PSYCH 313: Traumatic Brain Injury & Communication - Lecture Notes

Cognitive-Communication Disorder Following TBI

Introduction

  • Philippa M. Friary, Director of Clinical Education, School of Psychology (Speech Science), Grafton Campus, The University of Auckland.
  • Acknowledgements to Assoc. Prof. Clare McCann.

Karakia Timatanga

  • A Māori prayer to clear the space and create a positive environment:
    • Te reo Māori
    • Te reo Pākeha (English translation provided)

Learning Outcomes

  • By the end of this lecture, students will be able to:
    • Differentiate the features of an acquired cognitive-communication disorder (following TBI).
    • Identify some of the psychosocial consequences of living with a cognitive-communication disorder.

What is Cognitive-Communication Disorder?

  • A wide range of specific communication problems resulting from damage to regions of the brain that control the ability to think (cognition).
  • Can impair communication by decreasing the efficiency and effectiveness of:
    • Comprehension
    • Expression (meaningful speech, language, writing, or gestures and pragmatics)

ASHA Definition (2005)

  • Encompasses difficulty with any aspect of communication affected by the disruption of cognition.
  • Communication may be verbal or nonverbal.
  • Includes listening, speaking, gesturing, reading, and writing in all domains of language (phonologic, morphologic, syntactic, semantic, and pragmatic).
  • Cognition includes cognitive processes and systems (e.g., attention, perception, memory, organization, executive function).
  • Areas of function affected by cognitive impairment include:
    • Self-regulation
    • Social interaction
    • Activities of daily living
    • Learning and academic performance
    • Vocational performance

Key Characteristics

  • Cognitive-communication disorder is a disorder of language use (as opposed to language form e.g. syntax, grammar).
  • The language disruption is consistent with the disruption of executive functions.
  • People with TBI talk better than they communicate.

Example Illustration

  • Example question: "What would happen if you left ice-cream out on the bench overnight?"
  • Response demonstrating cognitive-communication difficulties: "Ah… that is a very good question, leaving icecream out on the bench. It depends on many things and mostly depends on the bench and of course it depends on the icecream. It depends if the twirly thing is present or not, I like icecream, hokey pokey is my favourite"

Examples of Cognitive-Communication Difficulties

  • Difficulty with naming

Traumatic Brain Injury (TBI)

  • A TBI is ‘an episode of external force to the head and brain (including deceleration force) with the consequent presence of neurological symptoms or signs, including loss of consciousness and amnesia’ (ACC 2001).
  • A leading cause of death and disability in the 1-40 year age group.
  • Deficits can be:
    • Physical (neurological deficits)
    • Cognitive
    • Behavioural
    • Psychological
    • Personality impairments
  • More than 50% are related to traffic accidents, the rest are falls, assault, firearms.
  • Combined with spinal cord injuries in 25-50% cases.

Epidemiology and Risk

  • Approximately 9000 TBIs per year in NZ.
  • Recovery is predicted and measured by scales (neurological, behavioural and/or cognitive scales).
  • Risk:
    • From 1st → 2nd injury, risk increases by a factor of 2.
    • From 2nd → subsequent injury, risk increases by a factor of 8.
  • Concussion effects can be cumulative.

Types of TBI

  • Coup/contra-coup (frontal & occipital lobes)
  • Diffuse axonal injury (DAI) – when the brain rapidly shifts inside the skull as an injury occurs. The long connecting fibres (axons) are sheared off as the brain rapidly accelerates and decelerates inside the hard bone of the skull
  • Haemorrhage (extradural, subdural)
  • Hypoxia – When the brain is deprived of oxygen
  • Multiple concussions

Coup/Contra-coup

  • Acceleration and deceleration.
  • Frontal and occipital lobes damaged.

Diffuse Axonal Injury (DAI)

  • A form of TBI when the brain rapidly shifts inside the skull as an injury is occurring.
  • The long connecting fibres in the brain (axons) are sheared off as the brain rapidly accelerates and decelerates inside the hard bone of the skull.

Haemorrhage

  • Extradural: Blood clot or hematoma on top of the dura.
  • Subdural: Blood clot or hematoma under the dura.

Secondary Intra-cerebral Haemorrhage

  • Leading to increased ICP and/or hydrocephalus.
  • Hematoma or clot.
  • Swollen brain tissue (edema).
  • Enlarged ventricles.

Hypoxia and Multiple Concussions

  • Hypoxia: When the body or a region of the body is deprived of adequate oxygen supply at the tissue level.
  • Multiple concussions: potential development of CTE (Chronic Traumatic Encephalopathy).

