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19PSYCHOLOGICAL SCIENCES
EXECUTIVE DYSFUNCTION AFTER TRAUMATIC BRAIN INJURY: LONG-TERM
CONSEQUENCES
Kozytska I.
Candidate of Psychological Sciences (Ph. D.)
Associate Professor at the Department of General Psychology Taras Shevchenko National University of Kyiv
Lytvyn S.
Postgraduate student Taras Shevchenko National University of Kyiv
Malysheva K.
Candidate of Psychological Sciences (Ph. D.)
Associate Professor at the Department of Psychodiagnostics and Clinical Psychology
Taras Shevchenko National University of Kyiv
Solonovich O.
Candidate of Medical Sciences (M. D.)
The State Institution "Romodanov Neurosurgery Institute " National Academy of Medical Sciences of Ukraine
Abstract
The purpose of the study is to define the criteria for the objectivity of cognitive disorders in patients with mild traumatic brain injury. The research is based on examination of 70 patients, aged from 18 to 45, with mild traumatic brain injury. The control group included 40 apparently healthy volunteers of the same age as the persons examined. Methods: clinico-neurological observation, neuropsychological testing and digital electroencephalography, cognitive evoked potential P-300. Results: frequency of complaints in the interim and remote periods of mild traumatic brain injury, was: complaints of headache - 21, 43%; memory impairment -30%. According to neuropsychological testing - signs of impaired attention function was observed in 21,31%, memory impairment -34,42%, anxiety and depression - 26,31%. Methods of cognitive evoked potentials P-300 showed increased latency P3 in 42,1% and decreased amplitude in 44,72%. According to digital electroencephalography was trend to disorganization of the main cortical rhythms as a type of diffuse deceleration and rapidity, disruption of the alpha rhythm in frequency and amplitude. Cognitive impairment in patients in the interim and remote periods of mild traumatic brain injury, with the greatest frequency was manifested in domains: random-access memory, attention and delayed propagation. The severity of cognitive impairment is correlated with the latency indices of the evoked P300 potentials, the decrease in amplitude corresponded to a low score. In current study were identified predictors of cognitive impairment in patients with mild head trauma by neurophysiological methods.
Keywords: mild brain injury, cognitive dysfunction, diagnosis, cognitive evoked potentials P300.
Introduction. The problem of head trauma is one of the most complicated and urgent problem in the modern medicine, it is caused by the high prevalence of brain injury - 30-40% of total number of injuries. Every year in the world 2-4 persons per 1000 people has got brain injury, this number is constantly increasing due to increasing of road accidents, wars, sports and domestic accidents.
The most common type of brain injury is a mild traumatic brain injury which includes the brain moderate concussion (70-80% of the injured persons) and a mild brain contusion (10-15%). These forms are predominantly clinical reversible and under the absence of complicating circumstances it results in the recovery of the patient with full vocational rehabilitation. However, the moderate disability is formed in about 3% brain concussion accidents [1,2,3].
In contrast to the generally accepted ideas about the nature of cognitive impairment in the acute period of brain injury there is questions about the higher cerebral functions impairment in patients with mild brain injury in the moderate and long-term periods. This also
applies to the relationship between cognitive and emotional-volitional disorders. The world science does not stop searching for diagnostic criteria that would provide an objective diagnosis of cerebral function disorders of patients who have had the mild brain injury.
The problem of executive functions brain organization (these functions toponymically are often called "the frontal functions" or "functions of the prefrontal cortex") is actively investigated by modern neuropsy-chology. The planning and goal-setting, selection of the desired type of behavior and its initiation, timely and effective execution of the idea, the ability to complete the initiated action and to stop the inappropriate actions - all these behavioral manifestations were isolated in a separate functional block of the brain in the works of Luria A.R. However the question of an adequate neu-ropsychological assessment of the correspondent constructs is still relevant. The executive functions disorders are an important predictor of maladaptation in neurological patients, it often prevails over the cognitive impairments. For this reason neuropsychological evaluation along with the standard measuring instruments should rely on techniques sensitive to manifestations of
rigidity, disinhibition, disorganization, the random-ac- The table below provides a comparative analysis
cess memory efficiency, attention decrease and other of the scientists' views on the core qualities inherent to prefrontal cortex functions disorders. the executive functions of the individual.
Table 1.
