|Year : 2014 | Volume
| Issue : 1 | Page : 19-23
Assessment and comparison of the memory profile in traumatic brain injury and subarachnoid hemorrhage patients
Ashima Nehra1, Avantika Sharma2, Swati Bajpai1, V Sreenivas3
1 Department of Clinical Neuropsychology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India
2 Guru Nanak Dev University, Amritsar, Punjab, India
3 Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||3-Nov-2014|
Dr. Ashima Nehra
Room No. 718, Clinical Neuro Psychology, 7th Floor, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Background: Traumatic brain injury (TBI) and Subarachnoid Hemorrhage (SAH) are the leading cause of death and disability in both developed and developing countries. They have significant cognitive and behavioral consequences, affecting the quality of life of both patients and their families. Aim: To compare the memory functioning of TBI and SAH and study the effect of demographics on the same through a retrospective study. Materials and Methods: A sample of 210 patients clinically diagnosed as TBI (N = 165; M = 145/F = 20) and SAH (N = 45; M = 35/F = 10) were using post graduate institute of memory scale (PGI-MS) which assesses 10 memory domains. Results: Odds Ratio (OR) was calculated by categorizing the scores as average and impaired on PGI-MS, the percentage of impaired cases of SAH were significantly less as compared to TBI (8.9% vs. 22.4%; OR = 0.34) Moreover, only two domains were found to have significant results, i.e. delayed recall and recognition. When the scores were adjusted for age, education and gender, memory impairment was found to be statistically significant in domains of remote memory (OR = O.10) recent memory (OR = 0.32), delayed recall (OR = 0.26), immediate memory (OR = 0.30), new learning ability (OR = 0.38), and recognition (OR = 0.17). Conclusion: A primary prevention (awareness program about risk factors) and tertiary prevention (holistic rehabilitation) would play a crucial role in improving the quality of life of both patients as well as the population at risk.
Keywords: Memory, neuropsychology, subarachnoid hemorrhage, traumatic brain injury, India
|How to cite this article:|
Nehra A, Sharma A, Bajpai S, Sreenivas V. Assessment and comparison of the memory profile in traumatic brain injury and subarachnoid hemorrhage patients. J Mental Health Hum Behav 2014;19:19-23
|How to cite this URL:|
Nehra A, Sharma A, Bajpai S, Sreenivas V. Assessment and comparison of the memory profile in traumatic brain injury and subarachnoid hemorrhage patients. J Mental Health Hum Behav [serial online] 2014 [cited 2021 May 13];19:19-23. Available from: https://www.jmhhb.org/text.asp?2014/19/1/19/143885
| Introduction|| |
Traumatic brain injury (TBI) occur when a sudden trauma causes a closed or a penetrating head injury. The resulting brain damage can be focal (confined to one area of the brain), or diffuse (involving more than one area of the brain). A focal TBI usually is caused by sudden contact. Diffuse injury is more likely to be caused by an acceleration/deceleration trauma. Incidence rates of TBI are high in both industrialized and non-industrialized countries and have been estimated variously to be between 150 and 250 cases/100,000 population/year.  In specific to India, it was estimated that nearly 1 million persons are disabled due to TBI annually, a likely underestimation of the current scenario.  Subarachnoid Hemorrhage (SAH) refers to etravasation of blood into the subarachnoid space between the Pia and Aachnoid membranes. It comprises of 1-7% of all strokes.  It is a medical emergency and can lead to death or severe disability, even when recognized and treated at an early stage. Up to half of all cases of SAH are fatal and 10-15% of casualties die before reaching a hospital and those who survive often have neurological or cognitive impairment in which memory is one of the cognitive domains most frequently affected. ,, It can also occur in people who have suffered a head injury as well. Unfortunately there is a lack of epidemiologic studies regarding SAH due to stroke, though internationally it has a high mortality rate and disability rate.  Studies have shown that there TBI and SAH cause significant cognitive and behavioral consequences thereby, affect the quality of life of such patients and their families.  In specific to TBI, A systematic review  has shown clear evidence of an association between traumatic brain injury and long-term cognitive impairments. According to post-acute rehabilitation and community integration study on TBI patients,  individuals who sustain brain injuries frequently have difficulties in arousal, attention, concentration, memory, and other cognitive abilities that impede their ability to perform their occupation in everyday life. Alterations in perception, motor control, balancing, emotional functioning, social interaction and control of behavior are also common after brain injury and are closely linked with cognitive issues. A similar study has shown impaired cognition (thinking, memory, and reasoning) are the most frequent sequel after TBI.  