Neurological Disorders associated with Cognitive Impairments

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Common Symptoms of ABI: Emotional/Behavioral

Irritability

Quick to anger

Decreased motivation

Anxiety• Depression

Social withdrawal

Does not get the "gist" of social interactions

May comment on or react to things that seem random to others

Behavioral changes

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COMMON SYMPTOMS OF ABI: Cognitive and Communicative

Self monitoring and awareness Feeling dazed or in fog Disorientation Confusion Difficulty concentrating Slowed information processing Difficulty learning new information Difficulty with memory

Difficulty juggling multiple tasks

Executive functions Difficulty with concentration and attention Impulsive Task initiation

Difficulty understanding or producing language (aphasia)Slurred, weak, spastic, uncoordinated execution of speech(dysarthria)Difficulty with motor programming of speech (apraxia)

Reading fluency and/or comprehension

Writing formulation, spelling

Social communication (turn taking, maintaining conversational topics)

Communicating in "socially unacceptable" ways (pragmatics)

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What causes traumatic injury?

falls

motor vehicle and pedestrian-related accidents

collision-related (being struck by or against) events• violent assaults

Sport-related injuries and explosive blasts/military combat injuries

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incidence of TBI refers

the number of new cases identified in a specific time period

2010, 2.5 million diagnosed with TBI

Some statistics show a person suffers a mild traumatic brain injury (mTBI) or concussion

seconds in the U.S.

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Most likely to sustain a TBI

Older adolescents 15-19 years

Young adults age 20-24

Adults aged 65 and older

Adults aged 75 and older have the highest rates of hospitalization and death

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prevalence

refers to the number of individuals who are living with are living with TBI and related deficits within a given period of time

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mortality brain injury

53,000 deaths per year

284,000 hospitalizations

2,214,000 ED visits

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Once an individual sustains a TBI, he/she, is:

3x more likely to have a 2nd injury

8x more likely to have a 3rd injury

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Women have a 1.6x more likely to have a poorer outcome compared to males

are more likely to experience Post Concussive Syndrome (PCS)

Are more likely to be cognitively impaired

Are more likely to have decreased reaction time after a sports-related injury

Are more likely to be diagnosed with post-injury depression Have a greater incidence of PTSD following ABI

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TBI due to impact

Closed injuries

Open injuries

Lacerations, contusions (bruises) or intracerebral

hemorrhage to the brain (focal injuries)

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Lacerations, contusions (bruises) or intracerebral

hemorrhage to the brain (focal injuries)

Can include coup-contre-coup injuries (initial blow/event, subsequent blow/event)

Can include Diffuse Axonal Injuries (DAI) (more diffuse

damage due to a shearing of axons)

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Open injuries

Breach of meninges or skull

Result in focal injuries (hematomas or hemorrhage)

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TBI due to intertia

Non-impact injuries

Result from acceleration-

deceleration forces

Can also result in coup-contre-

coup injury

Can result in DAI injury

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Mild -mTBI or concussion

Usually not life-threatening

Effects can be serious

Can occur in any sport or reactivity

Frequently not diagnoses or mis-diagnosed (under-diagnosed)

Brief or no LOC

AOC moment up to 24 hours

GCS score 13-15

Vomiting, HA, sensitivity to light and sound

PTA 0-1 day

Often CT unremarkable or normal structural imaging

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Moderate

LOC 30 minutes - 24hours

AOC greater than 24hours based on severity/other criteria

Neuro signs (skull fx, bleeding, bruising)

GCS score 9-12 PTA 1-7 days Normal or abnormal structural imaging

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Severe

LOC 24 hours +

AOC• GCS score 3-8

PTA greater than 7 days

Normal or abnormal structural imaging

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Statistics of mTBI

2010, 2.5 million diagnosed with TBI concussion/mTBI (1.1-1.8 million)

Some statistics show a person suffers a mild traumatic brain injury (mTBI) or concussion every 21 seconds in the U.S.• 2,651,581 children 19 years and younger were treated for sports and rec-related injuries between 2001 and 2009 (CDC).• Since that time, there has been both increase in participation in sport/rec-related activities for kids AND better diagnosis for concussion, and therefore, that number has increased by 57% in recent years.

