A comprehensive assessment of each person is necessary because brain injury results in a complex mix of physical, emotional and cognitive changes. It is essential to understand the person’s experience, skills and abilities prior to the brain injury to understand the impact of the brain injury. Early post brain injury, the Glasgow Coma Scale provides insights into the severity of the brain injury. During the period of post-traumatic amnesia (PTA), a comprehensive assessment of cognition is not recommended because of the poor attention and likelihood of rapid changes.  Standardized assessment of PTA can better quantify the duration of PTA and a number of tools exist. Musculoskeletal and other trauma is frequently associated with brain injury; therefore, it is important that those with severe musculoskeletal or spinal trauma be screened for concomitant cognitive and other sequelae of brain injury.

Health care professionals should be trained in using standardized tools to assess the person with brain injury including the Glasgow Coma Scale, Glasgow Outcome Scale, Activities of Daily Living and PTA Scales. The interprofessional team should include those with specialized skills and training in cognitive and behavioural assessment. These assessments may require the purchase of equipment and test materials.

Indicators exemples

• Proportion of conscious individuals with TBI for whom there is evidence of assessment for each of the following six impairments:

  1. Motor impairments;

  2. Bulbar problems affecting speech and swallowing;

  3. Sensory dysfunction;

  4. Reduced control over bowels and bladder;

  5. Cognitive dysfunctions;

  6. Behavioural dysregulation

• Proportion of individuals with TBI for whom there is evidence of assessment for each of the following eight cognitive impairments after emergence from PTA/PTD:

  1. Attention (including speed of processing);

  2. Visuospatial function;

  3. Executive function;

  4. Language, social communication;

  5. Social cognition;

  6. Learning and memory;

  7. Awareness of impairments;

  8. Detection/expression of emotion

• Proportion of individuals with TBI for whom there is presence of a family/caregiver interview form completed in the chart.

The following are suggestions of tools and resources that can be used to support the implementation of the recommendations in this section. Healthcare professionals must respect the legal and normative regulations of the regulatory bodies, in particular with regards to scopes of practice and restricted/protected activities, as these may differ provincially

Clinical Tools:

• Brain Injury Medicine: Principles and Practice 2nd Edition David B. Arciniegas, M. Ross Bullock, Douglas I. Katz, Jeffrey S. Kreutzer, Ross D. Zafonte, Nathan D. Zasler, Demos Medical Publishing, 2012 – 280 pages
• Manual of Traumatic Brain Injury – Assessment and Management, 2nd Edition Felise Zollman, Demos Medical Publishing, 2016 – 608 pages
• Cognitive Rehabilitation Manual from American Congress of Rehabilitation Medicine (ACRM)
• Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003 Through 2008. Cicerone, K. D., D. M. Langenbahn, et al. Archives of Physical Medicine and Rehabilitation 92(4): 519-530
• Algorithm for PTA (figure 2, p. 304) and Health Records Chart audit (p. 306) (INCOG publications)

To be Developed Locally:

• Family interview forms

Individuals should be assessed for common impairments.  Clinical assessments and protocols based on the Glasgow Coma Scale Score can guide the initial management. In some instances, relatives are able to offer clinicians information regarding the patient’s level of awareness that is more accurate than a patient’s self-report measure (Sohlberg, Mateer, Penkman, Glang, & Todis, 1998; Spikman, Boelen, Lamberts, Brouwer, & Fasotti, 2010). In an observational study, patients and relatives who completed functional assessment questionnaires focused on the patient following a rehabilitation program, both scored similarly (Svendsen, Teasdale, & Pinner, 2004).

The transition from post-traumatic coma to post-traumatic delirium (PTD) or PTA is characterized by impairments in selective and sustained attention (Arciniegas, 2010). During the period of PTA, impairments in executive functioning, language and declarative learning are prominent. When emerging from PTA, executive function deficits manifest in problem solving, abstract thinking and cognitive flexibility. Emotional lability is also present during PTA expressed as agitation and aggression (Ponsford & Sinclair, 2014). Neuropsychologists/psychiatrists have found the following outcome measures valuable in determining PTA duration and TBI severity: Glasgow Coma Scale and the Galveston orientation and amnesia test (Arciniegas, 2010).

When an individual emerges from PTA, cognitive function should be evaluated. Throughout this process, caregivers should receive information and education regarding the patient’s injury and care to reduce the burden of care (Calvete & de Arroyabe, 2012) and maintain their mental health (Doyle et al., 2013).
It is also important to assess individuals with other forms of poly trauma and particular spinal cord injury because the concomitant injuries have an impact on clinical recovery and costs of care. Individuals with traumatic SCI and TBI had worse cognitive function and higher rehabilitation costs compared to those without TBI (Bradbury et al., 2008). Sharma et al. (2014) found a 58.5% frequency of missed traumatic brain injuries in a sample of 92 individuals with traumatic spinal cord injury.

REFERENCES
Arciniegas, D. B. (2010). Neuropsychiatric Assessment of Traumatic Brain Injury During Acute Neurorehabilitation* Neuropsychiatric disorders (pp. 123-146): Springer.

Bradbury, C. L., Wodchis, W. P., Mikulis, D. J., Pano, E. G., Hitzig, S. L., McGillivray, C. F., . . . Green, R. E. (2008). Traumatic brain injury in patients with traumatic spinal cord injury: clinical and economic consequences. Arch Phys Med Rehabil, 89(12 Suppl), S77-84.

Calvete, E., & de Arroyabe, E. L. (2012). Depression and grief in Spanish family caregivers of people with traumatic brain injury: The roles of social support and coping. Brain Injury, 26(6), 834-843.

Doyle, S. T., Perrin, P. B., Diaz Sosa, D. M., Espinosa Jove, I. G., Lee, G. K., & Arango-Lasprilla, J. C. (2013). Connecting family needs and TBI caregiver mental health in Mexico City, Mexico. Brain Injury, 27(12), 1441-1449.

Ponsford, J., & Sinclair, K. (2014). Sleep and fatigue following traumatic brain injury. Psychiatr Clin North Am, 37(1), 77-89.

Sharma, B., Bradbury, C., Mikulis, D., & Green, R. (2014). Missed Diagnosis of Traumatic Brain Injury in Patients with Traumatic Spinal Cord Injury. Journal of Rehabilitation Medicine, 46(4), 370-373.

Sohlberg, M. M., Mateer, C. A., Penkman, L., Glang, A., & Todis, B. (1998). Awareness intervention: Who needs it? J Head Trauma Rehabil, 13(5), 62-78.

Spikman, J. M., Boelen, D. H., Lamberts, K. F., Brouwer, W. H., & Fasotti, L. (2010). Effects of a multifaceted treatment program for executive dysfunction after acquired brain injury on indications of executive functioning in daily life. Journal of the International Neuropsychological Society, 16(01), 118-129.

Svendsen, H., Teasdale, T., & Pinner, M. (2004). Subjective experience in patients with brain injury and their close relatives before and after a rehabilitation programme. Neuropsychological Rehabilitation, 14(5), 495-515.