Multidimensional Assessment of Acute Confusion After Traumatic Brain Injury


      Sherer M, Nakase-Thompson R, Yablon SA, Gontkovsky ST. Multidimensional assessment of acute confusion after traumatic brain injury.


      To describe the phenomenology of posttraumatic confusional state (PTCS) and to provide preliminary validation of a new procedure, the Confusion Assessment Protocol (CAP), for assessing PTCS.


      Criterion standard investigation.


      Inpatient traumatic brain injury (TBI) rehabilitation program.


      Two consecutive series of patients (n=62, n=93) with TBI admitted for inpatient rehabilitation.


      Not applicable.

      Main outcome measures

      Clinical diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria, classification of posttraumatic amnesia (PTA) based on the Galveston Orientation and Amnesia Test (GOAT), and Disability Rating Scale score at time of rehabilitation hospital discharge.


      Agreement between the diagnosis of PTCS with the CAP and DSM-IV classification of delirium was 87%, and agreement between PTCS and PTA using GOAT criteria was 90%. Patients classified as in PTCS sustained more severe injuries and required longer rehabilitation stays. Confusion status was associated with poorer functional status at rehabilitation discharge.


      The CAP is a brief, structured, repeatable measure of multiple neurobehavioral aspects of PTCS. Confusion status as determined by CAP assessment contributed to prediction of outcome at rehabilitation discharge after adjustment for other potential predictors.

      Key words

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        • Ommaya A.K.
        • Gennarelli T.A.
        Cerebral contusion and traumatic unconsciousness.
        Brain. 1974; 97: 633-654
        • Teasdale G.
        • Jennett B.
        Assessment of coma and impaired consciousness.
        Lancet. 1974; 2: 81-83
        • Murray G.D.
        • Teasdale G.M.
        • Braakman R.
        • et al.
        The European Brain Injury Consortium Survey of head injuries.
        Acta Neurochir (Wien). 1999; 141: 223-236
        • Giacino J.T.
        • Ashwal S.
        • Childs N.
        • et al.
        The minimally conscious state.
        Neurology. 2002; 58: 349-353
        • Russell W.R.
        Cerebral involvement in head injury. A study based on the examination of two hundred cases.
        Brain. 1932; 55: 549-603
        • Symonds C.P.
        Mental disorder following head injury.
        Proc Royal Soc Med. 1937; 30: 1081-1094
        • Trzepacz P.T.
        in: Silver J.M. Hales R.M. Yudofsky S.C. Neuropsychiatry of traumatic brain injury. Am Psychiatric Pr, Washington (DC)1994: 189-218
        • Russell W.R.
        Amnesia following head injuries.
        Lancet. 1935; (Oct 5): 762-763
        • McEvoy J.P.
        Organic brain syndromes.
        Ann Intern Med. 1981; 95: 212-220
        • Frances J.
        • Martin D.
        • Kapoor W.N.
        A prospective study of delirium in hospitalized elderly.
        JAMA. 1990; 263: 1097-1101
        • American Psychiatric Association
        Diagnostic and statistical manual of mental disorders. 4th ed. Am Psychiatric Pr, Washington (DC)1994
        • Fugate L.P.
        • Spacek L.A.
        • Kresty L.A.
        • Levy C.E.
        • Johnson J.C.
        • Mysiw W.J.
        Definition of agitation following traumatic brain injury: I. A survey of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation.
        Arch Phys Med Rehabil. 1997; 78: 917-923
        • Fugate L.P.
        • Spacek L.A.
        • Kresty L.A.
        • Levy C.E.
        • Johnson J.C.
        • Mysiw W.J.
        Measurement and treatment of agitation following traumatic brain injury: II. A survey of the Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation.
        Arch Phys Med Rehabil. 1997; 78: 924-928
        • Stuss D.T.
        • Binns M.A.
        • Carruth F.G.
        • et al.
        The acute period of recovery from traumatic brain injury.
        J Neurosurg. 1999; 90: 635-643
        • Nakase-Thompson R.
        • Sherer M.
        • Yablon S.A.
        • Nick T.G.
        • Trzepacz P.T.
        Acute confusion following traumatic brain injury.
        Brain Inj. 2004; 18: 131-142
        • Levin H.S.
        • O’Donnell V.M.
        • Grossman R.G.
        The Galveston Orientation and Amnesia Test.
        J Nerv Ment Dis. 1979; 167: 675-684
        • Jackson W.T.
        • Novack T.A.
        • Dowler R.N.
        Effective serial assessment of cognitive orientation in rehabilitation.
        Arch Phys Med Rehabil. 1998; 79: 718-720
        • Artiola Y.
        • Fortuny L.
        • Briggs M.
        • Newcombe F.
        • Ratcliff G.
        • Thomas C.
        Measuring the duration of post traumatic amnesia.
        J Neurol Neurosurg Psychiatry. 1980; 43: 377-379
        • Shores E.A.
        • Marosszeky J.E.
        • Sandanam J.
        • Bachelor J.
        Preliminary validation of a clinical scale for measuring the duration of post-traumatic amnesia.
        Med J Aust. 1986; 144: 569-572
        • Gustafson Y.
        • Berggren D.
        • Brannstrom B.
        • et al.
        Acute confusional states in elderly patients treated for femoral neck fracture.
        J Am Geriatr Soc. 1988; 36: 525-530
        • Neelon V.J.
        • Champagne M.T.
        • Carlson J.R.
        • Funk S.G.
        The NEECHAM Confusion Scale.
        Nurs Res. 1996; 45: 324-330
        • Trzepacz P.T.
        • Baker R.W.
        • Greenhouse J.
        A symptom rating scale for delirium.
        Psychiatry Res. 1988; 23: 89-97
        • Hart R.P.
        • Levenson J.L.
        • Sessler C.N.
        • Best A.M.
        • Schwartz S.M.
        • Rutherford L.E.
        Validation of a cognitive test for delirium in medical ICU patients.
        Psychosomatics. 1996; 37: 533-546
        • Kennedy R.E.
        • Nakase-Thompson R.
        • Nick T.G.
        • Sherer M.
        Use of the Cognitive Test for Delirium in patients with traumatic brain injury.
        Psychosomatics. 2003; 44: 283-289
        • Trzepacz P.T.
        • Mittal D.
        • Torres R.
        • Kanary K.
        • Norton J.
        • Jimerson N.
        Validation of the Delirium Rating Scale–Revised.
        J Neuropsychiatr Clin Neurosci. 2001; 13: 229-242
        • Corrigan J.D.
        Development of a scale for assessment of agitation following traumatic brain injury.
        J Clin Exp Neuropsychol. 1989; 11: 261-277
        • Goodglass H.
        • Kaplan E.
        The assessment of aphasia and related disorders. 2nd ed. Lea & Febiger, Philadelphia1983
        • Rappaport M.
        • Hall K.M.
        • Hopkins K.
        • Belleza T.
        • Cope D.N.
        Disability Rating Scale for severe head trauma.
        Arch Phys Med Rehabil. 1982; 63: 118-123
        • Landis J.R.
        • Koch G.G.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Katz D.L.
        • Alexander M.P.
        Traumatic brain injury.
        Arch Neurol. 1994; 51: 661-670
        • Zafonte R.D.
        • Mann N.R.
        • Millis S.R.
        • Black K.L.
        • Wood D.L.
        • Hammond F.
        Posttraumatic amnesia.
        Arch Phys Med Rehabil. 1997; 78: 1103-1106