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Grade 1 - mild

symptoms last for less than 15 minutes, with no LOC

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Grade 2 - moderate

smptoms last longer than 15 minutes, with no LOC

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Grade 3 - severe

LOC even just for a few seconds

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CVA

Stroke or cerebrovascular accident used interchangeably

One of the 3 major neurological causes of death and disability

Third leading cause of death in the USA

25% occur in patients less than 65 years of age

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Hemorrhage or bleed:

Occurs when a blood vessel

weakens, tears, or bursts and blood leaks into

surrounding tissue

occurs when a blood vessel weakens, tears, or bursts and blood leaks into surrounding tissue

Most often occurs at the junction of vessels

most often occurs at the posterior/anterior communicating artery or the origin of the MCA• Intracerebral and subarachnoid = ~15% of strokes• 30% acute mortality

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Ischemic/embolic

occurs when a blood vessel is blocked by a blood clot(thrombosis) or a atherosclerotic plaque

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MCA (most commonly involved artery on either side)

Supplies most of the lateral surface of the frontal, temporal, and parietal lobes

L - aphasia, AoS, verbal learning impairments

R - visual spatial impairments, nonverbal learning impairments, impaired awareness of deficits, pragmatics, attention

36% suffer depression- more severe in left sidedn strokes, especially deep frontal lesions

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PCA

relatively rare, bilateral thalamic strokes can result in very severe deficits of attention, MEMORY, apathy, flat affect confabulation, amnesia) (occipital and temporal lobes)

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ACA

Communicating- connects the anterior cerebral arteries; part of the Circle of Willis

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Glasgow Coma Scale (GCS)

tool to assess impairment of conscious level in response to defined stimuli - used in acute care settings

high score = mild TBI

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Best Eye Response. (4)

No eye opening

Eye opening to pain

Eye opening to verbal command

Eyes open spontaneously

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Best Verbal Response. (5)

(1) No verbal response

(2) Incomprehensible sounds.

(3) Inappropriate words.

(4) Confused

(5) Oriented

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Best Motor Response. (6)

1. No motor response

2. Extension to pain

3. Flexion to pain

4. Withdrawal from pain

5. Localizing pain

6. Obeys commands

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Ranchos Los Amigos

Revised Levels of Cognitive Functioning tool used in acute rehab settings

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Attention includes...

Alertness and arousal (sustained brainstem or diffuse bilateral subcortical injury)

Resisting interference (distractions, selective, thalamus and frontal lobes)

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time dependent form of memory

Short-term ( and working memory)

temporary

Long-term Memory (permanent)

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Content-dependent form of memory (long- term)

declarative learning (explicit memory, free recall)

episodic and semantic

Nondeclarative (implicit and cued recall) procedural

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Nondeclarative

Acquired and used unconsciously

procedural memory (i.e., remembering to perform some

action, such as how to get out of a chair, swallowing techniques);

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Declarative Memory

Conscious recollection of factual information recent episodic memory (i.e., remembering recent personal events such as one's birthday, a dinner party)." semantic memory (i.e., remembering facts such as names of people and objects, current year, city and facility of residence room number)

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Everyday Memory

Ability to carry out everyday intentions

prospective memory (i.e., remembering future appointments, activities or tasks, such as looking at a calendar, taking medication)

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explicit memory

medial temporal lobe, diencephalon

facts (semantics)

events (episodic)

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implicit memory

procedural memory

skeletal musculature

classical conditioning

emotional regulation

priming

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attention sight of lesion (sol)

brainstem, diffuse, subcortical, thalamus, frontal lobe

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common dx attention

TBI, frontal lobe damage, focal and diffuse damage

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Content affected attention

Focused and Sustained attention Selective, alternating,(divided attention

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Encoding (SOL)

