Anne M. Buunk

Leisure and social participation in patients 4–10 years after aneurysmal subarachnoid haemorrhage

Abstract Objective: To investigate the long-term resumption of leisure and social activities in patients with aneurysmal subarachnoid haemorrhage (aSAH) and to determine the role of executive dysfunction and aneurysms in anterior brain regions in particular. Method: Leisure and social functioning of 200 patients with aSAH having anterior or posterior aneurysms was determined using the Role Resumption List (RRL). Executive functioning was investigated using the Dysexecutive Questionnaire (DEX) and sub-scales Social Convention (SC) and Executive Cognition (EC). Mood, fatigue and cognitive problems were investigated with the Hospital Anxiety and Depression Scale (HADS) and Brain Injury Symptom Checklist (BISC). Results: Of all patients, 46.5% reported complete return to previous leisure activities and 61.5% reported no changes in social interactions. HADS depression score, fatigue, DEX-EC sub-scale score and work status post-aSAH were predictors of leisure resumption. For social re-integration, HADS depression score, cognitive problems and fatigue were predictors. Aneurysm location did not influence leisure and social re-integration. Conclusions: A substantial number of the patients still experience problems in resuming previous activities in the chronic phase post-aSAH, influenced by cognitive, executive and depressive problems, as well as current work status and fatigue. Aneurysm location does not seem to influence this resumption.

Mental versus physical fatigue after subarachnoid hemorrhage: differential associations with outcome

Fatigue is a major consequence of subarachnoid hemorrhage (SAH), but the specific characteristics are unclear. Our objective was to investigate the nature of post‐SAH fatigue (mental or physical) and to determine the relationship with functional outcome in the chronic stage. Also, the possible influence of mood disorders and acute SAH‐related factors [SAH type and external cerebrospinal fluid (CSF) drainage] on the presence of fatigue was investigated.

Social cognition impairments after aneurysmal subarachnoid haemorrhage: Associations with deficits in interpersonal behaviour, apathy, and impaired self-awareness

&NA; Behavioural disturbances are frequently found after aneurysmal subarachnoid haemorrhage (aSAH). Social cognition impairments have been suggested as a possible underlying mechanism for behavioural problems. Also, aSAH is likely to result in damage affecting frontal‐subcortical circuits underlying social cognition. Therefore, we aimed to investigate social cognition after aSAH and its associations with behavioural problems (deficits in interpersonal behaviour, apathy, and impaired self‐awareness) and focal as well as diffuse brain damage. 88 aSAH patients (in the subacute phase post‐aSAH) and 60 age‐, sex‐ and education‐matched healthy controls participated. Tasks for emotion recognition, Theory of Mind (ToM), and empathy as well as questionnaires were used. Cortical infarctions in frontal and non‐frontal areas on MRI, aneurysm circulation and aSAH‐related events were taken into account. Compared to healthy controls, aSAH patients performed significantly worse on tasks for emotion recognition, ToM and empathy. Poor performance on ToM and emotion recognition was associated with proxy‐ratings indicating impaired interpersonal behaviour and apathy and with indications of impaired self‐awareness. No associations were found between deficits in social cognition and frontal or non‐frontal cortical lesions on MRI. Also, aneurysm circulation and aSAH‐related events such as hydrocephalus, vasospasm, and treatment method did not explain why and how social cognitive deficits did occur after aSAH. In conclusion, emotion recognition, ToM and empathy were clearly impaired in aSAH patients and these deficits were related to apathy and deficits in interpersonal behaviour as reported by proxies and to impaired self‐awareness. This association strengthens the assumption of impaired social cognition as an underlying construct of behavioural problems after aSAH. Consequently, social cognition tests and proxy‐ratings should be used in clinical practice, irrespective of lesion location on MRI or aneurysm circulation, to improve the detection and treatment of apathy and deficits in interpersonal behaviour after aSAH. HighlightsAspects of social cognition (emotion recognition, ToM, and empathy) were impaired post‐aSAH.Social cognition deficits were associated to behavioural disturbances after aSAH.An association between impaired self‐awareness and deficits in social cognition was found.Social cognitive deficits were not related to lesion location on MRI or aneurysm circulation.

