Current Research & Innovations in TBI Follow-up from the Defense & Veterans Brain Injury Center (DVBIC, Palo Alto)

Transcription

1 Current Research & Innovations in TBI Follow-up from the Defense & Veterans Brain Injury Center (DVBIC, Palo Alto) John H. Poole, PhD VA Health Care System, Palo Alto, California North American Brain Injury Society (NABIS) New Orleans, Louisiana September 20, 2013

2 History of Local DVBIC Studies DVBIC Database Foundations : clinical study data collected on patients hospitalized for TBI (moderate to severe) TBI Registry established current Clinical Tracking Form Long-Term Outcomes after TBI Study 2004-present Structured Telephonic Testing Study 2008-present

3 CTF Database Development

4 Prospective TBI Clinical Tracking Study CTF Data Collection: Patients in VA TBI-Polytrauma Programs: Polytrauma Rehabilitation Center (PRC) inpatient unit Polytrauma Transition Rehab Program (PTRP) day program Polytrauma Network Site (PNS) outpatient clinic Forms Clinical tracking form (CTF face sheet) Rancho Los Amigos Cognitive Scale Neurobehavioral Symptom Inventory (NSI-22) PTSD Check List (PCL-C) Satisfaction with Life Scale TBI Patient Follow-up Form Mayo-Portland Adaptability Inventory (MPAI-4) Glasgow Outcome Scale Extended

5 Purpose Study 1: Long-Term Outcomes after TBI Assess outcomes 5-17 years after TBI (veterans & service members) Coordinate services by phone for identified needs of patient & family. Study Design Structured phone interviews Patients & Collateral Informants report of functioning Patient interview Symptoms: Neurologic Sensory-motor, Cognitive, Emotional Community Integration: Home, Social, Work/School functioning Qualitative: Life Satisfaction, Coping Strategies, Locus of Control Informant interview (same areas) Symptoms, Community Integration, Coping Strategies, Caregiver Burden

6 Long-Term Outcomes after TBI Methodology Follow-up interviews: 127 Patients (95% male) 62 Informants (parent, spouse, sibling, close friend) Final sample: 62 Patients & Informants Index TBI: both military service members & veterans Age at injury: (median 25) LOC: 86% > 24 h, 36% > 3 wk PTA: 69% > 1 wk Years post-tbi at follow-up: 5-17 (median 9)

7 Long-Term Outcomes after TBI Methodology Follow-up interviews: 127 Patients (95% male) 62 Informants (parent, spouse, sibling, close friend) Final sample: 62 Patients & Informants Age at injury: (median 25) LOC: 86% > 24 h, 36% > 3 wk PTA: 69% > 1 wk Years post-tbi at follow-up: 5-17 (median 9) Analyses: Characterize Patients subjective outcomes Compare Patients & Informants ratings Awareness

8 Long-Term Outcomes after TBI: Results

9 Long-Term Outcomes after TBI

10 Symptoms and Community Integration: Comparison of Patient vs. Informant Ratings Subject and Informant Ratings: table entries are percent of maximum possible score for each scale. IQR = inter-quartile range (25-75 percentile). Rho = Spearman correlation, Subject & Informant ratings. *p <.05 **p <.001.

11 Long-Term Outcomes after TBI Agreement by Patients & Informants on Symptoms and Community Integration: Moderate agreement for: Emotional & Social functions (r =.5 -.6) Patients & family agree about what is going on in the patients emotional-interpersonal life. Low agreement in 4 areas: Cognitive, Neurologic, Home, Work Patients understated problems in the latter three (by SD) Agreement on one factor predicted Employment: Cognitive ratings (r = 0.45, p <.02). To fit with the work-place, the ability to have a mutual understanding of cognitive limitations and abilities is vital.

12 Long-Term Outcomes after TBI Predictors of subject-informant discrepancies: Injury severity (length of PTA) correlated significantly with discrepancies on the Social, Home, and Work indices (r = , p <.01). Continuing lack of awareness is associated with more severe injuries. Prior studies demonstrated improving awareness in the first 5 years post-tbi. In this study, time since injury was unrelated to discrepancies (p >.4). By 5-year after TBI, improvements in awareness appear to have plateaued.

