condition known as Post-traumatic Amnesia. This condition occurs when an individual suffers an acute brain damaging injury. Automobile crashes are said to be the most common origin of such injuries, and thus, the fundamental source of this disorder, in young adults. The condition persists for a few minutes or hours after the accident, or may go on for as long as weeks, months or years. Post-traumatic amnesia is accompanied chiefly by memory loss and other similar impairments.
The paper begins with an introduction to the disorder, followed by a section on the characteristics that help diagnose post-traumatic amnesia (PTA). The third section of the paper is dedicated to neuropsychological testing/evaluation for identifying behavioral or cognitive shortfalls, such as a patient might experience with post-traumatic amnesia. The factors for evaluation described here are: unconsciousness, scores on the Glasgow Coma Scale, and duration of diagnosed post-traumatic amnesia. Furthermore, treatment techniques for PTA that consider sensory, motor, cognitive, and behavioral issues are addressed in the fourth section.
Methods for cognitive rehabilitation are also explained, in the following section, taking into consideration the role of smells and sounds in sparking memories. The final section of the paper addresses general principles that ought to be followed while managing patients with traumatic brain injury. This is followed by a conclusion that concisely wraps up the paper.
Introduction
Post-traumatic amnesia (PTA) is a type of amnesia that occurs ‘post’ or after a traumatic incident; it refers to a phase of recuperation from a severe, moderate or mild brain injury. Patients who suffer from PTA are incapable of processing and retrieving new information or recording new memories. This type of amnesia can be stated to be a mental disturbance that is characterized by impaired attention, disorientation, illusions, mis-identification of friends, family members, nursing and medical staff, and by a failure to remember everyday events (Kneafsey, 2003).
The true pathophysiogical process of PTA is unknown, but it is argued by many that PTA can be linked with a traumatic injury to the brain and shearing of accelerative or decelerative axons in the brain’s temporal and frontal lobes. These forces cause bruising, breakage and/or inflammation of axons, with message pathways consequently being disrupted and/or damaged. This can be commonly described as DAI, Diffuse Axonal Injury. Evidence from magnetic resonance imaging (MRI), however, has shown that some PTA patients do not show any evidence of diffuse axonal injury on their MRI reports (Korinthenberg et al., 2004: Gumm et al., 2014).
The greatest source of Traumatic Brain Injury (TBI) is from car crashes. As many as 17% of TBIs, in fact, are caused by motor vehicle accidents (CDC, Centers for Disease Control and Prevention, 2010). For young males, TBIs remain the leading source of death. Evidence from numerous severe automobile crashes indicates that the victim’s head often crashes into the windshield, damaging the brain’s prefrontal lobes. This frontal lobe damage may cause long-term memory deficits, problems in planning/organizing and emotional complications. Further, damage may also occur in the temporal lobe regions, resulting in added memory complications. A blow at the back of the head, or counter-coup, may damage the brain’s occipital lobe, causing deficits in vision as well. A clearer grasp of the character of memory in the human brain can accord much-sought-after relief to such individuals. However, motorists should bear in mind to fasten their seat belts and not disconnect the safety airbag (Schwartz, 2014).
Treatment and care of patients suffering from brain damage comes under the clinical neuropsychology field. Given that a majority of victims of automobile crashes tend to be young adults likely having long lives ahead of them, traumatic brain injury treatment and rehabilitation are of immense social significance in today’s auto-centric culture. Thus, clinical neuropsychology concentrates on restoration and rehabilitation of intellectual skills for car-crash victims. However, because of the regular pattern of extensive damage in auto accidents, victims are rarely used for research to examine the relationship between behavior and brain (Schwartz, 2014).
