Neuropsychological evaluation consists of a clinical evaluation to understand an individual’s cognitive strengths and deficits. A neuropsychological evaluation may be completed for various reasons such as educational planning, documenting deficits due to a neurologic injury, or establishing the presence of a neurologic injury. To complete a neuropsychological evaluation, the individual must be able to follow simple directions, answer simple questions, and cooperate with the examiner. Due to these restrictions, neuropsychological evaluation cannot be completed with an individual who is in a coma, who is paralyzed and unable to speak, or who refuses to cooperate with the procedure.
Neuropsychological evaluation is often used to help in rehabilitation treatment planning and discharge planning. The results of a neuropsychological evaluation can be used to determine if the individual is able to make competent decisions, is able to return to competitive employment, able to drive a vehicle, etc. Recommendations can be made regarding the individual’s need for supervision, structure, and support.
Neuropsychological evaluation consists of standardized tests that allow an individual’s performance to be compared to others to determine his/her level of functioning. These tests look at functions such as auditory attention, working memory, learning slope, auditory memory, visual memory, problem solving, complex/divided attention tasks, visual processing, language skills, and motor skills. By comparing the individuals scores on these tasks areas of deficit can be identified and related to areas of brain injury/neurologic dysfunction.
In the early stages of recovery, neuropsychological evaluation will consist of determining the individual’s level of alertness and responsiveness. As she/he becomes more interactive, basic tests will determine if he/she is able to follow directions, to respond to stimuli, and to interact with the environment. Serial evaluations are beneficial to track the individual’s recovery over time and her/his response to therapeutic interventions. When a child has a brain injury, serial neuropsychological evaluation are important to track changes in his/her cognitive functioning, and her/his ability to reach expected stages of brain maturation.
Neuropsychological evaluations are often used to establish the degree of cognitive damage caused by a traumatic brain injury and how the damage will impact the individual’s ability to work, complete self-care independently, live independently, and interact with others. At times, the neuropsychological evaluation will be used to establish the presence or absence of cognitive deficits secondary to traumatic brain injury. This can happen when the objective measures, such as CTs or EEGs, have not demonstrated clear evidence of the degree of damage that has occurred. Tests of motivation are used during these evaluations to help determine if the individual is putting forth full effort, or possibly attempting to exaggerate the degree of deficit. A neuropsychologist will also examine the pattern of deficits to determine if the pattern is internally consistent, and if the pattern is consistent with the reported injury.
CT – Computerized Tomography
CT is used to initially evaluate potential damage to the skull and to the brain structures. It consists of multiple x-rays of the brain that can be taken in various orientations to highlight various areas of the brain. It is extremely useful in identifying areas of blood in the brain, and changes to the ventricles.
MRI – Magnetic Resonance Imaging
MRI is use to evaluate damage to the brain structures. The MRI consists of a reading of the magnetic impulses emitted from proteins in the brain and is very sensitive to the gray/white matter of the brain, and areas of chronic blood.
An angiogram is comprised of x-rays taken of the brain’s vascular structure. A dye is injected into the blood stream to help highlight the vascular structure of the brain.
EEG – Electroencephalogram
An EEG reveals the electrical impulses transmitted throughout the brain. Contact leads are attached to various spots on the skull to record the electrical impulses in each area of the brain. Brainwaves are detected as are epileptiform discharges and spikes. These can be tracked to a specific brain area and reflect the actual functioning of the brain.
QEEG – Qualitative Electroencephalogram
A QEEG is a more complex version of the traditional EEG. The QEEG is intended to be able to evaluate the brainwave patterns throughout the brain and compare them to samples of individuals with other neurologic issues.
PET Scan – Positron Emission Tomography
A PET scan uses a radionuclide tracer to produce positrons that emit two gamma rays that are detected. The tracer tends to be a glucose analog which allows the PET scan to detect the active uptake of glucose and image the actual function of the brain. This shows what areas of the brain remain active following an injury.
SPECT scan – Single Photon Emission Computed Tomography
The SPECT scan is similar to a PET scan with the exception that only one gamma ray is detected. It is a functional scan of the brain and will show areas of the brain that are actively using glucose demonstrating an increased level of activity.
