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About cognitive impairment
Cognitive impairment is an issue that is important to keep in mind when assessing and treating veterans. It is common for veterans to present with complex issues that involve more than one mental health disorder, and with alcohol abuse a common feature. In addition, the veteran population is ageing. This often means that practitioners have to disentangle the impact of mental health, substance and ageing related conditions on cognitive function in order to develop a meaningful treatment plan.
Other factors that can influence cognitive functioning include early life experiences (including trauma); learning and other developmental disabilities; and a range of injuries and medical conditions. Whilst the cognitive impacts associated with any of these factors can be subtle, they are nevertheless an important consideration when attempting to understand, diagnose and treat the veteran who presents with mental health problems.
Mental health and cognitive impairment
It is well established that mental health disorders can significantly affect an individual’s cognitive functioning. For many people who experience a mental health disorder, changes in cognitive functions such as memory and reasoning can often be some of the most distressing symptoms. Cognitive impairment can limit all aspects of a person's life, and exacerbate feelings of loss of control and mastery associated with many mental health problems. The table below outlines some of the cognitive changes that people with mental health issues can experience.
Ageing and cognitive impairment
The ageing process can influence cognitive functioning. People who develop a range of medical conditions as they age are more vulnerable to age-related cognitive changes. Interestingly, recent studies suggest that the ‘healthy aged’, (i.e., those who do not develop medical conditions that may affect the brain such as cardiovascular disease, dementia or brain injuries) are unlikely to demonstrate evidence of cognitive decline, at least until they reach their eighties (Wardill & Anderson, 2010). At that point, some deficits in executive functions, particularly in areas such as cognitive flexibility, concept formation, goal setting, planning and organisation, become apparent.
Dementia most commonly affects people who are aged 65 years and older, and is generally caused by Alzheimer's disease. As Australia's veterans age, it can be expected more will be affected by dementia, although no specific link has been found between war service and dementia. It is estimated that around 250,000 people in Australia currently have dementia (Access Economics, 2009).
Traumatic brain injury and cognitive impairment
A traumatic brain injury (TBI) can occur when something outside the body hits the head with significant force, e.g., a penetrating injury when a piece of shrapnel enters the brain, a blast injury, or blunt force as a head hits the windscreen during a car accident. The Australian Institute of Health and Welfare report a rate of 107 TBI-related hospital stays per 100,000 people in the population (Australian Institute of Health and Welfare, 2007). However, it is important to note that a disproportionate number (around two-thirds) of these are young males, often having developed an injury through a car accident. For this reason, it is likely that Defence personnel are overrepresented in this group. The vast majority of veteran-specific research has been conducted in the United States, where mild TBI (mTBI) is often referred to as the ‘signature’ injury of the recent conflicts in Iraq and Afghanistan. Prevalence estimates of mTBI in US veterans range from 12-20 per cent (McFarlane, Saccone, Clark, & Rosenfeld, 2011), while mTBI is estimated to affect around four percent of UK veterans (Rona et al., 2012). Generally speaking, severity of impact, loss of consciousness, posttraumatic amnesia duration, and number of TBIs influences the severity of cognitive impairment. Research suggests that TBIs amongst the veterans from recent conflicts rarely occur in isolation, but rather TBIs have high comorbidity with pain and PTSD (Otis, McGlinchey, Vasterling, & Kerns, 2011). In this case, the veteran’s treatment should target all three coexisting problems.
Substance use and cognitive impairment
It has been well established that excessive substance use, and in particular sustained alcohol use, can lead to permanent impairments in brain function. Although the prevalence of substance-related cognitive impairment is difficult to establish, a meta-analysis of almost 40,000 post-mortems found a prevalence of alcohol-related brain changes in 1.5 per cent of the general population, and in 30 per cent of heavy drinkers (Cook, Hallwood, & Thomson, 1998). In its early stages, alcohol-related brain damage may contribute to executive function impairments and memory loss. For many people who have experienced some problems with memory and thinking because of substance use, there may be an improvement in their brain function if they are able to achieve abstinence. For others, cognitive difficulties may continue even with abstinence. In all cases however, continued heavy substance use increases the risk of more severe and permanent brain damage. Age, gender and patterns of use, can all affect the cognitive impairment potential of substance use.
Medical conditions and cognitive impairment
There is a vast range of medical conditions that can have an impact on cognitive functioning. It is beyond the scope of this chapter to outline these conditions. However, it is important that clinicians be aware that chronic conditions involving the cardiovascular and endocrine systems, kidney and liver function, neurological disorders, some autoimmune disorders, neurotoxin exposure and some infectious diseases all carry with them risks of neuropsychological impairments. Chronic sleep disorders such as sleep apnoea and insomnia can also affect cognitive function. Having an awareness of a client’s medical history is fundamental to understanding their cognitive difficulties.
