Impact of Compensatory Recommendations on Consistency in Adherence to Behavioral Regimens in Traumatic Brain Injury

Background: Adherence is the extent to which one’s behavior aligns with prescribed healthcare recommendations and it has been found to be a mediating factor of rehabilitation success after traumatic brain injury (TBI). Individuals post- TBI are at risk due to executive dysfunction. Although methods of overcoming executive difficulties as they relate to adherence have been posited (e.g., compensatory strategies), there has been no systematic study of the relationship between adherence behaviors and executive functioning during an unstructured regimen in this population. Moreover, cognitively-mediated aspects of adherence, such as consistency, which may represent targetable mechanisms of non-adherence have not been explored. Objective: The current study aimed to investigate the relationship between compensatory recommendations, executive function, and adherence behaviors during a prescribed behavioral regimen. Primary aims were to investigate: 1) the impact of compensatory recommendations on consistency in adherence, 2) the impact of compensatory recommendations on overall adherence, and 3) the relationship between executive functioning and consistency in adherence. An exploratory aim investigated how relationship between compensatory strategy, executive function, and consistency in adherence changed over the course of the 4-weeks. Method: 13 adults with a history of non-penetrating head injury were recruited for the current study and randomized into two groups: one that received compensatory recommendations (n = 7; Mage = 43.71, SD = 12.16; 43% male) and one that received no strategy (n = 6; Mage = 46.00, SD = 7.13; 67% male). All participants completed cognitive testing before engaging in a 4-week online behavioral regimen. For each day of the regimen, three online cognitive activities were prescribed. Outcome measures included adherence (events completed of 84) and consistency in adherence (variability in timing of event completion). Participants also completed a follow-up survey. Results: A series of Pearson correlations and regression-based analyses revealed that presence of a compensatory strategy did not predict consistency in adherence, nor did it predict overall adherence after controlling for covariates. In supplementary analyses, individuals who received a compensatory strategy had better adherence for the CAT during week 1, but their adherence decreased to be equivalent to the no strategy group over the course of four weeks. Additionally, one measure of executive function (response inhibition) was significantly related to consistency in adherence. Upon further analyses, it was determined this relationship differed by group. Consistency in adherence followed a quadratic pattern over time, such that all individuals were least consistent during the third week of the regimen, but were more consistent before and after that point. Conclusions: Consistency in adherence does not appear to be improved by the addition of a compensatory strategy. Although this component of adherence was related to executive function, this association appeared strongest among individuals who did not receive a strategy and who were more cognitively compromised. Adherence improved with the addition of a compensatory strategy initially, but declined over time to be equal to the no strategy group. Clinically, these findings suggest that compensatory strategies may need to be nuanced and target specific mechanisms of non-adherence. Moreover, the need for regular follow-up during a behavioral regimen to encourage continued motivation over time may be necessary to maximize adherence. Limitations include a small sample size, uneven groups with respect to cognitive function, and executive functioning measures which do not approximate real-world behaviors. Future directions include continuing to identify mechanisms of non-adherence among cognitively compromised individuals as well as continued work into the importance of consistency as a support for adherence to treatment among individuals with cognitive decline.Ph.D., Psychology -- Drexel University, 201