Sociale cognitie en executieve functies na een aneurysmatische subarachnoïdale bloeding

SamenvattingEen aneurysmatische subarachnoïdale bloeding (aSAB) is een ernstige aandoening met een hoge mortaliteit (30 %). Veel van de patiënten die een aSAB overleven, zullen te maken krijgen met neurologische restverschijnselen en de gevolgen daarvan voor hun dagelijks leven. Veranderingen in emotie en gedrag, zoals apathie, ongepast sociaal gedrag en beperkt zelfinzicht, komen daarbij frequent voor. Deze gedragsveranderingen hebben een negatieve invloed op kwaliteit van leven en het dagelijks functioneren van zowel patiënten als de naastbetrokkenen. Desondanks zijn de factoren die ten grondslag liggen aan deze gedragsproblemen tot op heden nauwelijks onderzocht. Stoornissen in de ‘hogere orde’, prefrontaal gelokaliseerde, functies, waaronder ook de zogenaamde sociale cognitie valt, worden in de literatuur steeds vaker genoemd als mogelijke oorzaak. In het onderstaande artikel wordt het onderzoek beschreven dat momenteel wordt uitgewerkt tot een proefschrift over executief functioneren en sociale cognitie bij patiënten die een aSAB hebben doorgemaakt. In het bijzonder wordt daarin aandacht besteed aan de relatie tussen stoornissen in sociale cognitie en gedragsveranderingen.

Social cognition impairments after aneurysmal subarachnoid hemorrhage

Objective: Many patients with primary brain tumors suffer from cognitive deficits. Treatment options for these deficits are scarce, time-consuming and costly. Recent studies showed promising results on the efficacy of cognitive rehabilitation in these patients. Also, the cognitive rehabilitation program (CRP) developed by our group proved effective in an RCT. To increase its accessibility, it was converted into the app-based CRP ReMind. We performed a pilot study to evaluate feasibility and patient experience of this new method of training. Participants and Methods: Prior to surgery, 15 patients with a presumed meningioma or low-grade glioma were included in this study. The CRP ReMind incorporated both retraining of attention and practicing of compensational strategies of attention, memory and executive functioning. Patients started 3 months after neurosurgery and spent several hours per week on the program for 10 weeks. Neuropsychological assessments were conducted one day before surgery, 3 months after surgery (i.e. before starting the program) and 6 months after surgery (i.e. immediately after finishing the program). At all time-points, questionnaires on psychosocial and subjective cognitive functioning were administered to patients and caregivers. Results: Feasibility (i.e. percentages of interested, adhered and dropped-out patients) and patient experience will be presented. Also, results of paired t-tests will be presented for a first impression of possible changes in cognitive functioning and patient-reported outcomes (PROs). Conclusions: This is the first study that provides evidence-based cognitive rehabilitation via a tablet-app in brain tumor patients. An RCT on the effects of ReMind on cognitive functioning and PROs is forth-coming.Objective: Although there is a vast body of literature on cognition in patients with low-grade gliomas (LGG; WHO grade I or II), this study is first using a brief (30 min) computerized neuropsychological screening battery (cNPS; i.e., CNS Vital Signs) as clinical care to examine cognitive function in LGG patients at group and individual level. Methods: LGG patients underwent cNPS 1 day pre-surgery (N=69), with follow-up 3 months post-surgery (N=54). Results: Pre-operatively, patients demonstrated significantly lower means on 6 out of 7 domains assessed: memory, reaction time, cognitive flexibility, processing speed, complex attention, and executive function, compared to healthy controls (HC; 1,069 American subjects). Effect sizes were small, Cohen’s ds ranging from -.21 to -.36. Post-surgery, there were no differences between patients and HC anymore, except for memory where performance was still lower function, compared to healthy controls (HC; 1,069 American subjects). Effect sizes were small, Cohen’s ds = -.49. Preoperatively, 24% of the patients scored low, and another 25% scored very low (i.e., respectively 1.5 or 2 standard deviation below average) in at least one domain. Post-surgery, respectively 30% and 15% of the patients scored within the low or very low range on at least one domain. Conclusions: In line with studies using conventional neuropsychological tests, the cNPS demonstrated that pre-surgery, LGG patients are faced with mild cognitive dysfunction in several domains. Post-surgery, performance did not differ from HC, except for the memory domain for which performance still deviated from HC. Practice effects and surgery effects will be further examined. Selection bias was minimal and results are generalizable to LGG patients undergoing surgery.Objective: Impaired social cognition (SC) is a possible underlying cause of behavioral and interpersonal changes after aneurysmal subarachnoid hemorrhage (aSAH). To date, SC has not been investigated after aSAH. Therefore, we aimed to investigate SC after aSAH and its relationship with frontal lesions. Participants and Methods; 89 aSAH patients (mean age 53.2 years) conducted a neuropsychological test battery in the subacute phase (mean = 4.8 months) post-SAH. A broad range of SC tests was administered; Emotion recognition (Facial Expressions of Emotion - Stimuli and Test; FEEST), Theory of Mind (Cartoon Test, Faux Pas Test; FP), and emotional empathy (FP Empathy Score, Balanced Emotional Empathy Scale; BEES) were investigated. Frontal infarctions on post-SAH MRI were registered. Between-group comparisons and correlations were used. Results: ASAH patients scored significantly worse on the FEEST (M = 45.64), Cartoons (M = 18.30) and Faux Pas (M FP correct = 4.17, M FP Empathy = 1.84) than controls (M = 48.76, M = 23.50, M = 4.63, M = 2.52 resp.), all ps < 0.05. BEES scores did not differ significantly between patients and controls. No significant correlations were found between the presence of frontal infarctions and SC tests. Conclusions: In the subacute phase after aSAH, several aspects of social cognition were clearly impaired (i.e. emotion recognition, Theory of Mind, empathy). These impairments were not related to frontal lesions. Considering the adverse consequences for daily functioning of social cognitive deficits, neuropsychological assessment after aSAH should include social cognition tests for all patients regardless of their lesion locations

