Dementia in Head Injury

Symptoms of dementia resulting from head injuries may include problems thinking clearly, memory loss, difficulty concentrating, slowed thought processes, irritability, easy frustration, impulsiveness, mood swings, and more.

A head injury occurs when an outside force hits the head hard enough to cause the brain to move violently within the skull. This force can cause shaking, twisting, bruising (contusion), or sudden change in the movement of the brain (concussion).

• In some cases, the skull can break. If the skull is not broken, the injury is a closed head injury. If the skull is broken, the injury is an open head injury.
• In either case, the violent jarring of the brain damages brain tissue and tears nerves, blood vessels, and membranes.
• The severity of this damage depends on the location and force of the blow to the head.

Do concussions cause dementia?

Damaged brain tissue does not work normally.

• The brain has many different functions in the body, and any of them can be disrupted by this damage.
• Not all brain damage is permanent. Like all body organs, the brain can heal to a certain extent.
• Even this healing may not bring the brain’s function back to what it was before the injury.

Even a relatively mild head injury can cause prolonged or permanent declines in cognition. (Cognition is the process of thinking, remembering, understanding, reasoning, and communicating.) Head injury can also cause changes in emotions or behavior.

• Together, these changes are known as dementia.
• The nature of dementia in head-injured persons varies greatly by type and location of head injury and the person’s characteristics before the head injury.

After a head injury, a person may have symptoms such as changes in personality, emotional problems, and difficulty making decisions or solving problems.

• The exact symptoms depend on the parts of the brain that are injured.
• Likewise, the severity of symptoms can be related to the severity of the brain injury, but this is not always true.
• If the injury is not too severe, these symptoms may get better over time.

Direct damage to brain tissue and surrounding areas account for only part of the problems in head injury. The resulting bleeding (bruising), fluid collection (hydrocephalus), and infection can also damage the brain. A common complication is an epilepsy (seizures).

Dementia after a head injury is a significant public health problem.

• In the United States, an estimated 1.7 million people each year have some kind of head injury. Many do not seek medical care.
• Approximately 275,000 people are hospitalized in the United States every year for a head injury.
• Younger people are more likely to have a head injury than older people. Head injury is the third most common cause of dementia, after infection and alcoholism, in people younger than 50 years.

Can a fall in the elderly cause dementia?

• Older people with head injuries are more likely to have complications such as dementia. Children are likely to have more severe complications.
• Men, especially younger men, are more likely than women to have a head injury.

The following are the most common causes of head injury in civilians:

• Motor vehicle accidents
• Falls
• Assault or gunshot wound
• Sports, such as boxing (dementia pugilistica), or other recreational activity

The use of alcohol or other substances is a factor in about half of these injuries.

Certain groups are more likely than others to sustain a head injury.

• In children, bicycle accidents are a significant cause of head injury.
• Most head injuries in infants reflect child abuse. A common name for this is shaken baby syndrome.
• Elderly persons are especially likely to injure themselves by falling.

Dementia-related symptoms in head injury are those that affect thinking and concentration, memory, communication, personality, interactions with others, mood, and behavior.

• These are only some of the symptoms that might be experienced after a head injury.
• Individuals experience different combinations of these symptoms depending on the part of the head-injured, the force of the blow, the damage caused, and the person’s personality before the injury.
• Some symptoms appear rapidly, while others develop more slowly.
• In most cases, symptoms have at least started to appear in the first month after the injury.

Symptoms of dementia in head-injured persons include the following:

• Problems thinking clearly
• Memory loss
• Poor concentration
• Slowed thought processes
• Irritability, easily frustrated
• Impulsive behavior
• Mood swings
• Inappropriate behavior in social situations
• Grooming and dressing eccentric or neglected
• Restlessness or agitation
• Insomnia
• Aggression, combativeness, or hostility
• Headache
• Fatigue
• Vague, nonspecific physical symptoms
• Apathy

Some people develop seizures after a head injury. These are not part of dementia, but they can complicate the diagnosis and treatment of dementia.

Major mental disorders may develop after head injury. Two or more of these may appear together in the same person.

