Cognitive Rehabilitation following a Case of Severe Traumatic Brain Injury
Along with physical, sensory, and behavior difficulties, traumatic brain injury (TBI) can impair cognitive function and communication, all of which can impair an individual’s ability to function independently. Changes in cognition may occur in the areas of attention, memory/learning, and executive function such as planning, organizing, initiating, goal setting, problem solving, and self-awareness. Communication deficits can be characterized by difficulties in understanding or expressing both spoken and written language, or in the areas of pragmatics.
PY was a 53-year-old man found unconscious for an unknown duration outside his home and taken by ambulance to the hospital. Imaging revealed left subdural hematoma (SDH), extensive subarachnoid hemorrhage (SAH), and right temporal bone fracture. He underwent emergency craniotomy for SDH evacuation in the context of a decreasing Glasgow Coma Scale (GCS) score, reflecting a decline in his level of consciousness based on objective evaluation of eye, verbal, and motor responses. He remained in the acute hospital setting for 2 weeks, followed by 2 weeks in acute inpatient rehabilitation. His posttraumatic amnesia (PTA) was estimated at more than 4 weeks.
The initial outpatient speech/language assessment took place more than 1.5 years following the acute brain trauma. Comprehensive evaluation included an extensive interview with PY and his daughter regarding his injury and course of recovery, ongoing cognitive-communication limitations, current routine and day-to-day activities, use of compensatory strategies, additional mitigating factors (e.g., poor sleep, symptoms of depression), and patient/family goals for rehabilitation.
Prior to the injury, PY lived independently and was employed full-time as a microchip processing technician. Following the injury and subsequent recovery and rehabilitation, PY returned home to live with his wife and adult daughter. At the time of speech-language pathology (SLP) assessment, PY had not yet returned to work, but reported that employment was his primary goal. Although both he and his daughter reported significant improvement since his injury, he continued to require family assistance with many instrumental activities of daily living (IADLs) such as financial management, driving, shopping, meal preparation, and chores around the house. He primarily spent his time alone watching television, with weekly outings with family members.
PY initially denied cognitive-communication challenges, but ultimately reported having a difficult time “remembering stuff” including the television channels he preferred and the name of his dog. He also frequently forgot to eat at regular intervals. His daughter noted that she consistently observed PY having difficulty both initiating and completing tasks as well as decreased memory and word retrieval.
The Wechsler Test of Adult Reading (WTAR) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) were administered. His performance on the WTAR suggested premorbid intellectual functioning in the high average range (raw score = 44, standard score = 116). PY and his daughter each completed the Mayo-Portland Adaptability Inventory-4, Participation Index (M2PI) questionnaire to evaluate ability, activity, and social participation in patients following acquired brain injury. The results of the RBANS and M2PI are shown in ▶ Table 1 and▶ Table 2, respectively.
a, b, d, and e are incorrect. Although he did demonstrate difficulties with attention and language on standardized measures (performing in the 5th percentile rank in each domain), his performance on measures of immediate and delayed verbal recall reflected significant impairment (1st and 0.4th percentile rank). Additionally, PY reported difficulty “remembering stuff.”
Answer: e is correct. PY would benefit from referrals to neuropsychology, rehabilitation psychology, the sleep clinic, and vocational rehabilitation. Given the time since injury and PY’s desire to return to employment, he would likely benefit from a more comprehensive neuropsychological assessment, which would also be useful to guide support from vocational rehabilitation. Given that cognitive-communication function and performance on standard assessment is sensitive to many factors, he might benefit from intervention to address chronic insomnia and evaluation for possible depression; this would support a referral for formal sleep assessment and to rehabilitation psychologist.
Answer: d is correct. Assistive technology for cognition (ATC) has increasing evidence to support its effectiveness to improve independence and life participation for individuals with cognitive deficits. Given PY’s memory impairment and dependence on his family for most of his IADLs, he would benefit from evaluation for a cognitive prosthesis.
a is incorrect. PY did not demonstrate significant need for environmental modifications to his physical space, such as labeling kitchen cupboards and drawers or establishing a filing system for paying bills.
b is incorrect. Given that PY’s most severe deficits were in the memory domain, direct attention training such as APT-II would not be appropriate for mitigating his difficulties with immediate and delayed recall.
PY performed below expectation on tests of processing speed, working memory, and semantic and phonemic verbal fluency, as well as immediate and delayed learning. PY demonstrated word retrieval difficulties in conversation, poor initiation and planning, and reduced awareness and insight into his disabilities. His deficits were consistent with his injury and significantly impacted his general function and independence, and life participation/quality of life. Treatment recommendations included both restorative and compensatory approaches. Initial treatment goals included evaluation for and training of ATC, development of a regular daily/weekly routine, increased activity, socialization and participation in ADLs, engagement in regular cognitive-linguistic stimulation, training word retrieval strategies and semantic processing treatment activities, and components of goal management training.
PY was seen a total of 36 times over the course of 14 months and demonstrated both objective and subjective gains in cognitive function and overall independence and life participation. During cognitive-communication therapy, PY learned to use and rely on assistive device for technology to support memory (e.g., using an iPod/iPad to adhere to a regular routine including home-related tasks and responsibilities, independent management of medical appointments, and regular participation in cognitively-stimulating exercises) and wayfinding (e.g., smartphone GPS to support driving directions and geocaching). He independently employed word retrieval strategies during conversation and reported subjective improvement in language output. He continued to struggle with cognitive inflexibility, goal setting, and problem solving. His daughter, however, reported improved function initiating and completing more difficult home-related tasks (e.g., weekly meal planning and regular dinner preparation, installing new curtains). Overall, PY reported increased confidence in his cognitive functioning and reduced anxiety about his “new normal.”
PY’s gains following treatment were most significant with respect to his increased independence with ADLs, as reflected in pre- and posttreatment scores on the M2PI in ▶ Table 3 and ▶ Table 4. At discharge, PY was independently driving, shopping, and preparing meals, completing many home-related tasks, and managing his health and medical appointments, as well as becoming increasingly involved in social activities (e.g., brain injury support group, re-engagement with geocaching club, weekly outings with friends and family). Although one of his initial goals was to return to his same employment, at discharge he had no plans to return to the workforce.
Comprehensive evaluation of patients with TBI should include extensive clinical interview with patient and family members in addition to standardized assessment instruments to collaboratively develop an individualized treatment plan and method for measuring progress.
Therapy focused on training use of ATC must not only include the initial acquisition phase, but also emphasize generalization and maintenance to ensure continued use of the device to support optimal cognitive function.
The success of cognitive-communication therapy may be measured via pre- and poststandardized assessment results, but should emphasize functional and patient-centered measures such as subjective reports, participation indices, or Goal Attainment Scaling to better reflect functional gains.
4 Powell LE, Glang A, Ettel D, Todis B, Sohlberg MM, Albin R. Systematic instruction for individuals with acquired brain injury: results of a randomised controlled trial. Neuropsychol Rehabil. 2012;22(1):85-112.