Case 1 Comments

The child of a lower-middle-class, mid-west family, the patient was entering his third year in the US Army at the time of his accident. By all accounts, the patient would have served the minimum amount of time in the military then used the GI Bill to finance a college degree. Those plans were; unfortunately, forever put on hold. Although still possessing superior verbal intelligence, he has difficulty using these intellectual reserves in novel situations. Unpredictable, unusual, and changing patterns in the flow of life are very upsetting to this individual--he is now a creature of habit. He is able to cope with one-on-one interactions with a fair degree of tolerance; but when his environment becomes too complex, or emotionally provocative, deterioration in function and behavior are quickly observed.

Skills learned prior to his accident, such as playing chess, are relatively retained; although deficits in manual dexterity and complex coordinated movement make these activities effortful. Complex sequences, such as making a pot of coffee, are not linked seamlessly and automatically, but represent a series of distinct sub-activities that must be consciously considered, then reconsidered, before they are arranged in their proper sequence. Distracters, such as a telephone call or knock on the door, can be catastrophic, ruining this painfully constructed sequence of activities--a house of cards that will fall at the slightest provocation. After months of once-a-week sessions I have gained the patient's trust and now feel comfortable 'lending a hand' without offending the patient. Pride is relatively retained, and easily offended.

His difficulties in movement (he is a high risk for falling), poor social etiquette, and poor judgment isolate him from society at large. Attempts to provide him with an external connection to the world (i.e., Internet service) resulted in other, nefarious, individuals preying on his naivety.

Although at times crass, rude, and self-centered; I find him thoughtful and honest, although overly so, at times.

Research has shown that normal rats will not associate with brain-injured rats. The experimentally produced brain-injured rats are shunned by the 'normal' rats. Humans have not evolved from rodents, at least with regards to our compassion for brain-injured brothers and sisters.

Case 3 Anoxia (Monday evening)

Anoxia refers to a complete absence of available oxygen while hypoxia refers to an inadequate amount of oxygen. A high percentage of individuals who survive five or more minutes of oxygen deprivation (anoxia), or 15 or more minutes of oxygen insufficiency (hypoxia) sustain permanent brain damage.

Hypoxia and ischemia are not synonymous. In hypoxia the availability of oxygen is reduced, but the flow of the blood continues. Ischemia refers to reduced blood flow to a region of the body that negatively affects the delivery of glucose, oxygen, and other substances in the blood and prevents the removal of metabolic by-products from that region of the body.

Mild hypoxia usually presents with temporary cognitive dysfunction and impaired dexterity. If the condition is severe, prolonged, or frequently recurs, the abnormalities may become permanent.

Following prolonged anoxia, if the individual does not die outright, coma or persistent vegetative states are common occurrences. If the individual survives and is not comatose, the patient typically presents with impaired learning but relatively intact recall of information stored before the anoxic episode, a condition known as anterograde amnesia. The overall severity of the cognitive deficits can range from a relatively isolated memory dysfunction to global cognitive dysfunction, depending on the extent of the cortical damage. Memory disturbances, changes in personality and behavior, and visuospatial or visual recognition problems are not uncommon. Changes in social competency have also been reported. Such changes may include lack of motivation/reduced spontaneity, deficits in planning, impulsivity and loss of self-control, decline in social hygiene, and deterioration in social habits. Such changes in social competency may actually be more debilitating than the memory problems.

Cardiac and pulmonary failure are the conditions most frequently associated with acute oxygen deprivation. Near-drowning accidents, failed hanging attempts, and anesthesia are also potential causes of acute oxygen deprivation. Conditions that result in a combination of hypoxia and reduced blood flow, hypoxia and ischemia, are most likely to result in injury to the brain.

Case 2 Dementia (Monday afternoon)

"Dementia" is not a single disease, but a term that refers to a constellation of symptoms. It is an 'umbrella' term that can be caused by numerous diseases and conditions. In order to be labeled as suffering from "dementia" an individual must be experiencing some form of memory impairment and impairment in one, or more, cognitive domains.

Alzheimer's disease is, by far, the most common form of dementia.