The comparative analysis of the psychological constructs in the composition of executive functions at __different stages of the problem development.__
Luria (1966) Stuss and Benson (1986) Lezak (1995) Sohlberg and Mateer (2001) Keil and Kaszniak (2002)
Foresight (intent, anticipation) Initiative Will (including self-report and self-control) Initiative and implementation (ability to start) Planning, using strategy, adhear-ance to rules
Planning Planning Planning Braking reaction (ability to stop) Productivity, speed, initiative
Implementation Sequence of actions determination Consciously directed action Commitment to the achievement of the tasks (ability to hold the course) Change (switching) and braking (undesirable behavior)
Self-control Organization The effective performance Organization (actions and opinions) Formation of the concepts and abstract thinking
Regulation Productive thinking (creativity, speed, cognitive flexibility)
Awareness (monitoring and the changing of own behavior)
All of the above mentioned justifies the choice of the research direction - the comprehensive clinical-neurological, neuropsychological and neurophysiology (-NF) study to determine the impairments of executive functions in patients in the moderate and long-term periods of mild brain injury.
It was the clinical-instrumental study of 70 patients with mild brain injury and 40 apparently healthy volunteers without brain injury in a history in the "Institute of Neurosurgery by acad. Romodanov A.P. of the National Academy of Medical Sciences of Ukraine" State Institution. They made up a control group (comparison group) in which 110 people were examined.
The criteria for including patients in the study were following: the documented mild brain injury in the history got by patient no later than a year ago; the young age - from 18 to 45 years; the absence of somatic pathology. 70 patients have formed the "General Clinical Group" of patients havingn mild brain injury of mo-darate and long-term period. The exclusion criteria for the research participants: age over 45 and under 18; the term of injury is more than two years; the organic damage of the nervous system (vascular, infectious-inflammatory, cancer damage etc.); mental disorder; the alcoholic abuse.
The control group consists of 40 apparently healthy volunteers without previous mild traumatic brain injury in the history and any signs of damage to the nervous system, it was provided that cognitive and behavioral disorders, depression, anxiety, alcohol or drug abuses are absent. The average age of healthy volunteers in the control group (comparison group) was 23 ± 2.6 years (18 to 45 years), there were 15 women and 25 men among them.
The age of the patients in general group with mild brain injury was 25.4 ± 2.8 years; it consisted of 13 women and 57 men.
All patients and volunteers - the control group participants - have given their written consent to participate in the study.
By level of the patients education was distributed as follows: the completed higher education - 39 (55.7%); the incomplete higher education - 29 (41.4%), secondary education - 2 (2.9%); in the control group (correspondingly): 5 (12.5%), 26 (65%) and 9 (22.5%).
The mechanism of injury: blow to the head - 31 (44.3%); falling from the own high - 16 (22.9%); falling from a higher altitude - 10 (14.3%); the traffic accidents - 13 (18, 6%). The nature of impaired consciousness of patients with mild brain injury is assessed in anamnesis as: moderate stunning in 48 (68.5%); deep stunning - 22 (31.5). Concussion of the brain was diagnosed in case of 44 patients (62.9%), the mild injury -26 (37.1%).
The distribution of patients in accordance with the period after the mild brain injury: 2 weeks - 2 months -6 people (8.6%), 2-6 months - 41 (58.6%), more than 6 months - 23 (32.8).
The patients' comprehensive examination was carried out according to the single scheme: the clinical-neurological study with careful analysis of complaints and anamnesis data about mild brain injury - the terms and character of the trauma, the duration of consciousness loss, the presence and characteristics of memory impairment to the moment of injury; alcoholic intoxication at the moment of trauma; neurologic pathology before trauma, if any (as a background or premorbid one); concomitant pathology.
All patients were subjected to the neuropsycholog-ical testing (NPT) using the Montreal Cognitive Evaluation Scale (MoCA) - to evaluate the level of attention and concentration, executive functions, memory, speech, visual constructive skills, abstract thinking, counting, orientation; HADS scales - for the diagnostics of anxiety and depression disorders [4,5].
All the research participants were subjected to quantitative electroencephalography (digital electroen-cephalography) by means of 24-channel computer elec-troencephalograph "BRAINTEST" ("DX systems", Ukraine) using standard (international) methods. Computer analysis of the electroencephalography was based on the spectral analysis, power mapping [6]. It was stated according to electroencephalography data (if possible): the signs of brain injury; the character and localization of pathological changes. The registration of cognitive evoked potentials (CEP) P300 was done according to the standard procedure [7, 8].
