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Residual memory deficits may represent a problem to the everyday functioning of a large number of people, including those who have sustained traumatic brain injury (TBI). The present exploratory study sought to investigate the interrelationships between subjective memory reports, performance on traditional memory tests, and performance on tests of prospective memory. These interrelationships were contrasted between a group of 24 adults who had sustained TBI and a group of 24 matched control subjects. Prospective memory was hypothesized to be indicative of everyday memory functioning. The results provided preliminary evidence that prospective memory tests are sensitive to TBI-related neurological impairment and, in comparison to traditional tests, may be better indicators of functional memory capacity. This pattern was particularly true for control subjects, possibly because TBI subjects had difficulties in evaluating their memory functioning.

A group of 175 traumatic brain injury (TBI) patients who had undergone intensive rehabilitation at Bethesda Hospital attended a follow-up interview 2 years after injury. The majority of patients had suffered severe TBI. Outcome was documented in ten areas: medical/physical, mobility, activities of daily living (ADLs) accommodation, marital status, leisure and recreation, employment/study, communication, cognition and behaviour. Whilst most patients were physically independent and competent in personal and domestic activities of daily living, a third of the group were still reliant on assistance with community skills and transport, and more than half of those who previously had a job, were not working at 2 years post-injury. Around two-thirds of the sample reported cognitive, behavioural and emotional changes. There is clearly a need for ongoing community-based support and assistance in dealing with practical difficulties and psychological problems as they are experienced after return to the community.

Severe traumatic brain injury (TBI) is a condition often associated with grave consequences and it remains a major public health problem globally. Clinical trials to improve management and treatment of this condition are a necessity; however, there are many issues that impact on the design and conduct of such trials including the complex and sensitive issue of consent. Obtaining consent for severe TBI trials is inherently complicated and difficult because the family are being asked to make an informed decision when they are shocked, anxious, grieving and frequently physically exhausted. We established a process during the DECRA trial to minimise the difficulties and to ensure that consent was obtained with sensitivity and in an informed manner.

In the past two decades we have seen a plethora of studies examining the psychological sequelae of closed head injury. This in itself represented an important step, where previously the emphasis had been on documenting survival statistics and residual physical disability. The earlier psychological studies, such as those conducted by Brooks and his colleagues [1] and Levin and his colleagues [2], focused largely on cognitive functions, including intelligence, language, memory and perception, following the localizationist models of neuropsychology which predominated at the time.

Traumatic brain injury is the leading cause of disability in people under 40, severely disabling 150-200 people per million annually. Neuropsychiatric sequelae outstrip the neurophysical (such as ataxia or incontinence) as the major cause of disability. Problems with memory, attention, executive function, behavioural control, and regulation of mood, associated with injury to the frontal and temporal lobes, are particularly troublesome. The vast majority of recovery after traumatic brain injury takes place in the two years after injury; after this the brain injured patient faces an uncertain future. In some patients further improvement is seen even as late as 5-10 years after injury. Thus some long term studies, unfortunately often weakened by low rates of follow-up, show surprisingly good outcomes.1 New-combe found that veterans who had had a head injury in the second world war showed no evidence of deterioration many years after injury.w1 This might have been due to the expert and systematic care they received very soon after the injury. But other researchers found that a proportion of patients deteriorated when assessed 10-20 years later. Millar et al studied 418 patients, 85% of whom had had a severe head injury, on average 18 years after they had been assessed at six months after the injury.w2 Twice as many had deteriorated as had improved (30% v 14%). Head injuries are most likely to occur in people aged 15-24 and as a result often disrupt important developmental processes, such as attaining independence from parental support, completing study and establishing a vocation, and forming social networks. The result is loss of self esteem, social isolation, and a considerable burden for families. Regardless of the age of the patient, it is the changes in cognition and behaviour that represent the greatest burden to families after a traumatic brain injury.2 Difficulties with social skills may arise from deficiencies in self monitoring and social judgment. Morris et al found that avoidance of social contact may be partly due to the injured person's inability to keep up with conversation as a result of slowed information processing, which in turn creates social anxiety.w3 Some of the symptoms the patients described at interview are often overlooked. They reported feeling self conscious about physical signs of their injuries. They had a persisting sense of loss, due to failure to fulfill their dreams, and some described negative feelings from others, perhaps due to lack of understanding of the consequences of head injury. There is also a growing awareness of the high incidence of long term psychiatric disorders after traumatic brain injury.3 Depression, anxiety, and substance misuse are common. Koponen et al found that psychiatric disorders persist at 30 year follow-up, with patients particularly susceptible to depressive episodes, delusional disorder, and persistent changes in personality.w9 Who develops psychiatric problems and why are poorly understood; associations with injury severity are weak. Socioeconomic status before the injury still has an impact on outcome many years after injury. Curran et al found that the presence of anxiety and depression was more strongly associated with coping style than with severity or even the presence of brain injury in trauma patients.w5 They found higher levels of symptoms in those with a non-productive coping style, characterised, for example, by self blame and ignoring problems, than in those who dealt with problems in an active manner. Neuropsychological assessment in the early stages of recovery will facilitate awareness of the cognitive and behavioural consequences of the injury. Educational programmes directed at the families, friends, and associates of those injured, and at the community at large, facilitate greater understanding and acceptance of the complex and often invisible problems of people with brain injury. The brain injured person will then need easy timely access to a variety of services. The recent National Service Framework for long term conditions in the UK (www.dh.gov.uk/assetRoot/04/10/53/69/04105369.pdf) describes how this can be achieved. Though it aims to meet the needs of all those with long term neurological disorders,4 its relevance for those with traumatic brain injury cannot be overemphasised. But change is needed. Early post-injury assessments may be concentrating more on physical disability than cognition,w6 perhaps partly explaining why unmet need is most evident in cognitive and psychosocial rehabilitation.w7 Equity of access is still an issue; for example, poorer access to services in rural areasw8 is probably a global problem. In the end, it is the injured person who must negotiate a lifelong journey with a brain injury. Their perspective needs to be understood.

