revealed that age was unrelated to CI outcomes, and Brown et al 17 found that current age was not related to participation when using the POPS measure. Three studies found injury severity to be an indicator of poorer community outcomes, 13,16,20 and 3 show sex to affect CI outcomes post-TBI. ...
To explore the scope, reliability and validity of community integration measures for older adults following traumatic brain injury (TBI).
A search of peer reviewed articles in English from 1990 -April 2011 was conducted using the EbscoHealth and Scopus databases. Search terms included were community integration, traumatic brain injury or TBI, 65 plus or older adults, and assessment.
Forty-three eligible articles were identified, with 11 selected for full review using a standardized critical review method.
Common community integration measures were identified and ranked for relevance and psychometric properties. Of the eligible articles (43) studies reporting community integration outcomes post TBI were identified and critically reviewed. Older adults' community integration needs post TBI from high quality studies were summarized.
There is a relative lack of evidence pertaining to older adults post TBI, but indicators are that older adults have poorer outcomes than their younger counterparts. The Community Integration Questionnaire (CIQ) is the most widely used community integration measurement tool used in research for people with TBI. Due to some limitations many studies have used the CIQ in conjunction with other measures to better quantify and/or monitor changes in community integration.
Enhancing integration of older adults following TBI into their community of choice, with particular emphasis on social integration and quality of life, ought to be a primary rehabilitation goal. However, more research is needed to inform best practice guidelines to meet the needs of this growing TBI population. It is recommended that subjective tools like quality of life measures are employed, in conjunction with well established community integration measures such as the CIQ, during the assessment process.
... Older age is associated with poor outcomes and lower levels of CIQ after TBI [7,8,16,30,[35][36][37][38][39][40]. Compared with younger counterparts with TBI, older people are more likely to sustain fall-related TBI [41,42], need longer recovery time, and are less likely to return to work and engage socially after TBI. ...
This study evaluated the impact of baseline injury characteristics and one-year functional level on the 10-year community integration outcomes for working-age patients with moderate-to-severe traumatic brain injury (TBI). Patients aged 16–55 and diagnosed with moderate-to-severe TBI within 24 h of injury were eligible for the study. Multivariable hierarchical linear regression was utilized to assess the impact of baseline characteristics and one-year functional measures on the mean Community Integration Questionnaire (CIQ) scores 10 years after injury. Of 133 original study participants, 97 survived 10 years, and 75 were available for this study. The mean total CIQ score changed positively from one to 10 years post-injury, from 18.7 (±5.5) to 19.8 (±4.8) (p = 0.04). The results suggested that age (β = −0.260, p = 0.013), FIM-Cognitive subscale (β = 0.608, p = 0.002), and the bodily pain subscale (BP) (β = 0.277, p = 0.017) of the SF-36 were significantly associated with the mean CIQ scores. In conclusion, this study demonstrated improved community integration from one to 10 years in a sample of working-age patients with moderate-to-severe TBI. The findings also showed that age, cognitive function, and bodily pain were significant predictors of long-term community integration, suggesting post-acute rehabilitation should focus on factors related to long-term risk and protective factors to improve long-term outcomes.
... Several studies have reported worse outcome for people above 50 years of age many years after injury, in particular in those with a more severe TBI. 36,37 As interest regarding the long-term outcome after TBI in the older population has increased considerably in recent years, 38 understanding the life situation for older people with a TBI is an interesting area for future research. ...
Objectives:
With increased long-term survival after traumatic brain injury (TBI), there is a need to understand the life situation many years after the injury. In this study, we have assessed persons on average 16 years after their injury and determined changes over six years in overall outcome, living condition, marital status and vocational situation, and in their functioning and disability.
Materials & methods:
Individuals (n = 49, mean age 45 years, 28-70 years) who were assessed 6-15 years (average 10 years) post TBI were reassessed 12-21 years after their injury (average 16 years) using internationally established TBI outcome measures.
Results:
From the first to the second assessment, overall outcome using the Glasgow Outcome Scale (GOS) was stable for a large majority and no significant changes in marital status or vocational situation was found. There was some significant, but very small, decline regarding cognitive function, home integration and social integration. In the multiple regression analysis, there was a small significant decline in the Mayo-Portland Adaptability Inventory (MPAI-4) Adjustment subscale score for women with a moderate-to-severe injury.
