Neuropsychologic and functional outcome after complicated mild traumatic brain injury

Kashluba S, Hanks RA, Casey JE, Millis SR. Neuropsychologic and functional outcome after complicated mild traumatic brain injury.

Objective

To investigate the extent to which neuropsychologic and functional outcome after complicated mild traumatic brain injury (TBI) parallels that of moderate TBI recovery.

Design

A longitudinal study comparing neuropsychologic and functional status of persons with complicated mild TBI and moderate TBI at discharge from inpatient rehabilitation and at 1 year postinjury.

Setting

Rehabilitation hospital with a Traumatic Brain Injury Model System.

Participants

Persons with complicated mild TBI (n=102), each with an intracranial brain lesion documented through neuroimaging and a highest Glasgow Coma Scale (GCS) score in the emergency department between 13 and 15, and 127 persons with moderate TBI.

Interventions

Not applicable.

Main Outcome Measures

FIM instrument, Disability Rating Scale, Community Integration Questionnaire, Wechsler Memory Scale logical memory I and II, Rey Auditory Verbal Learning Test, Trail-Making Test, Controlled Oral Word Association Test, Symbol Digit Modalities Test, Wisconsin Card Sorting Test, and block design.

Results

Few differences in neuropsychologic performance existed between the TBI groups. Less severely impaired information processing speed and verbal learning were seen in the complicated mild TBI group at rehabilitation discharge and 1 year postinjury. Despite overall improvement across cognitive domains within the complicated mild TBI group, some degree of impairment remained at 1 year postinjury on those measures that had identified participants as impaired soon after injury. No differences on functional ability measures were found between the TBI groups at either time period postinjury, with both groups exhibiting incomplete recovery of functional status at the 1-year follow-up.

Conclusions

When classifying severity of TBI based on GCS scores, consideration of a moderate injury designation should be given to persons with an intracranial bleed and a GCS score between 13 and 15.     

A Preliminary Model for Posttraumatic Brain Injury Depression

Malec JF, Brown AW, Moessner AM, Stump TE, Monahan P. A preliminary model for posttraumatic brain injury depression.

Objective

To develop, based on previous research, and evaluate a model for depression after traumatic brain injury (TBI).

Design

Cross-sectional structural equation modeling (SEM) of data from consecutively recruited patients.

Setting

Acute hospital and inpatient rehabilitation units.

Participants

Adult patients (N=158) after hospital admission for moderate to severe TBI.

Interventions

Not applicable.

Main Outcome Measures

External appraisal of ability in participants was measured by the Mayo-Portland Adaptability Inventory (MPAI-4) Ability Index completed by a TBI clinical nurse specialist. Patient self-appraisal of post-TBI ability and depression were measured by the Awareness Questionnaire and Beck Depression Inventory-II. Functional outcome 1 year after injury was assessed with the MPAI-4 Participation Index.

Results

Successive SEM resulted in a parsimonious model with excellent fit. Consistent with prior research, a moderately strong association between self-appraisal of post-TBI ability and depression was found. Injury severity, as measured by the duration of posttraumatic amnesia (PTA), was not significantly associated with post-TBI depression. The 1-year functional outcome was associated with depression and TBI severity.

Conclusions

The strong association between self-appraisal of post-TBI ability and depression is consistent with the cognitive-behavioral model of depression and recommends consideration and further study of cognitive-behavioral therapy for post-TBI depression. The lack of association between TBI severity and depression may represent the indirect and proxy nature of current measures of TBI severity such as PTA. Emerging neuroimaging techniques (eg, diffusion tensor imaging, magnetic resonance imaging spectroscopy) may provide the more direct measures of disruption of brain function after TBI that are needed to advance this line of research.     

Functional limitations and depression after traumatic brain injury: examination of the temporal relationship

Pagulayan KF, Hoffman JM, Temkin NR, Machamer JE, Dikmen SS. Functional limitations and depression after traumatic brain injury: examination of the temporal relationship.

Objective

To examine the temporal relationship between self-reported injury-related functional limitations and depressive symptomatology after traumatic brain injury (TBI).

Design

A longitudinal cohort study with 3 evaluation points.

Setting

A level I trauma center.

Participants

Adolescents and adults (N=135) with complicated mild to severe TBI (72% had complicated mild injuries) who were recruited within 24 hours of injury and then completed the measure at all 3 time points.

Interventions

Not applicable.