Alzheimer's disease (AD) is characterized by unavoidable, progressive degeneration of the nerve cells of the brain. This deterioration initially begins in the hippocampus, structures that are located in the anterior poles of the temporal lobes. As the disease progresses, the association cortex of the parietal-occipital lobe junction and structures in the prefrontal cortex are negatively affected. Atrophy (shrinkage) is prominent in frontal, temporal, and parietal lobes. Microscopic findings are death of neurons in the cortex (outer covering of the brain), neurofibrillary tangles in the large neurons of the frontal and medial temporal structures, and senile plaques which are primarily concentrated in the medial temporal lobes. Neurochemical loss is associated with destruction of the nucleus basalis, the major source of cholinergic innervation to the cerebrum.

The most prominent cognitive deficits associated with AD are impairment in new memory and learning, difficulties with complex mental tracking, and deficits in language functioning and visuospatial abilities. Initially these cognitive deficits are insidious and may not be readily apparent, even to family members. Decline in work performance, or difficulty adjusting to unpredictable or unfamiliar events; however, may be noted. As the disease progresses, more cognitive abilities are disrupted and the disruptions become more severe.

Retrogenesis is a concept that refers to the process by which degenerative mechanisms reverse the order of acquisition in normal development. With AD, functional losses occur in the precise reversal in which they were acquired. In other words, things that an individual learned most recently are the very things that they will lose first. An Alzheimer's patient deteriorates backwards in time...losing first their ability to perform complex daily activities (such a managing their check book), then losing their ability to perform less complex daily activities (such as shopping, cooking, doing the laundry); as the disease progresses dressing becomes more difficult, then daily hygiene begins to suffer. Eventually the individual become totally dependent on others to provide the most basic of needs.

Case 1 Mechanisms of TBI (Monday morning)

The patient's traumatic brain damage was the result of a deceleration injury. As the patient's vehicle came to a violent stop, his head was catapulted into the windshield. As the movement of his skull is suddenly stopped, the front part of the patient's brain, the frontal lobes, is crushed against the inner surface of the skull (a coup injury) causing a massive contusion. This movement also impales the inferior surfaces of the temporal lobes onto the rough, bony surface of the base of the skull, resulting in lacerations and maceration. A temporary negative pressure gradient (suction) forms between the occipital lobes and the back of the skull resulting in damage to the surface of the occipital lobes (a contrecoup injury). Cavitation (the formation of microbubbles) occurs in the cerebral spinal fluid as this fluid is sloshed around within the skull, damaging cellular projections and forming cracks on the surface of the brain. Blood vessels on the brain's surface stretch and tear. Axons stretching from the front of the brain to the posterior portions of the brain snap. Swelling causes increased intracranial pressure (ICP) which places increased pressure on various structures of the brain. This increased ICP decreases blood flowing into the brain, setting the stage for ishemia. Respiratory insufficiency, abnormal respiratory patterns, cardiac abnormalities, and metabolic alterations may cause additional, secondary, damage to the integrity of the brain.

Damage to different structures in the frontal lobes of the brain can result in various cognitive and behavioral difficulties.

Damage to the orbitofrontal regions have been associated with disinhibition, inappropriate expression of emotions, impaired judgment, lack of insight, and distractibility.

Damage to the dorsolateral regions of the frontal lobes may result in so-called executive function deficits (impaired volition, planning, purposive behavior, and effective performance), perseveration, stimulus-bound behavior, and diminished verbal fluency.

Damage to the medial frontal regions of the frontal lobes have been associated with apathy, mutism or transcortical motor aphasia, lower extremity paresis, and incontinence.

Damage to the temporal lobes of the brain may result in defective auditory recognition, inability to comprehend spoken words, inability to recognize familiar voices, word-finding difficulties, impaired verbal learning, trouble organizing complex information, impaired ability to enjoy music, and impaired odor perception.

Damage to the occipital lobes can result in blindness, disruptions in visuo-perception, visual inattention, difficulty performing mathematical operations, and difficulty recognizing faces.