Conclusions:
The very small changes over 6 years imply that persons with a TBI can reach and maintain a stable level of functioning many years post TBI. Women with a moderate-to-severe TBI seem to be more vulnerable and may experience a small decline in some aspects of their functioning related to anxiety, depression, irritability, pain and headache, and fatigue. The relatively small sample requires further studies to confirm these findings.
... Of the demographic variables, age, pre-morbid IQ, and education contributed significantly to the prediction of participation. Consistent with previous research, younger individuals with higher IQ and higher education were found to have higher participation (10,14,22,28,29,(95)(96)(97)(98). It is possible that increased participation with younger age may be related to improved mobility and physical capabilities in youth compared to the elderly (22,28,99,100). ...
Traumatic brain injury (TBI) causes physical and cognitive-behavioral impairments that reduce participation in employment, leisure, and social relationships. Demographic and injury-related factors account for a small proportion of variance in participation post-injury. Personal factors such as resilience may also impact outcomes. This study aimed to examine the association of resilience alongside demographic, injury-related, cognitive, emotional, and family factors with participation following TBI. It was hypothesized that resilience would make an independent contribution to participation outcomes after TBI. Participants included 245 individuals with mild-severe TBI [Mage = 44.41, SDage = 16.09; post traumatic amnesia (PTA) duration M 24.95 days, SD 45.99] who completed the Participation Assessment with Recombined Tools-Objective (PART-O), TBI Quality of Life Resilience scale, Family Assessment Device General Functioning Scale, Rey Auditory Verbal Learning Test, National Adult Reading Test, and Hospital Anxiety and Depression Scale an average 4.63 years post-injury (SD 3.02, R 0.5–13). Multiple regression analyses were used to examine predictors of PART-O scores as the participation measure. Variables in the model accounted for a significant 38% of the variability in participation outcomes, F(13, 211) = 9.93, p < 0.05, R² = 0.38, adjusted R² = 0.34. Resilience was a significant predictor of higher participation, along with shorter PTA duration, more years since injury, higher education and IQ, and younger age. Mediation analyses revealed depression mediated the relationship between resilience and participation. As greater resilience may protect against depression and enhance participation this may be a focus of intervention.
... Pese a la existencia de evidencias sobre la eficacia de la rehabilitación cognitiva en DCA 2 , la variabilidad interindividual observada en la respuesta de los pacientes al tratamiento dificulta establecer pronósticos fiables respecto a la recuperación. La gravedad y/o localización de las lesiones cerebrales, así como los déficits asociados, son factores que desempeñan un destacado papel en el proceso rehabilitador; sin embargo, son múltiples las variables que influyen en cómo el paciente responde a la rehabilitación cognitiva: edad en el momento de la lesión 3,4 , género 5,6 , reserva cognitiva 7,8 , variabilidad genética 9,10 , tipo y gravedad de la lesión 11,12 o momento de inicio e intensidad de la rehabilitación 13,14 , entre otros. ...
Objetivo
Identificar qué variables se relacionaban con la respuesta a un programa de rehabilitación cognitiva en una población de pacientes con daño cerebral adquirido.
Material y métodos
En este estudio retrospectivo participaron 528 pacientes con daño cerebral adquirido que recibieron rehabilitación cognitiva en nuestro centro entre febrero de 2008 y enero de 2013. Mediante análisis de regresión logística se analizó la respuesta al tratamiento (variable dependiente). La respuesta al tratamiento se calculó a partir de las diferencias entre las exploraciones neuropsicológicas pre- y post-tratamiento para las variables atención, memoria y funciones ejecutivas.
Resultados
La edad en el momento de la lesión (OR=0,97; 95% CI: 0,96-0,98) y el lugar donde se realizó el tratamiento (OR=0,45; 95% CI: 0,27-0,73) se asociaron positivamente con una mejor respuesta al tratamiento para el índice atencional. En el caso del índice mnésico fueron la edad (OR=0,98; 95% CI: 0,96-0,99), etiología (OR=0,63; 95% CI: 0,39-1) y lugar de realización del tratamiento (OR=0,48; 95% CI: 0,29-0,79); tales variables también resultaron significativas para el índice ejecutivo.