• Depression - Sadness, tearfulness, lethargy, withdrawal, loss of interest in activities once enjoyed, insomnia or sleeping too much, weight gain or loss
• Anxiety - Excessive worry or fear that disrupts everyday activities or relationships; physical signs such as restlessness or extreme fatigue, muscle tension, sleeping problems
• Mania - State of extreme excitement, restlessness, hyperactivity, insomnia, rapid speech, impulsiveness, poor judgment
• Psychosis - Inability to think realistically; symptoms such as hallucinations, delusions (false beliefs not shared by others), paranoia (suspicious and feeling of being under outside control), and problems thinking clearly; if severe, behavior seriously disrupted; if milder, behavior bizarre, strange, or suspicious
• Obsessive-compulsive symptoms - Development of obsessions (uncontrolled, irrational thoughts and beliefs) and compulsions (odd behaviors that must be carried out to control the thoughts and beliefs); preoccupation with details, rules, or orderliness to such a degree that the larger goal is lost; lack of flexibility or ability to change
• Suicide risk - States feelings of worthlessness or that life is not worth living or that world would be better off without him or her talks about suicide, states intention to commit suicide, develops a plan to commit suicide

Any of the symptoms and signs described in the Symptoms section warrants a visit to the person’s health care provider. This is true regardless of whether the person has a known head injury. Be sure the health care provider knows about any falls or accidents that could have involved even a mild head injury.

In most cases, the appearance of dementia symptoms is clearly linked to a known head injury. The health care provider will ask for a detailed account of the onset of symptoms. This account should include the following:

• The exact nature of any injury and how it happened, if known
• Medical attention received in the period immediately after the injury: Hospital emergency room or other medical records should be available.
• The person’s state since the injury
• A description of all symptoms and their timing and severity
• An account of all treatment undergone since the injury
• Whether any legal action is pending or under consideration

The medical interview will ask for details of all medical problems now and in the past, all medications and other therapies, family medical history, work history, and habits and lifestyle.

• In most cases, a parent, spouse, adult child, or other close relative or friend should be available to provide information that the head-injured person cannot provide.
• At any time in this evaluation process, the primary health care provider may refer the head-injured person to a neurologist (specialist in disorders of the nervous system, including the brain).

A thorough physical examination will be done to identify neurological and cognitive problems, problems in mental or social function, and unusual appearance, behavior, or mood.

• The examination probably will involve tests of the person’s mental and emotional states. These involve answering the examiner’s questions or following simple directions.
• Many health care providers refer head-injured persons for neuropsychological testing. This is the most reliable way to document cognitive impairments following head injury.

Neuropsychological testing

Neuropsychological testing is the most sensitive means of identifying dementia in persons with a head injury. It is carried out by a specialist trained in this specific area of clinical psychology. The neuropsychologist uses clinical rating scales to identify subtle cognitive problems. This testing also establishes clear baselines for measuring changes over time.

Imaging studies

Head injury warrants a brain scan to detect which parts of the brain are injured.

• CT scan is a type of x-ray that shows details of the brain. It is the standard test for a person who has had a head injury. A scan performed 1-3 months after injury may detect damage not visible immediately after the injury.
• MRI is more sensitive than CT scan in demonstrating certain types of injury.
• Single-photon emission computed tomography (SPECT) scan is a relatively new imaging method that is still being studied in people with head injuries. It may be better than a CT scan or MRI in detecting functional problems in the brain. SPECT is available only at some large medical centers.

Other tests

Electroencephalogram (EEG) measures the electrical activity of the brain. It may be used to diagnose seizures.

Head injuries often bring an abrupt “coping crisis.” The sudden adverse changes that go with a head injury inevitability cause many emotions. Anxiety is a common response, and the person may become demoralized or depressed. Damage to the brain may impair the person’s ability to cope at a time when the need to adapt is greatest. Persons with head injuries typically are more distressed and have more difficulty coping with their injury than persons who have other types of injuries.

Usually, a particular family member assumes most of the responsibility for the injured person’s care. Ideally, more than one family member should be closely involved in caregiving. This helps family members share the burdens of providing care and helps the primary caregiver keep from becoming isolated or overwhelmed. Caregivers should be included in all significant interactions with health care professionals.

Caregivers must encourage and expect the injured person to be as independent and productive as possible. At the same time, caregivers need to be patient and tolerant. They should accept that the person may have real limitations and that these will likely worsen if the person is tired, ill, or stressed. Emphasizing what the person can still do, rather than what seems to be lost, is helpful.