When someone has suffered a brain injury, once they have been evaluated in the trauma unit, they are often admitted to the neurologic intensive care unit. On that unit, they will be continually monitored for signs that they are becoming more responsive. The staff will observe the brain injured patient for signs that they are opening their eyes, moving their extremities, attempting to speak, etc. The individual will often be intubated for protection of their airway which may include sedation that will reduce their responsiveness. This sedation is usually administered intravenously, and the neurologist will have the medications stopped for a period of time prior to evaluating their neurologic functioning. As the individual becomes more medically stable, they will eventually be transferred to a general medical floor where they will continue to be monitored, but will not require the same intensity of medical interventions.
Medications in survivors of traumatic brain injuries (TBI) should be used sparingly with the focus being on ameliorating or decreasing, psychiatric symptoms, behavioral manifestations and maladaptive behaviors that can interfere or impede the rehabilitative process. Survivors of TBI can present with a myriad of psychiatric symptom manifestations, with the most common ones being depression, explosivity (violent behaviors), which may be situational as well as out of the blue, apathy, lack of interest, anhedonia, particularly in individuals with frontal lobe trauma. In individuals with dominant hemisphere trauma, symptoms may include psychosis (being out of touch with reality), auditory or visual hallucinations, delusions (having fixed firm beliefs) which may be paranoid or persecutory in nature, symptoms of bipolarity with manic qualities such as pressured speech, racing thoughts, poor concentration, increased energy with alterations in circadian rhythms are common in survivors of TBI with the most common symptoms being insomnia, difficulty falling asleep, maintaining sleep or reversal of sleep-wake cycle. Survivors of TBI may experience a change in personality either regressive or expansive of underlying pre-morbid personality traits. It is not unusual for survivors of TBI to develop dis-inhibition and may act out in a sexually inappropriate manner towards self or others. From a cognitive stand point, survivors of TBI usually experience deficits in recent memory, recall and working memory. With executive dysfunction, i.e. difficulty with organization, there is an inability to complete tasks in a sequential fashion, attention deficit, poor concentration and difficulty with abstract concepts, frequently found as sequelae to TBI, particularly frontal lobe injuries. What the family members or support group of a survivor should remember is that symptoms and behaviors change with time from the date of injury. What is initially seen in terms of symptoms-behaviors will change, improve or fluctuate, as time goes by. Most individuals reach maximum medical improvement 1 ½ to 2 years from the date of injury.
In an effort to help survivors of TBI and their loved ones understand the advantages and disadvantages of psychiatric medications, Dr. Villalba, M.D. FAA CAP, has compiled a brief synopsis of same, with emphasis on how these medications affect an individual who has had a TBI. The emphasis, however, is that there is no such thing as “one size fits all” treatment, and what is effective for one individual may not be effective or even contraindicated in another.
Generally work by increasing serotonin and or norepinephrine in the connection between neurons (synapse), decrease in these neurotransmitters have been implicated in the development of mood disorders. Low serotonin levels in the central nervous system (CNS) have also been implicated with violent behaviors to self (suicidality) and others. Anti-depressants are generally classified according to the neurotransmitter they affect such as SSRI for selective serotonin re-uptake inhibitor or SSNERI mixed type. There are older anti-depressants called tricyclic anti-depressants which also have similar pharmacological action depending on whether they are a tertiary or secondary amine such as Amitriptyline (Elavil) and Nortriptyline (Pamelor), respectively. Elavil is sometimes used for its pain management properties as well as an anti-depressant.
SSRI’s: fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Citalopram (Celexa), escitalopram (Lexapro), duloxetine (Cymbalta), fluvoxamine (Luvox)
- Uses: depression, irritability, anxiety, obsessive-compulsive disorder, trichotillomania, premature ejaculation, social anxiety-phobias, apathy, psychomotor retardation, anhedonia, eating disorders.
