Zakzanis CAT GOS-E CSME CAT CAME BACK March April 2017 … · 2018. 4. 4. · 3/31/2017 1 on the...

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on the nature of traumatic brain injury and the GOS-E and the new catastrophic definition

Professor Konstantine K. Zakzanis, Ph.D., C.PsychDepartment of Psychology

University of Toronto Scarborough

outline the GOS-E what is it? qualification pathways | case studies

before we can talk about the GOS-E in the beginning… evidence based assessment? witches, crystal balls, superheroes, and do we all have traumatic

brain injuries? evidence based examinations | assessment of functioning breadth, severity, veracity

what is a traumatic brain injury? review of diagnostics for an uncomplicated mild TBI,

complicated mild TBI, moderate TBI, and severe TBI

Professor K. K. Zakzanis, Ph.D., C.Psych

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in the beginning…evidence based assessment?


evidence based assessment?


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is neuroimaging the answer?

what’s missing here?


here is a hint…

what’s missing here?


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the localization of upper severe disability (i.e., functioning), ain’t so convenient, is it?


what else can go wrong here? the problem of false positives in the context of Catastrophic determination


Neuropsychology. 1997 Jul;11(3):437-46.Is it possible to be schizophrenic yet neuropsychologically normal?

Palmer BW1, Heaton RK, Paulsen JS, Kuck J, Braff D, Harris MJ, Zisook S, Jeste DV.

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what else can go wrong here? MORE IMPORANTLY: the problem of false negatives in the context of Catastrophic determination


Published in Cerebral Cortex by Israeli researchers Shlomi Haar and colleagues, the new research reports that there are virtually no differences in brain anatomy

between people with severe autism and those without.Cereb Cortex. 2016 Apr;26(4):1440-52. doi: 10.1093/cercor/bhu242. Epub 2014 Oct 14.

evidence based examination of functioning


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evidence based examination of functioning?


evidence basedexaminationof function?


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evidence based examination of function?


DO YOU HAVE:• superhuman strength?• superhuman speed?• superhuman vision (including X-ray,

microscopic, telescopic, and infrared?• superhuman hearing?• heat vision?• flight?• super breath (also freeze breath)

MULTI-KRYPTON PSYCHOMETRIC INVENTORY OF SUPERHEROISM

evidence based examination of function?

The Rivermead Post-Concussion Symptoms Questionnaire*

After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please circle the number closest to your answer. = Not experienced at all = No more of a problem = A mild problem = A moderate problem = A severe problem Compared with before the accident, do you now (i.e., over the last 24 hours) suffer from: Headaches.................................................. 0 1 2 3 4 Feelings of Dizziness ................................. 0 1 2 3 4 Nausea and/or Vomiting ........................... 0 1 2 3 4 Noise Sensitivity, easily upset by loud noise ......................... 0 1 2 3 4 Sleep Disturbance ...................................... 0 1 2 3 4 Fatigue, tiring more easily ......................... 0 1 2 3 4 Being Irritable, easily angered .................. 0 1 2 3 4 Feeling Depressed or Tearful .................... 0 1 2 3 4 Feeling Frustrated or Impatient ................ 0 1 2 3 4 Forgetfulness, poor memory ..................... 0 1 2 3 4 Poor Concentration .................................... 0 1 2 3 4 Taking Longer to Think .............................. 0 1 2 3 4 Blurred Vision ............................................. 0 1 2 3 4 Light Sensitivity, Easily upset by bright light ........................ 0 1 2 3 4 Double Vision ............................................. 0 1 2 3 4 Restlessness........................................................01234


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assessment of function: breadth | severity | veracity

Wrong!


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Right!

Right!


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Right!

assessment of function: breadth, severity, veracity

evidence based assessment of function:learning and memory | attentional abilities |expressive and receptive language abilities |executive function | information processing | spatial abilities | behavioural function (insight; motivation; social intelligence; temperament; personality and so on)

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assessment of function: breadth | severity | veracity The concept of normative comparison

assessment of function:what about veracity?


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what about veracity?




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what about veracity?Non Credible Test Results

MalingeringFactitious | Conversion Disorder

Exaggeration Poor Effort Bonefide Impairment


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non credible test findings| malingering

non credible test findings conversion disorders (FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER in DSM 5)

https://www.youtube.com/watch?v=V8ITCYijzYo

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non credible test findings | exaggeration

non credible test findings | poor effort

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Non credible test findings |bonefide impairment

what is a traumatic brain injury?