Conclusiones
Los resultados sugieren que parte de las diferencias interindividuales observadas en la respuesta al tratamiento cognitivo en pacientes con daño cerebral adquirido podrían ser explicadas por las variables edad, etiología y lugar de realización del tratamiento.
... The TMT measures executive functions (i.e., processing speed, attention and mental switching) particularly sensitive to the effects of brain injury(Ponsford et al., 2008;Senathi-Raja, Ponsford, & Schönberger, 2010). 4 However, the CT scan taken of this patient may not have revealed the full extent of his injury, and the damage to his frontal lobe may have been implicated in his verbal learning and memory impairment. ...
Psychosis following traumatic brain injury (PFTBI) has received modest empirical investigation, and is subsequently poorly understood, identified and treated. The current article reports on consistencies in PFTBI phenomenology according to the existing peer-reviewed literature. The potential for psychotic symptoms post TBI, aetiological propositions, prevalence, significance of onset latency and injury severity, clinical and cognitive neuropsychological presentation and injury localisation/neuroimaging data are reviewed. Substantial methodological limitations associated with the majority of publications informing this work are also discussed. Despite controversies in the literature, psychosis following TBI appears to be three times more prevalent than psychotic disorders in the general population, and comparable in presentation to other idiopathic psychotic spectrum disorders, including schizophrenia.
... A number of studies have shown that older age at injury-particularly age older than 50-results in poorer functional outcomes and greater cognitive impairments. 19,21,22,24,25 However, there has been no clear evidence of accelerated decline over time post-injury associated with older age at injury. 24,26 Two previously published studies from our research group examined changes in function at two 4 and five years 19 following TBI. ...
Abstract Introduction: The deleterious consequences of traumatic brain injury (TBI) impair capacity to return to many avenues of premorbid life. However, there has been limited longitudinal research examining outcome beyond five years post-injury. The aim of this study was to examine aspects of function, previously shown to be affected following TBI, over a span of 10 years. Materials and Methods: One hundred and forty one patients with TBI were assessed at two, five, and 10 years post-injury using the Structured Outcome Questionnaire. Results: Fatigue and balance problems were the most common neurological symptoms, with reported rates decreasing only slightly over the 10-year period. Mobility outcomes were good in over 75 percent, with few participants requiring aids for mobility. Changes in cognitive, communication, behavioral and emotional functions were reported by approximately 60% of the sample at all time-points. Levels of independence in activities of daily living were high over the 10-year period, and up to 70 percent return to driving. Nevertheless, approximately 40% required more support than before their injury. Only half of the sample returned to previous leisure activities and less than half were employed at each assessment time post-injury. Whilst marital status remained surprisingly stable over time, approximately 30% reported difficulties in personal relationships. Older age at injury did not substantially alter the pattern of changes over time, except in employment. Conclusions: Overall, problems that were evident at 2 years post-injury persisted until 10 years post-injury. The importance of these findings is discussed with reference to rehabilitation programs. Keywords: traumatic brain injury, functional outcome, structured outcome questionnaire.
Traumatic brain injury results in some distinctive patterns of cognitive, behavioural and physical impairment which impact significantly on independent living skills and participation in work or study, social and leisure activities and interpersonal relationships. There is, however, still considerable variability in outcome across individuals in each of the reported domains. This has led to a significant body of research examining factors associated with outcome. A range of injury-related, personal and social factors have been shown to influence survival, as well as cognitive, functional and employment outcome.
This paper reviews the factors associated with each of these aspects of outcome specifically injury-related factors, including neuroimaging findings, GCS and PTA, other injuries, and cognitive and behavioural impairments; demographic factors, including age, gender, genetic status, education, pre-injury IQ and employment status; and social factors including family and other social support, cultural factors, pre-injury psychiatric history and coping style.
The paper identifies contributions and complex interrelationships of all of these factors to outcome following TBI. It concludes with a brief discussion of the implications of these factors for the rehabilitation process.
Objective: To identify predictors of return to work for individuals with traumatic brain injury (TBI).