- Advantages: generally work well with therapeutic effects seen in 2-3 weeks, the obsessive-compulsive disorder may have a longer period for therapeutic effect, sertraline (Zoloft) has a low drug to drug interaction.
- Disadvantages: may lower the seizure threshold, can have activating features, i.e. causing increased aggression or even mania, rebound anxiety upon discontinuation especially true of Paroxetine (Paxil), can affect serum levels of other medications such as anticonvulsants, can cause erectile dysfunction, weight gain, reports of increased suicidal ideation, inappropriate antidiuretic hormone (SIADH), decrease in serum sodium, akathisia, motor restlessness (inability to sit still) especially common in the elderly.
S-NERI: Serotonin – Norepinephrine reuptake inhibitor, venlafaxine (Effexor) works on the two major neurotransmitters implicated in depression.
- Uses: depression, anxiety
- Advantages: may have activating-energizing features, may improve attention and concentration.Disadvantages: may also lower seizure threshold, may cause an increase in blood pressure (usually modest), may cause activation-mania, hyponatremia (low serum sodium) due to SIADH, serotonin syndrome, and cardiac arrhythmias (rare). Buproprion (Wellbutrin)is a miscellaneous anti-depressant that may work by blocking the re-uptake of dopamine.
- Uses: depression, smoking cessation, attention deficit disorder short attention span in individuals with Attention Deficit Disorder.
- Disadvantages: may significantly lower seizure threshold (5%) and is contraindicated in individuals with a seizure disorder or eating disorders such as anorexia nervosa or bulimia. Should be used with extreme caution in individuals with head injuries. Can be activating but is generally considered to be the least activating for the development of manic symptoms.
Buproprion (Wellbutrin)is a miscellaneous anti-depressant that may work by blocking the re-uptake of dopamine.
- Uses: depression, smoking cessation, attention deficit disorder short attention span in individuals with Attention Deficit Disorder.
- Disadvantages: may significantly lower seizure threshold (5%) and is contraindicated in individuals with a seizure disorder or eating disorder such as anorexia nervosa or bulimia. Should be used with extreme caution in individuals with head injuries. It can be activating but is generally considered to be the least activating for the development of manic symptoms.
Typical antipsychotics: generally older medications, are generally less expensive, have been proven to be just as efficacious in the treatment of psychosis (see CATIE trials) but may have more extrapyramidal symptoms pseudo-Parkinsonian symptoms i.e. motor restlessness – or retardation Akathisia-Akinesia, dystonias and tardive dyskinesia (TD), which are irreversible involuntary movements (note: atypical antipsychotics such as risperidone (Risperdal) have also been known to cause Tardive Dyskinesia (TD). Typical antipsychotics may also be less efficacious on negative symptoms such as flattening of effect, social withdrawal and cognitive dulling than some but not all of the atypical anti-psychotics. They work by blocking the neurotransmitter dopamine at the level of the D2 receptor.
- Examples of typical anti-psychotics: chlorpromazine (Thorazine), fluphenazine (Prolixin), haloperidol (Haldol), perphenazine (Trilafon), trifluoperazine (Stelazine), molindone (Moban).
- Uses: psychosis, agitated states, tics, Gilles de la Tourette Syndrome, all psychiatric disorders associated with psychotic states, Bipolar Disorder.
- Advantages: work well on hallucinations, delusions, formal thought disorders, agitation, violent patients.
- Disadvantages: can lower the seizure threshold, anticholinergic side effects i.e. dry mouth paralytic ileus, Tardive Dyskinesia, pseudo-Parkinsonian Symptoms i.e. flat affect, shuffling gait (Thorazine shuffle), neuroleptic malignant syndrome, weight gain (exception Moban), hyperlipidemia and diabetes (may be less pronounced than the atypical anti-psychotics, especially when compared to Olanzapine (Zyprexa)), extrapyramidal symptoms, dystonias, cardiac arrhythmias, hyponatremia, leukopenia-neutropenia and decrease in white blood cell count.