Case 3 data (Monday evening)

The patient takes a seat in one of the recliners in his room and I 'block' him in with a hosptial table placed in front of him. He quickly grabs the Kleenex box on the table and starts to pull out the tissues one at a time. One, two, three...I lose count after fifty tissues have been removed and piled on top of the table. I have him start with drawing a complex geometric design. He approaches this test in a very disorganized manner, each detail is treated as an independent, discreet part of the design. There are no relationships among the parts; no 'Gestalt' of the entire design is recognized. Although all the details are finally reproduced, the overall quality of the design is fragmented, like a patchwork quilt. I present him with a booklet of drawings that depict various objects. I ask him to name the first object (a cluster of grapes), the patient says "I see a window on there, and here are taking certain sections, and here is a system configuration." When pesented with a picture of a tiger the patient says "This is a drawing like someone's computer system. A computer across here. A computer system. It's got two, would usually be considered, an inventory with so much data within it." Reading was severely impaired as the patient read the printed words "Open your mouth" as "O-u-e-g-n your y-w-n-d."

Case 2 data (Monday afternoon)

Because of the patient's extreme agitation, no formal testing was attempted. After disarming the patient of her cane, maintaining a very calm demeanor, avoiding direct eye-contact, and firmly holding onto the patient's wrists, she was able to gradually calm down; a process that was accelerated with a dose of Lorazepam. After this period of aggression/agitation, the patient became tearful and attempted to apologize for her behavior, although she was unable to verbalize what had prompted this catastrophic reaction. Interviewing the patient's daughter uncovered a history of poverty, mental and physical abuse perpetrated by her husband (a former preacher), and emotional loss/abandonment during the patient's lifetime. The patient exhibited poor short-term memory; however, she exhibited good recall of historical events (remote memory) as evidenced by her ability to recognize photographs from her early adulthood and discuss events associated with those photographs.

Case 1 data (Monday morning)

A neuropsychological evaluation was performed approximately nine months ago. The results of the evaluation indicated that he has a verbal IQ of 125, but a performance IQ of 96 (100 represents the mean). This discrepancy in test performance suggests excellent skills derived from formal, academic training (i.e., vocabulary, arithmetic, similarities), but a relative weakness in his adaptive problem solving abilities (his ability to use his intellectual reserves when confronted with novel problems). 'Severe' deficits were found in his sequential processing abilities, logical analysis skills, deductive reasoning/concept formation abilities, manual dexterity, and in his verbal fluency. 'Mild to moderate' deficits were noted in his facial recognition abilities and in his verbal list learning abilities (verbal short-term memory). Relative strengths were noted in his basic language functioning, visuospatial abilities, and in his nonverbal short-term memory. Behaviorally, the patient shows a tendency to be naive, he has repeatedly demonstrated poor social judgment; and while he may develop an interest in something, his passion for such interests quickly wanes. He lives alone in a small duplex and is provided with sitters and various therapists throughout the week. If left to his own devises, he would either sleep or sit repeatedly watching the same movies. Interactions with him are generally one-sided with the patient rarely expressing any care or concern for those with whom he interacts, a behavior that others view as ego-centric and selfish.

Monday Evening, Case 3

This a referral from a local rehabilitation hospital. The patient is a 61 year old gentleman who had a recent myocardial infarction while at work as a computer programmer. Someone at work attempted CPR and started chest compressions. When the EMTs arrived an external defibrillator was repeatedly used in order to restart his heart. After 25 minutes and five shocks with the defibrillator, a cardiac rhythm was reestablished; unfortunately, the patient's brain had been hypoxic for an extended period of time. The physical effects of this incident were minimal (no paralysis or motoric weakness), the cognitive effects; however, were profound. Upon meeting the patient the patient's mental confusion was very evident. He had a bewildered expression on his face, and his eyes darted around the hospital room attempting to make sense of his current situation and surroundings. I introduced myself to him and he said "Who's Dr. AH?" I said "I am." He responded "Who's Dr. AH?" This exchange happened so many times that it became an Abbott and Costello routine ("Whose on first?"). The clinical interview revealed an individual with severe receptive and expressive aphasia, impaired short-term memory, distractibility, dyslexia without dysgraphia, and either prosopagnosia or a visual apperceptive agnosia. He also exhibited an environmental dependency syndrome, temporal disorientation, and geographical disorientation. He was unable to recognize members of his family, he kept taking off his portable external defibrillator; and he would raise objects up to his nose and sniff them intently, apparently trying to determine what the objects were and if they were edible. When shown a photograph of a recent family reunion, he was unable to recognize himself. "Who are these people?" he asked.