Study Design: Data gathered from a retrospective chart review that included predictor variables (demographic, intellectual, and memory) and an outcome variable (employment status 1 year postprogram) were entered into a logistical regression analysis.
Setting: A Commission for Accreditation of Rehabilitation Facilities-accredited outpatient brain injury program.
Participants: Forty-three adults with TBI who completed the brain injury program.
Main Outcome Measure: Employment status at 1 -year follow-up.
Results: Individuals with higher scores on measures of Performance IQ and Verbal Memory were more likely to return to work.
Conclusions: When the effects of many demographic variables are controlled for, intelligence and memory variables can provide valuable information to patients, families, and service providers (e.g., rehabilitation centers) with regard to returning to work after TBI. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This study aimed to explore the relationship between current post-traumatic brain injury psychiatric disorders and psychosocial outcome.
A total of 100 participants and 87 significant others were interviewed using the Structured Clinical Interview for DSM-IV Diagnosis.
Participants with mild to very severe traumatic brain injury up to 5.5 years post-injury.
The Sydney Psychosocial Reintegration Scale assessed changes in vocational status, relationship status and independent living status.
The vocational domain of the Sydney Psychosocial Reintegration Scale revealed the greatest degree of change. Current depression and/or anxiety contributed significantly more variance to the regression models than did any other variables. Pre-injury psychiatric disorders and substance use disorders were not predictive of any outcome variables. Longer post-traumatic amnesia duration, fewer years of education, male gender and greater time post-injury were predictive of certain outcome domains. There were no significant differences between traumatic brain injury participants' self-report and the reports of their significant others regarding psychiatric symptoms or outcome measures.
The presence of current depression and anxiety are strongly related to poor outcome in terms of vocational status, relationship status and independence. The causative direction of these relationships is unclear. Using a 3-domain outcome measure has shed some light on the factors that contribute to different aspects of outcome following traumatic brain injury.
The present study aimed to examine long-term family and emotional adjustment in close relatives of individuals with TBI, who had access to comprehensive rehabilitation services. It also examined the relative influence thereon of factors including injury severity, handicap and cognitive and behavioural changes in the injured person, relationship with the injured person and caregiver status.
Participants were 143 TBI individuals and their close relatives. They completed the Family Assessment Device (FAD), Leeds Scales of Anxiety and Depression, Structured Outcome Questionnaire, CHART, SIP Psychosocial Dimension and Novaco Anger Control Questionnaire 2-5 years post-injury.
Results showed that families were, on average, functioning in the normal range on the FAD. Anxiety and depression were more likely to be present in those responsible for care of their injured relative. There were no differences between spouses and parents. Presence of cognitive, behavioural and emotional changes was the strongest predictor of anxiety and depression in relatives and of unhealthy family functioning.
Every attempt should be made to develop models of long-term support and care that alleviate these sources of burden on relatives.
Constraint-based path selection is an invaluable part of a full-fledged quality of service (QoS) architecture. Internet service providers want to be able to select paths for QoS flows that optimize network utilization and satisfy user requirements and as such increase revenues. Unfortunately, finding a path subject to multiple constraints is known to be an NP-complete problem. Hence, accurate constraint-based path selection algorithms with a fast running time are scarce. Numerous heuristics and a few exact algorithms have been proposed. In this article we compare most of these algorithms. We focus on the restricted shortest path algorithms and multi-constrained path algorithms. The performance evaluation of these two classes of algorithms is presented based on complexity analysis and simulation results and may shed some light on the difficult task of selecting the proper algorithm for a QoS-capable network.
Objective: To identify predictors of return to work for individuals with traumatic brain injury (TBI). Study Design: Data gathered from a retrospective chart review that included predictor variables (demographic, intellectual, and memory) and an outcome variable (employment status 1 year postprogram) were entered into a logistical regression analysis. Setting: A Commission for Accreditation of Rehabilitation Facilities-accredited outpatient brain injury program. Participants: Forty-three adults with TBI who completed the brain injury program. Main Outcome Measure: Employment status at 1-year follow-up. Results: Individuals with higher scores on measures of Performance IQ and Verbal Memory were more likely to return to work. Conclusions: When the effects of many demographic variables are controlled for, intelligence and memory variables can provide valuable information to patients, families, and service providers (e.g., rehabilitation centers) with regard to returning to work after TBI.