Fatigue in patients 3-10 years after aneurysmal and angiographically negative subarachnoid haemorrhage

Background: Acquired brain injury (ABI) is often a lifelong disability that entails a marked change in a person’s life. It involves biopsychosocial levels and return to work (RTW) is one of the mai ...Accepted Abstracts from the International Brain Injury Association’s Eleventh World Congress on Brain InjuryObjective: To investigate whether: 1) traumatic brain injury (TBI) reduces striatal dopamine transporter (DAT) levels; 2) TBI causes structural changes to the substantia nigra and/or nigrostriatal tract; 3) DAT levels following TBI correlate with substantia nigra or nigrostriatal tract damage; 4) DAT levels relate to behavioural measures of apathy and/or speed of processing. Background: Persistent cognitive problems following TBI are common. The heterogeneous nature of TBI means that the basis of cognitive dysfunction is likely to be multi-factorial. Animal and human studies have shown dopaminergic disruption following TBI. However, the cause of this disruption is unclear and may relate to damage to the dopaminergic nuclei or their ascending projections. Design/Methods: 32 moderate/severe TBI patients with persistent cognitive problems and 15 healthy controls had an ioflupane ( 123 I) SPECT scan (DaTscan), MRI and full neuropsychological assessment. DAT levels in the striatum were measured. MRI was used to calculate substantia nigra volumes and nigrostriatal tract diffusion metrics. Results: Quantitative assessment showed reduced DAT levels in TBI patients. Patients had substantia nigra atrophy, as well as increased mean diffusivity in the nigrostriatal tract. There was a significant relationship between (1) DAT levels and substantia nigra volumes in patients and (2) mean diffusivity in the nigrostriatal tract and anterior striatal DAT levels. DAT levels showed a significant relationship with apathy measures but not speed of processing. Conclusions: A proportion of TBI patients with persistent cognitive problems have reduced striatal DAT levels implying a disruption to their dopaminergic system. DAT levels are correlated with structural changes in the substantia nigra and nigrostriatal tract. This supports a causal relationship between damage to these regions by TBI and functional dopaminergic dysfunction. Reduced DAT levels also relate to apathy. Dopaminergic therapies may therefore benefit those patients with evidence of disruption to their dopaminergic systems. Study Supported by: Guarantors of Brain NIHR Disclosure: Dr. Jenkins has nothing to disclose. Dr. De Simoni has nothing to disclose. Dr. Bourke has nothing to disclose. Dr. Cole has nothing to disclose. Dr. Sharp has nothing to disclose.Objectives: The majority of patients with traumatic brain injury (TBI) sustain a mild TBI, of which the prognosis isgenerally favourable. However, patients with moderate-to-severe TBI can experience long-lasting cognitive, emotional and behavioural deficits that interfere with functioning in daily life and the resumption of work. Current literature suggests that executive functioning and coping style are important factors affecting outcome. Moreover, it is suggested that intact executive functioning is a pre-requisite for the use of adaptive coping; as executive processes such as foresight, planning and initiation seem essential for the employment of active coping strategies. So far, the exact association between executive functioning and coping remains unclear, as literature has pro-vided us with mixed results. The aim of the present study is 2-fold. First, we aim to assess the association between executive functioning and coping among patients with TBI at different levels of severity. Second, we aim to investigate to what extent injury severity influences the association between executive ability and coping as a moderating factor.Methods: We included 109 TBI patients from two prospective follow-up studies, of which 53 patients were classified as mild TBI, 19 patients as moderate and 37 patients as severe. Additionally, 33 healthy controls were included. Executive functioning and coping style were assessed by neuropsycho-logical examination in the post-acute and chronic phase after TBI. Results: Greater self-reported executive dysfunction was related to greater use of passive coping styles in all separate levels of severity and in the mixed TBI group (β= 0.591,p<0.001). Additionally, a lower amount of self-reported executive dysfunction was related to higher levels of active coping in the mixed TBI group (β=–0.457,p< 0.001) and the mild and severe TBI groups. Additionally, better performance on an executive test for response inhibition was related to greater use of active coping in the total