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“…traumatically induced physiological disruption of brain function”Kay, T., Harrington, D. E., Adams, R., Anderson, T., Berrol, S., Cicerone, K., … Malec, J. (1993). Definition of traumatic brain injury. Journal of Head Trauma Rehabilitation, 8(3), 86-87.

Manifested by one or more of the following: Period of loss of consciousness Loss of memory for events immediately before or after the accident Alteration in mental state at the time of the incident(e.g. feeling

dazed, disoriented, or confused) Focal neurological deficit(s) that may or may not be transient Neuroanatomical abnormalities (e.g., contusion, hemorrhage etc.)

Not a Necessary

Requirement


open traumatic brain injuryclosed traumatic brain injury

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diagnosis is based on the acute injury characteristics and imaging. initial GCS duration of lost consciousness duration of post traumatic amnesia presence or absence of intracranial injury on neuroimaging examination alteration in mental state at the time of the incident(e.g. feeling dazed,

disoriented, or confused)



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severe tbi GCS corresponds to 8 or less Duration of lost consciousness is greater than 24 hours Duration of Post Traumatic Amnesia is greater than seven days NO neuropathological abnormality on neuroimaging required



moderate tbi GCS corresponds to 9 to 12 Duration of lost consciousness is corresponds to greater than 30

minutes and less than 24 hours Duration of Post Traumatic Amnesia is greater than 24 hours and less

than seven days NO neuropathological abnormality on neuroimaging required

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complicated mild tbi GCS corresponds to 13 to 15 Duration of lost consciousness corresponds to less than 30 minutes Duration of Post Traumatic Amnesia is less than 24 hours and less

than seven days BUT Presence of neuropathological abnormality on neuroimaging is

required



mild tbi GCS corresponds to 13 to 15 Duration of lost consciousness corresponds to less than 30 minutes Duration of Post Traumatic Amnesia is less than 24 hours and less

than seven days NO neuropathological abnormality on neuroimaging required

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TBI symptoms


Behavioural/Emotional Drowsiness Fatigue/lethargy Irritability Depression Anxiety Sleeping more than usual Difficulty falling asleep

Cognitive Feeling slowed down Difficulty concentrating (e.g., poor

attention) Difficulty learning and remembering (e.g.,

need reminders | prompting) Difficulties with decisions, planning (e.g.,

dealing with money) Difficulties with receptive and expressive

speech

Physical Symptoms: Headaches Nausea Vomiting Blurred or double vision Seeing stars or lights Balance problems Dizziness Sensitivity to light or noise Tinnitus

The Catastrophic Error in TBI diagnosis:if this, then that……

the not uncommon mistake of interpretation error made when examiners overgeneralize their findings to come to a TBI diagnostic conclusion in the context of Catastrophic Impairment Rating

in other words, “because a dog meets the test of being an animal

with four legs (then) any newly encountered dog with four legs must be a dog”

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My 11 month old boy, named Hunter, believes that because a dog meets the test of being an animal with four legs (then) any newly encountered animal with four legs must be a dog…” And he hates dogs.

Even my boy Hunter can learn that because a dog meets the test of being a large animal with four legs (then) any newly encountered dog with four legs IS NOT ALWAYS a dog…”

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The Catastrophic Error in TBI diagnosis:the importance of base rates

base rates are particularly relevant when evaluating “diagnostic” signs or symptoms (as in traumatic brain injury).

when a sign occurs more frequently than the condition it indicates, relying on that sign as a diagnostic indicator will always produce more errors than would the practice of completely disregarding the sign.

do we all have TBI’s?


The Rivermead Post-Concussion Symptoms Questionnaire* After a head injury or accident some people experience symptoms which can cause worry or nuisance. We would like to know if you now suffer from any of the symptoms given below. As many of these symptoms occur normally, we would like you to compare yourself now with before the accident. For each one, please circle the number closest to your answer. = Not experienced at all = No more of a problem = A mild problem = A moderate problem = A severe problem Compared with before the accident, do you now (i.e., over the last 24 hours) suffer from: Headaches.................................................. 0 1 2 3 4 Feelings of Dizziness ................................. 0 1 2 3 4 Nausea and/or Vomiting ........................... 0 1 2 3 4 Noise Sensitivity, easily upset by loud noise ......................... 0 1 2 3 4 Sleep Disturbance ...................................... 0 1 2 3 4 Fatigue, tiring more easily ......................... 0 1 2 3 4 Being Irritable, easily angered .................. 0 1 2 3 4 Feeling Depressed or Tearful .................... 0 1 2 3 4 Feeling Frustrated or Impatient ................ 0 1 2 3 4 Forgetfulness, poor memory ..................... 0 1 2 3 4 Poor Concentration .................................... 0 1 2 3 4 Taking Longer to Think .............................. 0 1 2 3 4 Blurred Vision ............................................. 0 1 2 3 4 Light Sensitivity, Easily upset by bright light ........................ 0 1 2 3 4 Double Vision ............................................. 0 1 2 3 4 Restlessness........................................................01234

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YES. we do all have TBI’s


YES. we do all have TBI’s


Remember… this is the point for objective psychometric testing of functioning…….

