Every 21 seconds a person in the United States suffers a head injury. More than 1,500 people in Alabama are disabled every year, and 5.3 million U.S. citizens live with a disability due to head injury.

Christi Culpepper (left), Dan Marson (center) and Roy Martin (right) are beginning work on the Reclaimed Study, a National Institutes of Health-funded research project that examines recovery of medical decision-making abilities in adults with closed-head injuries.

One of the immediate consequences of many head injuries is the inability to make medical treatment decisions. Physicians and other care providers often must turn to legal representatives or family members for such decisions.

But at what point does the patient regain sufficient cognitive ability to resume control of medical decisions? Daniel Marson, J.D., Ph.D., a neuropsychologist and professor in the UAB Department of Neurology, is principal investigator of the Reclaimed Study, a National Institutes of Health-funded research project that examines recovery of medical decision-making abilities in adults with closed-head injuries.

The Reclaimed Study is a five-year grant funded by the National Institute of Child Health and Human Development and the National Center for Medical Rehabilitation and Research. The project, which studies recovery of medical decision-making ability over a one-year period in patients with mild, moderate and severe head injuries, is intended to help rehabilitation clinicians, patients and families better understand recovery and medical decision-making.

“One of the challenges for rehabilitation clinicians is determining when a patient has recovered sufficiently to resume medical decision-making on their own,” Marson says.  “It is a challenging issue because patients often want to resume making these decisions prematurely, because they lack insight into their own impairments. In addition, family members may want patients to resume making decisions before the patients are ready, or alternatively, families may not want patients to make these decisions even when the patients are ready to do so. There often is considerable pressure placed on rehabilitation clinicians on these issues, and they have had very little data available to guide their decisions.” 

Key study collaborators are Roy Martin, Ph.D., in the Department of Neurology who will help Marson coordinate the study, and Tom Novak, Ph.D., in Physical Medicine and Rehabilitation, who will direct recruitment of patients at Spain Rehabilitation. Other collaborators include Janyce Sanford, M.D., and Christopher Rosko, M.D., of Emergency Medicine, who will assist with recruitment of patients with mild injuries. Cleveland Kinney, M.D., and Terri Steele, M.D., in the Department of Psychiatry will conduct interviews with patients to make a clinical assessment of medical decision-making capacity independent of the study’s quantitative outcome measures. Christi Culpepper in the Department of Neurology is the study’s project manager.

The impetus for the present NIH study came from a project led by Marson and Novak in the late 1990s as part of Novak’s traumatic brain injury model systems project grant. They investigated medical and financial decision-making capacity in traumatic brain injury patients over a six-month period.

“We were interested in studying traumatic brain injury, where there was immediate impairment of decisional capacity followed by recovery, in contrast to diseases like Alzheimer’s where there was slow, relentless decline,” Marson says. “Traumatic brain injury represented an entirely different trajectory for understanding changes in decisional capacity.”

The patients
Because males are about 1.5 times more likely than females to suffer head injuries, Martin expects the bulk of mild traumatic brain injury patients in the study to be males.

However, Martin says the study is not restricted to young males or younger adults.

“We’re looking across the age spectrum, from about 19 to 65,” Martin says. “It definitely will be weighted more heavily toward the younger population, but older people are often at risk to fall and be involved in accidents as well, so we’re looking at a broad age range.”

The study will assess patients at three different time intervals: one month post injury, six months post injury and 12 months post injury.

During each visit there will be pencil-and-paper testing that will examine decision-making, memory and thinking skills. A separate clinical interview and assessment of decision-making by a study psychiatrist also will be conducted.

“We’re giving the patients standardized measures of cognition so we can measure their memory, their information processing speed and their conceptual abilities,” Marson says. “These all are cognitive functions related to medical decision-making.”

A major goal is to compile an empirical longitudinal database for studying impairment and recovery of decisional capacity. This data will provide clinicians with objective information concerning the likely prospects of recovery of decisional capacity in patients they are treating.

“We will have data that will allow us to assess the likelihood that patients with specific head-injury profiles will be able to make medical decisions at one month, six months or after one year,” Marson says.

Marson notes that the Reclaimed Study has a “hopeful aspect,” as it spotlights the fact that recovery from a traumatic brain injury is a process in which there is the prospect of reclaiming lost decisional abilities and powers.