Main Outcome Measures

Sickness Impact Profile and Center for Epidemiological Studies−Depression Scale.

Results

Individuals who reported more depressive symptomatology consistently endorsed more injury-related difficulties, showing the strong relationship between depression and perceived psychosocial functioning. Examination of these relationships over time revealed that increased depressive symptomatology follows higher levels of perceived injury-related changes but that reports of injury-related changes are not associated with earlier depression. These findings suggest a unidirectional temporal relationship between these variables.

Conclusions

Perceived changes in daily functioning appear to influence emotional well-being over time after TBI. However, depressive symptoms do not appear to negatively impact individuals' perception of later functioning. These results further our understanding of the complicated relationship between these variables and may have important implications for treatment of depression after TBI.     

Poor sleep quality and changes in objectively recorded sleep after traumatic brain injury: a preliminary study

Parcell DL, Ponsford JL, Redman JR, Rajaratnam SM. Poor sleep quality and changes in objectively recorded sleep after traumatic brain injury: a preliminary study.

Objectives

To evaluate changes in sleep quality and objectively assessed sleep parameters after traumatic brain injury (TBI) and to investigate the relationship between such changes and mood state and injury characteristics.

Design

Survey and laboratory-based nocturnal polysomnography.

Setting

Sleep laboratory.

Participants

Ten community-based subjects with moderate to very severe TBI and 10 age- and sex-matched controls from the general community.

Interventions

Not applicable.

Main Outcome Measures

Pittsburgh Sleep Quality Index for self-report sleep quality, nocturnal polysomnography for objective sleep recording, and Hospital Anxiety and Depression Scales.

Results

Compared with controls, TBI patients reported significantly poorer sleep quality and higher levels of anxiety and depression. Objective sleep recording showed that TBI patients showed an increase in deep (slow wave) sleep, a reduction in rapid eye movement sleep, and more frequent nighttime awakenings. No significant relationship was observed between these changes in sleep and injury severity or time since injury. Anxiety and depression covaried with the observed changes in sleep.

Conclusions

The findings contribute to the growing body of evidence that sleep is involved in the physiologic processes underlying neural recovery. The association between anxiety and depression and the observed changes in sleep in TBI patients warrants further examination to determine whether a causative relationship exists.     

Cognitive and Behavioral Impairment in Traumatic Brain Injury Related to Outcome and Return to Work

Benedictus MR, Spikman JM, van der Naalt J. Cognitive and behavioral impairment in traumatic brain injury related to outcome and return to work.

Objective

To evaluate the cognitive and behavioral disturbances related to return to work (RTW) in patients with traumatic brain injury (TBI) with the application of a differentiated outcome scale.

Design

Longitudinal cohort study.

Setting

Level I trauma center.

Participants

Adults (N=434) with TBI of various severity.

Interventions

Not applicable.

Main Outcome Measures

Extended Glasgow Outcome Scale (GOS-E), Differentiated Outcome Scale (DOS), and RTW.

Results

Patients encountered problems in the physical (40%), cognitive (62%), behavioral (55%), and social domains (49%) of the DOS, with higher frequency related to severity of injury. Even those with mild TBI experienced cognitive (43%) and behavioral problems (33%). Patients with good recovery (58%) according to the GOS-E experienced problems in 1 or more domains of the DOS. Half the patients were able to resume previous vocational activities completely, although 1 in 3 experienced cognitive or behavioral problems. Using multivariate logistic regression analysis, the cognitive (odds ratio [OR], 10.548; confidence interval [CI], 5.99-18.67), behavioral (OR, 2.648; CI, 1.63-4.29), and physical domains (OR, 2.763; CI, 1.60-4.78) were significant (P<.01) predictors of RTW. For subcategories of TBI, the cognitive domain was predictive for RTW in those with moderate and severe TBI, whereas both the cognitive and behavioral domains were predictive for RTW in those with mild TBI.

Conclusions

With application of a more detailed outcome scale, cognitive and behavioral impairments interfering with RTW were present in a substantial part of patients with TBI in the chronic phase after injury. More research is needed exploring the cognitive and behavioral outcome in different categories of injury severity separately.     

The reliability and validity of the brief symptom inventory-18 in persons with traumatic brain injury

Meachen S-J, Hanks RA, Millis SR, Rapport LJ. The reliability and validity of the Brief Symptom Inventory−18 in persons with traumatic brain injury.