Traumatic Brain Injury (TBI) diagnosis
Guidelines have been published by numerous national organizations to define and describe the causes of mild traumatic brain injury (MTBI). They include the Veterans Affairs/Department of Defense (VA/DoD), the Centers for Disease Control and Prevention (CDC, 2010), the 2001 EAST practice management guidelines (PMG), and the American College of Rehabilitation Medicine. All of the definitions concur that the process must comprise a direct external force, accompanied by a subsequent physiologic alternation in the brain’s functioning. Though the language that describes the nature of alteration in the brain’s function differs, it is agreed by most that presenting Glascow Coma Scale (GCS) scores ought to be in the range of 13-15 (Barbosa et al., 2012), that any unconsciousness must be under half an hour, and that the post-traumatic amnesia duration must be lesser than a day. Post-traumatic amnesia (PTA) can be distinguished by one or more of the following conditions:
• Disorientation and/or perplexity
• Restlessness, a need to wander, thrashing
• Aggressiveness and/or anxiety
• Combativeness, such as tugging at medical tubes and/or devices
• Moaning, “childish” behavior, calling out
• Inappropriate or disinhibited social behavior
• Paranoia and fear
• Over-sensitivity to light
• Fatigue
• Decreased attentiveness and/or focus
• Lack of constant memory
• Hallucinations
• Confabulation (making up stories)
• Repetitious thoughts or movements
• Obsessed with a single issue
• Sleeping/waking cycle disruption
• Impulsiveness
• Reduced planning ability or problem solving skills
An ending to the PTA may be explained as disappearing of confusion, along with the capability of recording new information. PTA can last for periods as short as a few minutes, or even up to days, several weeks, or as long as many months. (However, as described above (vide supra) most organizations such as the VA, describe PTA as ending within one day). As well, PTA symptoms can be seen to vary from one person to another. The individual may be talkative or drowsy, aggressive or docile, irritable or impudent. While some individuals may, after a period of suffering from PTA, make a brilliant physical recovery, it is also possible that a range of emotional and cognitive issues might disable these individuals in the long run. The duration of PTA and coma can help to predict how severe the total brain injury is (Gumm et al., 2014).
Neuropsychological Testing/Evaluation
A formal neuropsychological examination may identify various behavioral, cognitive or other shortfalls. Limited information exists to guide clinicians on which of their patients to send for evaluation. Research on the topic is likely to be influenced by various weaknesses summarized by Sherer et al. (2010). Also, the influence on patient’s result is uncertain. This therapy has been considered to be more beneficial in case of mild traumatic brain injury than in cases of moderate to severe traumatic brain injury. However, in research conducted on patients suffering from significant post-concussive syndrome (PCS), a decrease of symptoms was not caused by neuropsychological therapy (Barbosa et al., 2012). Researchers can study the relationships between behavioral and cognition deficits, and the correlation to the locus of injury in the individual’s brain through neuropsychological research. Generally, most brain damage is rather evenly dispersed over large parts of the person’s brain. In some instances, however, often resulting from strokes, bullet wounds, or surgery, damage may be relatively localized; therefore, clear correlations can be drawn, of brain damage with memory deficits (Schwartz, 2014).
Perhaps the first step taken by healthcare experts when treating an individual with traumatic brain injury is to evaluate the injury’s severity. Severity level is determined for facilitating initial triage, as well as to help treatment planning. Various factors are to be considered when evaluating the severity of injury, and these include unconsciousness, scores on the Glasgow Coma Scale, and length of post-traumatic amnesia (Struchen et al., 2009).
Loss of Consciousness (LOC)
Individuals may lose consciousness after receiving head injuries (Struchen et al., 2009). In general, the longer the duration of unconsciousness, the greater is the severity of the injury. In a perceptive hospital environment, the consciousness of the patient will be tracked hourly as well as daily by the medical team. Usually, this tracking is carried out using the Glasgow Coma Scale (GCS), described below (O’Donnell et al., 2010).
Glasgow Coma Scale (GCS)
The Glasgow Coma Scale is essentially a measurement that assesses responsiveness of patients after traumatic brain injury. It is widely used in hospitals all over the United States (U.S.), and other countries of the world. This scale evaluates three responsiveness factors: eye opening (whether the patient is capable of spontaneously opening his/her eyes); motor responses (whether the individual is capable of moving when requested or when reacting to painful stimulus); and lastly, verbal responses (whether the individual is capable of speaking, and whether he/she is oriented or not). Typical GCS scores range from 3-15, with 13-15 on the scale being considered as mild injury levels, 9-12 as moderate levels and 3-8 as severe injury levels. The medical unit generally uses this scale to evaluate the patient in the place where the accident has occurred, if the victim is transported through emergency medical services (EMS). The GCS can also be completed on arriving at a hospital’s emergency room. If hospitalization is required because of the injury, GCS evaluation can be carried out on an hourly basis and/or many times a day until the patient responds consistently as oriented and alert (Struchen et al., 2009).