Comorbidity and cognitive impairment
An additional layer of complexity is added to a veteran’s presentation when, as is often the case, more than one underlying condition may be influencing cognitive functioning. For example, among people hospitalised with a TBI, approximately half met criteria for depression within the year after the injury (Bombardier et al., 2010). Depressive disorders are more common in people aged 75 years and older than in the general population, with lifetime prevalence ranging between 4.5 and 37.4 per cent (Luppa et al., 2012). It is important, therefore, to consider that multiple factors may be affecting a veteran’s cognitive functioning at any one time, and be mindful of this when conducting an assessment, developing a case formulation and treatment plan.
Screening and assessment
In some cases, cognitive impairment may be transitory, and its progression can be slowed, or reversed, if the underlying cause is addressed. Therefore, early identification of cognitive impairment and its underlying cause is important, as it allows the veteran to get early access to the most appropriate treatment.
A screen of cognitive functioning (past and present) is an important aspect of any thorough clinical assessment. This should include a comprehensive history, including developmental (e.g., pregnancy, birth and milestones), medical, psychiatric, substance use, and educational/occupational history and, if possible, the use of a cognitive screening tool. Some useful questions to ask a client include:
- At any stage throughout your life, have you suffered a knock to the head, a fit, a concussion or a period of loss of consciousness? (If veteran responds ‘yes’, obtain details.)
- Have you, or any members of your family, had difficulties with learning or poor school performance? (If ‘yes’, obtain details.)
- Has anyone in your family suffered from a form of dementia? (If ‘yes’ - who, what, when?)
- Have you (or anyone close to you) noticed any changes in your ability to do the following things:
- Carry out your usual daily activities, e.g., planning, getting started, sequencing, completing?
- Concentrate on tasks, e.g., reading a book, watching television, following conversations?
- Remember things, e.g., recall a shopping list, remember to do things?
- Solve problems, e.g., do you sometimes choose the wrong way to do something, or make the same mistake repeatedly?
Cognitive screening tools are not, and do not, replace the need for a comprehensive diagnostic assessment. They will however, give a broad indication as to whether a person's cognition is intact or whether it requires closer examination. One widely used screening tool is the Mini Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975). This includes measures of orientation, working and short-term memory, and language functioning. In administering the MMSE it is important to be aware that people from different cultural backgrounds or those with lower levels of education may perform poorly even in the absence of cognitive impairment. Alternatives screening tools include:
- Mini-Cog Test (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000) – This is used to screen and monitor executive functioning. It is available at www.alz.org/documents_custom/minicog.pdf.
- Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE; Jorm, 1994) – This is useful for gathering information on onset, duration and impact on daily functioning. It is available at crahw.anu.edu.au/risk-assessment-tools.
If you suspect that a veteran is experiencing difficulties or a decline in cognitive functioning, inform their general practitioner. The veteran can then be referred for further assessment to a specialist such as a clinical neuropsychologist, geriatrician, neuropsychologist or psychiatrist to provide a diagnosis and identify underlying causes of the cognitive impairment.
Treatment and management
It is important that the appropriate treatment is sought for the underlying cause of the cognitive impairment. This treatment may involve psychological or pharmacological treatment in the case of mental health disorders, or medical treatment in the case of other underlying medical conditions.
Strategies for managing attention and memory difficulties
Regardless of the cause of the cognitive impairment, it is useful to provide the veteran with strategies to help compensate for their attention and memory difficulties. The veteran is more likely to get benefit from a strategy by getting their family’s assistance with implementing it, and by practicing it often enough that it becomes habitual. Helpful strategies for managing attention difficulties include:
- Keep noise to a minimum and remove unnecessary distractions
- Allow longer time than usual to process information and reach decisions
- Break large amounts of information down into manageable chunks
- Plan important activities when most alert
Helpful strategies for managing memory difficulties include:
- Rehearsal and repetition - Repeat information in head over and over, or say information out loud
- Add meaning - Make up a story that gives meaning to the information
- Visualise - Make a visual story out of what needs to be remembered
- Form links - Find a common theme for the things that the person wants to remember
- Chunking - Divide large amounts of information into smaller ones (e.g., phone numbers)
- Word systems – Use rhyming words or acronyms
Everyday memory aids include:
- Write things down in a diary or on a memo pad/calendar hanging on a cupboard/door
- Have a designated place for frequently lost items, e.g., bowl for wallet, keys, mobile phone
- Link forgotten tasks (e.g., taking pills) with a regular activity during the day, e.g., a meal
- Ask a friend to remind veteran about things, or have them accompany veteran to appointments
- Make use of electronic devices for reminders, e.g., computer, mobile phone, iPad
- Establish a routine (e.g., request the same time for appointments) to reduce memory load
Adapting psychological treatment for veterans with cognitive impairment
It is not uncommon for mental health disorders and cognitive impairment to co-occur (whatever the underlying cause of the impairment). Psychological therapy can still be effective with veterans with cognitive impairment, although it is important to accommodate for the veteran’s cognitive difficulties. Below is a list of principles for adapting cognitive behavioural therapy (CBT).
