Clinical practice guidelines on post-traumatic cognitive impairment: Assessment and remedial measures

INTRODUCTION Traumatic brain injury (TBI) is an increasingly urgent public health issue and a major cause of morbidity and mortality in India. As India advances in urbanization and experiences rapid motorization, the incidence of TBIs is expected to rise significantly. Individuals who survive a TBI often face chronic disabilities. These disabilities have a profound impact on various aspects of life, including cognitive, behavioral, psychosocial, physical, and vocational areas. Cognitive impairments are difficult to manage and cause problems for the patients and their families. These impairments in cognitive functions can negatively impact the activities of daily living, employment, social relationships, recreational activities, and active community participation. The severity of TBI can be mild or moderate or severe. This is decided depending on the consciousness. The major factor that is taken into account is the coma period; the other factor considered will be post-traumatic amnesia (PTA). Significant cognitive impairments are typically observed around 1 month after the injury or shortly after PTA resolves, and this is usually seen in severe TBI or moderate TBI. In patients with mild TBI, cognitive functions improve and this improvement will be rapid and within 3 months, they may reach their baseline.[1] Persistent cognitive impairments beyond 3 months are associated with a higher frequency of disability. In patients with severe or moderate TBI, the recovery in the cognitive domain may not happen even after 2 years. Research and literature indicate that timely and effective cognitive rehabilitation interventions following TBI can significantly improve the recovery process and reduce functional disability. To ensure effective treatment, it is crucial to develop detailed guidelines for cognitive rehabilitation in individuals experiencing multiple cognitive impairments as a result of TBI. Indian literature in this domain is limited. Hence, global studies and intervention modules have laid a path to develop management strategies and guidelines in the Indian context. Cognitive testing itself is still in infancy in Indian context.[2] Cognitive rehabilitation recommendations should become a priority in the Indian context for various reasons as mentioned in Table 1. Furthermore, there are many challenges in the formulation of guidelines for cognitive remediation and implementation in the Indian context, which are outlined in Table 2.Table 1: Why should cognitive rehabilitation in TBI patients be a priority?Table 2: Challenges in Formulation and Barriers for Implementation of Guidelines for Cognitive rehabilitation in patients with TBIScope and purpose of the present document This document provides evidence-based guidelines for evaluating and rehabilitating cognitive function in moderate TBI patients and in severe TBI patients. These are for all phases of care. The primary focus is on enhancing patient outcomes and managing cognitive impairments post TBI. While some aspects may apply to mild TBI, the guidelines are specifically tailored to moderate to severe TBI (MS-TBI) due to the increased complexity of cognitive issues associated with it. Key details including target population, process, limitations, and evidence level are summarized in Table 3.Table 3: Cognitive Rehabilitation post TBI: key areas, target population, the process followed, and limitationsTarget users This document can be used by the healthcare professionals, specifically for those working in the cognitive rehabilitation of TBI patients. Guidelines are based on the existing literature mainly from the global settings as Indian literature in this is limited. Defining traumatic brain injury According to ICD 11, “Damage inflicted on the tissues of the brain as the direct or indirect result of an external force, with or without disruption of structural continuity” constitutes TBI.[9] Furthermore, a case is defined as a head injury (brain) caused by blunt force, penetration, or acceleration–deceleration forces if it leads to one or more of these signs: changes in consciousness (noticed by others or reported by the person), memory loss, visible neurological or psychological issues, or an identified brain injury. The TBI can be concussion, subdural hemorrhage, extradural hemorrhage, or intraparenchymal hemorrhage. However, a simplest definition of TBI can be “a disruption in brain function or signs of brain damage caused by an external force”.