Background: Findings from prognostic studies of functional and psychosocial recovery after traumatic brain injury (TBI) reported to date have been limited by the restricted timeframe for prediction, generally within the first 5 years post-trauma. This investigation examined prediction of functional and psychosocial recovery in the medium-term (6 years post-trauma; Time 1) and long-term (23 years post-trauma; Time 2). Methods: The participants comprised a consecutive series of the first 100 patients with severe TBI receiving their primary rehabilitation at a regionally based unit. At the 23-year follow-up, 91% of the sample was traced: 17 had died, 5 declined participation, and 69 were interviewed, with 68 participating at both Time 1 and Time 2. Five outcome domains were examined: mobility, self-care, employability, relationships and living skills. Results: Very few of seven pre-injury variables were significantly correlated with any of the outcome variables. A series of logistic regression analyses successfully predicted levels of recovery in all domains using four predictor variables: pre-injury occupational status, duration of post-traumatic amnesia, and physical and neuropsychological disability at rehabilitation discharge. At Time 1, 60% or more of the variance was accounted for in four of the five domains, and at Time 2, more than 40% of the variance was accounted for in all domains. Sensitivity ranged from 62% (self-care) to 90% (mobility). With a single exception (employability at Time 2), specificity was also high, ranging from 80% (relationships) to 98% (mobility). Comparable accuracy rates were also found for positive and negative predictive power. Conclusions: These results demonstrate impressive predictive capacity of early post-trauma variables for the very long-term levels of recovery. They provide guidance for the tailoring of individual rehabilitation programs and the identification of people who may require special supports after rehabilitation discharge.
This article presents a systematic review identifying variables and their prognostic value for return to work (RTW) after traumatic brain injury (TBI). RTW has been identified as being a key goal following TBI, with estimates ranging from 10% to 70%. Prediction of postinjury employment is important for planning rehabilitation and structuring individualised vocational services. Studies examining prognostic factors were identified by searching four electronic databases, until June 2006. Searches yielded 1948 studies of which 55 met inclusion criteria and were subsequently rated for methodological quality. Mean methodological score for included studies was 3.9/6 (SD 0.9, range 1–6). Analysis focused on a subset of 27 studies which provided sampling from all three domains of preinjury, injury and early postinjury variables. Few studies considered preinjury variables, apart from simple demographics. Only five studies considered preinjury employment, which was a significant predictor in each case. Severity of injury variables were invariably examined, but were significant predictors in only 8/27 studies (30%). For early postinjury variables, 14/27 studies entered cognitive variables with 12/14 (86%) identifying them as significant predictors; 3/27 studies examined neurophysical variables, with 2/3 (67%) studies finding them significant; and 12/27 studies examined multidimensional/participation variables which were statistically significant individual predictors in 8/12 (67%) cases. The results are discussed in the context of methodological issues encountered during the course of the review that require addressing in future studies.
Rating scales are often used in the assessment of depression and anxiety in traumatic brain injury (TBI), but few have been validated for use with this population. Overlap of symptoms between such disorders and TBI may lead to under- or over-diagnosis of depression or anxiety.
100 participants with mild to severe TBI, and 87 informants, were interviewed using the SCID-IV (Axis I). The HADS was administered at the same time.
According to the SCID-IV, 34 participants were diagnosed with major depression and 36 with an anxiety disorder. Higher HADS scores were associated with a greater likelihood of depression and anxiety. However, the "clinical" categories of the HADS did not strongly correspond with the clinical diagnoses of depression and anxiety. Compared with SCID diagnoses, the depression subscale of the HADS had a sensitivity of 62% and a specificity of 92%. The anxiety subscale had a sensitivity of 75% and a specificity of 69%. Positive predictive and negative predictive values were calculated.
This study included mostly moderate to severe TBI individuals, recruited from a rehabilitation hospital. Therefore, they may not necessarily be representative of the entire TBI population.
The HADS was a reliable measure of emotional distress in this TBI sample; however the cut-off scores and categories were not useful in predicting caseness of depression and anxiety. Clinicians should be mindful of the sequelae of TBI that may confound the scores yielded in rating scales and should follow up with a psychiatric interview when diagnosis is unclear.
