Postconcussive Syndrome Follow-up

  • Author: Roy H Lubit, MD, PhD; Chief Editor: David Bienenfeld, MD   more...
 
Updated: Jun 14, 2011
 

Further Outpatient Care

A multisite US prospective cohort study found that at the 12-month postinjury time point, 21.8% (2228 of 10,203) of patients endorsed symptoms consistent with a diagnosis of PTSD, and patients with more severe traumatic brain injury (TBI) had a lower risk of developing PTSD. However, all patients with TBI, regardless of severity, should have access to treatment programs that include intervention approaches to PTSD.[11]

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Deterrence/Prevention

  • Primary prevention of head injury involves the use of protective gear in contact sports, seat belts, bicycle and motorcycle helmets, and hard hats in appropriate jobs.
  • For elderly patients, altering the environment to minimize the risk of falls is important.
  • Protecting children from child abuse helps prevent head injuries.
  • Patients who have had one head injury are at risk for others.
  • Identification and treatment of substance abuse makes subsequent injury less likely.
  • Some patients with head injury are parasuicidal. They may benefit from treatment of depression, character disorders, and other conditions associated with suicide.
  • Restricting return to play for athletes prevents SIS.
  • Prevention of sequelae in patients once they have been injured is an active area of research. Recent reviews of the subject suggest hypothermia during the period of coma may mitigate tissue damage. Prophylactic use of anticonvulsants is not recommended.
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Complications

  • Reactions to anticholinergic, analeptic, and parkinsonian adverse effects of medication
  • Subdural and epidural hematomas
  • Hydrocephalus
  • Partial complex or grand mal seizures
  • Exacerbations of preexisting psychiatric disorders, including preexisting dementia
  • Conversion symptoms
    • Conversion symptoms typically occur when a person feels trapped in a threatening situation, especially if he or she is unable to openly talk about the dilemma with others who are trusted.
    • Patients with head injury often face such dilemmas, being forced to return to work when they feel unable, being expected to perform normal family roles despite significant problems of cognition or mood, and being subject to hostile legal scrutiny. Moreover, the head is a symbolically significant part of the body. For all of these reasons, some of the nonspecific distress of patients with head injury and, more rarely, some of their focal complaints may be understood as conversion symptoms or somatization.
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Prognosis

The prognosis of mild or moderate dementia and PCS remains difficult to provide with certainty. Some patients recover fully from severe injuries with prolonged coma; others remain disabled for long periods after much milder insults.

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Patient Education

Patients with dementia

These patients need simple explanations of their impairments. While they may be aware of cognitive dysfunction, they may lack insight into impairments in judgment, changes in personality, elevated mood, or paranoid symptoms. Education should include the expected course of improvement, with the greatest improvement expected in the first 6 months but delayed improvement possible as long as 5 years after injury.

Caretakers of patients with dementia need a great deal of ongoing education and support. Importantly, the patient's environment must be neither tedious nor overstimulating. Maintaining consistent routines of light and dark, eating, sleeping or lying in bed, performing bathroom activities, and participating in therapeutic or recreational activities help patients remain emotionally balanced and minimize caregiver burden.

Keeping the environment safe by eliminating area rugs to reduce falls, providing tub bars, and putting child locks on cabinets or stove knobs also is important in the care of patients with dementia. If the patient is capable of going out alone, the caregiver should ensure that he or she knows the routes well, carries identification, wears a medic alert bracelet, and knows how to use phones (especially cell phones) and busses.

Caregivers for patients with mild dementia need to decide whether the person should continue to have access to checking accounts or credit cards. If the person is willing and competent, the caretaker should consider getting power of attorney, in order to monitor the person's use of financial resources. If the patient has markedly poor judgment or seems seriously incompetent, the caregiver should seek formal conservatorship, to have legal authority to manage the person's resources.

Caregivers should be included in the patient's relationship with health care professionals. They should be specifically told to seek help if the patient has very disrupted sleep; does not eat a balanced diet; or is incontinent, aggressive, or sexually inappropriate. Any marked change in behavior should prompt a call to the clinician. Because patients with dementia do not always show typical symptoms when acutely ill, taking the patient's temperature and looking for signs of infection is a particularly important step if the patient shows a change.

Clinicians, in turn, must be accessible to caregivers. Meeting with more than one family member to stress the importance of having family members and friends share the burdens of providing care often is an overlooked step. Although one particular friend or relative may know the most about a patient and assume most of the responsibility, sharing this with others reduces the likelihood of the caregiver becoming isolated or depressed, an otherwise common outcome of providing long-term family care.

Patients with postconcussional syndrome

Patients with PCS need to know that headaches, dizziness, fatigue, irritability, poor concentration, and decreased memory are common in the first 3-6 months after injury. These symptoms fully resolve in most patients after mild injury. However, persistent impairment is possible. Patients should know that anxiety, depression, decreased concentration, and other persistent symptoms may improve with rehabilitation, psychological support, and medication.

Caregivers need to adopt a posture of encouragement and expectation that the patient will try to be as independent and productive as possible. At the same time, caregivers need to be patient and tolerant. They should accept that the patient may have real limitations and that these will likely worsen if the person is tired, ill, or acutely stressed. Emphasizing what the person can still do, rather than what seems to be lost, is generally helpful.

Online resources

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Contributor Information and Disclosures
Author

Roy H Lubit, MD, PhD  Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice

Disclosure: Nothing to disclose.

Specialty Editor Board

Jennifer S Morse, MD  Associate Medical Director, Optum Health

Jennifer S Morse, MD is a member of the following medical societies: Academy of Psychosomatic Medicine, Aerospace Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

David Bienenfeld, MD  Professor of Psychiatry, Vice-Chair and Director of Residency Training, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Julia Frank, MD to the development and writing of this article.

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