13 Long-Term Outcomes after TBI

14 Long-Term Outcomes after TBI Summary: Awareness by Patients & Significant Others Factors related to Quality of Life (r =.4 -.6, p <.05) Patient Satisfaction with Life: related to self-perceived functioning Regardless of whether the Informant agreed. Caregiver Burden: related to their rating of patients sx, social & work Regardless of whether the Patient agreed. Kelley, Sullivan et al et Poole JH (2012). Self-awareness and neurobehavioral outcomes, five or more years after moderate to severe brain injury. J Head Trauma Rehabilitation, e- publication ahead of print: DOI /HTR.0b013e31826db6b9, PubMed

15 Long-Term Outcomes after TBI

16 Long-Term Outcomes after TBI: The Next Phase (in progress) Analyzing: Predictors of Current Functional Outcome Present-Day Resources Family Members Access to Care (VA, non-va) Coping Strategies Locus of Control (Current Interview Data) Baseline TBI Evaluation Premorbid Functions TBI Severity Standard Tests Discharge FIM Ratings (Current Interview Data) Outcome Criteria Symptoms & Problems Independent Functions Quality of Life Service Needs (Current Interview Data) (DVBIC Legacy Data)

17 Long-Term Outcomes after TBI: Conclusions

18 Long-Term Outcomes after TBI Questions on Study 1?

19 Veterans Affairs Health Care System Palo Alto, California Regional TBI-Polytrauma VA Medical Center for Western United States Regional Defense & Veterans Brain Injury Center (DVBIC) for NW United States

20 Telephonic Testing Rationale Goals Large proportion veterans live far from facilities that provide specialized assessment and treatment. Travel often burdensome, resulting in gaps in needed care Telephones are universally available and already help connect patients with needed services Facilitate initial cognitive evaluations (by phone) for patients who live far from VA services Evaluate Reliability and Validity of telephone-based neuropsychological testing post-tbi

21 Telephonic Testing Phase I Goals: Test-retest reliability of phone-based cognitive testing Completed Predictive validity of baseline measures (legacy data) Ongoing (Legacy Patients had moderate to severe TBI) Phase II Ongoing Goals: Concurrent validity of phone-based cognitive testing Develop & validate verbal tests of spatial abilities (New Patients cover full range of TBI from mild to severe) (Recruited from VA Palo Alto Polytrauma Network Site [PNS] outpatient clinic)

22 Telephonic Testing Phase I Test-Retest Reliability 23 Subjects tested twice by phone (test-retest design) Test-retest median time difference (T1-T2) = 15 days

23 Cognitive Measures Verbal Intelligence Information (WAIS-III) Similarities (WAIS-III) Telephonic Testing Test-Retest Reliability N T1-T2 Correlation.91 **.72 ** [ p<.10, * p<.05, ** p<.001 ] T1-T2 Change (Z) Simple Attention Temporal Orientation (Benton) Digit Span Forward (WAIS-III) **.72 ** Executive Complex Attention Oral Trail Making B Paced Auditory Serial Addition (PASAT) **.95 ** Executive Fluent Retrieval Phonemic Verbal Fluency Semantic Verbal Fluency **.86 ** Working Memory Verbal: Digit Span Backwards Digit Span Sequencing Visual: Mental Rotation Object Mental Rotation Self **.81 **.82 **.68 * Short-Term Memory List Recall Immediate (HVLT-R) Delayed (% Retention) Story Recall Immediate (WMS-III) Delayed *..77 **.80 **.78 ** * ** *

24 Telephonic Testing Phase I Conclusions Telephonic testing was readily completed by patients with history of moderate to severe TBI, who live far from VA services. Neuropsychological testing by phone was reliable Phase I Limitations Not assessed: Correlations with in-person tests (concurrent validity) Visual-spatial abilities TBI severity was limited to moderate-severe Restriction of range reduces magnitude of reliability and validity coefficients, and limits conclusions about utility for patients with mild TBI These limitations are being addressed in Phase II of study (in progress)

25 Telephonic Testing: Phase II Concurrent Validity Phase II (in progress) Subjects: TBI outpatient clinic, VA Palo Alto (mild to severe TBI) 2 test sessions: in-person, by phone (counter-balanced) Tests (commonly used screening batteries): Montreal Cognitive Assessment (MoCA) Repeatable Battery for Assessing Neuropsychological Status (RBANS) Five visual-spatial subtests were adapted for oral administration.

26 Telephonic Testing Planned Analyses: Validity of Telephonic Testing Telephonic Tests General Intellectual Skills Verbal Skills (Concurrent Validity) (Verbally Assessed) Visual Skills Spatial Skills Standard In-person Tests General Intellectual Skills Verbal Skills Visual Skills Spatial Skills Motor Skills (Predictive Validity) Functional Criteria Symptoms & Problems Independent Functions Safety & Competency Quality of Life Service Needs

27 DVBIC Palo Alto Research Team Odette Harris, MD, MPH Site Director John Poole, PhD Neuropsychologist, PI Nytzia Licona, MPH, CCTDM Research Coordinator Carmelinda Mann, PhD Research Associate David Horton, BA Research Associate Jennifer Zahm, BS Research Volunteer

28 DVBIC Palo Alto

29 Telephonic Testing Questions & Discussion