The disablement that occurs following traumatic brain injury (TBI) can be extensive and severe and consequently has been difficult to report on in a comprehensive and thorough manner. We were able to address this difficulty by analysing a sub group of data from the Canadian Health and Activity Limitation Survey (HALS) using the theoretical framework of disablement developed by the World Health Organization, the International Classification of Impairment, Disability and Handicap (ICIDH). There were 454 survey respondents (representing 12,290 in the Canadian population) with disability resulting from a TBI and a mean time post-injury of 13 years. Three handicaps identified in the ICIDH were the focus of the study: physical independence, work, social integration. The prevalence of long term handicap was very high with 66% of the sample reporting the need for ongoing assistance with some activities of daily living, 75% not working, and 90% reporting some limitations or dissatisfaction with their social integration. Multivariate regression analysis was used to investigate the determinants of the handicaps. The determinants included: age, gender, level of education, living alone, physical environment, and specific disabilities. The implications of these findings are discussed in relation to rehabilitation issues, the usefulness of the ICIDH as a model to investigate outcomes, and directions for future research.
The psychosocial problems of decreased social contact, depression, and loneliness that occur for many with traumatic brain injury (TBI) create a major challenge for enhancing efforts at community re-entry. Despite dramatic physical progress within the first six months after injury, these psychosocial problems remain a persistent long-term problem for the majority of individuals with severe TBI. Researchers have consistently suggested that the psychosocial problems associated with TBI may actually be the major challenge facing rehabilitation. The majority of individuals who sustain TBI are young males between the ages of 19 and 25, who are in the early stages of establishing their independence in areas including friendships, leisure activities, intimate relationships, residence, and employment. The problem of social isolation and decreased leisure activities create a renewed dependence of the survivor on his/her family to meet these needs. In this article we review a large number of papers which examine the psychosocial and emotional sequelae for TBI patients. The results of those studies demonstrate four primary themes. The first theme depicts that individuals who experience severe TBI are at high risk for a significant decrease in their friendships and social support. The second theme relates to the lack of opportunity for establishing new social contacts and friends. The third theme relates to the decrease in leisure activities for individuals with severe TBI. Finally, anxiety and depression are found at high levels for prolonged periods of time following severe TBI. Several clinical recommendations are drawn from this literature review. They are: (1) Clinicians such as psychiatric social workers, psychologists, or psychiatrists may need to be called upon more quickly for intervention. The treating physiatrist cannot be expected to provide the insight and frequency of psychological services that may be necessary for many of these patients. (2) Since the literature seems to suggest that the presence of one psychosocial deficit, e.g., anxiety, will often be followed by other similar types of problems, e.g. depression, the treatment team needs to be sensitive to how rapidly these problems can cascade into a very dangerous situation. (3) Perhaps the most compelling recommendation we can make is for community rehabilitation specialists to focus significantly more energies and resources upon the psychological health of clients with TBI. Staff need to be trained to detect these signals that clients with TBI are often sending. It is apparent that psychosocial factors contribute to a rising obstacle level to community adjustment.
To examine the effects of age on outcome in persons with traumatic brain injury.
Longitudinal cohort design.
Level I trauma center.
A total of 411 hospitalized subjects with mild to severe traumatic brain injury prospectively studied to 1 year; their age range was 18 to 89 years.
Glasgow Outcome Scale, living situation, and employment.
Increasing age is associated with increasing levels of psychosocial limitations, especially in persons 60 years of age and older. Part of the reason is the greater severity of injury sustained by older persons as reflected in longer coma (despite equivalent initial coma depth) and greater numbers of complications and surgeries for subdural hematomas. However, the consequences of traumatic brain injuries appear to worsen with increasing age at each level of brain injury severity examined, including the milder injuries.
Older adults clearly show less complete recovery 1 year after brain injury than younger adults, either because they have reduced reserves with which to tolerate brain injury or because their physiologic status creates a more destructive injury. Glasgow Coma Scale alone may underestimate the severity of brain injury in the aged as well as its associated consequences. Caution is advised in generalizing findings based principally on younger individuals to older adults with traumatic brain injuries.
