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Mild Neurocognitive Disorder due to Traumatic Brain Injury
According to Petersen et al. (2018), mild cognitive impairment of all etiologies affects about 7% of the population in their early sixties then sharply increases to up to a quarter of the octogenarian population. Dementia will develop in up to 15% of this 65-and-over group.
As for mild traumatic brain injuries, Willis, Williams, Sladky, and McClean (2015) explain that although these patients typically have favorable recoveries soon after the injury regardless of age group, the risk of future neuropsychiatric deterioration from inflammation, impaired blood flow, and reduced plasticity is always there. Any preexisting condition like ADHD or behavioral disorders can also compound a neurocognitive disorder that arises after a brain injury, as can consequent PTSD from the injury event itself. Secondary brain injuries as those seen in certain sports can magnify the impact and severity of traumatic neurocognitive decline (Willis, Williams, Sladky, and McClean, 2015).
The DSM-5 lists the diagnostic criteria for Mild Neurocognitive Disorder due to Traumatic Brain Injury in a fairly straightforward way. Mild neurocognitive disorder (generally speaking) is characterized by a clinically verified modest deterioration in learning, memory, complex attention, language, social aptitude, executive function, or perceptual-motor ability; none of which should be the result of delirium or a psychotic/mood disorder. Despite this decline, the patient should still be able to perform their basic and instrumental daily activities with little to no difficulty (American Psychiatric Association, 2013).
For Mild Neurocognitive Disorder due to Traumatic Brain Injury in particular, the decline in cognition would have presented and persisted after a head injury in which the brain was displaced within the cranium and caused the patient at least one of the following: losing consciousness, confusion, amnesia, disorientation, and/or changes or decline in neurological status (American Psychiatric Association, 2013). The brain injury could be the result of anything from a seemingly mild concussion to a serious closed-head injury.
As for psychotherapy, there does not appear to be any specific psychotherapeutic approach since Mild Neurocognitive Disorder Due to Traumatic Brain is more of a structural change in the brain rather than of a psychological nature. However, reminiscence therapy has been used for years in patients with all degrees of neurocognitive changes with success. The goal of guiding the patient to reminisce is to help stimulate and preserve as much mental function as possible through improved self-esteem and communication skills, and enhanced individuality and identity. Reminiscence involves boosting attention span and encouraging recall, vocalization, and interaction with others (Dempsey et al., 2014).
The American Academy of Neurology (AAN) does not have any official psychopharmacological recommendations for treating mild cognitive impairment, but cholinesterase inhibitors can be used off-label should the patient wish to try them. It would be off-label because there is not enough evidence to suggest these drugs are useful when cognitive decline is mild. Instead, the AAN asserts that clinicians should use validated assessment tools to detect neuropsychiatric or behavioral symptoms, modifiable risk factors, and functional impairment. Any medications that could further impair cognitive function should be stopped if feasible, and patients should be encouraged to engage in cognitive training and biweekly physical exercise (Petersen et al., 2018).
In the context of neurocognitive decline, cholinesterase inhibitors essentially increase the availability of acetylcholine in the brain by preventing its breakdown into choline and acetate, and this can be useful in counteracting the effects of the death of acetylcholine-producing cells that is normally seen in neurodegenerative disorders. However, too much acetylcholine can cause the parasympathetic nervous system to over activate resulting in bradycardia, hypotension, hypermotility, and miosis. A cholinergic crisis can be recognized with the ‘SLUDGE’ mnemonic: salivation, lacrimation, urination, diaphoresis, GI upset, and emesis (Singh & Sadiq, 2021). The risk of these adverse effects may not outweigh the potential benefits in someone who only has Mild Neurocognitive Disorder due to Traumatic Brain Injury.
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Dempsey, L., Murphy, K., Cooney, A., Casey, D., O’Shea, E., Devane, D., Jordan, F., & Hunter, A. (2014). Reminiscence in dementia: a concept analysis. Dementia (London, England), 13(2), 176–192. https://doi.org/10.1177/1471301212456277
Petersen, R. C., Lopez, O., Armstrong, M. J., Getchius, T., Ganguli, M., Gloss, D., Gronseth, G. S., Marson, D., Pringsheim, T., Day, G. S., Sager, M., Stevens, J., & Rae-Grant, A. (2018). Practice guideline update summary: Mild cognitive impairment: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology, 90(3), 126–135. https://doi.org/10.1212/WNL.0000000000004826
Singh. R., Sadiq. N.M. (2021). Cholinesterase Inhibitors. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK544336/
Willis, A.M., Williams, J.P., Sladky, J.H., McClean, J.C. (2015). Management of Mild Traumatic Brain Injury. Psychiatric Times, 32(2).