Post-Traumatic Amnesia (PTA)
The severity of the injury may also be estimated by investigating post-traumatic amnesia. After a traumatic brain injury, patients may be disoriented or confused for some duration of time. They might not be aware of their surroundings for some minutes, hours and in some cases, even for days. They might not be capable of accurately stating the time, date, day, month or year. This time period is referred to as post-traumatic confusion or post-traumatic amnesia, and is common for those with traumatic brain injuries. In this period, individuals may not be capable of making new memories, and may not recall this period later. Generally, a longer PTA duration is associated with a more severe brain injury. In astute hospital and rehabilitation settings, testing of the patient’s mental orientation is normally performed at least on a day-to-day basis. This may be found in a report from the nursing staff or treating physician, and in reports from the therapy staff or neuropsychologist. One of the instruments used frequently for assessing orientation following traumatic brain injury is the Galveston Orientation and Amnesia Test, also known as GOAT (Barbosa et al., 2012; O’Donnell et al., 2010).
The Galveston Orientation and Amnesia Test consist of questions regarding the patient’s orientation to time, place, situation and person; this test is attached as the Appendix. Specific questions are asked; error points listed alongside each question are used for evaluating total scores. The total score for a patient at a particular time can be acquired by subtracting total error points from 100. Scores on the GOAT scale go from -8 to 100. For instance, an individual who cannot remember a specific incident after suffering the injury, and was also highly disoriented with regards to the date and month, would acquire 30 negative points for an overall mark of 70. Scores below 66 are taken as defective, while those ranging from 66 to 75 are deemed borderline. Individuals acquiring a score of 76 and over on two successive days are deemed ‘oriented’, and thus, are no longer suffering from post-traumatic amnesia (O’Donnell et al., 2010; Struchen et al., 2009).
Traumatic Brain Injury (TBI) Treatment
Treatment for individuals suffering from TBI is complex and varied. Evidence supporting initial early rehabilitation interventions at definable recovery stages for those who come out of traumatic coma (such as early use of techniques for stimulating awareness), and PTA management (use of environmental modification for reducing agitation), is not clear (Chung & Khan, 2013). Generally, TBI treatments aim at stabilizing rehabilitation and medical issues, preventing secondary complications, restoring functional abilities, and providing adaptive equipment for improving functional independence as well as social reintegration into society. Evidence supporting psychological interventions (such as attention training); in addition to cognitive interventions following traumatic brain injury has been shown to be sound (Chung & Khan, 2013).
Cholinergic drugs are the sole prescription drugs that can be found for memory improvement. Although no evidence exists to show that memory enhancements occur by these drugs in healthy persons, they have shown a boost in memory performance for those suffering from memory ailments like Alzheimer’s. This they achieve by giving chemicals, which act as precursors for essential neurotransmitters in the brain. Because several memory circuits make use of the neurotransmitter acetylcholine, cholinergic drugs provide acetylcholine precursors. Piracetam was the first of this category of drugs to become available. As of now, piracetam is not prescribed in the U.S., but can be obtained on prescription in almost all of Europe (Schwartz, 2014; O’Donnell et al., 2010).
Sensory Effects of Traumatic Brain Injury
Vision: As mentioned earlier, patients afflicted with traumatic brain injury may possibly have lost a portion of their visual field (known as visual field cut), or experience blurred or double vision. If the patient’s vision seems to be affected, using written material ought to be limited for such clients (patients), because their ability of seeing this material and/or reading it might be affected. Written forms should be read to patients by the clinician or the clients’ family members or friends (Struchen et al., 2009).