With head injuries, the greatest improvement is expected in the first 6 months, but delayed improvement is possible as long as 5 years after injury.

The extent to which a person with a head injury can care for himself or herself at home depends on his or her disabilities. If self-care is possible, a plan should be developed with input from the professional care team and family members. The team should assess the person’s ability to function on his or her own and comply with medical treatment. In many cases, the person must be supervised by a caregiver to ensure compliance and safety.

The injured person's surroundings must be neither too calm nor too hectic. He or she should have regular routines of light and dark, eating, sleeping, relaxing, using the bathroom, and taking part in rehabilitation and leisure activities. This helps the injured person remain emotionally balanced and minimizes the caregiver’s burden.

• The environment should be made safe by taking away area rugs to reduce falls, removing hazards, providing tub bars, and putting child locks on cabinets or stove knobs if necessary.
• If the patient is capable of going out alone, he or she should know the route well, carry identification, wear a medic alert bracelet, and be able to use phones (especially cell phones) and public transportation.

Caregivers must decide whether the person should have access to checking accounts or credit cards. In general, the person should continue to handle his or her own money if he or she seems willing and able. The caretaker can get power of attorney to monitor the person's financial responsibility. If the person has a markedly poor judgment or seems unable to handle financial matters, the caregiver should seek formal conservatorship, which gives legal authority to manage the person's resources.

Many over-the-counter (nonprescription) drugs can interfere with medications that might be prescribed by the health care team. These interactions can decrease how well the prescription drugs work and might worsen side effects. The person’s care team must know what sorts of nonprescription medications the head-injured person uses.

Caregivers should seek help if the person has very disrupted sleep, does not eat enough or eats too much, loses control of his or her bladder or bowels (incontinence), or becomes aggressive or sexually inappropriate. Any marked change in behavior should prompt a call to the professional who is coordinating the person’s care.

The head-injured person who has become demented benefits from emotional support and education. This may include any of the following:

• Behavior modification
• Cognitive rehabilitation
• Medication for specific symptoms
• Family or network intervention
• Social services

One goal of these interventions is to help the head-injured person adapt to his or her injury mentally and emotionally. Another is to help the person master skills and behaviors that will help him or her reach personal goals.

• These interventions also help family members learn ways that they can help the head-injured person and themselves cope with the challenges a head injury poses.
• These interventions can be especially important in establishing realistic expectations for outcome and pace of improvement.

Behavior modification

Behavior modification is very helpful in the rehabilitation of brain-injured persons. These techniques may be used to discourage impulsive, aggressive, or socially inappropriate behavior. They also help counteract the apathy and withdrawal common in head-injured persons.

• Behavior modification rewards desired behaviors and discourage undesirable behaviors by withdrawing rewards. The goals and rewards are, of course, tailored to each individual. The family usually becomes involved to help reinforce the desired behaviors.
• Persons who have insomnia or other sleep disturbances are taught “sleep hygiene.” This instills daytime and bedtime habits that promote restful sleep. Sleeping pills are generally avoided in persons with a head injury, who are more sensitive to the side effects of these drugs.

Cognitive rehabilitation

In general, cognitive rehabilitation is based on the results of neuropsychological testing. This testing clarifies problems and strengths in persons with dementia. The goals of cognitive rehabilitation are as follows:

• Encouraging recovery in functions that can be improved
• Compensating for areas of permanent disability
• Teaching alternative means of achieving goals

For example, gradually increasing the time spent reading helps a person both improve concentration and develop confidence in his or her ability to concentrate. Keeping lists allows a person to compensate for decreased memory.

Medication

The use of medication to treat dementia symptoms in head-injured persons is discussed in the next section.

Family or network intervention

Head injuries often cause substantial family distress.

• Changes of personality in head-injured persons, especially apathy, irritability, and aggression, can be burdensome to family members, especially the main caregivers.
• Family members must understand that undesirable behaviors are due to the injury and that the head-injured person is unable to control these behaviors.

Even when family members understand that the person is unable to control his or her behavior, the person’s slowness, inappropriateness, and erratic responsiveness can be exasperating or even frightening.

• Family members become isolated from usual support, especially when the person’s impairments are severe, prolonged, or permanent.
• Counseling for family members, especially caregivers, is highly recommended by mental health professionals.
• Family caregivers can speak directly to the injured person’s health care provider to vent feelings and voice concerns. In many cases, the health care provider can refer the caregivers to professionals who can help solve problems and to family support groups. These interventions improve morale and help family members cope.

