SUMMARY In a follow up study of 57 patients who had sustained a severe closed head injury, 84% still reported some residual deficit in their psychological functioning after two years, with forgetfulness being the most common complaint. Expressing the severity of the injury in terms of both the duration of post-traumatic amnesia (PTA) and the extent to which previous work could be resumed (RTW), principal components analyses showed that the occurrence of "impairment complaints"-viz forgetfulness, slowness, poor concentration and inability to divide attention over two simultaneous activities-was positively related to severity. The other complaints, which in the main could be labelled as "intolerances" were not. The same pattern was found when the analyses were based on deficits of the patients as they were reported by relatives. Severity was not appreciably related to the total number of complaints. The correlation between PTA and RTW was 052, indicating that with longer PTA duration, work is likely to be resumed at a lower level, or not at all. Though Russell's cut-off of one week PTA to differentiate between severe and very severe concussion appeared useful, in the present study a further cut-off point at the unlucky number of 13 days was considered.The head-injured patient can be viewed as a relative expert in the field of head injury, and examining his or her complaints more fully can serve two goals: firstly, a description of post-traumatic states cannot be complete if the subjective aspects are neglected; secondly, listening to the patient might be helpful in generating hypotheses about the nature of the deficits, hypotheses that can be tested within an experimental psychological framework. The studies to date indicate that after head injury, people may mention a large variety of complaints, such as headache, dizziness, poor memory, poor concentration, fatigue, irritability and anxiety. The majority of these investigations, however, have studied patients who had sustained minor or moderately severe head injuries, with PTA durations of up to a few days.1 The search for stable combinations of complaints, which would justify the word "syndrome" has, however, not been successful with such patients. Lidvall' used the word "polymorphous" when describing the symptom picAddress for reprint requests: AH van Zomeren,

This paper is a literature review on assessment of fitness to drive in older drivers with cognitive impairment. Early studies on dementia and driving generally failed to distinguish between safe and unsafe drivers on the basis of cognitive test performance. Predictive studies demonstrated that cognitively impaired persons as a group perform significantly worse than controls on both neuropsychological and driving measures. A high prevalence of cognitive impairment was found in groups of older drivers involved in traffic accidents and crashes. However, a large range in neuropsychological test scores has been found. Low to moderate correlations could be established between neuropsychological test results and on-road driving performance, making it difficult to discriminate between cognitively impaired subjects who are fit or unfit to drive. The review concludes with a discussion of methodological difficulties in the field of dementia and driving, including participant selection, the choice of neuropsychological tests, and the operationalization of driving performance. (JINS, 2000, 6, 480-490.)

The performance of a group of 60 severely closed-head-injured patients in the subacute stage of recovery on a series of tests addressing focused, divided, and sustained attention, and supervisory attentional control was compared to the performance of a matched group of 60 healthy controls. Patients performed significantly worse on each test with time pressure (those addressing focused and divided attention), indicating basic slowness of information processing, and on the self-paced tasks for supervisory attentional control. No indication was found of a sustained attention deficit. In a subsequent analysis the influence of the demonstrated slowness of information processing and other possibly confounding cognitive factors was controlled for by means of covariance analyses. This resulted in a disappearance of group differences on tests for focused and divided attention. The only difference that remained concerned a test for supervisory attentional control.

To study the presence and nature of dysexecutive problems after CHI, a series of unstructured tasks tapping executive functioning were selected. These were administered to a group of 51 participants with CHI in the chronic stage (i.e. several years post-injury) and to 45 healthy controls. In addition, well-known structured tests of attention and planning were administered. Of the executive tasks, only the Executive Route Finding task showed a significant difference between both groups. A multivariate analysis on the attention tests showed a significant difference between groups, indicating that patients in the chronic stage still process information slower than controls. Within the patient group, patients with and without frontal focal lesions were also compared on executive and attention tests. No differences were found with respect to the latter. However, patients with frontal lesions performed worse on a measure of the Executive Route Finding task. It is concluded that patients with CHI, especially when they have frontal damage, have to rely more heavily on externally provided cues, but this dysexecutive problem can only be demonstrated in tasks that resemble daily life tasks by providing very little structure.

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