Operating characteristics of executive functioning tests in traumatic brain injury

2004·4.1 MB·English

by  Demery, Jason Andrew

OPERATINGCHARACTERISTICS OFEXECUTIVEFUNCTIONINGTESTS
INTRAUMATICBRAININJURY
By
JASONA. DEMERY
ADISSERTATIONPRESENTEDTOTHEGRADUATE SCHOOL
OFTHEUNIVERSITYOFFLORIDAINPARTIALFULFILLMENT
OFTHEREQUIREMENTSFORTFIEDEGREEOF
DOCTOROFPHILOSOPHY
UNIVERSITYOFFLORIDA
2004
Copyright2004
by
JasonA. Demery
ACKNOWLEDGMENTS
Iwishto acknowledgeRussellM. Bauer, Ph.D. (Chair), andWilliamM. Perlstein,
Ph.D. (Cochair), fortheirassistanceand supportduringtheentirecourseofthisproject. I
alsowishtoexpressmygratitudeto myotherdissertationcommitteemembers. Dawn
Bowers, Ph.D., DuaneDede, Ph.D., RonaldHayes, Ph.D., andChristianaLeonard, Ph.D.,
fortheirassistancewiththisendeavor.
IwouldliketothanktheEvelynF. andWilliamL. McKnightBrainResearch
GrantProgramattheUniversityofFlorida, andtheFloridaBrainand SpinalCordInjury
ResearchTrustFundforprovidingfinancial supportforthisproject.
Iwouldliketothankmyfamilyfortheirencouragementandsupportthroughout
theentiretyofmycollegeeducation. Finally, IwouldliketothankmywifeElliewhoisa
remarkablewomanandwhoexemplifieswhat successisreallyabout.
TABLEOFCONTENTS
page
ACKNOWLEDGMENTS
iii
ABSTRACT v
INTRODUCTION
1
TheProblemofTraumaticBrainInjury 1
SusceptibilityoftheFrontalLobesinTBI 2
ModelsofExecutiveFunctioning 4
ReliabilityandValidityofExecutiveFunctioningTests 10
IssuesrelatedtoDiagnosticAccuracyofExecutiveFunctioningTests 14
Purposesofthe Study 15
METHODS 18
Participants 18
Procedure 21
Measures/Apparatus 22
RESULTS 37
HypothesisOne 39
HypothesisTwo 48
HypothesisThree 100
DISCUSSION 104
BetweenGroupPerformanceDifferences 104
OperatingCharacteristics 106
DiscriminatingGroups 113
APPENDIXSTRUCTUREDCLINICALINTERVIEWFORM 118
REFERENCES 122
BIOGRAPHICAL SKETCH 132
AbstractofDissertationPresentedtotheGraduate School
oftheUniversityofFloridainPartialFulfillmentofthe
RequirementsfortheDegreeofDoctorofPhilosophy
OPERATINGCHARACTERISTICS OFEXECUTIVEFUNCTIONINGTESTS
INTRAUMATICBRAININJURY
By
JasonA. Demery
August 2004
Chair: RussellM. Bauer
Cochair; WilliamM. Perlstein
MajorDepartment: ClinicalandHealthPsychology
Theprimarypurposesofthisstudywereto(1)determineifcontrols, mild, and
moderate/severetraumaticbraininjury(TBI)participantsperformeddifferentlyona
batteryofexecutivefunctioningtests;(2)identifytheoperatingcharacteristicsof
executivefunctioningtestsincontrolsandtraumaticbraininjuryparticipants; and(3)
developalinearcombinationofpredictorvariablesthatdistinguishedgroupmembership.
Participantsconsistedof46braininjuredindividualsand24nonbraininjuredcontrols.
Allparticipantscompletedanextensivebatteryofexecutivefunctioningtests. Multiple
one-wayANOVAsshowedthat, ingeneral, nodifferencesintestperformancewerenoted
betweencontrolsandmildTBIparticipants, butmoderate/severeTBIparticipants
consistentlyperformedworsethaneithergroup. Resultsalso showedthatacomputerized
versionoftheWisconsinCard SortingTestyieldedthehighestpositivepredictivepower
amongalltests, andtheproportionofperseverativeerrorsbestdistinguishedgroupsina
discriminantfunctionanalysis. Thesefindingsprovideinformationregardingthe
diagnosticaccuracyofexecutivefunctioningtestsinTBIand shouldassistclinical
neuropsychologistsinaccuratelyidentifyingindividualswithbraindysfunction.