Although the frequency and implications of disorders of attention in head-injured subjects have been recognised in recent years, there have been few carefully controlled attempts to evaluate remedial interventions. The present study employed a multiple baseline across subjects design to evaluate a computer-mediated programme for the remediation of deficits in speed of information processing in 10 severely head-injured subjects, aged 17-38 years. Following a baseline period, the effectiveness of computer training alone was compared with that combined with therapist feedback and reinforcement in separate training phases, each lasting 3 weeks. The final phase involved a return to baseline conditions. Dependent measures of attention, taken across all phases, included psychometric measures of processing speed, a rating scale completed by the patient's Occupational Therapist, and a video of the patient working in therapy. Results suggested that, once spontaneous recovery and practice effect were controlled, the patients showed little response to the interventions in terms of the dependent measures used.

The development of clinical neuropsychology has shown a gradually changing emphasis, from tests of organicity, through actuarial approaches, towards a more flexible approach, which utilises qualitative observations of patient behaviour. In recent years clinical neuropsychologists have played a greater role in patient management, in addition to diagnosis, particularly in the rehabilitation setting. The emphasis has thus changed gradually from measurement to application. Relationships between test performance and functional efficiency in daily life have not always been addressed, however. The focus tends to be on “impairment” as opposed to “disability”. The limitations of conventional neuropsychological assessment in predicting disabilities have been demonstrated in a number of studies. Possible solutions to this problem are discussed critically. These include the use of behavioural observation, rating scales or checklists. and standardised assessment procedures that simulate everyday activities. I...

Ten patients suffering from vertebrobasilar insufficiency (VBI) were assessed with a number of neuropsychological tests in order to investigate the qualitative nature and permanency of cognitive deficits associated with this disorder. Results suggested that VBI may produce a mild memory problem which has the characteristics of an axial amnesia. Qualitative features of this disorder are discussed. There appeared to be some correlation between severity of memory deficit and clinical neurological status. Results of follow-up testing suggested that regression of symptoms may lead to a slight improvement in the mental status of the patient.

A case of transient global amnesia of clear vascular aetiology is described. Results of neuropsychological testing carried out during the attack clarify the nature of the memory disorder and suggest that the critical region of ischaemia is the medial temporal area around the hippocampus. Follow-up testing suggests that no lasting memory impairment resulted.

SynopsisThis study examined the usefulness of self-report measures of emotional disorder in a relatively acute, severely head injured population (i.e. individuals who had sustained their injuries cwithin the previous two years). The General Health Questionnaire, the Leeds Scales of Depression and Anxiety, and Visual Analogue Scales of Depression and Anxiety were administered to 39 severely head injured subjects and 35 ‘close others’ who were required to give their opinions on how they thought the head injured subjects were feeling. Twenty head injured subjects were re-tested within a week. Results indicated that the head injured are able to reliably complete self-report scales as indicated by the ‘close’ others similar reports. The head injured seem to be relatively aware of their overt behaviours and emotions, at least when utilizing the General Health Questionnaire and the Leeds Scale of Depression. According to the measures of emotional disposition used in the present study, emotional disorder was found to be common. From the results it was further suggested that lack of a close confiding relationship predicts emotional disorder and may be used to identify those subjects at risk. Overall, the results provide confidence for the use of self-report scales as a preliminary approach to the identification of emotional disorder in the severely head injured.

Procedural discourse is a monologue discourse task concerned with explaining to a listener how a particular activity is carried out. The study reported here is part of a series of investigations into discourse abilities following severe traumatic brain injury (TBI). The aim of this study was to compare the procedural discourse skills of a group of 26 TBI speakers, with those of two demographically distinct control groups. The first control group comprised 26 non-TBI orthopaedic patients, and the second control group comprised 26 university students. These control groups were selected because of the hypothesis that premorbid demographic factors could influence sociolinguistic skills, and hence performance on a procedural discourse task. The TBI group was systematically compared with the control groups on content, productivity, and pragmatic measures. They were not significantly different from orthopaedic patients on measures relating to content and productivity; however, they did differ significan...

The major aim of this study was to describe the conversational abilities of a group of severely injured TBI speakers, at a minimum of 2 years post-injury. The association between conversational impairment and (a) selected measures of executive function and (b) psychosocial handicap was also examined. Twenty-four members of the group of 26 severely injured TBI speakers who had initially been assessed between 3 and 6 months post-injury were reviewed at a minimum of 2 years post-injury (mean = 2 years, 10 months). At initial assessment, TBI speakers were compared with non-TBI orthopaedic patients and with a group of university students. At follow-up, however, they were compared only with the orthopaedic patients. Conversational assessment was carried out using a modified form of Damico's Clinical Discourse Analysis. As a group, the TBI speakers' conversational abilities did not improve over time. There was, however, a subgroup (n = 8) of speakers who did improve, and these could be distinguished by greater initial severity of injury and a significantly longer period of speech-language pathology intervention than the speakers who either remained the same or worsened over time. Modest associations between conversational discourse skills and measures of executive function and a measure of psychosocial handicap were identified. These findings indicate that disruptions in conversation persist into the longer term. More assiduous efforts may need to be made to (a) identify subtle discourse changes in the early months after injury and (b) engage TBI speakers in speech-language pathology services. Such services are also required over a longer time frame, in community-based models of service provision.