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Treatment of Post-Traumatic Cognitive Impairments

  • PSYCHIATRIC MANIFESTATIONS OF NEUROLOGIC DISEASE (K ANDERSON, SECTION EDITOR)
  • Published:
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Opinion statement

• Cognitive impairment is a common consequence of traumatic brain injury (TBI) and a substantial source of disability. Across all levels of TBI severity, attention, processing speed, episodic memory, and executive function are most commonly affected.

• The differential diagnosis for post-traumatic cognitive impairments is broad, and includes emotional, behavioral, and physical problems as well as substance use disorders, medical conditions, prescribed and self-administered medications, and symptom elaboration. Thorough neuropsychiatric assessment for such problems is a prerequisite to treatments specifically targeting cognitive impairments.

• First-line treatments for post-traumatic cognitive impairments are nonpharmacologic, including education, realistic expectation setting, environmental and lifestyle modifications, and cognitive rehabilitation.

• Pharmacotherapies for post-traumatic cognitive impairments include uncompetitive N-methyl-D-aspartate receptor (NMDA) antagonists, medications that directly or indirectly augment cerebral catecholaminergic or acetylcholinergic function, or agents with combinations of these properties.

• In the immediate post-injury period, treatment with uncompetitive NMDA receptor antagonists reduces duration of unconsciousness. The mechanism for this effect may involve attenuation of neurotrauma-induced glutamate-mediated excitotoxicity and/or stabilization of glutamate signaling in the injured brain.

• During the subacute or late post-injury periods, medications that augment cerebral acetylcholinergic function may improve declarative memory. Among responders to this treatment, secondary benefits on attention, processing speed, and executive function impairments as well as neuropsychiatric disturbances may be observed. During these post-injury periods, medications that augment cerebral catecholaminergic function may improve hypoarousal, processing speed, attention, and/or executive function as well as comorbid depression or apathy.

• When medications are used, a “start-low, go-slow, but go” approach is encouraged, coupled with frequent reassessment of benefits and side effects as well as monitoring for drug-drug interactions. Titration to either beneficial effect or medication intolerance should be completed before discontinuing a treatment or augmenting partial responses with additional medications.

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Acknowledgments

This work was supported in part by the Department of Veterans Affairs VISN 19 Mental Illness Research, Education, and Clinical Center as well as the National Institute of Child Health & Human Development grants 5R01 HD047242 and 5R01 HD047242-S1. Dr. Wortzel is an employee of the Department of Veterans Affairs, and Dr. Arciniegas is President of the International Brain Injury Association and a civilian contractor for the United States Army Medical Research and Materiel Command–Telemedicine & Advanced Technology Research Center. The opinions expressed and information presented in this work do not necessarily reflect the views of these organizations and are not expressly endorsed by them.

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Authors and Affiliations

  1. VISN 19 Mental Illness Research, Education, and Clinical Center, Denver Veterans Affairs Medical Center, 1055 Clermont Street, Denver, CO, 80220, USA

    Hal S. Wortzel MD

  2. Neurobehavioral Disorders Program, Department of Psychiatry, University of Colorado School of Medicine, Aurora, CO, USA

    Hal S. Wortzel MD & David B. Arciniegas MD

  3. Behavioral Neurology Section, Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA

    Hal S. Wortzel MD & David B. Arciniegas MD

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Wortzel, H.S., Arciniegas, D.B. Treatment of Post-Traumatic Cognitive Impairments. Curr Treat Options Neurol 14, 493–508 (2012). https://doi.org/10.1007/s11940-012-0193-6

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