INTRODUCTION
TheProblemofTraumaticBrainInjury
Traumaticbraininjury(TBI) isaphysiologicaldisruptionofbrainfunctionthat
resultsfromtheheadbeingstruck, theheadstrikinganobject, orthebrainundergoingan
acceleration/decelerationmovement(e.g., whiplash)without directtraumatothehead
(AmericanCongressofRehabilitationMedicine [ACRM], 1993). Thereare
approximately 1.5-2 millionnewcasesofTBIintheUnited Stateseachyear(National
InstituteofHealth, 1998), andprevalenceestimates suggestthatapproximately5.3 million
Americans(2percentofthepopulation)livewithTBI-relateddeficitstoday.
EpidemiologicalevidencesuggeststhattheannualincidenceofTBI(200/100,000;Kraus,
1993)exceedsthatofotherseriousneurologicaldiseasessuchasmultiplesclerosis
(7.5/100,000;Mayretal. 2003), Parkinson'sdisease(20/100,000;Fahn, 1995)and
Alzheimer'sdisease(123/100,000; Schoenberg,Kokmen, & Okazaki, 1987)combined.
Adolescents, youngadults, andindividualsoverage75 areatgreaterriskforsustaining
TBI, andmalesaretwotimesmorelikelytobeinjuredthanfemales. Forty-ninepercent
ofTBI'saretransportationrelated(e.g., involvingmotorvehicles, bicycles, pedestrians,
andrecreationalvehicles), and26percentareduetofalls. Firearmsincidentsaccountfor
10percentofall TBI's, andassaultsaccountfor8 percent. Theresidual 7percentaredue
to"other"causes(e.g., fallingobjects; Thurman, Alverson, Dunn, Guerrero,& Sniezek,
1999; Thurman, 2001). Fromaneconomicperspective,thedirectcostsofmedicalcare
1
($4.5 billion), injury-relatedworklossanddisability($20.6billion), andlostincome
resultingfromprematuredeath($12.7billion)contributetoanestimatedannualcostof
$38billiondollarsintheUnited Statesalone(Max, MacKenzie&Rice, 1991). After
adjustingforinflation, thesescostsareapproximately$48.3 billiondollarsannually
(Lewin, 1992).
ThesymptomsfollowingTBIareoftendevastatingandmvolvephysical(e.g.,
nausea, vomiting,dizziness, headache,blurredvision, sleepdisturbance, quicknessto
fatigue, lethargy, orsensoryloss),cognitive(e.g., involvingattention, workingmemory,
learning, speech/language, orexecutiveftinctions), andbehavioralemotional(e.g.,
irritability, quicknesstoanger, disinhibition, oremotionallability; ACRM, 1993) systems.
SusceptibilityoftheFrontalLobesinTBI
Relativetootherareasofthecerebrum, thefrontallobesandpolarareasofthe
temporallobesaredisproportionatelysusceptibletodamagefollowingTBI(Bigler, 1999).
Theirproximitytothefrontalplateoftheskullandtheprotuberancesofthefloorofthe
anteriorcranialfossa(e.g., cribriformplate), andthemedialtemporalfossa, respectively,
compoundstheirvulnerabilitytodecelerationinjurieswithbluntheadtrauma(e.g., motor
vehicleaccidents, fall). Thisisevidencedbythehighfrequencyofcaseswithacute
cerebralcontusionsandhematomaeintheseregionsfollowingTBI(Benson&Miller,
1999; Stuss&Benson, 1986;). Follow-upneuroimagingstudiesattemptingtoelucidate
theresolutionoftheselesionsovertimehavefoundthatchroniclesionseventuallybecome
hypodense, suggestiveofencephalomalaciaandsubsequentfimctionalloss(Benson&
Miller, 1999). Whenthistypeofpathologyinvolvesthefrontallobes, fimctionaldeficitsin
behaviorandemotion(e.g., impulsivity, facetiousness, apathyandbehavioralregulation;
Benson&Miller, 1999; Blumer&Benson, 1975; Damasio& Anderson, 1993; Lhermitte,
Pillon, & Serdaru, 1985;Malloy, Bihrle, Duffy, & Cimino, 1993; Sarazinetal., 1998)and
cognition(e.g., sequencing, abstractthinking, planning, inhibition, andworkingmemory;
Anderson, Bigler, &Butler, 1995; Brown&Levin, 2001; Kimberg, D'Esposito, &Farah,
1999; Lezak, 1995;) mayfollow. Behavior, emotion, andcognitioncollectivelycontribute
toexecutivefunctioningwhich, accordingtoLezak(1995), is"thecapacitythatenablesa
persontoengagesuccessfullyinindependent, purposive, self-servingbehavior" (p. 42).