…..breadth | severity | veracity….

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know your base rates…


Uncomplicated mild TBI

Reviews: Full recovery after 3 months is the norm with no long-term residual deficits

(Alexander, 1995; Binder, 1997; Ponsford et al., 2000; McCrea et al., 2009; Voller et al., 1999)

Meta-analysis: 97% overlap of control (i.e., those with no brain injury) and mild

traumatic brain injury test performance by one month post-trauma Confidence interval of effect size estimates between 30-89+ days post-

trauma included zero (Schretlen & Shapiro, 2003)

d = -0.07 “for an impaired subgroup to exist, the level of impairment would have to be just under a tenth of a SD, equivalent to a WMS-IV Index score value of 1 point” (Rohling, Larrabee, & Millis, 2012)

This all suggests that the maximum prevalence of persistent neuropsychological deficit after 3 months post-injury is likely to be little to none (Binder, 1997; McCrea et al., 2009)



Uncomplicated mild tbi However: Persistent neuropsychological impairments have been reported

beyond expected recovery period… 15% of persons suffering mTBI were still symptomatic (Alexander, 1995)

10-20% have persistent symptoms after 3 months (Ruff, 2005)

11-24% presented with persistent symptoms post 6-months (Pertab et al., 2009)

Range: 7% - 40% (Alves et al., 1993; Binder et al., 1997; Iverson et al., 2000)

Even in non-litigating patient populations (Bohnen et al., 1992; Kraus et al., 2014; Kelly, 1975; Rimel et al., 1981; Wrightson and Gronwall, 1981)

“miserable minority” – a subgroup of persons who continue to be symptomatic after 3 months (Rohling et al., 2012)

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uncomplicated mild traumatic brain injuryis there a door to the GOS-E pathway? Persisting cognitive impairment (“miserable minority”) pain, mood, headache, fatigue, preexisting, post non-accident

related factors(McCrea et al., 2009; Garden & Sullivan, 2010; Youngjohn et al., 1995)

misattribution of relatively common symptoms to accident related injury (expectation as etiology hypothesis)

good old day hypothesis (tendency to recall past symptoms and functioning more favorably than was actually the case)

nocebo effect (Expectation of symptoms and associated emotional distress leading to increased symptoms

iatrogenic disability Premorbid personality characteristics (Mittenberg & Strauman, 2000)

Malingering (Binder et al., 1997; Belanger et al., 2005)

Unremitting neuropathological alterations in mTBI (Bigler, 2001, 2003, 2004)



complicated mild TBI| moderate TBI

the research literature demonstrates that severe (i.e., complete) disability does occur after a complicated mild or moderate traumatic brain injury, although it is uncommon. Some reports indicate that no injured patients remained with severe disability at 6 months post-injury, whilst others found that 6% to 14% had severe disability. Moderate disability is a more common outcome and is seen in about 25% of patients at 6 months post-injury. Yet, good recovery is by far the most common outcome after a complicated mild or moderate traumatic brain injury, with 53% to 73% of cases showing good recovery by 6 months post-injury.

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severe TBI

when using an evidence based approach, for survivors of a severe traumatic brain injury, the vast majority of neurobehavioral recovery is made in the first year after the injury. Moreover, recovery typically proceeds in a curvilinear fashion with the most rapid recovery occurring within the first one to six months and the plateau typically occurring at approximately one year. Moreover, some data suggest that survivors of severe traumatic brain injury may continue to make additional recovery past the one-year plateau.

are we there yet, are we there yet, are we?