[10] This external force can lead to breach in the skull structures or due to movement of the intracranial structures. Severity grading The next step in the process is severity grading. Based on the Glasgow coma scale (GCS),[11] the severity of TBI is classified into mild, moderate, and severe. For severe TBI, the GCS score should be ≤8; if the score is in the range of 9–12, then it is considered as moderate severity. Any score above 13 falls under the mild category. These scores are in the time frame of within 30 minutes of the injury. However, additional factors are used to grade the severity. These factors include post-traumatic amnesia and duration of loss of consciousness. This is depicted in Table 4. Further clinical evaluation and neuroimaging findings need to be included while assigning a severity grade. In mild TBI, the clinical features will be headache, dizziness, fatigue, confusion, memory issues, and sometimes subtle cognitive or emotional problems.Table 4: Severity of Traumatic Brain InjuryConfirmation that the cognitive impairments are due to TBI After confirming a TBI in a patient, the next step is to determine if their cognitive issues, such as complaints or impairments, are attributable to the injury. Although cognitive difficulties immediately following the injury might appear directly related to the TBI, the underlying causes can be varied. Considerations include the patient’s pre-existing cognitive abilities; other neurological, medical, or psychiatric conditions; additional physical problems from the injury (like headaches or seizures); the influence of substances or medications on cognition; trauma-related dissociative states; and the possibility of exaggeration or malingering. Estimation of preinjury cognitive functioning level is essential prior to attributing deficits to the TBI. The patient’s educational status and occupation level may hint about these. Alcohol and other substance use prior to the TBI will also impact the cognitive functioning of the individual. It is also crucial to compare the patient’s cognitive difficulties and functional limitations with what is expected for their specific type and severity of injury. Cognitive impairments are typically most pronounced right after the injury and tend to improve over time, though not always completely. If the patient’s cognitive issues do not follow this expected trajectory or cause functional impairments that cannot be fully explained by the TBI alone, further investigation into alternative or additional causes (including medications as mentioned Table 5) is necessary.Table 5: Medications that can significantly impact cognition in patients with TBIPsychiatric assessment and comorbidities of TBI A detailed psychiatric assessment prior to cognitive function evaluation is essential. This can be a clinical interview which can establish the diagnosis. Inpatient evaluation will be useful to evaluate and observe as single session evaluation may not yield a clear picture. Immediate assessment may not be useful as the recovery phase from ongoing physical ailments needs to settle. Post-TBI symptoms will be akin to the many psychiatric disorders, and differentiating them as independent entities or a part of the TBIs will be important.[12] History of pre-existing psychiatric diagnosis will help in evaluation as these may reappear or worsen post TBI.[12] Symptoms like irritability, anger, mood fluctuations, behavioral disturbances, and anxiety may be part of TBI and other psychiatric disorders which may pose a challenge in diagnosis. The prevalence of mood disorders varies in the range of 6–77%.[13] The prevalence of anxiety disorders is around 29% among all severities of head injuries, and right hemispheric TBIs are more commonly associated with anxiety disorders.[14] A 30-year follow-up study and a review revealed that generalized anxiety disorder is seen in 3–28% patients, panic disorder in 4–17% patients, phobias in 1–10% disorders, obsessive compulsive disorder in 2–15% patients, and post-traumatic stress disorder in 3–27% patients post TBI.[15,16] Psychotic symptoms post TBI are seen infrequently, and these will be in the form of hallucinations, delusions, and some disorganized thinking, which may manifest as inappropriate laughing, behavior, agitation, aggression, and ideas of reference. One review mentioned that 0.7–9.8% of TBI patients will develop schizophrenia like psychosis.[17] In a review, a three- to fourfold increased risk of death by suicide is found in comparison to the general population. Furthermore, the risk has been mentioned to persist for the first one and half decade post TBI.[18] Behavioral abnormalities like aggression may manifest in various ways. Aggression can present as verbal or physical aggression, violence, partner violence, sexual violence, or sexual disinhibition, or it can be part of other psychiatric disorders. A study reported the aggression frequency to be 11% to 96% (varied based on the tool used to assess aggression).[19] Management of these will involve symptomatic management. These are important because when unaddressed, these will be the hurdles in cognitive function assessment and any intervention modules which will be planned. Mental health professionals are involved to assess the disability following TBI, and Indian Disability Evaluation and Assessment Scale (IDEAS) provides a broader framework for the assessment disability across domains involving activities of daily living, communication, independent living, and work to name a few.[20] Before initiating evaluations and medication trials, it is essential to conduct thorough investigations. Hematological and biochemical investigations are essential and are part of routine care: hemogram, serum electrolytes, blood sugar, hormonal assay when needed, cardiac evaluation, and infection workup as and when indicated. In clinical practice, getting an MRI scan done before starting a neuropsychiatric evaluation and intervention plan is needed. Invariably, MRI brain would have been done. 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