Dementia after a head injury is a significant public health problem.
- In the United States, roughly 2 per 1,000 people each year have some kind of head injury. Many do not seek medical care.
- Between 400,000 and 500,000 people are hospitalized in the U.S. every year for 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.
- 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 nature of dementia in head-injured persons varies greatly by the type and location of head injury and the person's characteristics before the head injury.
The dementia that follows a head injury differs from other types of dementia. Many types of dementia, such as Alzheimer's 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.
Dementia and Causes of Head Injury
The following are the most common causes of head injury in civilians:
- Falls (40%)
- Unintentional blunt trauma (15%)
- Motor vehicle accidents (14%)
- Assaults (11%)
- Unknown causes (19%)
Use of alcohol or other substances is a factor in about half of these injuries.
Certain groups are more likely than others to sustain 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.
- Older adults are especially likely to injure themselves by falling.
Symptoms of Dementia in Head Injury
Dementia-related symptoms in head injury include those that affect thinking and concentration, memory, communication, personality, interactions with others, mood, and behavior.
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 people with head injuries include:
- 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
- Aggression, combativeness, or hostility
- Vague, nonspecific physical symptoms
Some people develop seizures after a head injury. These are not part of the 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 (fixed 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 -- Feelings of worthlessness or that life is not worth living or that world would be better off without them, talks about suicide, states intention to commit suicide, develops a plan to commit suicide
When to Seek Medical Care for Dementia
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.
Exams and Tests for Dementia After a 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 (such as a visit to the emergency room; medical records should be available.)
- The person’s state since the injury
- Any prescription or over-the-counter medications, or illicit drugs, the person may be taking
- 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 injured person cannot provide.
At any time in this evaluation process, the primary health care provider may refer the injured person to a neurologist (specialist in disorders of the nervous system, including the brain).
A thorough physical exam will be done to identify neurological and cognitive problems, problems in mental or social function, and unusual appearance, behavior, or mood.
Many health care providers refer head-injured persons for neuropsychological testing. This is the most reliable way to document cognitive impairments following a head injury.
Neuropsychological testing for dementia
Neuropsychological testing is the most sensitive means of identifying dementia in persons with 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 for head injury, dementia
Head injury warrants a brain scan to determine whether any brain structures show physical abnormalities
- A 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 one to three 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 CT scan or MRI in detecting functional problems in the brain for some types of dementia or other brain disorders. SPECT is available only at some large medical centers.
Other tests for head injury
Electroencephalogram (EEG) measures the electrical activity of the brain. It may be used to diagnose seizures or abnormally slow rates of brain activity.
Treatment for Dementia in Head Injury
Head injuries often bring an abrupt "coping crisis." The sudden adverse changes that go with a head injury inevitably 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 injury 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 six months, but delayed improvement is possible as long as five years after the injury.
Home Care After a Head Injury
The extent to which a person with a head injury can care for themselves at home depends on their 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 their own and comply with medical treatment. In many cases, the person must be supervised by a caregiver to ensure compliance and safety.
he injured person's surroundings must be neither too calm nor too hectic. They 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 grab bars in bathtubs and showers and around toilets, and putting child locks on cabinets or stove knobs if necessary.
- If the patient is capable of going out alone, they 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 their own money if they seem willing and able. The caretaker can get power of attorney to monitor the person's financial responsibility. If the person has 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 their 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.
Treatment for Dementia After a Head Injury
The head-injured person who has become demented will benefit from 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 their injury cognitively and emotionally. Another is to help the person master skills and behaviors that will help them 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 outcomes and pace of improvement.
Behavior modification has been shown to be very helpful in the rehabilitation of brain-injured persons. These techniques may be used to discourage impulsive, aggressive, or socially inappropriate behaviors. They also help counteract the apathy and withdrawal common in head-injured persons.
- Behavior modification rewards desired behaviors and discourages 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 head injury, who are more sensitive to the side effects of these drugs.
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:
- 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 their ability to concentrate. Keeping lists allows a person to compensate for decreased memory.
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. It is important that family members 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 their 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.
Mental health professionals recommend counseling for family members, especially those in caregiving roles. Ask your loved one's health care provider for a referral to a mental health provider and family support groups. These interventions improve morale and help family members cope.
Social services for head injury and dementia
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 their own affairs. Social services can help in establishing a guardian, conservator, or other protective legal arrangement.
Medications for Dementia After a Head Injury
There are no medications formally approved by the FDA specifically to treat dementia in people who have sustained a traumatic brain injury. Persons with a head injury may require medication to treat symptoms such as depression, mania, psychosis, impulsivity-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. Doctors do not fully understand how exactly they work, but it is thought that they help to dampen down the activity of brain areas where there is too much excitation and help regulate the activity of brain regions involved in thinking, behavior, mood regulation and impulse control. 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 caused by other diseases. In many cases, these drugs have not been specifically tested in persons with head injury. There are no established guidelines on psychotropic drug treatment after head injury.