Use behavioural techniques early in treatment
- Behavioural techniques such as relaxation exercises or activity scheduling are often easier to understand than the cognitive elements of CBT, so introducing these early in treatment can help build the veteran’s confidence and engagement with the CBT approach.
Simplify cognitive therapy techniques
- Match the language to the client’s cognitive abilities (i.e., carefully manage use of analogies, vocabulary and amount of material presented at one time or in one session).
- It may be necessary to suggest alternative ways of thinking to clients who have difficulty challenging their own unhelpful thoughts.
- Use behavioural experiments to help make cognitive challenging more concrete.
- Explore the veteran’s beliefs about their cognitive impairment. Note this may involve issues of shame and/or guilt as well as grief and loss if cognitive changes are permanent.
Adapt therapy delivery to the client’s strengths
- Use the results of any neuropsychological assessment that identify strengths and weaknesses, to adapt therapy delivery. For example, use diagrammatic representations to explain concepts with clients who have good visual memory.
- Slow down the therapy process by focussing on only a couple of concepts each session, and make the most of review and repetition.
- Utilise memory aids where possible. For example, provide the client with recordings of relaxation exercises, provide diagrammatic representations or written summaries, use calendars/diaries, or cue cards that can be carried in the veteran’s wallet, and make the most of technology, e.g., phone reminder alerts.
Enlist the support of a ‘therapy partner’
- The therapy partner could be a family member or close friend who can help reinforce the therapy techniques in between appointments. It is important to encourage repeated practise of skills in naturalistic settings, and a therapy partner can be helpful in implementing strategies.
Referral and coordinated care
- It important to notify the veteran’s general practitioner of possible cognitive impairments, as GPs can refer to specialists such as geriatricians, neuropsychologists or psychiatrists.
- Clinical neuropsychologist: There may be assessment and clinical issues that require the input of a neuropsychologist. A list of private clinical neuropsychologists can be found at www.psychology.org.au/FindaPsychologist when the using the advanced search function.
- The Aged Care Assessment Service (ACAS) and Psychogeriatric Assessment and Treatment Services (PGAT) can provide assessment, care plans and referrals as required. More information is available at My Aged Care.
- Alzheimer’s Australia provides information, counselling and support for people with all forms of dementia and their families and carers. See www.fightdementia.org.au or call the National Dementia Hotline on 1800 100 500.
- My Aged Care has information on dementia-related topics: http://www.myagedcare.gov.au
- Traumatic Brain Injury: The Journey Home website provides veteran-specific information about mild and moderate-severe TBI for clients, family and caregivers: www.traumaticbraininjuryatoz.org.
- Vasterling, J.J. & Brewin, C.R. (Eds.). (2005). Neuropsychology of PTSD: Biological, cognitive, and clinical perspectives. New York: Guilford Press.
- David, A., Fleminger, S., Kopelman, M., Lovestone, S. & Mellers, J. (2009). Lishman’s organic psychiatry: A textbook of neuropsychiatry (4th ed). Oxford: Wiley-Blackwell.
- Clinical practice guidelines and care pathways for people with dementia living in the community. Available from eprints.qut.edu.au.
- Guidelines for mild traumatic brain injury following closed head injury. Available from www.maa.nsw.gov.au. Summary guidelines for GPs are also available.
- Norton, F. & Halay, L. (2011). Cognitive brain deficits associated with alcohol abuse: Treatment implications. The American Association of Behavioural and Social Sciences Journal.
 This list has been adapted from the principles designed for use of CBT with people with TBI: Wong, D., McKay, A. & Hsieh, M.-Y. (2012). Can psychological interventions be adapted for people with moderate to severe traumatic brain injury? InPsych, 34, 14-15. Retrieved from www.psychology.org.au/publications/inpsych.