Frontal, temporal, occipital lobes, thalamus, diencephalon

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encoding common dx

Korsokoff's Bilateral thalamic strokes

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content affected for encoding storage and retrieval

Episodic and semantic

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storage SOL

Hippocampus; bilateral medial temporal lobes

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storage common dx

Anoxia Herpes encephalitis Early Alzheimer's

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retrieval SOL

Deep in the midial temporal lobes, semi-passive loop "holds" info

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retrieval common dx

TBI, frontal lobe damage

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semantic

a structured record of facts, concepts and skills that we have acquired (general facts and knowledge)

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Episodic

our memory of events and experiences in a serial form. It is from this memory that we can reconstruct the actual events that took place at a given point in our lives(personal facts and experience)

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amnesia

partial or total loss of memory

caused by brain damage, disease, or psychological trauma

caused temporarily by the use of various sedatives and hypnotic drugs

•either wholly or partially lost due to the extent of damage that was caused

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Post Traumatic Amnesia (PTA)

Loss of memory for events AFTER the injury

Cannot recall events from moment to moment

Period of confusion following coma

Difficulty storing or recalling events

better prognostic indicator than length of com

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Retrograde

Loss of memory for events PRIOR to injury (one doesn't remember shortly before accident because info. was in STM and never reached LTM)

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Ideation

when the concepts we wish to express are generated

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Symbolization

when these concepts are put into a symbolic system congruent with the rules of the speaker's language

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Translation

when these linguistic units or symbols are translated into neuromotor commands that result in the innervation of the motor nerves

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Execution

the actual movements of the speech mechanism

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impairment at the ideation level will result in

mental- verbal dysfunction(or mental confusion, dementia, DOC, delirium

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impairment at the level of the symbolization will result in

aphasia

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impairment at the level of translation with result in

apraxia of speech

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impairment at the level of execution will result in

dysarthria

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motor area

controls of voluntary muscles

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sensory area

skin sensations (temperature, pressure, pain)

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frontal lobe

movement, problem solving, concentrating, thinking, behavior, personality, mood

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Broca's area

speech control

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temporal lobe

hearing, language, memory

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brain stem

consciousness, breathing, heart rate

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parietal lobe

sensations, language, perception, body awareness, attention

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occipital lobe

vision, perception

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Wernicke's area

language comprehension

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cerebellum

posture, balance, coordination of movememt

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frontal lobe functions

is considered the emotional control center and the home of our personality

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Neurological Disorders Associated with Cognitive Impairments

ABI, TBI/mTBI, stroke, DOC, RHD, epilepsy, hypoxia/anoxia, poisoning, encephalopathy, encephalitis, brain tumors, dementia, PPA, ALS, FTD, Parkinson's, MS, depression, delirium

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acquired brain injury (ABI)

is an injury to the brain that is not hereditary, congenital, degenerative, or induced by birth trauma. Essentially, this type of brain injury is one that has occurred after birth. The injury results in a change to the brain's neuronal activity, which affects the physical integrity, metabolic activity, or functional ability of nerve cells in the brain. An acquired brain injury is the umbrella term for all brain injuries.

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two main categories of ABI

Traumatic - injury caused by external force

TBI/ mTBI = concussion (falls, car accident, injury/trauma)

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Traumatic

Injury caused by external force falls, assaults, MVA, sports and rec, AHT/SBS, GSW, work-related, physical abuse/violence, military actions

2 primary mechanisms: Impact and inertia coup/contrecoup

•2 subcategories: open(penetrating) and closed (non-penetrating) head injuries

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Non-traumatic

CVA (ischemic/embolic or hemorrhagic) Infectious disease

Seizure disorders Electric shock

Tumors

Metabolic disorders (insulin shock, kidney function)

Anoxia (near-drowning, strangulation, choking, heart attack)

Toxins (carbon monoxide poisoning)

