By Léa Lomprez et Océane Verand
https://uncloud.univ-nantes.fr/index.php/s/iNB2gqHp35TzBkq
Podcast’s Dialogue :
Océane : In our presentation, we are going to tell you about head trauma. It’s a neurological disorder characterized by the destruction or dysfunction of brain tissue. We chose this subject because it’s a population that we often encounter as neuropsychologists. In addition, it’s important to ask questions about certain tools, such as cognitive remediation. Sixty percent of head trauma are the result of road accidents and twenty five percent are due to falls. They particularly affect men because they have more risky behaviors. To assess severity criteria for head trauma, we use the Glasgow Coma Scale. There are 3 levels of severity :
– Light level : this is when the score is over 13. It’s a brief loss of consciousness and it happens in eighty percent of head trauma.
– Moderate level : this is when the score is between 9 and 12. It’s a loss of consciousness of about 6 hours and it happens in about 10 percent of head trauma.
– Serious level : this is when the score is below 8. This is when there is a loss of consciousness for more than 6 hours. This happens in 10 percent of head trauma.
Following a head trauma, patients may suffer from post traumatic amnesia. Traumatic amnesia is therefore a memory disorder that can appear after exposure to one or more traumatic events. It can be complete, when the entire event is non-existent, or partial, when some fragments of the event are absent from the narrative memory. The patient may be confused, disoriented, have phases of drowsiness, agitation, be anxious, etc. Head trauma can lead to difficulties, even cognitive disorders.
Léa : In the moderate to severe brain injury, several deficits can be observed when performing a neuropsychological assessment. According to the article by Vallat-Azouvi and Chardin-Lafont, these deficits are present at the cognitive, behavioral and social levels. The psychologist specialized in neuropsychology can then observe cognitive deficits in executive functions (inhibition, planning, task initiation, selection of information, processing speed), attention (sustained, divided and shared attention), working memory (information maintenance and simultaneous processing of information), long-term memory (episodic, semantic and autobiographical) and language (pragmatic language). We also find major behavioral disorders that are often reported by families, which can observe irritability, bad mood, fatigue, depressive states, emotional lability, anxiety, violence and inappropriate social behavior. These disorders of social cognition are most often due to a deficit of the theory of the mind as well as to the disorder of the pragmatic language. In addition, patients often have little knowledge of their disorders which is caused by anosognosia preventing this recognition and their metacognition abilities. In constrast, the disorders present in the brain injured are difficult to objectify and will be present to different degrees depending on the lesion and the individual. It is therefore important for the neuropsychologist to carry out standardized psychometric assessments but also clinical observation during sessions as well as qualitative elements reported by relatives and the health care team. This assessment of neuropsychological disorders is essential because the disorders will have a negative impact on the patient’s family, social and professional reintegration. Moreover, the realization of a balance sheet will allow to observe the deficits but also to make a comparison of the cognitive state of the patient before and after a cognitive remediation that can be considered by the neuropsychologist in the management. However, sometimes the prescription of a cognitive remedy in brain injured patients can be debated in view of the increase in disorders.
Océane : On the one hand, I think cognitive remediation can be a solution for the care of people who have had a traumatic brain injury. It was formed in the neuropsychological field of cognitive rehabilitation to help people whose cognitive functions have deteriorated following cerebral accidents (of traumatic or vascular origin).There are two main cognitive remediation techniques that have been scientifically validated. The first is to intensively train the impaired function (e.g. training to learn new information if the patient has memory problems)
Léa : I see your point, to our knowledge, there is no article demonstrating the ineffectiveness of cognitive remediation in brain injured patients, but in clinical practice inefficiency sees that non-prescription can be observable. Indeed, between experimental laboratories and clinical practice, it is possible to see a gap. In fact, in clinical reality, it is sometimes difficult to apply what has been done in research.
Océane : I see exactly what you mean but the second strategy consists of circumventing the difficulty, by thinking about compensation strategies according to the preserved capacities of the patient (for example, writing down the information to be remembered, using mnemonic devices, etc.). The practitioner creates his own tools in order to adapt to the patient.
Léa : That’s a good point, however many practitioners often find themselves in situations where cognitive remediation will be more of a burden to the patient than a real help. Indeed, in severe brain injuries the increase of disorders is so important that the patient is obliged to remain institutionalized. When the deficits are too great, preventing the patient from performing the tasks that are requested by the practitioner, it is better for the patient’s well-being not to perform cognitive remediation. The risk of continuing this type of management is to continually put the patient in a situation of failure and lower his self-esteem. In addition, fatigability and significant attentional deficits in these patients prevent the accomplishment of the task, even simple at times. Also, some behavioral (violence) and social (pragmatic language, theory of the mind) disorders can hinder this management.
Océane : Well, I agree with you here though, either of these strategies can be used whether the remediation is more focused on neurocognition (concentration, attention, working memory) or social cognition (ability to interact with others). Studies show that rehabilitation in patients with traumatic brain injury indicate that the best results are obtained when intervention programs aim at a comprehensive and interdisciplinary management of the medical and psychosocial state of the patient, which includes intervention in its cognitive, emotional, family and social sphere.
Léa : Effectively that’s true, but The practitioner must then adapt the management of each individual and prioritize what benefits the patient. The results quest for the practitioner must not be an impediment to the well-being of the patient. Its first objective is to improve the quality of life and prioritize the needs of patients.
In conclusion, cognitive remediation can benefit most patients. However, it should not apply to all cases of head trauma. Sometimes, its use is excessive and ends up not being a help for the patient but a constraint bringing more risks (lower self-esteem, feeling of failure, ill-being) than benefits. In constrast, it is not to be banned because it can improve cognitive functions in some patients and be a real help in everyday life. It is then necessary to see cognitive remediation as only a tool that is not applicable to all, but is used with reflection and measurement by a practitioner who has performed a balance of benefits/ risks for the patient.