To review the literature of the validity of the Hospital Anxiety and Depression Scale (HADS).
A review of the 747 identified papers that used HADS was performed to address the following questions: (I) How are the factor structure, discriminant validity and the internal consistency of HADS? (II) How does HADS perform as a case finder for anxiety disorders and depression? (III) How does HADS agree with other self-rating instruments used to rate anxiety and depression?
Most factor analyses demonstrated a two-factor solution in good accordance with the HADS subscales for Anxiety (HADS-A) and Depression (HADS-D), respectively. The correlations between the two subscales varied from.40 to.74 (mean.56). Cronbach's alpha for HADS-A varied from.68 to.93 (mean.83) and for HADS-D from.67 to.90 (mean.82). In most studies an optimal balance between sensitivity and specificity was achieved when caseness was defined by a score of 8 or above on both HADS-A and HADS-D. The sensitivity and specificity for both HADS-A and HADS-D of approximately 0.80 were very similar to the sensitivity and specificity achieved by the General Health Questionnaire (GHQ). Correlations between HADS and other commonly used questionnaires were in the range.49 to.83.
HADS was found to perform well in assessing the symptom severity and caseness of anxiety disorders and depression in both somatic, psychiatric and primary care patients and in the general population.
To investigate the relation between selected acute injury and patient characteristics and subsequent return to work 1 to 5 years postinjury.
Longitudinal design with prospectively collected data. Data were collected on patients at the time of injury and each year postinjury for up to 5 years.
Four medical centers in the federally sponsored Traumatic Brain Injury Model Systems project that provide emergency medical services, intensive and acute medical care, inpatient rehabilitation, and a spectrum of community rehabilitation services.
Patients were selected from a national database of 538 rehabilitation inpatients admitted to acute care within 8 hours of traumatic brain injury (TBI) and seen at 1 to 5 years follow-up.
Not applicable.
Employment status (employed vs not employed) at 1 to 5 years postinjury. Logistic regression analyses were performed to determine the extent to which selected variables predicted employment status at years 1 to 5 postinjury.
At year 1 postinjury, preinjury productivity, age, education, and rehabilitation length of stay were all significantly associated with postinjury employment. Preinjury employment and productivity and age significantly predicted employment at postinjury year 2. At year 3 postinjury, preinjury productivity, age, and FIMtrade mark instrument discharge score significantly predicted employment status. Age was significantly associated with employment status at year 4 postinjury. Preinjury employment and productivity and Disability Rating Scale discharge score were found to be significant predictors of postinjury employment at year 5 follow-up.
The relationship between certain acute injury and patient variables (eg, age, preinjury productivity, education, discharge FIM) and subsequent return to work may provide rehabilitation professionals with useful information regarding the intensity and types of services needed for individuals in the vocational rehabilitation planning process.
This study compared the psychometric properties of two community integration measures used with people with acquired brain injury (ABI) in the community.
Questionnaires were mailed-out to people with ABI and nominated proxies.
Responses were obtained from 96 people with ABI and 121 proxies on the Community Integration Questionnaire (CIQ) and the Sydney Psychosocial Reintegration Scale (SPRS).
Matched client-proxy scores were not significantly different. The SPRS had greater internal consistency and more normal distributions than the CIQ. Correlations between the three pairs of theoretically parallel sub-scales were modest (0.41-0.60). Multi-dimensional scaling did not support the theoretical structure of the sub-scales, but found two dimensions underpinning the measurement of community integration.
Mail-out administration is associated with poor completion rates. The SPRS has sound psychometric properties when compared to the CIQ. Further research investigating the theoretical structure of community integration in ABI is recommended.
To explore pre-injury variables related to post-discharge psychosocial status and identify factors related to work and driving outcomes.
Ninety-three brain-injured patients attended a holistic milieu-oriented neurorehabilitation program and were contacted 1-7 years post-discharge.
Questionnaire data addressing pre-injury and post-injury work, driving, income, marital status and living situation.