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out with the GOS and in with the GOS-E traumatic brain injury that meets the following criteria:

i. The injury shows positive findings on a computerized axial tomography scan, a magnetic resonance imaging or any other medically recognized brain diagnostic technology indicating intracranial pathology that is a result of the accident, including, but not limited to, intracranial contusions or haemorrhages, diffuse axonal injury, cerebral edema, midline shift or pneumocephaly.

ii. When assessed in accordance with Wilson, J., Pettigrew, L. and Teasdale, G., Structured Interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale: Guidelines for Their Use, Journal of Neurotrauma, Volume 15, Number 8, 1998, the injury results in a rating of,

A. Vegetative State, one month or more after the accident,

B. Upper Severe Disability or Lower Severe Disability, six months or more after the accident, or

C. Lower Moderate Disability, one year or more after the accident.


GOS-E


> 6 months

> 1 year

> 1 month

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Glasgow Outcome Scale ExtendedGOSE Descriptor Key Features (Courtesy of Dr. Kurzman)

Death DeadVegetative State (1 month or more)

Unable to obey commands or say words

Lower Severe Disability(6 months or more)

Needs frequent help or someone to be around most of the time

Upper Severe Disability(6 months or more)

Does not need frequent help – Is able to be alone at home for up to 8 hrs.Not able to shop without assistanceNot able to travel locally without assistance

Lower Moderate Disability(1 year or more)

Not able to work, or can work only in a sheltered or non-competitive positionUnable to participate (or rarely, if ever) in regular social and leisure activities outside homeConstant and intolerable (daily) disruption of family relationships or friendships due to psychological problems

Upper Moderate Disability(NOT CAT)

Able to work or study but at a reduced capacityParticipates much less (less than half as often) in regular social and leisure activities outside homeFrequent but tolerable (once per week) disruption of family relationships or friendships due to psychological problems

Lower Good Recovery(NOT CAT)

Participates at least half as often as before in regular social and leisure activities outside homeOccasional disruption of family relationships or friendships due to psychological problemsOther problems relating to the injury (headache, dizziness, tiredness, sensory sensitivity, slowness, memory failures,concentration problems) affect daily life

Upper Good Recovery)(NOT CAT)

Able to work to previous capacityAble to resume regular social and leisure activities outside homeNo psychological problems resulting in ongoing family disruption or disruption to friendships

GOS-E how do we make a determination?


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GOS-E

In 1998, Wilson et al also describe “4 Rules” to consider when conducting the interview:

It’s important to learn about pre-injury status: E.g. work, social difficulties, anger, etc. to properly assess outcome following brain injury.

Only pre-injury status and current status should be considered: The time immediately following the accident (i.e. acute stage) and the person’s future hopes and goals are not relevant in the interview and assessment.

The disability must be a result of physical or mental impairment: It must be considered if the person is in fact capable of something even though they don’t actually do it. E.g., since the accident they have less money so now they don’t go out for dinner or to museums but they are physically and mentally capable of going.

Use the best source of information available: If the person lacks insight, a caregiver or companion should be consulted. Unclear or suspicious information must be corroborated.


GOS-E

In 1998, Wilson et al provide the following questions that must be included in the STRUCTURED INTERVIEW FOR THE GOS-E

Level of independence in the home: The person may require actual assistance with activities of daily living, they may need to be prompted or reminded to do things, or they may need someone to supervise them because they would be unsafe otherwise. All are considered dependent. The lower level of ‘Severe Impairment’ (Severe Worse) must be applied if the person cannot be left unsupervised for more than 8 hours.


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GOS-E


Shopping and Travel outside the home: These activities require the ability to plan, deal with money and behave appropriately in public.


GOS-E


Work and School: A return to work or school should be interpreted with caution as it may be revealed that many accommodations have been put in place and the person would not be able to cope if accommodations and support from others were not available


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GOS-E


Social and Leisure Activities: Typical problems that may interfere with social and leisure activities include lack of motivation or initiative, avoidance of social involvement, physical problems such as loss of mobility, cognitive problems such as poor concentration, problems such as poor temper control or impatience.


GOS-E


Family and Friendships: The person may have difficulties initiating and maintaining personal relationships due to behavioural issues, physical barriers and cognitive limitations. The presence of a reported change in personality is not of itself sufficient to warrant classifying the person as moderately or severely disabled – the change must be having an adverse impact on family and friendships.


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GOS-E


Overall return to normal life: A person may experience various problems after a brain injury but it must be taken into consideration if the problems actually impinge on normal daily functioning and that they occurred since the accident. A person may have been injured but may be experiencing “everyday” life problems that were present before the injury and do not or should not impact normal life. E.g. many uninjured people will report difficultly paying attention at times but it does not impact their overall daily functioning.


qualification pathway | case studyGlasgow Outcome Scale: GOS-E Upper SD and Upper SD* at six monthsa. patient is dependent for daily support for mental or physical disabilityb. if can’t be left alone for 8 hours is Lower SD = CATc. if can be left alone for more than 8 hours is Upper SD = CAT.