There is also evidence of severe deficits in the areas like speed processing, divided attention, working memory, executive function and long term memory after traumatic brain injury.  Hence, there is ample of literature supporting the memory is one of the most common cognitive domain found to be affected after TBI. Whereas SAH cognitive sequel is concerned, they suffer from short-term and/or long-term deficits, which vary as a result of the bleed or the treatment. The most frequent cognitive domain found to be impaired is memory.  However, evidence for more diffuse deﬁcits, such as reduced psychomotor speed and decreased sustained attention, have also been reported.  A recent meta-analysis has shown  patients with SAH commonly experience deficits in memory, executive function, and language. These cognitive impairments interact to affect patients' day-to-day functioning, including activities of daily living, instrumental activities of daily living, return to work, and quality of life. Hence, there is no dearth of research pertaining to memory or cognitive impairment after TBI or SAH internationally. Both neurological conditions pose a serious hindrance in the overall well being of the patients ranging from physical, to neuropsychological, emotional and social domain of life which is quite evident from the researches mentioned above. Unfortunately there is a paucity of such research on Indian population; hence, this is an attempt to study the comparison in memory functioning after TBI and SAH and the effects of age education and gender on the same.
The study aimed to compare the memory functioning profile in patients with TBI and SAH, and also to study the effect of age, education and gender on the memory profile of patients with TBI and SAH.
| Materials and Methods|| |
This was a retrospective study following a purposive sampling. A data of 434 patients was available out of the OPD work. Out of which only 210 (TBI [N = 165; M = 145/F = 20] and SAH [N = 45; M = 35/F = 10]) patients within the age ranges of 20-69 years shared the same evaluation and hence, were included in the study. The remaining patient data records were incomplete (availability of part assessment) or did not fulfill the inclusion criteria. Inclusion criteria included:
- All adults between 20 and 69 years of age
- Clinically diagnosed with TBI and SAH
- Both genders
- All education levels
- Urban and rural
- Right/left handedness
- All patients assessed within one year of injury.
Exclusion criteria included any history of psychiatric illness, any acute systemic illness and mental retardation. All 210 patients suffered from acquired brain injury clinically diagnosed by neurologists and neurosurgeons and were referred to clinical psychology service in neurosurgery for neuropsychological assessment at PGI-Chandigarh, from 2002 to 2005. Since it is an OPD generated work following a retrospective design, all neuropsychological assessment were done as a part of clinical services.
Tool of assessment
The memory evaluation was done using Post Graduate Institute Memory Scale (PGI-MS),  by Pershad and Wig  gives a valid clinical evaluation of memory functions. It is a specially designed test for evaluation of memory in semi-literate people suitable for the Indian population. It has age and education specific norms for age range from 20 to 69 years of age. It is a structured verbal test which measure different components of memory (remote and recent memory, mental balance, attention and concentration, delayed and immediate recall, verbal retention of similar and dissimilar pairs, visual retention and recognition of common objects). The scoring was done using mean and standard deviation for the whole study sample (irrespective of the age) to maintain the homogeneity of the sample scores. The Table below represents the 10 subtests of PGIMS along with its functions as given below.
A statistical analysis was done using an odds ratio (OR) using Fisher's Exact Probability statistic. It is used to measure the association which quantifies the relationship between the two groups. The odds ratio was used to determine whether a particular exposure (TBI or SAH) is a risk factor for a particular outcome (memory impairment), and to compare the magnitude of various risk factors (age, education and gender) for that outcome. The 95% confidence interval (CI) is used to estimate the precision of the OR. A small CI indicates a higher precision of the OR. Hence, all the results were seen at the P value of 0.05.
| Results|| |
As evident in [Table 1], age was found to be highly statistically significant between TBI and SAH (37.1 ± 12.51 vs. 44.6 ± 9.46; P ≤ 0.001). There was a difference of (−7.56 years) which indicates that younger population suffer from TBI more than SAH. There was also an evidence of just significant difference in marital status (P = 0.08) and gender (0.09) showing that unmarried male population are probably more prone to TBI than SAH. However, there was no significant difference evident between educational level (P = 0.16).