Objective

To investigate the psychometric properties of the Brief Symptom Inventory−18 (BSI-18) among persons with traumatic brain injury (TBI).

Design

Inception cohort design with cross-sectional follow-up of 6 months to 15 years.

Setting

Rehabilitation hospital.

Participants

Adults (N=257) with moderate to severe TBI (81 inpatients and 176 follow-up participants, analyzed separately).

Interventions

Not applicable.

Main Outcome Measures

The BSI-18 is a brief screen of psychologic distress with a Global Severity Index (GSI), and 3 clinical subscales: somatization, anxiety, and depression.

Results

Internal consistency of the GSI was high in both follow-up participants (α=.91) and inpatients (α=.84), whereas estimates for the somatization, anxiety, and depression subscales were more variable (α range, .61-.84). As would be expected for a measure of affective state, retest reliability estimates were only moderate. The BSI-18 GSI correlated with multiple measures of psychosocial adjustment. After accounting for demographics, injury severity, inpatient functional status, years since injury, and various psychosocial factors, the BSI-18 showed incremental validity in predicting concurrent functional, psychosocial, and psychologic status.

Conclusions

The BSI-18 GSI had excellent reliability and validity among inpatients and follow-up participants. Modest reliability estimates may place an upper bound on the validity of the BSI-18 clinical subscales in inpatient TBI populations.     

Relationship of Preinjury Caregiver and Family Functioning to Community Integration in Adults With Traumatic Brain Injury

Sady MD, Sander AM, Clark AN, Sherer M, Nakase-Richardson R, Malec JF. Relationship of preinjury caregiver and family functioning to community integration in adults with traumatic brain injury.

Objective

To investigate the relationship of preinjury caregiver and family functioning to community integration outcomes in persons with traumatic brain injury (TBI).

Design

Inception cohort.

Setting

Three TBI Model Systems inpatient rehabilitation facilities.

Participants

Persons with TBI (N=141) and their caregivers admitted to inpatient rehabilitation and followed up at 1 to 2 years after injury.

Interventions

Not applicable.

Main Outcome Measures

Community Integration Questionnaire and the Social and Occupation scales of the Craig Handicap Assessment and Reporting Technique.

Results

There were significant interactions of several preinjury caregiver and family variables with injury severity. For persons with complicated mild/moderate injury, better family functioning was associated with greater home integration, and less caregiver distress was associated with better social integration. For persons with severe injuries, greater caregiver perceived social support was associated with better outcomes in productivity and social integration.

Conclusions

Preinjury caregiver and family characteristics interact with injury severity to affect outcomes in persons with injury. Research on outcomes should include measures of caregiver and family functioning. Early interventions targeted toward decreasing caregiver distress, increasing support, and improving family functioning may have a positive impact on later outcomes.     

Mortality Over Four Decades After Traumatic Brain Injury Rehabilitation: A Retrospective Cohort Study

Harrison-Felix CL, Whiteneck GG, Jha A, DeVivo MJ, Hammond FM, Hart DM. Mortality over four decades after traumatic brain injury rehabilitation: a retrospective cohort study.

Objective

To investigate mortality, life expectancy, risk factors for death, and causes of death in persons with traumatic brain injury (TBI).

Design

Retrospective cohort study.

Setting

Used data from an inpatient rehabilitation facility, the Social Security Death Index, death certificates, and the U.S. population age-race-sex-specific and cause-specific mortality rates.

Participants

Persons with TBI (N=1678) surviving to their first anniversary of injury admitted to rehabilitation from an acute care hospital within 1 year of injury between 1961 and 2002.

Interventions

Not applicable.

Main Outcome Measures

Vital status, standardized mortality ratio, life expectancy, cause of death.

Results

Persons with TBI were 1.5 times more likely to die than persons in the general population of similar age, sex, and race, resulting in an estimated average life expectancy reduction of 4 years. Within the TBI population, the strongest independent risk factors for death after 1 year postinjury were being older, being male, having less education, having a longer hospitalization, having an earlier year of injury, and being in a vegetative state at rehabilitation discharge. After 1 year postinjury, persons with TBI were 49 times more likely to die of aspiration pneumonia, 22 times more likely to die of seizures, 4 times more likely to die of pneumonia, 3 times more likely to commit suicide, and 2.5 times more likely to die of digestive conditions than persons in the general population of similar age, sex, and race.

Conclusions

This study demonstrated life expectancy after TBI rehabilitation is reduced and associated with specific risk factors and causes of death.     