Deficitsinexecutivefunctioning(executivedysfunction)havebeenreferredtoasthe
&
"dysexecutive" (Wilson, Evans, Emslie, Alderman, Burgess, 1998)or"frontallobe"
syndrome(Malloyetal., 1993), but someresearchers(Bigler, 1988; Stuss& Alexander,
2000)havecautionedagainstthenotionofdescribingasyndromebasedonitsanatomical
locus.
Althoughthefrontallobesandtemporalpolesaremost susceptibletodamage
followingTBI(Bigler, 1999), theeffectofrapidinertialchangestotheheadorbody
sometimesresultsindiffusepathologythroughoutthecerebrum. Ininjuriesthatinclude
bluntheadtrauma, thesiteofimpacttotheskull(e.g., thefrontalplatewhenstrikingthe
windshieldinanMVA)representsthe"coup" siteand isthelocationwherebraindamage
isusuallymaximal. The sitedirectlyoppositefromthecouplocation(e.g., theoccipital
pole)isthe"contra-coup" site. Significantpathologymayoccuratthecontra-coup site
duetothebrainretractingand strikingtheocciput followingtheinitial rapiddeceleration
oftheskull. Massivenegativepressuregradientsresultingfromtheinitialimpactalso
contributetodamageatthecontra-coup site. Contusions, sub- and epi-duralhematomae,
intracerebralhemorrhagesandprimaryaxotomyareallexamplesoftheprimaryinjuryin
TBI. Secondaryinjuryincludesintracellularcytotoxicity, herniation, ischemiaand
secondaryaxotomythatmaydifferentiallyaffectoutcome.
Becauseofthediffuseandheterogeneousnatureoftheprimaryinjuryandthe
uniquesecondaryinjuriesthatareuniqueineachcase, TBIpatientshavenotgenerally
beenconsideredidealcandidatesfordiscretestructure/functionstudies(Damasio&
Damasio, 1999;Damasio&Geschwind, 1985;Damasio&Damasio, 1989). However,
theirproclivityforsustainingprefrontalpathologysuggeststhattheymaybegood
candidatesforstudyingdysexecutivebehavior.
ModelsofExecutiveFunctioning.
Attemptstoelucidatethenatureofexecutivefunctioninghavebeenmadeby
neuropsychologists, physiologicalpsychologistsandmostrecentlycognitivepsychologists.
Earlyexplanationsbasedonneuropsychologicalunderstandingofprefrontal/frontallobe
functioningwereespousedbyLuria(1973). AccordingtoLuria,thebrainisorganized
hierarchicallyintothreefunctionalunits. Thefirstfianctionalunitprovides"regulating
toneandwakingandmentalstates"(p. 44)andinvolvestheascendinganddescending
reticularactivatingsystems. Thesecondfunctionalunitisinvolvedinreceiving, analyzing
and storinginformationandinvolvesprimary, secondary, andtertiarycorticalzones.
Medial-temporallobestructuresarealsopartofthisunit. Thefinalfunctionalunit, which
sitsatoptheneuraxisinthepositionofthefi-ontallobes, programs, regulates, andverifies
activityandinvolvesthefrontallobes. Thisunitperformsexecutivefunctioningandis
highlyreliantupontheintegrityoftheprefi^ontalcorticesforperformance. Although
Luriaprovidedanintegratedneuropsychologicalexplanationofexecutivebehavior, other