Monday Afternoon, Case 2

This afternoon I travel to the home of a 91 year old patient. This is a new referral and I have no information about the patient--just the name and address. As I park in the driveway, another gentleman is leaving, he looks distraught. I approach the front door, and am greeted by elderly woman in a nightgown. I ask if she is the patient, "No" she answers. She invites me in and introduces me to her mother who is laying on a daybed. The house is clean but decorated with a cacophony of family photographs, dolls of various sizes, decorated Easter eggs, and an artificial Christmas tree. The tree prominently fills the corner of the dining room and it is so covered with ornaments that the limbs of the tree are concealed. The patient slowly sits up and glares at me. "Who let you in? Are you here to kills us?" I try to introduce myself but the patient continues her verbal barrage--"What did you take? Are you here to steal my things? Is that a gun? Do you have a gun?" I attempt to calm her, but she only becomes more agitated. The other woman, the patient's 66 year old daughter, tries to intervene. "Shut up you!" yells that patient. The patient begins to pace, accusing me of stealing, plotting to kill her, planning to take everything that is hers. She briefly leaves the room and returns with a metal quad-cane. She approaches me and begins to brandish the cane in my face. Her daughter tries to appeal to her, but the patient quickly includes her into a conspiracy of her own making, we are now both part of the plot to kill her. "I'll knock your head off!" the patient screams, then she swings the cane at me, indeed aiming at my head. She then lashes out at her daughter with kicks, followed by a swing of the cane. "I'll call the law! You're a bunch of thieving bastards! I'll cut your heads off!" Her face is contorted in anger, her eyes are glazed with hate, and spittle runs down her chin. The daughter is apologizing for her mother's behavior; she pleads, "She only gets like this sometimes." A granddaughter with her two children enter the front door for a family visit, but they are not recognized and are immediately assimilated into the patient's self-derived conspiracy. The great grandchildren have "evil intent" in their eyes, and she waves the cane at them. The granddaughter is the one who "contacted" me and "let [me] in." She swings again at me with the cane and tries to kick, then bite, her daughter. The granddaughter and grandchildren leave, the children looking a little un-nerved . The patient begins to relax and says that if I am to be "friends with her daughter" that is fine with her.

Monday Morning, Case 1

Mondays start the same, I travel to a patient's house to provide cognitive rehabilitation and psychotherapy. This individual was involved in a head-on automobile collision with a drunk driver some 20 years ago. He sustained a significant brain injury that involved the frontal precortex, or the so-called 'dashboard' of the brain. He was in a coma for several months following this unfortunate accident, and he was left permanently disabled as a result of his injuries. If seated and involved in casual conversation, he may appear a bit guff, but most of his cognitive deficits would go unnoticed. When he attempts to walk, or tries to manipulate objects with his hands; however, limitations in his ability to coordinate purposeful movement become painfully apparent. Today we are planning to build a game board for the game "Othello." The board that he currently has uses small glass beads for the game pieces, objects that are very difficulty for the patient to place accurately on the game board. A trip to several stores and we have some pegboard for the game board and golf tees for the game pieces. We then discuss the dimensions for the board and discuss how to elevate the board so that the golf tees will stand perpendicular to the board. We consider the pros and cons of raising the board versus shortening the golf tees. After drawing the dimensions on the pegboard we play a game of chess. The patient beats me once again--he played chess for ten years prior to his accident, I, on the other hand, am a novice player. After the game I tell him that I noticed how he staggers his pawns in order to defend aggressive attacks, and he beams with pride that he has taught me something. Most people (family included) familiar with this patient treat him like a child and only put up with him for a minimum amount of time. He is discredited by others, viewed as 'damaged,' and considered a burden. He is frequently socially inappropriate, occasionally responds to others with sexually explicit comments, and becomes temperamental when his needs are not immediately met. He reminds me of fraternity brothers in my past.