Driving and community integration after traumatic brain injury

Rapport LJ, Coleman Bryer R, Hanks RA. Driving and community integration after traumatic brain injury.

Objective

To examine resumption of driving after traumatic brain injury (TBI) and its relation to community integration.

Design

Cross-sectional cohort study; survey and cognitive data.

Settings

Inpatient rehabilitation hospital of the Traumatic Brain Injury Model Systems and community.

Participants

Persons (N=261) ranging from 3 months to 15 years postinjury.

Interventions

Not applicable.

Main Outcome Measures

Barriers to Driving Questionnaire, Driver Survey, Community Integration Measure, and Craig Hospital Assessment and Reporting Technique.

Results

Forty-four percent of survivors had resumed driving; of nondrivers, 48% reported a strong desire to resume driving. Nondriver survivors who sought to resume driving generally rated themselves as currently fit to drive, viewed themselves as having physical and cognitive profiles like those of survivor drivers, and reported their greatest barriers to driving as social and resource related. However, cognitive functioning was similar to nondriver survivors who did not seek to resume driving and significantly worse than survivors who were currently driving. Nondrivers showed poorer community integration than did drivers, even after accounting for injury severity, social support, negative affectivity, and use of alternative transportation. Use of alternative transportation was common among nondrivers, but it was unrelated to community integration outcomes. Cognitive functioning moderated risk of adverse incident: among survivors with low cognitive functioning and high self-estimates of driving ability, which is indicative of unawareness of deficit, adverse incidents showed positive relation to amount of driving and inverse relation to cognitive functioning.

Conclusions

Driving status has unique and independent association with post-TBI community integration. Additional research is needed to evaluate transportation barriers that undermine full engagement in community living after TBI and to determine which barriers to driving reflect valid risk to survivors and the public.     

Impact of Traumatic Brain Injury on Participation in Leisure Activities

Wise EK, Mathews-Dalton C, Dikmen S, Temkin N, Machamer J, Bell K, Powell JM. Impact of traumatic brain injury on participation in leisure activities.

Objective

To determine how participation in leisure activities for people with traumatic brain injury (TBI) changes from before injury to 1 year after injury.

Design

Prospective evaluation of leisure participation at 1 year after TBI.

Setting

Level I trauma center.

Participants

Rehabilitation inpatients (mean age, 35.3 years; 77% male; 77% white) with moderate to severe TBI (N=160).

Interventions

Not applicable.

Main Outcome Measure

Functional Status Examination.

Results

At 1 year after injury, 81% had not returned to preinjury levels of leisure participation. Activities most frequently discontinued included partying, drug and alcohol use, and various sports. The activity most often reported as new after injury was watching television. Of the small fraction who returned to preinjury levels, 70% did so within 4 months of injury. Sixty percent of those who did not return to preinjury levels were moderately to severely bothered by the changes.

Conclusions

At 1 year after injury, many TBI survivors engage in a reduced number of leisure activities, which are more sedentary and less social, with a substantial fraction dissatisfied with these changes. While discontinuing some activities may be viewed as a positive change, there are few new ones to replace them.     

Modality-Specific, Multitask Locomotor Deficits Persist Despite Good Recovery After a Traumatic Brain Injury

McFadyen BJ, Cantin J-F, Swaine B, Duchesneau G, Doyon J, Dumas D, Fait P. Modality-specific, multitask locomotor deficits persist despite good recovery after a traumatic brain injury.

Objective

To study the effects of sensory modality of simultaneous tasks during walking with and without obstacles after moderate to severe traumatic brain injury (TBI).

Design

Group comparison study.

Setting

Gait analysis laboratory within a postacute rehabilitation facility.

Participants

Volunteer sample (N=18). Persons with moderate to severe TBI (n=11) (9 men, 3 women; age, 37.56±13.79y) and a comparison group (n=7) of subjects without neurologic problems matched on average for body mass index and age (4 men, 3 women; age, 39.19±17.35y).

Interventions

Not applicable.

Main Outcome Measures

Magnitudes and variability for walking speeds, foot clearance margins (ratio of foot clearance distance to obstacle height), and response reaction times (both direct and as a relative cost because of obstacle avoidance).