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Neurological Disorders Associated with Cognitive Impairments

3 primary dimensions of the injury/event/diagnosis include:

1. The distribution (how much of the brain was

affected): focal lesions, multifocal lesions, and diffuse

brain injury

2. Severity

3. Type of underlying pathology (cause)

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Focal lesions

stroke, tumors, brain abscesses, focal trauma/penetrating injury (GSW)

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Multifocal

multiple, distributed occurrence, such as in MID (multiple strokes) or TBI

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Diffuse brain injury

rotational OR diffuse

axonal injury (DAI) TBI, hypoxia, metabolic or

infectious brain issues

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Primary Injury

Primary damage

Mechanical damage

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Secondary Injury

Cascade of physiological events

Delayed non-mechanical

processes (metabolic changes, cell loss, etc)

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Cognitive

Feeling mentally foggy, difficulty concentrating and remembering, repeats questios

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emotional

irritability, sadness, more emotional, nervousness

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Common Sytmoms of ABI: physical

Dizziness and balance issues Weakness (paresis, paralysis)

Nausea, vomiting, vertigo

Headaches

Changes in vision and visual processing

Changes in hearing and auditory processing

Sleep disturbances

Fatigue

Seizures

Sensory issues (sound and light sensitivity,issues with taste, smell and touch)

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COMMON SYMPTOMS OF ABI: COGNITIVE and COMMUNICATive

Self monitoring and awareness Feeling dazed or in fog Disorientation Confusion Difficulty concentrating Slowed information processing Difficulty learning new information Difficulty with memory Difficulty juggling multiple tasks Executive functions Difficulty with concentration and attention Impulsive Task initiation

Difficulty understanding or producing language (aphasia)

Slurred, weak, spastic, uncoordinated execution of speech(dysarthria)Difficulty with motor programming of speech (apraxia)

Reading fluency and/or comprehension Writing formulation, spelling

Social communication (turn taking, maintaining conversational topics)Communicating in "socially unacceptable" ways (pragmatics)

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COMMON SYMPTOMS OF ABI emotional/behavioral

Irritability

Quick to anger Decreased motivation

Anxiety

Depression

Social withdrawal

Does not get the "gist" of social interactions

May comment on or react to things that seem random to others

Behavioral changes

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What causes TBI

falls

motor vehicle and pedestrian-related accidents collision-related (being struck by or against) events

violent assaults

Sport-related injuries and explosive blasts/military combat injuries

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How common is TBI and mTBI

2010, 2.5 million diagnosed with TBI

75% were concussion mTBI

every 21 seconds in the US

13.5 million people live with long- term disabilities

57 increase in sport related injuries due to better diagnosis

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who is more likely to have a TBI

males

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women are ___ times more likely to have poorer outcomes than males

1.6 times

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TBI due to impact

closed injuries

laceration, contusions (bruises) or intracerebral hemorrhage to the brain

open injuries

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open injuries

Breach of meninges or skull

Result in focal injuries (hematomas or hemorrhage)

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Lacerations, contusions (bruises) or

hemorrhage to the brain (focal injuries)

coup

diffuse axonal injuries (DAI)

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TBI due to inertia

non-impact injuries

Result from acceleration- deceleration forces

coup- contre- coup injury

DAI injury

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3 levels of severity of TBI

mild, moderate and severe

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mild- mTBI or concussion

not life threatening

effects can be serious

Can occur in any sport or reactivity

not diagnoses or mis-diagnosed (under-diagnosed)

Brief or no LOC

AOC moment up to 24 hours• GCS score 13-15

Vomiting, HA, sensitivity to lightand sound• PTA 0-1 day

Often CT unremarkable ornormal structural imagin

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moderate TBI

LOC 30 minutes - 24hours

AOC greater than 24hours based on severity/other criteria

Neuro signs (skull fx, bleeding, bruising)• GCS score 9-12• PTA 1-7 days• Normal or abnormal structural imaging