TBI group (β=–0.178,p=0.047). No evidence for a moderating effect of injury severity on the association between executive functioning and coping was found. Conclusions: Self-reported executive functioning was a significant predictor of coping style at all levels of injury severity inpatients with TBI. Individuals who reported greater executive problems were predisposed to rely on a maladaptive passive coping style. Furthermore, these results suggest that less self-reported executive dysfunction was related to a higher use of an active coping style.Libra Rehabilitation & Audiology Dept. of Neurorehabilitation PO Box 1355, 5602 BJ Eindhoven E info@libranet.nl I www.libranet.nl Correspondence to Ingrid Brands, MD, PhD i.brands@libranet.nl Introduction  Self-efficacy refers to the belief in one’s ability to achieve goals. In patients with acquired brain injury (ABI) higher levels of general self-efficacy and self-efficacy for managing brain injury-specific symptoms have shown to be associated with better quality of life (QoL).1  Being highly self-efficacious in managing one’s health issues is assumed to be a key factor in successful chronic disease selfmanagement.2  Neuropsychological rehabilitation programmes focus on teaching patients to compensate for and manage their cognitive deficits and the social and emotional consequences of ABI. Yet, do these programmes lead to higher levels of self-efficacy in managing brain injury-specific symptoms? Results  QoL and brain injury-specific self-efficacy increased significantly after neuropsychological rehabilitation. Table 2  Both general and brain injury-specific self-efficacy were positively associated with QoL after neuropsychological rehabilitation. Table 3  A lower initial level of cognitive functioning predicted worse QoL after neuropsychological rehabilitation (β = −.63, p = .05).  Cognitive functioning was not significantly associated with initial brain injury-specific self-efficacy (r = .13, p = .60). Objective We examined:  the influence of neuropsychological rehabilitation on general and brain injury-specific self-efficacy and on QoL,  whether initial levels of general and brain injury-specific selfefficacy and cognitive functioning would predict QoL after neuropsychological rehabilitation,  whether cognitive functioning was associated with initial selfefficacy for managing brain injury-related symptoms.Objectives: Disability research as an academic field was established in the 1960s and 1970s in the Nordic countries and in the Anglo-Saxon world. Disability research was studied within the medical model, e.g. in medical and rehabilitation studies, while disability studies became a part of the social model, e.g. in social and psychological studies. It has been a lack of theoretical perspective in disability research and according to that a discussion of theoretical approaches in disability studies that has been raised during recent years. The aim of the study is to describe and illustrate conceptually how vertical and horizontal knowledge integration appear in disability research, exemplified within a case from a person with acquired brain injury.Methods: The study adopted a qualitative approach to answer the research aim, undertaking a literature review to accompany an analysis of the concepts, vertical and horizontal. The concepts were thereafter analysed within theories from disability research and exemplified with a case from brain injury rehabilitation.Results: Tentatively the conceptions, vertical and horizontal, are described and, in addition, a bio-psycho-social perspective is mentioned andtwo theoretical approaches within disability research are described: human functioning sciences and interdisciplinary research. Vertical knowledge integration can be seen as a stratification between differentlevels on a biological, psychological and social level. Horizontal knowledge integration can be understood across varying disabilities. The study indicates that vertical and horizontal knowledge integration in disability research are useful for a broader and deeper understanding of disability and functional impairment where, over the last few years, different theoretical perspectives have become increasingly common. Furthermore, the study shows that acquired brain injury, in a scientific context, has been studied within different levels of society. For example:●On a biological level, e.g. within biochemical bloodanalysis;●On a psychological level, e.g. within neuropsychologicaldiagnostics; and●On a social level, e.g. as a changeover process duringrecovery.Conclusions: The study indicates that a variety of scientific contributions are needful in our understanding of the phenomenon of living withacquired brain injuryin the contemporary society.