The statistical data processing was based on the standard statistical package of IBM SPSS Statistics 20. The application of the binary logistic regression method in processing the results of clinical neuropsy-chological and neurophysiological study allowed us to determine the risk factors associated with the development of cognitive pathology, predictors of cognitive impairment of patients with mild brain injury.
The following were identified among the complaints during the clinical-neurological examination: headache 41 (58.6%), dizziness 39 (55.7%), muffled-ness feeling 18 (25.7%), asthenic disorders (increased fatigue, working capacity decrease, general weakness) - 34 (48,6%), sleep disorders - (8,9%), quality of life deterioration - 30 (42,9%). There are no abnormalities in neurological status in 65 (71.5%) patients. The asymmetry of tendon reflexes (5.7%) was revealed in case of 4 patients with a mild brain injury, and in case of 6 patients - shakiness in the Romberg pose (5.5%). In case of 4 patients with concussion of the brain and 3 patients with mild brain contusion there are signs of vegetative disfunction in the form of changes in temperature and moisture content of the skin (10%). Thus the incidence of neurological disorders was relatively small.
Clinical neurological characteristics of the patients were supplemented with neuropsychological testing based on the MoCA scale, the concentration of attention disorders in accordance with this sensitivity scale were revealed in 68% of cases, specificity - 86%. There were revealed also the impairments of random-access memory, the nominative function of speech. The
majority of the research participants have mild impairments of attention, orientation in time, abstract thinking, constructive praxis. According to the MoCA scale in this category of patients the overall average score was lower (24.24 ± 0.372) than in the control group (27.70 ± 0.386), but this difference was not statistically significant (p> 0.05).
The patients with mild brain inquiry have significantly higher anxiety level (6.5 ± 0.556) than in the control group (4.9 ± 0.565) (p = 0.034); the level of depression is significantly higher (p = 0.0091). The identified cognitive impairments were referred by us to neu-rodynamic type. The hospital scale of anxiety and depression HASD was proved as highly informative one. In some cases according to neuropsychological testing data no signs of the cognitive impairments were revealed, but the patient has noticed such signs. We regarded it as an early manifestation of cognitive impairments, and we have detected disorders of the anxiety-depressive type. The frequency of individual symptoms of depression of patients with mild brain injury was significantly higher than in case of healthy patients in the control group according to their age and sex. The relationship between the severity of emotional-volitional disorders and the presence of cognitive impairments, their resistance was revealed.
The results of neuropsychological testing of patients on the scales were supplemented by a neurophys-iologic study: digital electroencephalography and cognitive evoked potentials P300. According to the digital electroencephalography data the patients with mild brain injury frequently have the diffuse type of changes of main cortical rhythms disorganization. Alpha rhythm was preserved in case of 48 (68.6%) patients, in case of 10 (14.3%) patients the alpha-rhythm was irregular, 12 (17.1%) patients the dominant alpha-rhythm was not recorded, alpha activity was presented in the form of separate groups of waves. In terms of frequency and amplitude alpha rhythm was organized in case of 30 (42.9%) patients, in case of 40 (57.1%) patients it was disorganized. Zonal differences were preserved in case of 43 (61.4%) research participants, in case of 27 (38.57%) patients it was smoothed.
In accordance with the results of the study and statistical processing of clinical-neuropsychological and neurophysiological data based on the binary logistic regression method we have identified the following risk factors associated with the development of pathology, the predictors of cognitive impairments of patients with mild brain injury (table).
Table 2.
Predictors of cognitive impairments of patients with mild brain injury in the moderate and long-term periods
Predictors of cognitive impairment Classification ability of the model in%
Complaints
Headache, fatigue 76,4%
The neurological signs
The steady recovery of tendon reflexes Cephalic syndrome 75%
Neuropsychological testing
Anxiety (HADS), Memory and orientation impairment (MoCA) 72%
Digital electroencephalography indicators
The alpha rhythm frequency and amplitude, The intensification of diffuse slow-wave activity (in the zone of maximum intensity the index is more than 30%) Beta activity increasing 70%
Dysfunction of nonspecific median structures The measles of the brain irritation 69%
CEP-P300 indicators
P3 amplitude on the right, on the left P3 latency on the right, on the left 89%
Among the factors analyzed by the binary logistic regression method there are: impairment of consciousness at the time of injury; complaints at the time of examination for cognitive impairment, headache, dizziness, fatigue, loss of hearing, feeling of muffledness, deterioration in the quality of life - a complaint of headache and fatigue was revealed in patients with mild traumatic brain injury up to 7 times more often than in control group (p <0.05 ).