Results

The TBI group had well-recovered walking speeds and a general ability to avoid obstacles. However, these subjects did show lower trail limb toe clearances (P=.003) across all conditions. Response reaction times to the Stroop tasks were longer in general for the TBI group (P=.017), and this group showed significant increases in response reaction times for the visual modality within the more challenging obstacle avoidance task that was not observed for control subjects. A measure of multitask costs related to differences in response reaction times between obstructed and unobstructed trials also only showed increased attention costs for the visual over the auditory stimuli for the TBI group (P=.002).

Conclusions

Mobility is a complex construct, and the present results provide preliminary findings that, even after good locomotor recovery, subjects with moderate to severe TBI show residual locomotor deficits in multitasking. Furthermore, our results suggest that sensory modality is important, and greater multitask costs occur during sensory competition (ie, visual interference).     

Aging With Traumatic Brain Injury: Cross-Sectional Follow-Up of People Receiving Inpatient Rehabilitation Over More Than 3 Decades

Sendroy-Terrill M, Whiteneck GG, Brooks CA. Aging with traumatic brain injury: cross-sectional follow-up of people receiving inpatient rehabilitation over more than 3 decades.

Objective

To investigate aging with traumatic brain injury (TBI) by determining if long-term outcomes after TBI are predicted by years postinjury and age at injury after controlling for the severity of the injury and sex.

Design

Cross-sectional follow-up telephone survey.

Setting

Community residents who had received initial treatment in a comprehensive inpatient rehabilitation hospital.

Participants

Survivors of TBI (N=243) stratified by years postinjury (in seven 5-year cohorts ranging from 1 to over 30 years postinjury) and by age at injury (in 2 cohorts of people injured before or after age 30).

Interventions

None.

Main Outcome Measures

Measures of postconcussive symptoms, major secondary conditions including fatigue (Modified Fatigue Impact Scale), physical and cognitive activity limitations (FIM, Alertness Behavior Subscale of the Sickness Impact Profile, Medical Outcomes Study 12-Item Health Status Survey Short Form), societal participation restrictions (Craig Handicap Assessment and Reporting Technique), environmental barriers (Craig Hospital Inventory of Environmental Factors), and perceived quality of life (Satisfaction with Life Scale).

Results

Most problems identified by the outcome measures were reported by one fourth to one half of the study participants. Increasing decades postinjury predicted declines in physical and cognitive functioning, declines in societal participation, and increases in contractures. Increasing age at injury predicted declines in functional independence, increases in fatigue, declines in societal participation, and declines in perceived environmental barriers.

Conclusions

This investigation has increased our understanding of the aging process after TBI by demonstrating that both components of aging (years postinjury and age at injury) are predictive of several outcomes after TBI.     

Community Reintegration in Rehabilitated South Indian Persons With Spinal Cord Injury

Samuelkamaleshkumar S, Radhika S, Cherian B, Elango A, Winrose W, Suhany BT, Prakash MH. Community reintegration in rehabilitated South Indian persons with spinal cord injury.

Objectives

To explore community reintegration in rehabilitated South Indian persons with spinal cord injury (SCI) and to compare the level of community reintegration based on demographic variables.

Design

Survey.

Setting

Rehabilitation center of a tertiary care university teaching hospital.

Participants

Community-dwelling persons with SCI (N=104).

Interventions

Not applicable.

Main Outcome Measures

Craig Handicap Assessment and Reporting Technique (CHART).

Results

The mean scores for each CHART domain were physical independence 98±5, social Integration 96±11, cognitive independence 92±17, occupation 70±34, mobility 65±18, and economic self sufficiency 53±40. Demographic variables showed no statistically significant difference with any of the CHART domains except for age and mobility, level of education, and social integration.

Conclusions

Persons with SCI in rural South India who have completed comprehensive, mostly self-financed, rehabilitation with an emphasis on achieving functional ambulation, family support, and self-employment and who attend a regular annual follow-up show a high level of community reintegration in physical independence, social integration, and cognitive independence. CHART scores in the domains of occupation, mobility, and economic self-sufficiency showed lower levels of community reintegration.     

Incidence of Gait Abnormalities After Traumatic Brain Injury

Williams G, Morris ME, Schache A, McCrory PR. Incidence of gait abnormalities after traumatic brain injury.

Objective

To identify the most common gait abnormalities presenting after traumatic brain injury (TBI) and quantify their incidence rate.

Design

Case series.

Setting

Biomechanics laboratory.

Participants

A convenience sample of 41 people with TBI receiving therapy for gait abnormalities, and a sample of 25 healthy controls.

