Abstract
Objective: To examine the use of the Barrow Neurological Institute Screen for Higher Cerebral Functions (BNIS) in assessing disorientation in patients with traumatic brain injury (TBI) during the acute phases of rehabilitation.
Design: Persons with TBI (n = 65) were compared with patients with spinal cord injury (SCI; n = 18) and to controls (n = 35).
Setting: Inpatient neurorehabilitation unit.
Outcome measures: Orientation items from the BNIS measuring time (day, month, date of month, year) and place (city and hospital).
Results: TBI patients showed a significantly greater proportion of incorrect responses to time and place compared with the SCI and normal control groups. There was a greater accuracy on orientation to place compared with orientation to time, and date of month produced the lowest rate of accuracy in all three groups. The single best predictor of disorientation to time was increasing age, and increasing age was most associated with disorientation to date of month.
Conclusions: The BNIS was shown to be a sensitive measure of disorientation in TBI patients and yielded similar patterns of performance as documented by other measures.
Disorientation to time and place is often clinically observed in patients with traumatic brain injury (TBI) during the acute phase of rehabilitation. It is typically evident during recovery from posttraumatic amnesia (PTA), particularly in those with severe brain injuries. In fact, it is one of the most salient cognitive features observed during PTA.1 However, disorientation has been shown to persist in mild TBIs as well. For example, Levin and colleagues2 used the Galveston Orientation and Amnesia Test (GOAT) to examine orientation in patients with mild TBI as they approached discharge. They found that the greatest difficulty in orientation was naming the date of month, with approximately 50% of patients responding incorrectly. Prolonged periods of disorientation may preclude a patient's involvement/participation in therapies and have implications for recovery. Dowler and colleagues3 showed that disorientation, as measured by low scores on the Orientation Log (O-Log),4 was the single best predictor of cognitive difficulties at 6 months and of functional outcome at 6 and 12 months after injury.
Disorientation has most often been studied with regard to its sequence of recovery in patients with closed-head injuries during the acute phase, when such disturbances are expected to be most pronounced. Using the GOAT, High and colleagues5 tracked patients' level of disorientation during their acute hospitalization stay. They found that orientation to person returned first, followed by orientation to place, and then orientation to time. This pattern of recovery has also been reported by other researchers and in other clinical populations.7 Israelian and colleagues8 found that orientation to hospital name and date of month was more difficult to regain during hospital stay in a sample of patients with severe TBI than year, month, and city. Tate and colleagues6 measured the pattern of resolution between amnesia and disorientation during posttraumatic amnesia (PTA) in severe TBI patients. Although they found a strong relationship between amnesia and disorientation components (person, place, and time), amnesia resolved before disorientation in 94% of cases.
Specific subject variables also have been reported in previous research, although they have not been systematically studied. For example, Levin and colleagues2 showed that disorientation, as measured by duration of impaired scores on the GOAT, was associated with injury severity. Less severe injuries, as indicated by higher Glasgow Coma Scale (GCS)9 scores, were associated with higher O-Log scores and shorter intervals between injury and testing.8 High and colleagues5 found that disoriented patients, particularly those with severe brain injuries, most often gave a date that had occurred earlier than the date of testing. The displacement of date was associated with age, with greater displacement occurring in older patients.
Few measures have been developed specifically to assess orientation. The GOAT is perhaps the most widely recognized measure of disorientation. It was developed to measure disorientation and amnesia after closed-head injury and evaluates orientation to time, place, and person, and posttraumatic and retrograde amnesia. Unfortunately, the GOAT cannot be easily applied to non-TBI patients because of the trauma-related questions. It also has been criticized for being too confusing for patients with more severe injuries, its variability in scoring of items, and the subjective nature of some of the questions.8 The O-Log also was developed for serial administrations in a rehabilitation setting to track orientation. It assesses orientation to time, place, and circumstance in a rehabilitation population. The nature of its questions allows for administration to a wide variety of neurologic groups. Unlike the GOAT, the O-Log also allows for cueing of the confused patient. However, although cueing may help patients respond to questions, it may lead to scores that inaccurately reflect level of disorientation by providing structure and organization to patients' responses.
Both the GOAT and O-Log were designed for serial assessments to track orientation resolution, which may provide interesting and important information concerning recovery. Unfortunately, serial assessments are not always feasible on inpatient neurorehabilitation units. Variability is common among patients with respect to their daily schedules and mental status. For some patients, disorientation may occur or worsen when they are fatigued, which for some may occur in the morning and for others in the afternoon. Furthermore, serial assessments require additional time for the examiner, which on inpatient neurorehabilitation units may not always be easily scheduled or cost-effective.
The majority of tests that allow for the assessment of orientation are brief cognitive measures that have orientation items embedded within them, as outlined by Levin and colleagues.2 One brief cognitive test that has not been examined for its assessment of orientation is the BNI Screen for Higher Cerebral Functions (BNIS),10 a brief screening measure that was developed for use with acute and postacute neurologic patients. It contains items that assess orientation to time (day, month, year, and date of month) and place (name of hospital and city), in addition to providing an index of overall cognitive impairment. Initial studies have demonstrated its interrater and test-retest reliability11 as well as its concurrent and construct validity.10,12 This test and its various subtests reliably differentiate people with brain dysfunction from patients with psychiatric disorders and from patients with acute medical illness.12 Unlike the GOAT and O-Log, the BNIS is not designed for serial assessment to track disorientation. Rather, it provides information concerning orientation to place and time as part of a brief cognitive screen. In addition, as with other brief cognitive tests that include orientation items, the BNIS produces a single score for time and a single score for place, although each of these scores comprises several variables. Whether or not these individual variables produce patterns of performance that resemble previous studies on disorientation in TBI has not been established.
The purpose of the present study was to identify patterns of performance of disorientation as measured by the BNIS in acute TBI patients compared with a referred non-TBI neurologic group. It was predicted that the TBI group would perform worse on BNIS orientation items compared with the non-TBI group and a control group. It was also predicted that people with TBI would have greater difficulty orienting to the time variables than to the place variables. Finally, because disorientation is often clinically observed in TBI patients, regardless of injury severity, it was of interest to systematically examine and identify the contribution of individual subject variables as possible underlying mechanisms of disorientation on the BNIS.