As evident in [Table 2], the overall total PGI-MS score (P = 0.05) and two domains, namely, delayed recall (P = 0.04), recognition ability (P = 0.05) were found to be statistically significant showing that memory impairment is evident in both the groups. Moreover, memory functioning was found to be more impaired in TBI than in SAH, i.e. (66% vs. 34%).
Whereas, when the scores were adjusted (OR) on age, gender, marital status and education there was an evidence of high statistically significant results in total PGI-MS (P = 0.002) along with six domains, namely, delayed recall (P ≤ 0.001), recognition ability (P ≤ 0.001), immediate recall (P = 0.005), remote memory (P = 0.05), new learning ability (P = 0.02) and recent memory (P = 0.01) in both the groups. This result shows that there was 20% increase in the memory impairment in the TBI as compared to SAH cases when they were adjusted (86% vs. 14%). Hence, these results show that demographics mentioned above pose more memory impairment in younger, unmarried male populations.
| Discussion|| |
The cognitive sequel after TBI and SAH are quite prominent, especially in the areas of memory, information processing speed, attention and concentration and executive function.  Since SAH and TBI share similar clinical features including cognitive and behavioral consequences such as amnesia, loss of consciousness, impaired attention and concentration.  Hence, the present study was planned for Indian population to study and compare the memory sequel after TBI and SAH and also study the effect of age, education and gender on the same. A standardized test was used to assess the memory. The overall memory and specific individual memory domain were statistically analyzed using odds ratio. Both the groups (TBI and SAH) were assessed on ten memory domains recent memory, remote memory, mental balance, attention and concentration, delayed recall, immediate memory, simple memory, new learning ability, visual retention and recognition as seen in [Table 2]. On categorizing the total score of PGI-Memory Scale as average (>40) and impaired (≤40) the results showed that memory was impaired in both the TBI and SAH cases. The obtained results correlate well with the systematic review which suggests that there is a strong relationship between (TBI) and short/long-term cognitive impairments involving memory loss, attention deficit and language irrespective of severity of injury.  Similar findings were also evident in a meta-analysis which stated that survivors of SAH commonly experience deficits in memory, executive function, and language. Moreover, this cognitive impairment, including memory effect patients' day-to-day functioning, including activities of daily living, instrumental activities of daily living, return to work, and quality of life, hence, leading to various behavioral issues such as depression, anxiety, fatigue, and sleep disturbances.  Though there is an evidence of memory impairment in both the TBI and SAH group. But the percentage of impaired cases in SAH is significantly less as compared to TBI (8.9% vs. 22.4%; OR = 0.34) which means that there is 66% of less chance of memory impairment in SAH as compared to TBI. The findings are consistent with the study where memory dysfunctions are found to be subtle in SAH cases, in contrary to patients with non-focal, extensive, or generalized brain injury are more likely to have memory dysfunction and alterations in consciousness.  Moreover out of ten domains, only 2 domains; delayed recall (P = 0.04) and recognition ability (P = 0.05) were found to be statistically significant which mean that there are less chances of impairment in their delayed memory (assessing verbal memory) and recognition ability (visual memory) (91% and 95%) as compared to TBI (75% and 59%) respectively. Since these two abilities assesses, verbal and visual memory. This could also be correlated with a study which has shown that patients with SAH show normal performance on tests of verbal cognition and memory.  The present study was also analyzed from socio-demographic angle where scores were adjusted for age, education and gender. Results were found to be highly statistically significant when adjusted for the variables age, education and gender (P = 0.002) as compared to non-adjusted Odds Ratio (P = 0.05). As evident in [Table 2], that there was 20% increase in the memory impairment in TBI as compared to SAH cases. The total score on PGI-MS, showed that the percentage of impaired cases in SAH had significantly reduced as compared to TBI, which means that there is 86% of less chance of memory impairment in SAH as compared to TBI. Also, more memory domains were found to be significantly impaired in TBI and SAH. Six cognitive domains were found to be highly significant, namely, delayed recall (<0.001), recognition ability (<0.001), immediate recall (0.005), remote memory (0.05), new learning ability (0.02) and recent memory (0.01) as compared to non-adjusted Odds Ratio where only 2 memory domains were found to be significant which shows that age, education and gender has a significant impact on the memory domains post TBI or SAH. In specific, age was found to be highly statistically significant between TBI and SAH (37.1 ± 12.51 vs. 44.6 ± 9.46; P ≤ 0.001), there was a difference of − 7.56 years which indicates that younger population suffer from TBI more than SAH. These findings were also evident in an international study where they stated that the greatest incidence of TBI occurs in younger adults followed by the elderly population.  