74.3% were involved in competitive work and/or school with 86.0% productive at follow-up. Post-injury income decreased significantly compared with pre-injury levels. Pre-injury relationship status did not differ significantly from post-injury; 81.1% remaining in a stable relationship or married at follow-up. Pre-injury and post-injury accident rates were related; 73.1% drove at follow-up. Higher education, non-right hemispheric injury, shorter treatment length and return to work related to driving. Younger age, higher education, non-right hemispheric injury and driving post-injury related to positive work status.
Pre-injury psychosocial data provide an important context for understanding post-discharge outcome after brain injury. Holistic milieu-oriented rehabilitation facilitates long-term successful work, driving and relationship stability.
Demographic factors and cognitive impairment have been found previously to have associations with outcome after brain injury. Kendall and Terry (1996) suggest that preinjury psychosocial functioning, neurological factors, and cognitive impairment have a direct relationship with multidimensional psychosocial adjustment, but that cognitive impairment also has an indirect relationship by means of the mediation of appraisal and coping variables. The aim of this study was to explore these theoretical relationships at very late stages of recovery after brain injury. A total of 131 participants who were more than 10 years after injury (mean = 15.31 yr) completed a neuropsychological assessment, plus outcome measures that included employment status, community integration, life satisfaction, quality of life (QoL), and emotion. Results indicated that injury severity was predictive of life satisfaction; gender and relationship status predicted community integration; and age at injury predicted employment status. Impairment in working memory directly predicted all outcomes except QoL and anxiety. An indirect relationship was also evident between working memory, life satisfaction, and depression. Results partially support Kendall and Terry's model but the variables that significantly influence outcome seem to be determined by the outcome dimensions selected.
To investigate the association of psychosocial outcome 10 years following traumatic brain injury (TBI) with demographic variables, injury severity, current cognitive functioning, emotional state, aggression, alcohol use, and fatigue.
Community-based follow-up.
Fifty-three participants with mild to very severe TBI sustained 10 years previously and significant others.
Sydney Psychosocial Reintegration Scale, Extended Glasgow Outcome Scale, Hospital Anxiety and Depression Scale, NFI Aggression scale, Fatigue Severity Scale, Alcohol Use Disorders Identification Test, neuropsychological tests of attention/processing speed, memory, and executive function.
Psychosocial functioning was lowest in the occupational activity domain and highest in the living skills domains. Variables including education, posttraumatic amnesia duration, numerous cognitive measures, concurrent fatigue, aggression, anxiety, and depression were all significantly associated with psychosocial outcome, although the strength of correlations varied between ratings of participants with TBI and relatives. Posttraumatic amnesia duration was most strongly associated with psychosocial outcome measured by relatives; anxiety, aggression, and depression were the strongest predictors when ratings were assigned by participants with TBI. Self-reported fatigue, depression, and alcohol use were the strongest predictors of aggression.
It is important to address problems with anxiety, depression, fatigue, and alcohol use as a possible means of improving long-term psychosocial outcome following TBI.
To determine whether older persons are at increased risk for progressive functional decline after traumatic brain injury (TBI).
Longitudinal cohort study.
Traumatic Brain Injury Model Systems (TBIMS) rehabilitation centers.
Subjects enrolled in the TBIMS national dataset.
Not applicable.
Disability Rating Scale (DRS), FIM instrument cognitive items, and the Glasgow Outcome Scale-Extended.
Participants were separated into 3 age tertiles: youngest (16-26y), intermediate (27-39y), and oldest (> or =40y). DRS scores were comparable across age groups at admission to a rehabilitation center. The oldest group was slightly more disabled at discharge from rehabilitation despite having less severe acute injury severity than the younger groups. Although DRS scores for the 2 younger groups improved significantly from year 1 to year 5, the greatest magnitude of improvement in disability was seen among the youngest group. In addition, after dividing patients into groups according to whether their DRS scores improved (13%), declined (10%), or remained stable (77%) over time, the likelihood of decline was found to be greater for the 2 older groups than for the youngest group. A multiple regression model showed that age has a significant negative influence on DRS score 5 years post-TBI after accounting for the effects of covariates.
This study supported our primary hypothesis that older patients show greater decline over the first 5 years after TBI than younger patients. In addition, the greatest amount of improvement in disability was observed among the youngest group of survivors. These results suggest that TBI survivors, especially older patients, may be candidates for neuroprotective therapies after TBI.