Severity of TBI

  • Mild/moderate/severe TBI
  • Caution: “mild injuries are not mild” (Feigin et. al.).
  • Determining severity requires the collective use of the following:
    • Length of coma (LOC)
    • Glasgow Coma Scale (GCS)
    • Post traumatic amnesia (PTA)
    • Neuro-imaging: e.g. presence of haematoma, contusions, diffuse axonal injury, haemorrhages
  • None on their own provides a gold standard.

Glasgow Coma Scale (GCS)

  • Aims to give a reliable, objective recording of the conscious state of a person.
  • Initial as well as continuing assessment.
  • The lower the mark, the more severe the brain injury.
  • Patient assessed against the criteria of the scale resulting in a score between 3 (indicating deep unconsciousness) and 15.
  • Components:
    • Best eye response [4]
    • Best verbal response [5]
    • Best motor response [6]

GCS Criteria

  • Best eye response (E):
    • Spontaneous - open with blinking at baseline: 4
    • Opens to verbal command, speech, or shout: 3
    • Opens to pain, not applied to face: 2
    • None: 1
  • Best verbal response (V):
    • Oriented: 5
    • Confused conversation, but able to answer questions: 4
    • Inappropriate responses, words discernible: 3
    • Incomprehensible speech: 2
    • None: 1
  • Best motor response (M):
    • Obeys commands for movement: 6
    • Purposeful movement to painful stimulus: 5
    • Withdraws from pain: 4
    • Abnormal (spastic) flexion, decorticate posture: 3
    • Extensor (rigid) response, decerebrate posture: 2
    • None: 1

Post-Traumatic Amnesia (PTA)

  • The interval from injury until orientated, forming, and later recalling new memories.
  • Even those who have suffered a mild brain injury and do not lose consciousness will experience a short period of PTA.
  • People generally retain memories from before the injury.
  • In the early stages of PTA, the person cannot retain information even for a few minutes.
  • They will not remember that his/her family and friends have been to visit and may accuse them of never visiting.

Behaviour During PTA

  • Behaviour during PTA can vary considerably from patient to patient:
    • Quiet and inert – pay little or no attention to their surroundings.
    • Extremely agitated – noisy.
    • Physically and/or verbally aggressive.
    • Disinhibition.
  • A temporary phase. The behaviour will improve as the patient emerges from PTA although the inappropriate behaviour may not disappear entirely.
  • Up to 24 hours [mild]
  • 1-7 days [moderate]
  • 7 days + [severe]
  • Not possible to make someone come out of PTA more quickly.
  • It ends when the person can retain new information.
  • It is helpful to remind them of where they are and orient them to time and place.

Severity and Prognosis

  • Length of Coma:
    • >4 weeks leads to poor prognosis.
  • Glasgow Coma Scale:
    • Severe: 3-8/15
    • Moderate: 9-12/15
    • Mild: 13-15/15
  • Post traumatic amnesia:
    • >11/52 inconsistent with independent living.

Cognitive Deficits

  • Reduced concentration and attention
  • Slow processing ability
  • Poor recent memory
  • Poor judgement and executive functioning
  • Language problems – aphasia
  • Agnosia
  • Visuo-spatial dysfunction

Behavioural Changes

  • Restlessness and agitation
  • Aggressive behaviour
  • Disinhibition and impulsivity

Effects of Cognitive-Communication Disorder

  • Miss the beginning, middle or end of a message leading to misunderstandings or failing to comply.
  • Any activities seen as boring.
  • Difficulty in a crowd (even 3 participants).
  • Problems understanding figurative language and therefore difficulty with jokes, cliches etc.
  • Teasing may be interpreted as an insult.
  • Compliment interpreted as a sexual invitation.
  • Loss of pleasure from social interaction.
  • Self-focused conversation, immature or inappropriate humour, frequent interruptions, sudden topic shifts or disinhibited remarks and slow comprehension.
  • Tendency to make a poor first impression (Spence et al 1993).
  • Increased effort for conversation partners to prompt, direct, maintain and repair conversation.
  • Present poorly at interviews and increased problems with relationships at work (Godfrey et al 2000).
  • Even those with a mild TBI can struggle with communication competence.
  • Old friends find interaction less rewarding and tend to cease contact (Godfrey et al 2000).
  • Difficulty making new social relationships.
  • Difficulty obtaining new work (Garcia et al 2002).
  • Difficulty maintaining work (Garcia et al 2002).

Successful Return to Work

  • A successful return to work is largely determined by:
    • Person’s ability to understand language
    • Psychosocial adjustment to communication disorder
    • Attitudes of others to communication impairment
    • Assessment of functional communication activities as well as impairment

Living with a Brain Injury

  • Attitude TV - ABI-Rehab

Wrap Up

Karakia Whakamutunga

  • A Māori prayer to conclude the session:
    • Te reo Māori
    • Te reo Pākeha (English translation provided)