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.