Social services

A trained social worker can help the head-injured person with dementia apply for disability benefits, locate specialized rehabilitation programs, attend to medical problems, and participate in treatment.

Dementia symptoms such as poor reasoning, impulsiveness, and poor judgment may render the person unable to make medical decisions or to handle his or her affairs. Social services can help in establishing a guardian, conservator, or other protective legal arrangements.

Persons with head injury may require medication to treat symptoms such as depression, mania, psychosis, aggression, irritability, mood swings, insomnia, apathy, or impaired concentration. Headaches may also get better with drug treatment.

Drugs used to treat such symptoms are called psychotropic or psychoactive drugs. They work by changing the way the brain works. Head-injured persons are more sensitive to drug side effects. Doses and schedules may require frequent adjustment until the best regimen is found.

Most people with dementia due to head injury are treated with the same drugs used to treat dementia or other causes. In many cases, these drugs have not been specifically tested in persons with a head injury. There are no established guidelines on psychotropic drug treatment after head injury.

Antidepressants

These drugs are used to treat depressive symptoms due to head injury.

• Selective serotonin reuptake inhibitors (SSRIs) are the antidepressants of choice because they work well and have tolerable side effects. The goal is to prescribe the drug with the fewest side effects and drug interactions. SSRIs also are used to treat behavioral disturbances resulting from head trauma. Examples include fluoxetine (Prozac) and citalopram (Celexa).
• Tricyclic antidepressants are used for people who cannot take SSRIs. They tend to have more side effects than SSRIs. Their advantages include that their levels can be measured in the blood and the dose adjusted readily. These drugs can cause problems with the heart and blood pressure. An example is amitriptyline (Elavil).
• Another group of antidepressants is useful for sleep disturbances in head-injured persons. These drugs are unrelated to other types of antidepressants and are less toxic in overdose. Examples are nefazodone (Serzone) and trazodone (Desyrel).

Dopaminergic agents

These drugs increase the amount of a brain chemical (neurotransmitter) called dopamine.

• Increasing the amount of dopamine may improve concentration, attention, and interest level in people who have sustained a head injury.
• These drugs may interact with antidepressants to improve mood swings.
• The most potent of these drugs is levodopa; it also has the most side effects.
• Other examples include bromocriptine (Parlodel) and the stimulant dextroamphetamine (Dexedrine), which increases levels of dopamine and another neurotransmitter called norepinephrine.

Antipsychotic agents

These drugs are used to treat psychotic symptoms such as agitation, delusions, and hallucinations.

• Traditional antipsychotics work well at relieving psychotic symptoms but are more likely to have side effects that may worsen cognitive function. These include haloperidol (Haldol).
• New antipsychotics (eg, risperidone [Risperdal], olanzapine [Zyprexa], quetiapine [Seroquel]) may be safer for demented patients than the traditional drugs. These drugs may work particularly well for the agitation and other psychotic symptoms common in head-injured persons.

Antiepileptic drugs

These drugs often work well in behavior disturbances (aggression, agitation) that occur as complications of head injury. They work by stabilizing mood. Examples include carbamazepine (Tegretol) and valproic acid (Depacon, Depakene, Depakote).

Mood stabilizers

Like some antiepileptic agents, the drug lithium (Eskalith, Lithobid) is a mood stabilizer. It is helpful in calming explosive and violent behavior. Lithium also decreases impulsive and aggressive behavior.

Benzodiazepines

These drugs quickly relieve agitation or violence in dementia. They have other uses, such as treating insomnia and relieving anxiety. Because they can worsen cognitive problems, they are not recommended in head-injured persons with dementia except as needed to calm a person rapidly. Examples are lorazepam (Ativan) and diazepam (Valium).

Beta-blockers

These drugs work well in treating aggression in some people with a head injury. They also reduce restlessness and agitation. An example of these drugs, which are most widely used to lower high blood pressure, is propranolol (Inderal).

Diet

Persons who are unable to prepare food or feed themselves are in danger of becoming malnourished. Their diets must be monitored to be sure that they are getting proper nutrition. Otherwise, no special dietary prescriptions or restrictions apply.

Activity

In general, the person should be as active as possible.