Hence, TBI is the leading cause of morbidity and mortality which represents a major public health burden for the individuals less than 45 years.  while the average incidence of subarachnoid hemorrhage is 9.1 per 100,000 annually with an increasing risk of 60% higher in the very elderly (over 85) than in those between 45 and 55 years as per the latest review of 51 studies from 21 countries.  Therefore, both the conditions pose a major public health problem in their respective age risk factor. The second factor that influences the prevalence of TBI and SAH is gender. In our study males were found to have suffered more memory impairment due to TBI than SAH [Table 1]. Our results are in line with the Brain Injury Association research,  which stated that males experience TBI as twice as often as females. This could be due to the fact that men are more likely to suffer from TBI as they are more likely to engage in activities that are vulnerable to TBI. 50-70% of TBI results of road traffic accidents involving car crash, motor cycle etc.  In contrary, the incidence of SAH were significantly higher in women than in men. ,, Risk of SAH is about 25% higher in women over 55 years compared to men the same age, probably reflecting the hormonal changes that result from the menopause, such as a decrease in estrogen levels.  Though this was not ruled out in present study. As far as education is concerned, no significant influence was evident in the present study (P = 0.16). Though there are very few international studies which suggests that low education leads to more cognitive deficits after brain injuries. , Hence, age and gender do play an important role in determining the risk factor associated with the condition and that was quite prevalent in our study too, where memory impairment was more prominent after we adjusted the scores of the variables mentioned above [Table 1] and [Table 2].
There are several limitations of the study which need to be mentioned. Complete data was only available for the PGI-Memory Scale. Clinical parameters were partly available for some of the samples. It was not included because from such incomplete information, no firm inferences could be drawn. Most of the patients did not maintain follow up in clinical psychology hence, no follow up data was available which could have impacted the result, if available. The segregation of the sample on the basis of severity of TBI and SAH (GCS scores) was partly available. Hence the severity of the injury and memory functions could not be correlated.
Overall from the present study findings, it can be said that TBI has more prominent memory sequel than SAH which not only impair memory functioning, but also hampers their wellbeing. Moreover, age and gender has influential role in determining the precipitating factors of TBI and SAH.
In terms of future directions, such study can be planned prospectively with a longitudinal design where complete neuropsychological assessment which can further be compared with other clinical parameters to make firm claims. A multidisciplinary approach to rehabilitation study can be planned to improve the quality of life of such patients in which at level of primary and prevention (awareness programs about the risk factors) would improve the quality of life of population at risk while at the tertiary prevention (holistic rehabilitation including early and timely neuropsychological rehabilitation) would aid in neuro-plasticity, thereby helping the patient to restore his functional capacity to an extent  and its efficacy has been proven by many national and international studies. ,,
| References|| |
León-Carrión J, Domínguez-Morales Mdel R, Barroso y Martín JM, Murillo-Cabezas F. Epidemiology of traumatic brain injury and subarachnoid hemorrhage. Pituitary 2005;8:197-202.
Gururaj G. Road traffic deaths, injuries and disabilities in India: Current scenario. Natl Med J India 2008;21:14-20.
Feigin VL, Rinkel GJ, Lawes CM, Algra A, Bennett DA, van Gijn J, et al.
Risk factors for subarachnoid hemorrhage: An updated systematic review of epidemiological studies. Stroke 2005;36:2773-80.
van Gijn J, Kerr RS, Rinkel GJ. Subarachnoid haemorrhage. Lancet 2007;369:306-18.
Suarez JI, Tarr RW, Selman WR. Aneurysmal subarachnoid hemorrhage. N Engl J Med 2006;354:387-96.
Brown GG, Eyler-Zorrilla LT. Neuropsychological Aspects of Stroke. Neuropsychology of Cardiovascular Disease. Mahwah NL: Lawrence Erlbaum Associates; 2001. p. 301-24.