Intervention

Three-dimensional gait analysis.

Main Outcome Measures

Spatiotemporal, kinematic, and kinetic data at a self-selected walking speed.

Results

People with TBI walked with a significantly slower speed than matched healthy controls. There was a significant difference between groups for cadence, step length, stance time on the affected leg, double support phase, and width of base of support. The most frequently observed biomechanical abnormality was excessive knee flexion at initial foot contact. Other significant gait abnormalities were increased trunk anterior/posterior amplitude of movement, increased anterior pelvic tilt, increased peak pelvic obliquity, reduced peak knee flexion at toe-off, and increased lateral center of mass displacement. Ankle equinovarus at foot-contact occurred infrequently.

Conclusions

People with TBI were found to have multijoint gait abnormalities. Many of these abnormalities have not been previously reported in this population.     

Pre-existing Health Conditions and Repeat Traumatic Brain Injury

Saunders LL, Selassie AW, Hill EG, Horner MD, Nicholas JS, Lackland DT, Corrigan JD. Pre-existing health conditions and repeat traumatic brain injury.

Objective

To assess and compare the effect of Pre-existing epilepsy/seizure disorder and drug/alcohol problem on the hazard of repeat traumatic brain injury (TBI) in persons with TBI who participated in a follow-up study.

Design

Retrospective cohort.

Setting

Acute care hospitals in South Carolina.

Participants

Participants were from the South Carolina Traumatic Brain Injury Follow-up Registry cohort of persons (N=2118) who were discharged from an acute care hospital in South Carolina and who participated in a year-1 follow-up interview.

Interventions

Not applicable.

Main Outcome Measures

Repeat TBI was defined by 2 isolated events of TBI in the same person at least 72 hours apart and recorded in hospital discharge or emergency department records from 1999 through 2005.

Results

A Cox proportional hazards model was used to assess the associations of Pre-existing epilepsy/seizure disorder and drug/alcohol problem with time to repeat TBI, controlling for other confounding factors. There were 2099 persons with information on both Pre-existing conditions. There were 147 (7%) persons who sustained repeat TBI after recruitment to the follow-up study, and 82 (3.9%) had a previous TBI before recruitment for which they were seen in the hospital discharge or emergency department since 1996. The hazard of repeat TBI for persons with Pre-existing epilepsy/seizure disorder was 2.3 times the hazard for those without (hazard ratio, 2.3; 95% confidence interval, 1.2-4.4; P=.011). Pre-existing drug/alcohol problem was not associated with repeat TBI. Other variables significantly associated with repeat TBI were having a prior TBI, being insured under Medicaid, and having no insurance.

Conclusions

Pre-existing epilepsy/seizure disorder predisposes to repeat TBI. Appropriate management of seizure control may be an important strategy to allay the occurrence of repeat TBI.     

Ethnic differences in discharge destination among older patients with traumatic brain injury

Chang P-F, Ostir GV, Kuo Y-F, Granger CV, Ottenbacher KJ. Ethnic differences in discharge destination among older patients with traumatic brain injury.

Objective

To estimate the association between ethnicity and discharge destination in older patients with traumatic brain injury (TBI).

Design

A retrospective analysis.

Setting

Nationally representative sample of older patients from the Uniform Data System for Medical Rehabilitation in 2002 and 2003.

Participants

Patients (N=9240) aged 65 years or older who received inpatient rehabilitation services for TBI.

Interventions

Not applicable.

Main Outcome Measures

Discharge destination (home, assisted living facility, institution) and ethnicity (white, black, Hispanic).

Results

Multinomial logit models showed that older Hispanics (odds ratio [OR]=2.24; 95% confidence interval [CI], 1.66-3.02) and older blacks (OR=2; 95% CI, 1.55-2.59) with TBI were significantly more likely to be discharged home than older whites with TBI, after adjusting for relevant risk factors. Older blacks were also 78% less likely (OR=.22; 95% CI, .08-.60) to be discharged to an assisted living facility than whites after adjusting for relevant risk factors.

Conclusions

Our findings indicate that older minority patients with TBI were significantly more likely to be discharged home than white patients with TBI. Studies are needed to investigate underlying factors associated with this ethnic difference.     

Relatives' Criticism Influences Adjustment and Outcome After Traumatic Brain Injury

Weddell RA. Relatives' criticism influences adjustment and outcome after traumatic brain injury.