Motor Effects of Traumatic Brain Injury
Hemiplegia or hemiparesis: As mentioned earlier, patients with TBI could have experienced a total or partial paralysis of one side of their bodies. This may affect their writing ability, and various physical functions, such as shaking hands, walking, and performing other functions of personal care. If the dominant hand of the patient is affected, his/her ability to write on hospital forms will obviously be very slow, as well as effortful, since the patient will be dependent on his/her non-dominant hand (Korinthenberg et al., 2004; Struchen et al., 2009).
Cognitive Effects of Traumatic Brain Injury
Memory difficulties: Patients suffering TBI may find it difficult to remember information. These difficulties with memory may involve problems with minute-to-minute information recollection, and forgetting of information over a certain time. Some patients may be more adept at identifying information with the help of cues, than at recalling information by themselves (Struchen et al., 2009).
Behavioral/Emotional Issues
Poor Initiation: Some patients with TBI face difficulties in beginning with things, meaning that they may possess difficulties in initiating a conversation, face trouble in thinking up questions while conversing, face trouble in getting started on completing tasks, etc. Some suggestions for facilitating initial interaction of therapists with clients who have initiation difficulties are as follows: Prompts should be provided to clients to find out if they have any questions; Family members or friends should be engaged to assist the patient in beginning and completing task requirements; and, a system for cueing should be developed, which can help the patient in bringing tasks to completion (Tucker et al., 2012).
Cognitive Rehabilitation
Patients suffering mild traumatic brain injury are generally referred for other rehabilitation techniques, which include interventions for enhancing memory, attention, as well as other executive functions. These may be carried out by specialists in various disciplines, and include physical therapy, speech therapy, occupational therapy, and more, referred to collectively as cognitive rehabilitation. Although evidence supporting the adoption of cognitive methods of rehabilitation is present for improving communication, memory and other executive functions, most of these studies were not focused exclusively on mild traumatic brain injury. Individuals suffering from other neurologic conditions and those with all kinds of traumatic brain injury can often be found to be grouped collectively in such studies, such that MTBI patients often make up only a minor percentage of individuals in a particular study. Presently, no particular collection of indications to refer individuals for cognitive rehabilitative techniques after MTBI is defined, and also, its influence on patient’s results is not known (Barbosa et al., 2012).
One TBI rehabilitation approach involves a wide range of treatment, using different interventions. Many interventions, however, haven’t yet been transferred into complete programs and are often offered in the form of individual interventions. On the basis of National Health and Medical Research Council (NHMRC) evidence levels, strong evidence can be found for the efficiency of cognitive interventions and psychological interventions like attention training following TBI (Chung & Khan, 2013).
General Principles for Managing TBI patients
Anything that may be seen, heard or felt by a patient, which might make them think, can be considered as a stimulus; thus, patients’ rooms must be as plain as possible. The means that treatment of patients with traumatic brain injuries seeks to avoid stimulus as much as possible.
This entails removal of all unnecessary furniture, tables, chairs, oxygen outlets, newspapers, magazines and signage (except those intended for PTA management). Low-level lighting must be maintained always and curtains must be closed. No televisions, DVD players, telephones, radios etc. must be present. Noise levels should be kept minimal. Conversations with patients, as well as any instructions, should be simple – they should be spoken in a reassuring and calm manner. Reliable yes/no responses should be established as soon as possible (Speech Pathologists may be required for assistance). Patients who suffer from PTA are incapable of making personal decisions (Gumm et al., 2014).