Atypical antipsychotics: block the re-uptake of dopamine at the level of D2-D4 (Clozapine) but also block the receptor for serotonin 5-HT – which has been linked to hallucinations. They have less cognitive dulling and pseudo-parkinsonian symptoms than the typical antipsychotics and have a more therapeutic effect on negative symptoms such as social withdrawal or flat affect. Clozapine (Clozaril ) and Olanzapine (Zyprexa) have been known to reverse symptoms of TD (tardive dyskinesia).
- Examples of atypical anti-psychotics: Risperidone (Risperdal), Olanzapine (Zyprexa), Aripiprazole (Abilify), Ziprasidone (Geodon), Quetiapine (Seroquel), Clozapine (Clozaril), Paliperidone (Invega).
- Advantages: less extrapyramidal symptoms than typical anti-psychotics, less cognitive dulling, have a positive effect on negative symptoms.
- Disadvantages: weight gain, hyperlipidemia diabetes, aripiprazole (Geodon), more weight neutral.
Anticonvulsants such as valproic acid (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), oxcarbazepine (Trileptal), lithium carbonate (Eskalith, Lithobid). These anticonvulsants are useful in the treatment of explosivity, violent behaviors, bipolar symptomatology, manic symptoms such as pressured speech, racing thoughts lability of mood, poor sleep, increased energy. In addition, valproic acid (Depakote) is useful for the treatment of post-traumatic headaches, migraines, and hyper-arousability associated with post-traumatic stress disorder.
- Advantages: useful for the treatment of seizures, bipolar symptomatology, post-traumatic headaches, frontal lobe syndrome, intermittent explosive disorder, post-traumatic stress disorder, (lithium) treatment-resistant depression.
- Disadvantages: side effects with anti-convulsants are generally rare and reversible but do occur, frequent blood monitoring is essential. These may include: bone marrow suppression, decreased white blood cell count, decreased red blood cell count, decreased platelet counts, hepato-toxicity, liver failure (especially in children), pancreatitis, cardiac arrhythmias, and lethal skin rashes are possible but rare. Lithium can slightly increase white blood cells (leukocytosis) with no clinical significance, can bind to the thyroid gland causing hypothyroidism treated with thyroid hormone supplementation, can cause polyuria, polydipsia (increased thirst and urination) and increase in serum sodium. Both anticonvulsants and lithium can cause a mild essential tremor as well as hair loss.
Used to prevent and reverse extrapyramidal symptoms associated with medications that decrease dopamine, i.e. anti-psychotics, generally used in combination with an antipsychotic agent.
- Advantages: work well on dystonias, akathisia, akinesia (EPS).
- Disadvantages: cause dry mouth, urinary retention, blurry vision, constipation, will not reverse tardive dyskinesia.
- Examples of anticholinergics: Benztropine (Cogentin), trihexyphenidyl (Artane), diphenhydramine (Benadryl).
Can be useful in treating individuals with attentional difficulties, apathy, psychomotor retardation, stuporous conditions and, of course, attention deficit disorder with and without hyperactivity in children and some adults.
- Examples of stimulants: methylphenidate (Ritalin), dextroamphetamine (Dexedrine), dextroamphetamine/amphetamine (Adderall), Modafinil (Provigil), armodafinil (Nuvigil), to name a few.
- Advantages: generally medications such as methylphenidate, dextroamphetamine have a short half-life (eliminated quickly from the body), work well on increasing attention and concentration, have a calming effect on hyperactive children, increase alertness, decreased need for sleep.
- Disadvantages: can lower the seizure threshold, can cause motor tics, decrease appetite, cause insomnia, can cause irritability-mood swings, some individuals can have idiosyncratic responses i.e., can prolong being in a coma rather than reversing it.
Can be useful in the treatment of tremors and headaches, violent behavior.
- Examples of beta-blocker: propranolol (Inderal), pindolol, atenolol (Tenormin).
- Advantages: works well on essential tremors, vascular headaches may respond to this medication, some violent individuals with episodic dyscontrol may respond to high doses of beta-blockers.
- Disadvantages: may cause bronchial constriction, may mask hypoglycemia, contraindicated in asthmatics and diabetics, may decrease heart rate (bradycardia), lowers blood pressure. Not always effective, may require doses to achieve therapeutic results in violent behavior that the individual cannot tolerate because of side effects.