As for the evaluation of the neurophysiologic indicators of the brain bioelectrical activity in the studied patients, the detailed analysis and evaluation of the statistical accuracy of the evidence of the quantitative electroencephalography are represented in research [10]. The authors have analyzed: which of the proposed in the literature criteria can be considered as the "instrument for mild traumatic brain injury detecting." It is concluded that the brain activity measuring with the help of electrophysiological methods can be useful for detecting neurological dysfunction, for example, such as an mild traumatic brain injury. Such an approach can be especially useful for screening diagnostics in groups with an increased risk of traumatic brain injury - military personnel and athletes in contact types of sports. Electrophysiological methods of electroencephalog-raphy and evoked potentials can be regarded as very perspective ones, but their use is still at the initial stage. It is necessary the further studies of the electroencephalography criteria specificity.
Conclusions. Based on the results of a comprehensive study with the use of clinical-neurological, neuro-psychological and neurophysiological methods, diagnostic criteria for the objectification of cognitive impairment of patients in the moderate and long-term periods of mild craniocerebral trauma, as well as predictors of cognitive impairment in such patients have been determined.
Moderate cognitive impairment is most often detected in the domains: random-access memory, attention, delayed reproduction (p <0.05), the degree of deviation from the normative level of the total neuropsy-chological evaluation of these functions correlates with the latency and amplitude of cognitive evoked potentials P300 (p <0.05).
References
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К ПРОБЛЕМЕ ВРМЕННОЙ ОРГАНИЗАЦИИ УЧЕБНОЙ ДЕТЕЛЬНОСТИ СТУДЕНТОВ В УСЛОВИЯХ ДИСТАНЦИОННОГО ОБУЧЕНИЯ
Бахтина Н.Н.
Северо-Восточный государственный университет, Кандидат психологических наук, доцент, Доцент кафедры социальных и гуманитарных наук
Марковский Р.Р. Северо-Восточный государственный университет, Студент 1 курса педагогического факультета,
группа ДПО-91
TO THE PROBLEM OF TEMPORARY ORGANIZATION OF EDUCATIONAL DETAILS OF STUDENTS IN THE CONDITIONS OF REMOTE TRAINING
Bakhtina N.
North-East State University, Cand. Sci (Psychology), docent, Associate professor at the department of social and human sciences.
Markovsky R. North-East State University, 1st year student of the Faculty of Education,
DPO-91 group
Аннотация
В статье рассмотрена проблема временной организации учебной деятельности студентов в условиях дистанционного обучения, описаны достоинства и недостатки дистанционного обучения в вузе, а также проблемы адаптации студентов к дистанционному обучению в современных условиях.
Abstract
The article considers the problem of the temporary organization of students' educational activities in the context of distance learning, describes the advantages and disadvantages of distance learning at a university, as well as the problems of students adapting to distance learning in modern conditions.
Ключевые слова: время, временная организация учебной деятельности, дистанционное обучение.
Keywords: time, temporary organization of educational activities, distance learning.
В нашей стране и за рубежом в образовательном процессе в различной мере используются дистанционные технологии. Многие студенты рассматривают дистанционное обучение как альтернативу привычным формам и не только при получении второго образования и повышении квалификации, но и выбирают этот способ для получения первого высшего образования.
В настоящее время, в связи со сложной эпидемической обстановкой, сложившейся во всем мире, российским вузам Министерством науки и высшего образования РФ, в целях предотвращения распространения коранавирусной инфекции, было рекомендовано перейти на дистанционное обучение с
16 марта 2020 года. Принимая как руководство к действию данную рекомендацию необходимо проанализировать особенности дистанционного обучения, для того, чтобы усилить положительные и минимизировать негативные моменты в процессе его реализации в вузе.
Дистанционное обучение можно определить с различных позиций: и как форму, и как средство, и как технологию [6]. В.С. Шаров, рассматривая данные подходы, предложил комплексное определение дистанционного обучения, «дистанционное обучение - это новая форма обучения, предоставляющая комплекс образовательных услуг широким слоям населения в стране и за рубежом с помощью