• In the early phases of rehabilitation, simple physical exercises and games may improve endurance and self-confidence. These activities should gradually increase in difficulty.
• Some head-injured persons may require devices to help them with mobility (walking or moving around). Persons using such mobility aids require monitoring to make sure they are safe.
• It may be necessary to change the surroundings to prevent falls and accidents that could cause repeat injuries.

Although medical professionals often recommend that the head-injured person resume normal activities or responsibilities, this is not always easily done.

• Persons who work at night, or whose work involves heavy machinery, hazardous conditions, or an overstimulating environment, may not be able to return to their previous positions.
• Returning to work before the person is ready may lead to failure and regression in recovery.
• The person may delay returning to work or previous activities for fear of further injury, embarrassment about disabilities, and uncertainty about abilities.
• A gradual return to work that allows the person to relearn or get used to the job is often helpful, although not always possible.

Persons who play contact sports should not return to play until cleared by their health care provider. Even a mild head injury makes the brain more fragile. A second blow to the head, even a very slight one, could cause a person with a recent head injury to die of sudden brain swelling. This is called second injury syndrome.

The head-injured person with dementia requires regularly scheduled follow-up visits with the medical professional coordinating his or her care. These visits give the coordinator a chance to check progress and make recommendations for changes in treatment if any are necessary.

Head injury and its resulting complications, such as dementia, are highly preventable.

• Use of protective gear in contact sports, seat belts and bicycle and motorcycle helmets aboard conveyances, and hard hats and safety equipment at work prevent head injuries.
• For elderly persons, altering the surroundings to lower the risk of falls is important.
• Protecting children from child abuse helps prevent head injuries.

A person who has experienced a head injury is at risk for further head injuries. Lower the danger by being aware of risk factors.

• Avoiding substance abuse makes further injury less likely.
• Some patients with head injury have suicidal thoughts. These people require immediate medical attention. In many cases, suicide can be prevented with treatment of depression, counseling, and other therapy.
• Athletes should not return to play until they have been cleared by their health care provider.

The outlook for persons with dementia after head injury is difficult to predict with certainty.

• In general, outcome relates to the seriousness of the injury. Outcome is not always predictable, however. Some persons recover fully from severe injuries; others remain disabled for long periods after much milder injuries.
• The dementia that follows head injury differs from other types of dementia. Many types of dementia, such as Alzheimer disease, get steadily worse over time. Dementia from head injury usually does not get worse over time. It may even improve somewhat over time. The improvement usually is slow and gradual and takes months or years.

If you are a caregiver, you know that caring for a head-injured person with dementia can be very difficult. It affects every aspect of your life, including family relationships, work, financial situation, social life, and physical and mental health. You may feel unable to cope with the demands of caring for a dependent, difficult relative. Besides the sadness of seeing your loved one’s condition, you may feel frustrated, overwhelmed, resentful, and angry. These feelings may in turn leave you feeling guilty, ashamed, and anxious. Depression is not uncommon.

Different caregivers have different thresholds for tolerating these challenges. For many caregivers, just “venting” or talking about the frustrations of caregiving can be enormously helpful. Others need more help, but may feel uneasy about asking for it. One thing is certain, though: if the caregiver is given no relief, he or she can burn out, develop his or her own mental and physical problems, and become unable to care for the person with dementia.

This is why support groups were invented. Support groups are groups of people who have lived through the same difficult experiences and want to help themselves and others by sharing coping strategies. Mental health professionals strongly recommend that family caregivers take part in support groups. Support groups serve a number of different purposes for a person living with the extreme stress of being a caregiver for a head-injured person with dementia:

• The group allows the person to express his or her true feelings in an accepting, nonjudgmental atmosphere.
• The group’s shared experiences allow the caregiver to feel less alone and isolated.
• The group can offer fresh ideas for coping with specific problems.
• The group can introduce the caregiver to resources that may be able to provide some relief.
• The group can give the caregiver the strength he or she needs to ask for help.

Support groups meet in person, on the telephone, or on the Internet. To find a support group that works for you, contact the following organizations. You can also ask your health care provider or behavior therapist, or go on the Internet. If you do not have access to the Internet, go to the public library.

For more information about support groups, contact these agencies:

• Brain Injury Association of America - (800) 444-6443
• Family Caregiver Alliance, National Center on Caregiving - (800) 445-8106
• National Alliance for Caregiving