Useful in the treatment of anxiety, seizures, insomnia (short term), violent behavior agitation as needed. Some benzodiazepines such as alprazolam (Xanax) can have antidepressant properties, used for withdrawal states.
- Advantages: short half-life benzodiazepines such as lorazepam (Ativan) are very useful in short term treatment of agitation and aggression. Long half-life benzos, such as Klonopin are useful in the treatment of seizure disorder, Benzodiazepines are not irritants to the central nervous system.
- Disadvantages: have abuse potential, cause tolerance, can cause memory loss, disinhibition.
- Example of benzodiazepines: clonazepam (Klonopin), lorazepam (Ativan), diazepam (Valium)
Individuals who have had a TBI are prone to sleep disturbances primary – secondary insomnia, a reversal of sleep-wake cycle, etc. Hypnotics are useful for short term management of sleep disorders. Some individuals may require longer treatment due to chronic insomnia. The main issue is the development of tolerance such as in the use of benzodiazepines with short half-life triazolam (Halcion). Medications that work on re-establishing circadian rhythms such as Rozerem and melatonin may be useful.
- Advantages: helps re-establish normal sleep patterns, establishes a sleep-wake cycle.
- Disadvantages: can cause tolerance, some individuals have amnesia and will even drive cars or perform other chores while asleep.
- Examples of Hypnotics: Zolpidem (Ambien), Triazolam (Halcion), Temazepam (Restoril), Trazodone (Desyral) though an antidepressant is often used as a hypnotic.
There have been some studies showing mild improvement in cognition (memory) in individuals with TBI who were treated with medications for Alzheimer’s. Some of these medications such as donepezil (Aricept) work by decreasing the degradation of acetylcholine the major neurotransmitter implicated in memory storage.
- Advantages: may help in improving recent memory.
- Disadvantages: not always effective, may lower the seizure threshold, can cause insomnia, depression, anorexia, urinary frequency, headaches, syncope.
- Example of cognitive enhancers: donepezil (Aricept), rivastigmine (Exelon), memantine (Namenda)
Clonidine (Catapres) and guanfacine (Tenex) are used (off label) in children with hyperactivity, poor impulse control. They work by downregulating the neurotransmitter norepinephrine. They work synergistically when used with lithium carbonate.
- Advantages: have a therapeutic effect on motor tics, decrease hyperactivity.
- Disadvantages: may cause irritability, sedation, lowers blood pressure, reports of cardiac arrhythmias, rebound hypertension if abruptly discontinued.
- Examples: clonidine (Catapres), guanfacine (Tenex).
In conclusion, survivors of TBI should be treated if at all possible with the least amount of medications. Symptoms and maladaptive behaviors that interfere with the rehabilitative process should be treated. Initial reasons for treatment will usually change as the survivor undergoes rehabilitation and nears maximum medical improvement (MMI). Attempts (when possible) to taper or wean off of psychiatric medications as the individual’s date of injury progresses should be made. Polypharmacy and the use of two or more medications of the same class should be avoided. The clinician and the loved ones of the survivor should be cognizant of the fact that psychiatric manifestations are common in TBI and not always permanent, but may represent a bump in the road in the rehabilitative process.
Behavior Services in Brain Injury Rehabilitation
A significant number of individuals who have suffered brain injuries have problematic behaviors following their acute rehabilitation. These behaviors may include increased anger, aggression, agitation, inappropriate sexual behaviors, drug use, or self-injury. To address these types of behaviors, Behavior Services begin by blocking the harmful actions and determining the goal of the behavior. Behavior Specialist will study the actions that precede the behavior, the actual behavior itself, and the consequences of the behavior. The individual’s behaviors can then be modified by adjusting the environmental factors that generally precede the action, teaching the individual alternate methods to respond to the factors, and providing desired results for the appropriate alternative responses. This may require multiple repetitions and extended time to ensure that the individual has adopted the new actions and uses the appropriate acceptable responses consistently.