Antidepressants after a head injury
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 behavior disturbances resulting from head trauma. Examples include fluoxetine (Prozac) and citalopram (Celexa). Sometimes, drugs that increase the activity of two chemicals -- serotonin and norepinephrine (called serotonin-norepinephrine reuptake inhibitors, or SNRIs) -- are also used.
- Tricyclic antidepressants are occasionally used for people who cannot tolerate SSRIs or SNRIs. 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 heart rhythm and blood pressure. An example is amitriptyline (Elavil).
- The antidepressant bupropion (Wellbutrin) is often avoided in patients with head injuries because it may cause seizures.
- Another antidepressant, mirtazapine (Remeron), is often useful for depression that involves sleep disturbances in head-injured persons. This drug is unrelated to other types of antidepressants and is not toxic in overdose.
These drugs increase the amount of a brain chemical (neurotransmitter) called dopamine, which may improve concentration, attention, and interest level in people who have sustained a head injury.
Dopamine enhancers may interact with antidepressants to improve mood swings.
The most potent of these drugs is levodopa, but it also causes the most side effects. Other drugs include bromocriptine (Parlodel) and the stimulant dextroamphetamine (Dexedrine), which increases levels of dopamine and another neurotransmitter called norepinephrine.
These drugs are used "off-label" in dementia to treat psychotic symptoms such as delusions or hallucinations, agitation, and disorganized thinking and behavior.
Newer antipsychotic drugs (such as risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel) may be better tolerated. These drugs may work particularly well for the agitation and other psychotic symptoms common in head-injured persons.
Keep in mind that all antipsychotic drugs carry a "boxed" FDA warning describing an increased risk of death from all causes when given to elderly patients with dementia-related psychosis. When prescribed, they must be administered cautiously and with the informed consent of individuals who are designated to make health care decisions if the patient themselves cannot. In addition, antipsychotic drugs can lower the seizure threshold and therefore must be used cautiously if there is concern about seizure risk following a head injury.
Certain anticonvulsant (antiepileptic) drugs often work well in behavior disturbances (aggression, agitation) that occur as complications of head injury. They can be helpful to treat impulsive or aggressive behavior and sometimes help with moment-to-moment changes in mood. Examples include carbamazepine (Tegretol) and valproic acid (Depacon, Depakene, Depakote).
Like some antiepileptic drugs, 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.
These drugs are sometimes used cautiously to quickly relieve agitation or violence on a short-term basis in people with dementia. They have other uses, such as treating insomnia and relieving anxiety. However, they can worsen cognitive and behavioral problems (e.g., impulse control) in people with head trauma and are therefore generally not recommended in head-injured persons with dementia, except when needed to calm a person rapidly. Examples are Ativan (lorazepam) and Valium (diazepam).
These drugs work well in treating aggression in some people with 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).
Other Therapy for Dementia After a Head Injury
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. Dementia patients who may have a poor gag reflex or difficulty swallowing may need special medical assistance for obtaining nutrition. Otherwise, no special dietary prescriptions or restrictions apply.
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.
It may be necessary to change the surroundings to prevent falls and accidents that could cause repeat injuries. Often, guidance from an occupational therapist and physical therapist can be helpful for maintaining a safe and appropriate environment and level of activity.
Although medical professionals often recommend that the head-injured person resume normal activities or responsibilities, this is not always easily done. People 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. Accommodations in the workplace may also be necessary to allow the person to perform their usual job role and responsibilities.
People 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.
Next Steps After a Head Injury and Dementia
The head-injured person with dementia requires regularly scheduled follow-up visits with the medical professional coordinating their care. These visits give the coordinator a chance to check progress and make recommendations for changes in treatment if any are necessary.
Head Injury Prevention
A head injury and its resulting complications, such as dementia, are highly preventable.
- Use of protective gear in contact sports and hard hats and safety equipment at work if applicable.
- Wear seat belts and bicycle and motorcycle helmets.
- For older adults, 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 illegal substances and alcohol 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.
Outlook for Dementia After a Head Injury
The outlook for persons with dementia after head injury is difficult to predict with certainty. Some people recover fully from severe injuries; others remain disabled for long periods after much milder injuries. In general, outcome relates to the seriousness of the injury.
Dementia from head injury usually does not get worse over time and may even improve over time.
For More Information
Brain Injury Association of America
3057 Nutley Street #805
Fairfax, VA 22031-1931
National Brain Injury Information Center: (800) 444-6443
National Institute of Neurological Disorders and Stroke, National Institutes of Health
31 Center Drive, MSC 2540
Building 31, Room 8A-06
Bethesda, MD 20892-2540
(800) 352-9424 (recording)
Mental Health America
500 Montgomery St., Ste 820
Alexandria, VA 22314
Toll free (800) 969-6642