TRAUMATIC BRAIN INJURY THAT RESULTS IN ANY OF THE FOLLOWING IMPAIRMENT |SYMPTOMATOLOGY, OR COMBINATION OF THE FOLLOWING AS CONFIRMED BY OBJECTIVE NEUROPSYCHOLOGICAL TESTING (i.e. breadth, severity, veracity) AND CONGRUENT WITH FUNCTIONAL OBSERVATIONS OF THE ASSESSING OCCUPATIONAL THERAPIST AND THE STRUCTURED INTERVIEW FOR THE GOS-E:

1. LACK OR REDUCED INSIGHT INTO COGNITIVE FUNCTION (ANOSOGNOSIA)

2. MEMORY DISORDER CHARACTERIZED BY INABILITY TO LEARN AND REMEMBER; AND INABILITY TO REMEMBER TO REMEMBER (I.E., PROSPECTIVE MEMORY).

3. DISTURBED EXECUTIVE FUNCTION CHARACTERIZED BY INABILITY TO PLAN, PROBLEM SOLVE, MAKE DECISIONS AND, OR BEHAVIOURAL IMPAIRMENT CHARACTERIZED BY APATHY, INAPPROPRIATE BEHAVIOUR AND SOCIAL COGNITION, JUDGEMENT, IMPULSIVITY, OUTBURSTS

4. ACTIVELY PSYCHOTIC (E.G., HALLUCINATIONS, DELUSIONS; SECONDARY TO TRAUMATIC BRAIN INJURY)

5. NO SUCH PERSON WOULD BE ABLE TO LIVE ALONE (INDEPENDENTLY) EVEN WITH EXTERNAL ASSISTANCE.

6. ANY SUCH IMPAIRMENT | SYMPTOMATOLOGY WOULD LIKELY NEED TO SATISFY DSM-5 DIAGNOSTIC CRITERIA FOR A MAJOR NEUROCOGNITIVE DISORDER.

7. KEY EVIDENCE WILL BE DEPENDENT ON REPEATED EVALUTION OF ATTENDANT CARE NEEDS BY WAY OF IN HOME OT EVALUATION AND NEUROPSYCHOLOGICAL EXAMINATION


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QUALIFICATION PATHWAY | case studyGOS-E Lower MD and Lower MD* at one yeara. Patient has some disability but is able to look after themselves. They are,b. Independent at home but dependent outside.c. If able to return to work even with special arrangement = Upper MD therefore not CAT.

i) Query whether has qualitatively or quantitatively “returned to work”If unable to return to work at one year = Lower MD = CAT.

TRAUMATIC BRAIN INJURY THAT RESULTS IN ANY OF THE FOLLOWING IMPAIRMENT |SYMPTOMATOLOGY, OR COMBINATION OF THE FOLLOWING AS CONFIRMED BY OBJECTIVE NEUROPSYCHOLOGICAL TESTING (i.e. breadth, severity, veracity) AND CONGRUENT WITH FUNCTIONAL OBSERVATIONS OF THE ASSESSING OCCUPATIONAL THERAPIST AND THE STRUCTURED INTERVIEW FOR THE GOS-E in terms of:

IMPEDES (I.E., MAKES MORE DIFFICULT) THE CLAIMANT FROM PERSONAL CARE (E.G., MEDICATION MANAGEMENT, APPOINTMENT SCHEDULING, APPROPRIATE DRESS), PREPARE AND COOK MEALS, MANAGE FINANCES, HOUSEKEEP, HOME MAINTENANCE; BUT DEPENDENT ON TRAVEL/TRANSPORTATION AND PRECLUDED (I.E., DISABLED) FROM WORKING.

AN EXAMPLE WOULD BE A PERSON WHO LIVES ALONE, BUT NEEDS EXTERNAL ASSISTANCE (e.g., Occupational Therapist; Rehabilitation Therapist) AND IS UNABLE TO RETURN TO REMUNERATIVE EMPLOYMENT (Pre-subject accident employment or any employment???).

ANY SUCH IMPAIRMENT/SYMPTOMATOLOGY WOULD NEED TO MEET DSM-5 DIAGNOSTIC CRITERIA FOR A MILD OR MAJOR NEUROCOGNITIVE DISORDER.



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