Managing PTA patients requires an unswerving team approach for creating and maintaining a quiet, supportive and low-stimulating environment. The following recommendations are made:
• single rooms, if feasible
• calm and quiet environment; reduction of external stimuli like TVs, radios, loud noises, bright lights and clutter
• encouraging a steady approach with structure and routine
• monitoring of visitors — 1 or 2 at a time, only for short durations
• creating a familiarity in environment; using some important personal items and photographs
Conclusion
The understanding of memory in terms of cognitive psychology is becoming increasingly influenced by neuroscience. This is moving towards formation of a hybrid field called cognitive neuroscience, science that examines the relationship of brain anatomy (and chemistry and physiology) with cognitive function. Diagnosis and managing of veterans with traumatic brain injury and post-traumatic stress disorder (PTSD) is a very challenging clinical task. The relation of these two conditions with their accompanying comorbidities, like substance use or chronic pain, has not yet been fully explored; clinicians will have to face situations wherein only a few published research findings may help in decision-making. Clinical assessment of veterans having mild traumatic brain injuries and PTSD must involve a bio-psychosocial design or a similar model. A few of the treatment options available for cognitive problems related to traumatic brain injury, like stimulant medication, might be harmful in comorbid PTSD.
References
Barbosa, R.R., Jawa, R., Watters, J.M., Knight, J.C., Kerwin, A.J., Winston, E.S., Barraco, R.D., Tucker, B., Bardes, J.M. & Rowell, S.E. (2012).Evaluation and management of mild traumatic brain injury: An Eastern Association for the Surgery of Trauma practice management guideline, J Trauma Acute Care Surg. Vol. 73, No. 5, Supplement 4
Capehart, B. & Bass, D. (2012). Review: Managing posttraumatic stress disorder in combat veterans with comorbid traumatic brain injury, JRRD, Volume 49, Number 5.
Centers for Disease Control and Prevention, (2010). Traumatic Brain Injury in the United States Emergency Department Visits, Hospitalizations and Deaths 2002 — 2006. U.S. Department of Health and Human Services
Chung, P. & Khan, F. (2013). Traumatic Brain Injury (TBI): Overview of Diagnosis and Treatment. J Neurol Neurophysiol 5: 182. doi:10.4172/2155-9562.1000182
Gumm, K., Taylor, T., Orbons, K., Carey, L. & PTA Working Party, (2014). Post Traumatic Amnesia Screening and Management, The Royal Melbourne Hospital.
Kneafsey R. (2003). Head injury: long-term consequences for patients and families and implications for nurses. Journal of clinical nursing, 13: 601-608.
Korinthenberg, R., Schreck, J., Weser, J. & Lehmkuhl, G. (2004). Post-traumatic syndrome after minor head injury cannot be predicted by neurological investigations. Brain & Development, 26(2): 113-117.
O’Donnell, M.L., Creamer, M., Holmes, A.C., Ellen, S., McFar-lane, A.C., Judson, R., Silove, D. & Bryant, R.A. (2010). Posttraumatic stress disorder after injury: does admission to intensive care unit increase risk? J. Trauma. 69(3):627 — 32.
Schwartz, B. (2014). Memory and the Brain (Chapter 2). Memory: Foundations and Applications. London, UK: Sage.
Sherer, M., Roebuck-Spencer, T. & Davis, L.C. (2010). Outcome assessment in traumatic brain injury clinical trials and prognostic studies. J Head Trauma Rehabil. 25:92Y98.
Struchen, M.A., Davis, L.C., McCauley, S.r. & Clark, A.N. (2009). Guidebook for Psychologists: Working with Clients with Traumatic Brain Injury. Baylor College of Medicine.
Appendix (Struchen, Davis, McCauley and Clark, 2009)
Galveston Orientation and Amnesia Test (GOAT)
1. What is your name? (
When were you born? (
Where do you live? (
2. Where are you now?
City? (
Hospital? (-5 points — unnecessary to state name of hospital)
3. On what date were you admitted to this hospital? (
How did you get here? (
4. What is the first event you can recall after the injury? (
Can you describe in detail (e.g., date, time, companions) the first event you recall after the injury? (
5. Can you describe the last event you recall before the accident? (
Can you describe in detail (e.g., date, time, companions) the last event you recalled before the injury? (
6. What time is it now? (-1 point for each 1/2-hour removed from correct time for maximum of
7. What day of the week is it? (-1 point for each day removed from the correct one for a maximum of
8. What day of the month is it? (-1 point for each date removed from the correct one for a maximum of
9. What is the month? (-5 points for each month removed from the correct one for a maximum of
10. What is the year? (-10 points for each year removed from the correct one for a maximum of –