Objectives

To apply some of the methods developed to study the effects of relatives' expressed emotion (EE) on psychiatric relapse rates and to test the prediction that relatives' criticism and psychiatric distress would be associated with outcome and emotional distress after traumatic brain injury (TBI).

Design

Retrospective cohort design with correlational analyses of quantitative and qualitative measures of TBI outcomes.

Setting

The author interviewed participants in the hospital. The research assistant interviewed close relatives at home.

Participants

Participants and relatives (N=78) were interviewed 34.3±15.2 months (mean ± SD) after a severe TBI.

Interventions

None.

Main Outcome Measures

Dependent variables in a series of hierarchical linear regression models were participants' scores on the Zung Depression Scale, Spielberger Trait Anxiety Inventory, State-Trait Anger Expression Inventory, an Anger Towards Relative questionnaire constructed for this study, and Extended Glasgow Outcome Scores. Participant-independent variables were social class, posttraumatic amnesia, Wechsler Memory Scale-Delayed Recall score, WAIS-R intelligence quotient, and a short version of the Smell Identification Test. Relative independent variables were the number of critical comments directed toward participants in the interview and psychiatric distress as measured by the General Health Questionnaire.

Results

The contributions of variance associated with relative independent variables (predominantly criticism) were significant in stage 2 of most hierarchical regression analyses after the adjustments for variance associated with participant independent variables made in stage 1.

Conclusions

Future application of EE research methods is warranted. If the present results are replicated, then evidence-based family interventions developed by EE researchers to reduce criticism might also improve TBI outcomes.     

Characterizing wandering behaviors in persons with traumatic brain injury residing in veterans health administration nursing homes

Belanger HG, King-Kallimanis B, Nelson AL, Schonfeld L, Scott SG, Vanderploeg RD. Characterizing wandering behaviors in persons with traumatic brain injury residing in Veterans Health Administration nursing homes.

Objective

To examine the prevalence and correlates of wandering in persons with traumatic brain injury (TBI) in nursing homes (NHs).

Design

Using a cross-sectional design, logistic regression modeling was used to analyze a national database.

Setting

One hundred thirty-four NH facilities operated by the Veterans Health Administration.

Participants

NH residents (N=625) with TBI as well as a sample (n=164) drawn from a larger dataset of NH residents without TBI using 1:K matching on age.

Interventions

Not applicable.

Main Outcome Measure

Wandering.

Results

Wanderers with and without TBI did not differ significantly overall. The prevalence of wandering among patients with TBI was 14%, compared with 6.5% of the general nursing home population. The results of the multivariate logistic regression suggested that wandering was associated with poor memory, poor decision making, behavior problems, independence in locomotion and ambulation, and dependence in activities of daily living related to basic hygiene.

Conclusions

Wandering is relatively common in NH residents with TBI. As expected, it is associated with cognitive, social, and physical impairments. Further research with a larger sample should examine those with comorbid dementia and/or psychiatric diagnoses.     

Predictors of Extended Rehabilitation Length of Stay After Traumatic Brain Injury

Arango-Lasprilla JC, Ketchum JM, Cifu D, Hammond F, Castillo C, Nicholls E, Watanabe T, Lequerica A, Deng X. Predictors of extended rehabilitation length of stay after traumatic brain injury.

Objective

To develop a prediction rule for acutely identifying patients at risk for extended rehabilitation length of stay (LOS) after traumatic brain injury (TBI) by using demographic and injury characteristics.

Design

Retrospective cohort study.

Setting

Traumatic Brain Injury Model Systems.

Participants

Sample of TBI survivors (N=7284) with injuries occurring between 1999 and 2009.

Interventions

Not applicable.

Main Outcome Measures

Extended rehabilitation LOS defined as 67 days or longer.

Results

A multivariable model was built containing FIM motor and cognitive scores at admission, preinjury level of education, cause of injury, punctate/petechial hemorrhage, acute-care LOS, and primary payor source. The model had good calibration, excellent discrimination (area under the receiver operating characteristic curve = .875), and validated well. Based on this model, a formula for determining the probability of extended rehabilitation LOS and a prediction rule that classifies patients with predicted probabilities greater than 4.9% as at risk for extended rehabilitation LOS were developed.

Conclusions

The current predictor model for TBI survivors who require extended inpatient rehabilitation may allow for enhanced rehabilitation team planning, improved patient and family education, and better use of health care resources. Cross-validation of this model with other TBI populations is recommended.