Ramamurthi B. Are subarachnoid haemorrhages uncommon in India? Neurol India 1965;13:42-3.
Dikmen SS, Corrigan JD, Levin HS, Machamer J, Stiers W, Weisskopf MG. Cognitive outcome following traumatic brain injury. J Head Trauma Rehabil 2009;24:430-8.
Bell KR, Sandell ME. Brain injury rehabilitation. Post-acute rehabilitation and community integration. Arch Phys Med Rehabil 1998;79:S21-5.
Ribbers GM. Brain Injury: Long term outcome after traumatic brain injury. In: Stone JH, Blouin M, editors. International Encyclopedia of Rehabilitation. 2010.
Serino A, Ciaramelli E, Santantonio AD, Malagù S, Servadei F, Làdavas E. A pilot study for rehabilitation of central executive deficits after traumatic brain injury. Brain Inj 2007;21:11-9.
Hackett ML, Anderson CS. Health outcomes 1 year after subarachnoid hemorrhage: An international population-based study. The Australian Cooperative Research on Subarachnoid Hemorrhage Study Group. Neurology 2000;55:658-62.
Ogden JA, Mee EW, Henning M. A prospective study of impairment of cognition and memory and recovery after subarachnoid hemorrhage. Neurosurgery 1993;33:572-86.
Al-Khindi T, Macdonald RL, Schweizer TA. Cognitive and functional outcome after aneurysmal subarachnoid hemorrhage. Stroke 2010;41:e519-36.
Pershad D, Wig NN. The Construction and Standardization of Clinical Test of Memory in Simple Hindi. Agra: National Psychological Corporation; 1977.
Miotto EC, Cinalli FZ, Serrao VT, Benute GG, Lucia MC, Scaff M. Cognitive deficits in patients with mild to moderate traumatic brain injury. Arq Neuropsiquiatr 2010;68:862-8.
Thompson HJ, McCormick WC, Kagan SH. Traumatic brain injury in older adults: Epidemiology, outcomes, and future implications. J Am Geriatr Soc 2006;54:1590-5.
Ates O, Cayli S, Altinoz E, Gurses I, Yucel N, Sener M, et al.
Neuroprotection by resveratrol against traumatic brain injury in rats. Mol Cell Biochem 2007;294:137-44.
de Rooij NK, Linn FH, van der Plas JA, Algra A, Rinkel GJ. Incidence of subarachnoid haemorrhage: A systematic review with emphasis on region, age, gender and time trends. J Neurol Neurosurg Psychiatry 2007;78:1365-72.
Anello B. Brain Injury Association of Nipissing (BIAN), The Center for Research on Brain Injury, Ontario; 2005.
Kennard J. What is Traumatic Brain Injury. National Center for Injury Prevention and Control, Centers for Disease Control; 2006.
Ingall TJ, Whisnant JP, Wiebers DO, O′Fallon WM. Has there been a decline in subarachnoid hemorrhage mortality? Stroke 1989;20:718-24.
Belanger HG, Curtiss G, Demery JA, Lebowitz BK, Vanderploeg RD. Factors moderating neuropsychological outcomes following mild traumatic brain injury: A meta-analysis. J Int Neuropsychol Soc 2005;11:215-27.
Kreiter KT, Copeland D, Bernardini GL, Bates JE, Peery S, Claassen J, et al.
Predictors of cognitive dysfunction after subarachnoid hemorrhage. Stroke 2002;33:200-8.
Wood RL, Rutterford NA. Long-term effect of head trauma on intellectual abilities: A 16-year outcome study. J Neurol Neurosurg Psychiatry 2006;77:1180-4.
Nehra A, Bajpai S. Effectiveness of cognitive retraining after brain trauma - Case studies. ANS J Neurocognitive Res 2013;54.
Mohanty M Ph D, Gupta SK. Home based neuropsychological rehabilitation in severe traumatic brain injury: A case report. Ann Neurosci 2013;20:31-35.
Salazar AM, Warden DL, Schwab K, Spector J, Braverman S, Walter J, et al.
Cognitive rehabilitation for traumatic brain injury: A randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group. JAMA 2000;283:3075-81.
[Table 1], [Table 2]